Dylan Cope: Boy’s sepsis death preventable

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

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

His father has told the BBC he believes it a was a “missed opportunity” to save Dylan.

A coroner in Newport found the boy’s death “would have been avoided if he had not been erroneously discharged”.

The senior coroner for Gwent, Caroline Saunders, also found his death “was contributed to by neglect”.

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”, resulting in “multiple risks”.

Emergency doctors and nurses therefore 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.

Dylan’s father, Laurence Cope, said multiple chances to save his son’s life were not taken.

“Every one of those could have been a point where that might have saved his life, a missed opportunity,” he said.

“You cannot believe the number… one after the other,” he added.

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, I think that is what is so alarming.”

Dylan was described by his family as a “unique character – feisty and sensitive, and very loving”.

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.

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

Dylan was then seen by an “unidentified” clinician who did not introduce himself and “dismissed any concern with Dylan’s appendix”.

The health board has been asked to identify this person, with Dylan’s parents offering to help find the male clinician.

Corinne Cope said the health board have not taken them up on the offer.

She added: “How can the health board claim to have learned lessons from something so catastrophic when they can’t even identify who saw this, all we want is his reasoning, his thinking, what was he doing seeing Dylan?”