Parents in 'living nightmare' after death of son from 'easily treatable condition'

Laurence and Corinne Cope, parents of Dylan Cope, outside coroner's court
-Credit: (Image: Conor Gogarty)

The heartbroken parents of a nine-year-old boy who died after neglect by a hospital have spoken out on the "chaotic and shambolic" failings. A coroner found "a gross failure of basic care" 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 discharged from hospital and his death would have been avoided if he had received further assessment. You can read our report from the inquest here.

Following the damning conclusion, Dylan's parents Corinne and Laurence Cope spoke movingly on the court steps. In a statement on the behalf of the family, Corinne said change was needed at Aneurin Bevan University Health Board, which runs the Grange University Hospital. "We have had to fight for answers that to us were painfully obvious," she said. "The system is broken and urgently needs change."

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Fighting back tears, she continued: "Dylan was our youngest son, a little boy with his whole life ahead of him. As a family, we have to adjust to being four instead of five. Our circle is forever broken. This pain will last our entire lives, not just through this hearing.

“Dylan is central to all of this. For our child to suffer and die from an easily treatable condition is unimaginable for most parents. This is now our living nightmare.”

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

Corinne said it was "painful" to learn that the Grange, which had been "touted as a state-of-the-art super hospital", was plagued with "chaotic and shambolic processes". The inquest had heard that Laurence and Dylan spoke with a male clinician on December 6 but that he never came forward to identify himself as having been involved in Dylan's care that night or to answer questions over his alleged involvement.

Laurence told WalesOnline he welcomed the conclusion of neglect but added: "Unfortunately, it doesn't really change anything for us, of course. Dylan is still gone and we have a very difficult time still ahead of us." Speaking about the unidentified male medic, Laurence said: "What really surprises me is that everybody else there that night states they do not recall who this person is. I do find it very strange that nobody else remembers that person... There are definite failings there. How can something like that happen?"

The inquest heard that on December 2, 2022, Dylan had been unwell and vomiting but two days later 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.

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. Nurse Hayden diagnosed Dylan with flu, but this failed to account for all his symptoms. The nurse 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".

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

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”. 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.

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. And she urged Aneurin Bevan health board to look at cultural issues that might prevent staff considering prior assessments. She said she had been "reassured" by the "organisational learning" that had taken place in the health board.

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.

Firdous Ibrahim, the Leigh Day solicitor representing the family, said: “It is rare for a coroner to find neglect in an inquest involving concerns with medical treatment, which further highlights what a tragic and avoidable loss this was."

A spokesman for Aneurin Bevan University Health Board, which runs the Grange University Hospital, 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. 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 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."