Dylan Cope: Boy died of sepsis after doctors missed GP note

A nine-year-old boy died of sepsis after doctors and nurses missed an “important” GP note, an inquest heard.

Dylan Cope, from Newport, was taken to Grange Hospital in Cwmbran, Torfaen, on December 6, 2022 after his GP wrote “question appendicitis”, but this note was not read.

The senior doctor on duty that evening said referrals to GPs were not printed and entered in patients’ notes due to the busy nature of the department.

The court also heard Dylan’s father should have been directed to a 999 call handler, but this was not due to an error..

Dylan was readmitted to the hospital on December 10 and died on December 14 from septic shock, with multiple organ dysfunction caused by a punctured appendix.

Dr Singh, consultant pediatric surgeon at Nottingham University Hospital, said the GP’s note identifying appendicitis and referring to Dylan “guarding” the right side of his abdomen was significant.

“It was very, very important information,” he said.

Dr. Singh explained that clinicians should rule out appendicitis “by whatever means possible” before moving on to other diagnoses.

The court heard the children’s emergency assessment unit at Grange Hospital was “operating well beyond capacity” on the night Dylan was admitted.

The court heard from a nurse practitioner who believed Dylan was going to be seen by a registrar, but this did not happen.

Dr Singh said if Dylan had been referred to a surgeon that night, the surgeon would have diagnosed appendicitis and kept him in hospital.

The court heard Dylan’s heart rate increased during his stay in hospital.

Dr Singh said: “This was a very important finding which should have prompted his admission. In the event of septic shock, every minute counts.”

The inquest was based on the expert testimony of Dr Simon Nadel, a consultant pediatric intensivist at St Mary’s Hospital, London.

He said: “In my opinion, on the balance of probabilities, Dylan was suffering from appendicitis when he presented on December 6.”

He said that in his opinion Dylan “would have died regardless of the treatment” when he presented himself at the hospital.

Dr Nadel said: “In my opinion, on the balance of probabilities, Dylan was suffering from appendicitis when he presented on December 6.”

He said that when Dylan was readmitted to hospital, his chance of survival was “50 percent or less.”

The court also heard that Dylan’s father, Laurence Cope, called the NHS non-emergency 111 service 111 days after his son’s discharge, but waited two hours to receive a response to his call.

An NHS 111 manager told the court that when the call was answered the handler recorded incorrect information, which failed to trigger a 999 response.

Peter Brown, head of 111 operations at the time, said Laurence Cope made the phone call at 12:48 a.m. on December 10, but his call was not answered until 2:49 p.m., a waiting more than two hours.

Mr Brown said the target for answering calls was 60 seconds.

“We just didn’t get it done,” he said, adding that on the day of Mr Cope’s call the service had received more than 9,000 calls – up from the usual 4,000 – in due to concerns about Streptococcus A.

He said call volumes were “beyond anything the service has seen before”.

The court heard Mr Cope managed to speak to a call handler who had recorded incorrect information.

The inquest heard Mr Cope was asked: “Is Dylan seriously ill?” ”, to which he replied that his son was “seriously ill”.

However, the call handler mistakenly recorded “no” in the system in response to this question.

Mr Brown said if the call handler had recorded ‘yes’ it would have connected him to a 999 call handler.

He then said “a number of critical pieces of information” had not been passed to a 111 clinician by the call handler.

“It was a missed opportunity,” he said.

The court heard the call handler has since left the service.

Mr Brown said changes had been made to the 111 system since Dylan’s death, including replacing the IT system with a “modern, fit for purpose” system which now allows clinicians to view GP notes.

He said call handlers and clinicians had been retrained and the service had “done a lot of work” to respond to more calls “in a timely manner”.

The court also heard from Dr Yvette Cloette, clinical director in pediatrics at Aneurin Bevan University Health Board, who investigated Dylan’s treatment at Grange Hospital.

She said “it was exceptionally busy” the night Dylan was admitted and that a colleague felt “the system was unsafe” during that time.

She said the health board failed to speak to Dylan’s parents as soon as they should have and she accepted the nurse practitioner who saw Dylan had not read his GP’s notes.

She said there was sometimes a delay of an hour or two before these notes were entered into the computer system, but she added that now they were transferred directly into the system.

Dr Cloete told the court Dylan should not have been sent home.

“I know he was, but he wasn’t supposed to be sent home,” she said.