Nine-year-old boy died after 'gross failure of basic care' by Welsh hospital

Dylan Cope: a picture provided by Dylan's family
-Credit: (Image: Family handout)

A nine-year-old boy died after a "gross failure of basic care" by a Welsh hospital. A coroner found neglect by Cwmbran's Grange University Hospital contributed to the death of much-loved Dylan Cope, who had been sent home despite having a perforated appendix.

Gwent Coroner's Court heard that "loving" and "feisty" Dylan, from Newport, died on December 14, 2022, eight days after he was taken to A&E by his parents when he was having abdominal pain. He had been referred by a GP, who had written a note saying “query appendicitis”, but this was not read by the hospital.

Senior coroner Caroline Saunders found "a number of individual errors" resulted in Dylan being wrongly discharged from hospital and that this amounted to "a gross failure of basic care". In a narrative conclusion she said Dylan's death would have been avoided if he had remained at the hospital for further assessment, adding: "His death was contributed to by neglect."

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On December 2, 2022, Dylan had been unwell and vomiting but by December 4 he had returned to normal other than having a mild cough. On December 6 he still had a cough and by this point was having lower abdominal pain. Later that day he said the pain had become "excruciating" and was taken to his GP, who noted he had stiffness in his lower abdomen, known as guarding, which is a sign of an inflamed appendix. His GP referred him to the emergency department of Grange University Hospital and he was taken there by his parents.

That night in A&E, Dylan was seen by nurse Samantha Hayden. The coroner said there was "no good reason" Ms Hayden failed to consider the GP's note. She was also troubled by Ms Hayden's evidence, in which she did not seem to consider the GP's assessment "particularly important" and said that "many GPs refer children with abdominal pain". Nurse Hayden diagnosed Dylan with flu, but this failed to account for all his symptoms. She thought it was unlikely Dylan had appendix issues as he had complained about the pain being worse on his left side, rather than his right. But Ms Saunders said that although the pain on his right was described as mild "it was still there", though it did not seem to "fit nurse Hayden's preferred diagnosis".

The senior doctor on shift that night said GP referrals were not being printed and put into patients' notes because of how busy the department was. The inquest heard the children’s emergency assessment unit was “operating well over capacity” that night. Dylan was discharged after 1am on December 7, with a cough and cold advice sheet, and his father was told to give Dylan Calpol and allow him to rest. Over the following days Dylan complained of intermittent abdominal pain. He was too unwell to attend school and was not eating.

Dylan Cope died in 2022
Dylan Cope died in 2022 -Credit:Cope family

On December 10 Dylan's family were concerned he was not improving and called the emergency number given to them when they left hospital. At 11.41am they got through at the 19th attempt and were told to call the NHS 111 number. His father Laurence rang 111 and was waiting for more than two hours before getting through at 2.45pm. He told the call handler his son had cold hands and feet. When Laurence was asked if Dylan was severely unwell, he responded that he was, but the handler mistakenly recorded 'no' in the system, meaning a 999 response was not triggered.

The handler told Laurence that a doctor would call him back but Dylan then began complaining of pain in his legs and his parents decided to drive him to A&E. They arrived at the Grange University Hospital at 4.10pm and it became clear he was in severe septic shock. He was then transferred to the University Hospital of Wales, where he underwent an appendectomy, but the coroner found that by this point he was "irretrievably" ill. Dylan died four days later. The medical cause of death was multi-organ failure caused by sepsis, which in turn was caused by the perforated appendix.

Ms Saunders had concerns over the hospital's failure to carry out a senior review of Dylan before he was discharged on December 7. Nurse Hayden claimed she had spoken to paediatric registrar Dr Lianne Doherty, who was the most senior doctor on duty that night, about Dylan's abdominal pain and was expecting the doctor to ensure there was a senior review. But Dr Doherty did not recall this being mentioned and the coroner said she "preferred" Dr Doherty's evidence on this point. Ms Saunders found this was a "breakdown in communication" and that if there had been a senior review, Dylan would have remained in hospital and his diagnosis would have become clear before December 10.

Picture of Dylan Cope provided by family
Dylan Cope was 'a lovely blend of feisty and sensitive' according to his parents -Credit:Family Handout

Ms Saunders also noted that the two-hour wait for 111 assistance was caused by "unforeseen and unprecedented pressures on the 111 service". She criticised the call handler who, as well as recording the wrong information on whether Dylan was severely ill, failed to "ask appropriate questions and pass on correct answers". But she added that she could not say this failure changed the outcome because Dylan's condition may already have been irretrievable by this point.

Ms Saunders urged Aneurin Bevan health board to look at cultural issues that might prevent staff considering prior assessments. She said she had been "reassured" by steps taken by the the "organisational learning" that had taken place in the health board. The coroner also said there was "no fault whatsoever" in Laurence Cope's agreement to take Dylan home on December 7. "That decision had been made for him and Dylan by others, and he had no choice in the matter", she said, before praising the "extraordinary bravery" of Dylan's parents in attending each day of the inquest.

Dylan Cope - family handout picture
Dylan Cope -Credit:Leigh Day

In a moving tribute Laurence said his son was "a lovely blend of feisty and sensitive". He enjoyed baking with his mother, wrestling with his brother and bouncing on the trampoline. Nothing delighted Dylan more than hearing Amazon's Alexa voice service say "free hugs available in the lounge" when he would eagerly run in to get a hug from one of his family, said Laurence.

Dylan had a quirky sense of humour and enjoyed computer coding and science at school. He enjoyed building Lego and enjoyed solving problems like a Rubik's cube. Laurence said: "On the day we were meant to be proudly watching Dylan in his school Christmas play dressed as a little reindeer, instead we watched him dying."