Lacey Brookman

Honorary Secretary of Council 

Dr Julian Morris 
Senior Coroner for the coroner area of London Inner South 

Sent by email to: 

Dear Dr Morris  

13 February 2025 

Regulation  28  Report  to  Prevent  Future  Deaths  -  touching  on  the  death  of  Lacey  May 
Brookman  

Thank you for sharing a copy of your report touching on the tragic death of Lacey May 
Brookman. I am responding on behalf of the Royal College of General Practitioners as Honorary 
Secretary to Council. Firstly, can I convey our sincere condolences to the family and friends of 
Lacey May. It is always tragic to hear of a death of a child and also recognise the effect it has on 
her family and friends.  

Abdominal pain in children is a common symptom but as highlighted can be on occasions 
extremely serious and life threatening.  

Background  

•  Decision to admit for Specialist Management We recognise that the second GP and 
possibly the A&E doctor considered that Lacey had appendicitis. Although the Registrar 
did not confirm the diagnosis of appendicitis and offered an alternative diagnosis, there 
was a recognition that Lacey required further hospital investigation and more senior 
decision making. This was undertaken by the Consultant Surgeon who reviewed the 
patient within a 24-hr period and then decided to admit and investigate. There was a 
further 24 hr delay before surgery at a specialised Paediatric unit by which time there 
were significant wider other organ responses to sepsis. 

•  Remote Consultation and Triage We recognise that original GP undertook a telephone 
triage consultation but used safety netting which supported the re-presentation with the 
second GP 3 days later. The college supports General Practitioners and other GP health 
professionals in undertaking Telephone consultation and Triage skills and runs courses 
on a regular basis which are often sold out and are a whole day event designed to offer 

Royal College of General Practitioners 
30 Euston Square, London, NW1 2FB 
Tel: 020 3188 7400  |  info@rcgp.org.uk  |  rcgp.org.uk 
Patron: HRH The Duke of Edinburgh (1972-2021)  |  Registered Charity Number 223106 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 skills to practice safe and comprehensive history taking within a telephone triage context 
to ensure the most appropriate outcome. The important lesson here is the consideration 
of the differential diagnosis of appendicitis, the history taking and examination. This point 
was highlighted as far back as 1961 in the BJGP journal note on Appendicitis ‘A GP who 
has to rely on his careful assessment of the patient’s symptoms and history should be 
able to make a much more accurate diagnosis in the majority of cases, than one who 
relies on less exacting examinations’. We recognise that the general skills for telephone 
consultation and triage in a modern age are important when General Practice is 
managing a significant proportion of on the day care. The work is therefore a core 
component of the GP Curriculum and GP Training and within the Clinical topic guides an 
area on Urgent and Unscheduled care which outlines the important issues relating this 
including a knowledge and skills guide highlighting appendicitis as one of a range of 
common and important conditions to be considered.  

•  Appendicitis and Managing Uncertainty The anatomical position of the appendix can 
vary considerably and drive the presentation. Many GPs use the NICE CKS guidance, 
and the current guidance highlights retrocaecal appendicitis and its features which may 
not include tenderness to deep palpation and muscular rigidity due to the distinct 
position of the appendix lying behind the caecum. The incidence of a retrocaecal 
appendicitis is between 20 and 65% and therefore not an uncommon presentation 
however its features are not as differentiating as other anatomical positions, and this 
may cause some delay in diagnosis. NHS England and the GIRFT team (Getting it Right 
First time) have reviewed the management of appendicitis from a prehospital through to 
hospital and discharge, Paediatric acute abdominal pain and appendicectomy, Best 
Practice pathway guidance .This work was undertaken by the NHS England National 
Clinical Director for Paediatrics Simon Kenny a Paediatric surgeon alongside a working 
group which included two General Practitioners with Urgent care experience. The 
pathway recommends close working between Paediatricians and the Surgical team, 
however it seems in the Regulation 28 report that there was no mention of the Paediatric 
team being involved in Lacey’s care. The pathway also promotes a case study which 
supports increasing the availability of imaging in centres admitting children with 
abdominal pain (see Case study 6E Reducing variation in access to abdominal 
ultrasound). This pathway aims to reduce the unwarranted variation in unnecessary 
appendicectomies for children presenting with abdominal pain for other reasons through 
more accurate and timely diagnosis. This issue of retrocaecal appendicitis and the 
associated diagnostic dilemma is not raised in the pathway, and this may be an area to 
investigate further.  

In answer to your matters of concern regarding suspecting appendicitis, it remains a common 
condition presenting with a range of clinical signs and symptoms which may vary according to 
anatomical and pathological variation. There is a potential risk of underdiagnosis for a variant of 
the condition ‘retrocaecal appendicitis’ which often presents in the later stages due to a delay in 
the symptom of pain. This creates diagnostic uncertainty, potential delay in investigation and 
hospital management. There are diagnostic solutions such as bedside ultrasound scanning, 
however this is not routinely available in either hospital emergency departments and not in the 
urgent and emergency care settings of General Practice. This would need policy change and a 
prioritisation of investment as well as training development opportunities in primary care 
settings.  

 
 
 
 
 NHS England and the GIRFT team have recently produced the Best Practice Guide and have 
an established process for its implementation which supports a whole pathway approach, 
however the guide does not specifically reference retrocaecal appendicitis. Most GPs refer to 
NICE CKS guidance which does specifically mention the presentation of retrocaecal 
appendicitis. The Royal College of General Practitioners remains committed to supporting 
ongoing educational resources for both the GP Curriculum and Continuing Professional 
Development in this area.  

I trust that this reply is helpful and if you have any questions, please do not hesitate to contact 
me. Our sincere condolences are with Lacey May’s family. 

Yours sincerely 

RCGP Honorary Secretary

Sent by email to: 

Dear Dr Morris, 

Dr Julian Morris 
Southwark Coroners Court  
1 Tennis Street  
London  
SE1 1YD  

23 December 2024 

Re: RCPCH Response to the Inquest Touching the Death of Lacey May Brookman 
A Regulation 28 Report – Action to Prevent Future Deaths 

Thank you for sharing your report with us regarding the tragic and untimely passing of Lacey 
May Brookman. I was very sorry to hear of Lacey’s death. I have shared your report with 
other senior paediatric colleagues within RCPCH, namely our Officers for Clinical Standards 
and Quality Improvement. 

We have read your report carefully. Of the four matters of concern noted, one is of particular 
note to the RCPCH given our role postgraduate medical education: 

The training of doctors in considering the diagnosis [of retrocaecal appendicitis] as a 
possible differential to generalised abdominal pain. 

An important learning outcome in our core syllabus for paediatric training is the ability to 
conduct a clinical assessment of babies, children and young people, formulating an 
appropriate differential diagnosis; plans appropriate investigations and initiates a treatment 
plan in accordance with national and local guidelines, tailoring the management plan to meet 
the needs of the individual. This includes the capability to recognise the potential life-
threatening events in babies, children and young people and lead resuscitation and 
emergency situations. Diagnosis of acute abdominal pain is an important part of this 
syllabus.  

We also support the training resource, Spotting the Sick Child, which includes abdominal 
pain as one of seven common symptoms.  

You have additionally noted the Best Practice Pathway Resource for paediatric acute 
abdominal pain and appendicectomy, which was published in June 2022 by Getting It Right 
First Time (GIRFT), which was developed with several College members. We will ensure we 
signpost to this accordingly.  

The College will be sharing information and suggestions for local improvement from your 
report with our paediatric members via its patient safety portal. The anonymised information 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 within your report will also be shared for discussion with the RCPCH Clinical Quality in 
Practice Committee, where further actions may be identified.   

Thank you for seeking our views and reminding us of the importance of this work. Our 
sincere condolences are with Lacey’s family.  

Yours sincerely 

RCPCH President

Dr Julian Morris 
Senior Coroner 
London Inner South  
Southwark Coroners Court  
1 Tennis Street  
London  
SE1 1YD 

10th December 2024 

Sent by email: 

Dear Dr  Morris, 

Royal College of Radiologists Response to Regulation 28: Prevention of Future 
Deaths report issued on 8 November 2024 in relation to the death of Lacey May 
Brookman. 

I was very sorry to read about the death of Lacey and I would firstly like to express my 
sincerest condolences to Lacey’s family for the very sad and tragic loss of their child. We 
take the matters raised in your report very seriously and I hope this letter is helpful in 
outlining how we are committed to learning from them. 

The Royal College of Radiologists (RCR) is the leading professional membership body for 
Clinical Radiologists and Clinical Oncologists, with over 17,000 members globally. The RCR 
is a charity and aims to lead, educate and support its members and improve the quality of 
care in its specialties for the benefit of patients and the public.   

A key priority for the RCR is to advocate for expansion of the radiology workforce. RCR 
census data has shown severe shortages in the radiology workforce, including a 30% 
shortfall of Consultant in Clinical Radiology. Almost all (97%) of radiology leaders (Clinical 
Directors who lead imaging departments in the NHS) report that workforce shortages cause 
delays and backlogs and 91% of Clinical Directors said that workforce shortages are 
impacting negatively on patient safety.  

We have been asked to address the diagnosis of retrocaecal appendicitis and specifically to 
consider availability and use of ultrasound scanning in abdominal pain at any time, but 
especially out of hours.  

In formulating our response, we have sought opinion from the following Special Interest 
Groups affiliated with the RCR: The British Medical Ultrasound Society (BMUS), The British 
Society of Paediatric Radiology (BSPR), The British Society of Gastrointestinal and 
Abdominal Radiology (BSGAR) and The British Society of Emergency Radiology (BSER). 

 
 
 
 
 
 
 
 
 
 Special Interest Groups are independent organisations who provide advice and expertise in 
certain areas of practice. 

Retrocaecal appendicitis is indeed relatively common as stated in your report and can be a 
difficult diagnosis to make clinically. All patients, including children presenting with abdominal 
symptoms suspicious for retrocaecal appendicitis (and other serious acute abdominal 
conditions), are referred for diagnostic imaging at the discretion of the clinical team treating 
them. The degree of urgency typically reflects the seriousness of the clinical presentation as 
assessed and conveyed by the referring clinician. 

Some patients remain remarkably "well" for a long time despite the presence and ongoing 
progression of serious acute abdominal pathology, and consequently the referral for 
diagnostic imaging may come late in the course of disease. Ultrasound and Computerised 
Tomography (CT) are the two commonest imaging investigations in this clinical scenario, with 
MRI as a relatively uncommon alternative (see RCR iRefer guideline p28). 

Ultrasound and CT are widely available in all hospital settings. What is critical is that the 
referral for abdominal ultrasound or/and a CT scan and the associated radiologist opinion is 
made in the first place.  This call can be very difficult and is dependent on training, 
experience and familiarity and with the availability of senior support for advice and 
discussion.   

Once the referral is made then urgent imaging is typically available within hours of admission 
to hospital and the exact algorithm of whether CT or Ultrasound will be preferred depends on 
the precise clinical scenario as well as the local availability of equipment and suitable 
expertise. Ultrasound is operator dependent and there is a considerable learning curve and 
requirement for ongoing practice in order to master diagnosis. In experienced hands, 
ultrasound is a very powerful diagnostic tool for the assessment of abdominal pathology and 
it has great benefits in the diagnosis of conventional appendicitis in that can be a relatively 
rapid, portable, bed-side test that does not involve ionizing radiation.  It also has a high 
sensitivity and specificity for the diagnosis of appendicitis and discriminating from other 
bowel pathologies (e.g. mesenteric adenitis, inflammatory bowel disease and ovarian torsion 
in girls), again when used in experienced hands. 

As with the clinical assessment of retrocaecal appendicitis, however, diagnosis with 
ultrasound can be challenging even with very experienced operators.  In expert paediatric 
radiology centres abdominal ultrasound can identify appendicitis with fairly high confidence, 
but identifying retrocaecal appendicitis can be challenging even in such expert hands. 

We recognise the GIRFT report: "Paediatric acute abdominal pain and appendicectomy: Best 
practice pathway guidance" from June 2022. This document does not specifically evaluate 
retrocaecal appendicitis but recommends ultrasound as the first line investigation in children 
with suspected appendicitis who require imaging with some further information around which 
children this will be.  This report recommends the use of a risk score and imaging for those 
with diagnostic uncertainty, an intermediate risk score or for those whose symptoms are not 
resolving with a low risk score.  It also details the importance of multidisciplinary working and 
involvement of paediatricians and general surgeons as well as paediatric surgeons when 
they are available. 

We note that ultrasound was available in the centre to which Lacey presented but that 
tragically even provision of ultrasound and CT on the day of the referral did not facilitate 
curative treatment. 

 
 
 
 
 
 More generally, the availability of ultrasound out of hours varies greatly between hospitals.  
Expertise in imaging severely ill children may be limited in non-specialist centres who may 
not see these cases regularly and that may necessitate transferring patients to a specialist 
paediatric centre.  NHS trusts which run most radiology services in the UK are currently 
further limited by workforce pressures and particularly by the availability of Consultant 
Radiologists because, as described above, there is currently a 30% shortage in the UK and 
91% of Clinical Directors state that workforce shortages are impacting negatively on patient 
safety. The location of the appendix can be extremely variable within the abdomen and the 
GIRFT document does not specifically address retrocaecal variations of appendicitis.   
We are not aware of specific guidance on retrocaecal appendicitis but advocate using similar 
imaging strategies to general appendicitis.  

However, as with more conventionally sited appendicitis, ultrasound is advised as the first 
line of imaging investigation following rigorous clinical assessment. Even in such a scenario, 
if a patient does have a retrocaecal appendicitis, then the initial ultrasound may be equivocal 
or not show a cause for the child's illness.   

This is because the retrocaecal appendix lies behind the caecum which can contain 
extensive gas and ultrasound cannot penetrate air or bowel gas and may therefore not be 
able to visualise the enlarged appendix, surrounding inflammatory change or, an abscess 
related to a perforated appendicitis.  

Even readily available expert-level abdominal and bowel ultrasound in specialist centres can 
miss a retrocaecal appendicitis, so the availability of point of care ultrasound in this case is 
unlikely to have been a critical factor. 

Even if the appendix is not visualised, secondary signs can sometimes be elicited on 
ultrasound to raise suspicion of a diagnosis of appendicitis.  On occasions, and when the 
appearance is initially equivocal, we advocate ongoing clinical evaluation and repeating the 
ultrasound at a short interval to assess for evolving features that may support a diagnosis. 
This is applicable whenever a positive diagnosis is not made and particularly relevant if 
ultimately a patient is shown to have retrocaecal appendicitis.  

Ongoing, clinical assessment is essential and if there are concerning clinical features or no 
clinical improvement then in the severely ill child where ultrasound cannot reach a diagnosis, 
the child should be further evaluated with additional imaging, a CT or Magnetic Resonance 
Imaging (MRI) scan being performed depending on the clinical expertise of the centre. 
Alternatively, an experienced paediatric surgeon may decide to take a severely ill, 
deteriorating child or a child with classical clinical symptoms of appendicitis directly to the 
operating theatre without obtaining further imaging.  

CT can identify retrocaecal appendicitis with high confidence without the requirement for 
expertise in paediatric bowel ultrasound and, outside of specialist paediatric centres, CT is 
more widely available than the level of ultrasound which would be required to identify 
appendicitis in children with confidence.   

 
 
 
 
 
 
 
 
  
 
 
 
 CT scanning is available 24 hours a day in all relevant hospitals in the UK, with due 
consideration given to the radiation exposure involved in abdominal CT in a child with non-
specific symptoms.  There are of course understandable reservations about referring children 
for CT scanning as it involves exposure to ionising radiation.  It is possible that due to these 
reservations, together with the generally late presentation of retrocaecal appendicitis and 
that, as above, some children with this condition remain remarkably "well" for a long time, 
results in a delay in considering the diagnosis and consequently in making a referral for CT 
scanning. 

If the exposure to radiation can be justified then CT scans with intravenous contrast of the 
abdomen and pelvis has the advantage over ultrasound in that the images are not obscured 
by gaseous distension of bowel and the appendix and associated inflammatory changes are 
more commonly seen.  Alternatively, MRI can be used to obtain a representation of the 
bowel/appendix and internal organs.  MRI techniques have an advantage of avoiding the use 
of ionizing radiation although the scanning time is typically significantly longer than CT and 
thereby posing particular problems in younger children who cannot lay still and the pool of 
experts who can confidently interpret them is smaller than that for CT. 

Ultrasound, CT and MRI all require considerable training to perform and interpret correctly 
and the availability of abdominal ultrasound which must be performed in person may be 
particularly limited by availability of on-site expertise. Images for CT and MRI may be 
acquired locally and transmitted remotely which is a common technique in multi-site trusts or 
when on-call services are provided through a network.  

In conclusion, we recognise that the diagnosis of retrocaecal appendicitis can be challenging 
both clinically and radiologically.  We advocate prompt assessment by experienced clinicians 
including expert surgeons and radiologists.  Given the workforce shortages in the UK and the 
ramifications for delayed diagnosis this may necessitate early transfer to specialist centres 
where paediatric surgeons and paediatric radiologists are more available.  

I am grateful to you for bringing these matters of concern to our attention and for giving us 
the opportunity to respond. Once again, I express my deepest condolences to Lacey’s family 
and loved ones. 
Yours sincerely, 

RCR President

Dr Julian Morris
Senior Coroner, London Inner South
London Inner South
Southwark Coroners Court
1 Tennis Street
London SE1 1YD

By email:

12 December 2024

Dear Dr Morris,

Thank you for providing us with your Prevention of Future Deaths Report following the tragic
death of Lacey Brookman. We are deeply saddened to read about the circumstances of her
passing and extend our deepest condolences to her family at this difficult time.

The senior Officers of the Royal College of Surgeons of England have carefully considered your
report, alongside those senior surgeons and staff involved in setting the surgical curricula, and
our education and policy departments. Our belief is that early formal clinical examination and
adjunctive investigations of abdominal ultrasound +/- abdominal CT scan, in cases of doubt,
would have aided early diagnosis of this problem, as noted in your report.

As you highlight, retrocaecal appendicitis is not a rare presentation. Within the postgraduate
Intercollegiate Surgical Curriculum Programme, its diagnosis and management are addressed
through the Core Surgery, Paediatric Surgery and General Surgery curricula, as part of the
focus on acute appendicitis and acute abdominal conditions. The condition therefore forms part
of the syllabus of the Intercollegiate MRCS and FRCS (Gen Surg) & (Paed Surg) examinations.
While we believe current curricula coverage is adequate, we recognise the importance of
continually reviewing our curricula and we have shared your report with our Specialty Advisory
Committee Chairs for their consideration during upcoming curricula reviews.

The curriculum refers to that followed by surgeons in training, with a national training number to
acquire a Certificate of Completion of Training (CCT), and those on the specialist register via
the CESR / portfolio pathways. It should be noted that not all surgical doctors are on training
pathways or following a specific curriculum, and that not all Consultants employed as such by
the NHS are currently on the specialist register, and therefore will have variable experience and

38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk

Registered Charity no: 212808

  training, not formally assessed by the Royal Surgical Colleges’ Joint Committee for Surgical
Training (JCST). For these doctors the local employers would be responsible for ensuring their
employees have the knowledge, skills and behaviour required to practice surgery at their
grade/level of employment.

The out of hours provision of paediatric radiology services, particularly ultrasound, is a service
availability and quality matter, determined by local Trusts/ICB's. It is not provided by surgeons in
any point of their training or curriculum, and advice from the Royal College of Radiologists might
be sought. An NCEPOD review may also help determine the current risks and requirements for
a safe paediatric radiology service going forwards.

Our education team has also reviewed your report and they are now exploring whether we can
explicitly refer to retrocaecal appendicitis. Specifically, we are reviewing the content of the Care
of the Critically Ill Surgical Patient (CCRISP) and the Clinical Skills in Emergency Surgery
courses. The updated version of CCRISP is scheduled for launch in 2025, while the Clinical
Skills in Emergency Surgery course is in the early stages of redevelopment.

This case has been forwarded to the Programme Director of the Confidential Reporting System
for Surgery (CORESS) and will be published as an anonymised educational Surgical Safety
vignette in the Annals of the Royal College of Surgeons of England, and in Surgeons’ News, the
Journal of the Royal College of Surgeons of Edinburgh, ensuring its dispersal to a wide surgical
audience. The case will also be discussed with the Surgical Safety Lead of NHSE.

We hope our organisation’s response demonstrates our commitment to learning from this case
and improving surgical training and education to support patient care. We would be happy to
discuss our response further or provide additional information if required.

Yours sincerely,

Chief Executive

38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk

Registered Charity no: 212808

 38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk

Registered Charity no: 212808