'Neglectful' death of boy, 9, from sepsis could have been prevented, coroner finds

The death of a nine-year-old boy from sepsis was "contributed to by neglect" after multiple failures by medical professionals, a coroner has concluded.

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.

The Senior Coroner for Gwent, Caroline Saunders, said: “I have heard no good reason for why she did not look at this important document… this was below the accepted standard”.

The coroner said the evidence she had heard indicated that it is possible that GP’s referrals were regularly disregarded, ad she urged Aneurin Bevan University Health Board to review that culture.

Dylan tested positive for Influenza A and was sent home in the early hours of the morning with just a leaflet about coughs and colds.

The coroner said she’d concluded that the reason the paediatric nurse who assessed Dylan failed to note the right sided abdominal in the discharge note she prepared was because “this symptom did not fit her preferred diagnosis”.

The coroner made it clear in her conclusions that the failings that contributed to Dylan’s death were the result of errors by individuals, rather than by the organisations who employed them.

Dylan’s notes were placed in the correct rack to lead to a senior review by an experienced doctor, but a miscommunication between two members of staff led to Dylan being discharged when he needed further care.

The coroner said she believes that if there had been a senior review of Dylan’s condition as there should have been, he would have been kept in hospital and his appendicitis would have been identified.

The coroner said his death, therefore, would have been prevented.

“Dylan’s death would have been avoided if he had not been erroneously discharged from hospital. His death was therefore contributed to by neglect”.

During the coroner’s conclusions, Dylan’s mother Corinne was quietly weeping in court.

Three days after he was discharged, Dylan’s symptoms worsened and his parents called NHS 111, leading to a wait of over two hours to speak to a call handler.

The coroner accepted that there were “unforeseen and unprecedented challenges” facing the 111 service on Saturday 10th December, which received twice the number of calls they would expect due to an outbreak of Strep A and flu.

However, she criticised the failure of the call handler to either ask the correct questions or accurately record the answers Dylan’s father gave about his condition. This failure led to an ambulance not being called when it should have been.

The coroner said Dylan was already suffering the effects of severe sepsis and therefore she did not conclude that the failures by the 111 service had changed the outcome.

“His fate was already sealed”, the coroner said.

When his condition further deteriorated, Dylan’s parents rushed him back to hospital.

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 and multi organ failure caused by a perforated appendix.

The coroner decided not to commission a prevention of future deaths report into the incident as she accepted that the health board and NHS 111 had made the required institutional learning.

The coroner paid tribute to Dylan’s parents’ bravery for attending the inquest every day and offered her sincere condolences before the court rose at the conclusion of the inquest.

Speaking outside the court, Dylan's father said, "It really cannot happen to children, there are such basic things that should’ve taken place.

Laurence added, "It should be straightforward to have processes in place to ensure this doesn’t happen again, I hope they put those in place so no other child or parent or family should go through this again for such a common and treatable illness that was missed."

Corinne Cope has been raising awareness about sepsis since her son's death so nobody else has to experience the same thing.

She said, "The only positive thing to come out of this is that we use this as something remotely positive to raise awareness of sepsis… it’s just the right thing to do.

"If anything is to come from this, it should be with a view to improving outcomes for future patients: adults and pediatric patients."

A spokesman for Aneurin Bevan University Health Board said:

“We are truly heartbroken and our thoughts and deepest sympathies remain with Dylan’s parents and his whole family. No parent should have to go through losing a child in such circumstances. We are all truly devastated.

“The Health Board has undertaken a detailed investigation into the circumstances leading to Dylan's death and sought independent clinical opinion to support its investigation. Our findings, actions and learning have been shared openly with the family, their representative, and with the Senior Coroner for Gwent.

“Senior members of the Health Board have met with the family in person to apologise for the tragic circumstances leading to the loss of their beloved son. The Health Board fully recognise that no apology will ever make up for the pain and suffering the family have experienced in losing Dylan.

“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.

“The Health Board would like to acknowledge the important and valued contributions from Dylan’s parents at such a difficult time to improve the way we undertake patient safety investigations and we are extremely grateful to them. We are working with Dylan’s parents to further raise awareness of the signs and symptoms of Sepsis and we will continue to work closely with them on this.

“The Health Board takes full responsibility for what happened to Dylan. We are deeply sorry and remain fully committed to supporting the family in any way we can.”

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