Boy died from sepsis after being 'erroneously discharged' from hospital, coroner says.

A nine-year-old boy who died from sepsis days after being sent home from hospital with a leaflet about flu was “erroneously discharged”, a senior coroner has concluded.

Dylan Cope from Newport went to A&E at the Grange Hospital, Cwmbran, Torfaen, on 6 December 2022 with a GP note saying "check for appendicitis" but this was not read.

The inquest heard from the senior doctor on shift on the night of Dylan's visit, who said GP referrals were not being printed off and put into patients' notes because the department was “operating well over capacity.”

The inquest also heard Dylan waited an hour longer than he should have to be triaged at the hospital and was eventually seen by a nurse practitioner who said it was not unusual to see patients without their GP notes. 

This meant that emergency doctors and nurses did not know that Dylan's GP had written “query appendicitis” and sent him home with a coughs and colds advice sheet.

Dylan was readmitted to hospital on 10 December, and died on 14 December from septic shock, with multi-organ disfunction caused by a perforated appendix.

A consultant paediatrician at Aneurin Bevan health board, Dr Nakul Gupta, said clinicians should be reading GP letters.

The senior coroner for Gwent, Caroline Saunders, found the boy's death “would have been avoided if he had not been erroneously discharged” and said what happened "amounts to a gross failure of basic care.”

Caroline Saunders, also found that Dylan Cope’s death “was contributed to by neglect” and that he “was suffering from appendicitis” when he first arrived at hospital but added that the failure by the nurse practitioner to read Dylan’s GP notes was “below an acceptable standard of care.”

She urged Aneurin Bevan health board to “review the culture” around clinicians reading GP notes.

Ms Saunders said the nurse practitioner failed to document an adequate history of how and where Dylan's pain had started which was an “inadequate” examination and found there was a “breakdown in communication” which was why Dylan did not receive a senior review.

Caroline Saunders added that, if Dylan Cope had received a senior review, he would have been kept in hospital, had a blood test taken and would have received a review by a surgical team and “the diagnosis would have become clear. On balance his death on the 14th would have been avoided."

The coroner said what happened "amounts to a gross failure of basic care” and concluded that “Dylan’s death was contributed to by neglect" adding he was “inappropriately discharged home” when his condition “warranted further observation and assessment.”

Dylan Cope’s parents said they “remain deeply concerned” about whether the hospital and health board had learned from this.

In a statement they said: “The system is broken and urgently needs change. Dylan was our youngest son, a little boy with his whole life ahead of him.”

Dylan’s father, Laurence Cope, said multiple chances to save his son's life were not taken and added: “Every one of those could have been a point where that might have saved his life, a missed opportunity."

Dylan’s mother, Corinne Cope, said: “The only person who seemed to get it spot on was the GP, and thereafter it seemed like everyone let him down. How is that possible? There were so many failures, that is what is so alarming."

Aneurin Bevan health board said it took full responsibility for what happened to Dylan Cope and added “We are deeply sorry and remain fully committed to supporting the family in any way we can.

"Dylan’s tragic death was as a result of an organisational system failure that occurred in a department whilst under extreme pressure with twice the number of patients normally attending and was not attributable to any individual member of staff.  

"We are working with Dylan’s parents to further raise awareness of the signs and symptoms of sepsis."