Boy died from sepsis after 'very significant information' missed by hospital staff, inquest hears

A nine year old boy died from sepsis after "very significant information" gathered by his GP about his symptoms was missed by hospital staff, a paediatric surgeon has told an inquest.

Dylan Cope was taken to Grange Hospital in Cwmbran on December 6th 2022 after being referred by his GP for suspected appendicitis, but the paediatric nurse who first assessed him in hospital did not read the referral notes.

Dylan tested positive for Influenza A and was sent home in the early hours of the morning with a leaflet about cold and flu symptoms, despite it being more than likely he already had appendicitis. Three days later Dylan was rushed back to hospital after going into septic shock.

After several days in intensive care, Dylan died at the University Hospital of Wales on December 14th. The official cause of death was recorded as sepsis caused by a perforated appendix.

On Thursday, Mr Shailinder Singh, a consultant paediatric surgeon who was asked by Aneurin Bevan University Health Board to assess Dylan’s case following his death, explained to the court why he believed Dylan probably already had appendicitis when he was first admitted to hospital.

On 6th December, Dylan’s GP referred him to the children’s assessment unit at the Grange Hospital querying possible appendicitis given she had identified some “guarding of the right iliac fossa”.

Mr Singh told the court that this was “very significant information”, because it is detected when the abdomen is pressed and is an indication that there may be inflammation of the inner abdominal surface, often due to appendicitis.

The consultant paediatric surgeon, giving evidence from the witness box, told the court that if involuntary guarding is identified in a child, “appendicitis must be ruled out by a senior clinician by all means at their disposal”, before any other diagnosis is pursued. This may have included assessing the trends of a child’s heart rate and temperature, as well as possible blood tests.

Earlier in the inquest the court heard that the children’s assessment unit at the Grange Hospital was “exceptionally busy” on the evening Dylan was first admitted, working at double capacity with around 45 patients. The night before Dylan was admitted the unit was working at four times capacity.

The paediatric nurse practitioner who first assessed Dylan previously told the inquest she had wanted to spend more time with Dylan, rather than at a computer reading his GP referral notes.

On Thursday, Mr Singh told the inquest that 90% of forming a diagnosis in a child is by assessing the history of their symptoms, with only a small amount being determined from physical examination and other tests.

After assessing the notes of Dylan’s hospital assessment, Mr Singh said that if there had been an extensive assessment of Dylan’s symptoms over the previous few days by hospital staff, which included severe abdominal pain, it was not documented.

The senior coroner for Gwent, Caroline Saunders, asked him: “That information would have been important for ongoing treatment wouldn’t it?”

“Absolutely, I agree with you”, he replied.

“If a surgeon had been called [on the night of December 6th], he would definitely - on the balance of probability - have diagnosed appendicitis”, Mr Singh told the court. He defined "on the balance of probability" as more than 50% chance.

Mr Singh said the upward trend of Dylan’s heart rate and temperature should also have been reason to at least keep Dylan in hospital for longer for further medical observations.

When first observations were taken after 8pm at the Grange Hospital, Dylan was defined as tachycardic, with a heart rate over 100.

“I’d be very worried about a heart rate of 152”, Mr Singh said, “150 plus heart rate is a trigger for me”.

The coroner, Caroline Saunders asked him: “Is that that the sort of red flag that should have been brought to the attention of a senior clinician?

“Absolutely”, replied Mr Singh.

The court heard that if Dylan had been diagnosed with appendicitis on the night of the 6th December, Mr Singh believes he would have been started on a course of antibiotics immediately, before being operated on the following day.

“When in doubt, operate”, Mr Singh told the court, “It is a very low threshold, particularly in children under the age of 10”.

Dylan and his father Laurence Cope were told they could go home in the early hours of December 7th and were given a factsheet about coughs and colds in children over the age of 1, due to Dylan’s positive test for flu.

The inquest had previously heard that a “breakdown in communication” had led to Dylan being sent home without a face-to-face senior review by a more experienced doctor.

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After a break for lunch, the inquest heard from Peter Brown, Assistant Director of Operations at the Welsh Ambulance Service. At the time of Dylan’s death, he had responsibility for managing the 111 service.

Mr Brown told the court that Dylan’s father Laurence Cope had called 111 at 12:48pm on December 10th, following a deterioration of Dylan’s symptoms.

The 111 service aims to answer every patient’s call within 60 seconds, but the court heard that Mr Cope did not have his call answered until 2:49pm. This more than two hour wait was “far in excess of what we would aspire to achieve”, Mr Brown said.

The inquest heard that a number of opportunities were missed to get Dylan admitted to hospital sooner, and therefore increase his chances of survival.

The call handler asked Mr Cope: “Is Dylan severely unwell?”, to which Dylan’s dad said “yes”. But Mr Brown told the inquest that the call handler had mistakenly recorded the answer as “no”, thereby not triggering an immediate referral for an ambulance.

Despite that, after asking all of the required questions, the call handler and the algorithm reach the conclusion that Dylan should be taken immediately to A&E.

However, a nurse that assessed that decision chose to downgrade that advice and instead recommend a full assessment by a clinician, which would be expected to call Mr Cope back within another 2 hours.

During the inquest, the court heard that this happened because the call handler did not relay that Mr Cope had said "yes" to the question around whether Dylan was severely unwell.

“Mr Cope had been extremely clear that Dylan would have needed some assistance to get to the emergency department and something to lie on when he got there”, Mr Brown said.

The court heard that the transcript of the call shows Mr Cope also informed the call handler about Dylan having a temperate and a rash on his legs.

“Regrettably the call handler recorded “no” to the question about whether there was a rash”, Mr Brown said, “That was another opportunity missed”.

The inquest heard that the call handler went on sick leave for a period of time after the incident and then she left the service.

The inquest, which is due to conclude on Friday, continues.

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