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Coroner’s Report Highlights Failures Leading to Teen’s Fatal Heart Misdiagnosis

The death of 15-year-old Jake Lawler from a genetic heart condition prompts calls for systemic healthcare reforms and improved diagnostic protocols.

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Overview

  • Jake Lawler, 15, died in November 2024 from a rare genetic heart condition, biventricular arrhythmogenic cardiomyopathy, misdiagnosed as exercise-induced asthma.
  • A coroner’s inquest revealed that an abnormal ECG and a prior collapse during football were not recognized as red flags by clinicians.
  • Coroner Alison Mutch ruled that proper referral and testing after his initial collapse could likely have prevented Jake’s death.
  • The Prevention of Future Deaths report criticizes diagnostic gaps, insufficient clinician training, and a lack of national guidance for exercise-induced syncope in children.
  • Healthcare organizations, including Manchester University NHS Foundation Trust, must respond to the coroner’s report by July 4, 2025, with action plans due by May 30.