Boy, nine, died of sepsis days after hospital discharge, coroner hears

Dylan Cope, from Newport, was taken to Grange Hospital in Cwmbran on December 6 2022.

He was discharged early the next day after being diagnosed with influenza and given a leaflet with advice for coughs and colds.

He died on December 14 of sepsis at the University Hospital of Wales in Cardiff.

His mother and father, Corrine and Laurence Cope, described their son as having been a “fit and healthy young boy”, who enjoyed life and loved his family, especially baking with his mother and wrestling with his brother.

Opening the inquest on Monday, senior coroner for Gwent Caroline Saunders said the hearing is being held to examine whether Dylan’s appendicitis, which led to sepsis, could or should have been picked up earlier.

In a statement read out by Ms Saunders, Dylan’s father said: “He was very loving and nothing delighted him more than hearing over Alexa that there were free hugs available in the lounge.”

He added: “When we should have been watching him perform as a reindeer in the school play, we were watching him die.”

Mr Cope’s statement went through the events leading up to his son’s death, with Dylan having been ill with what his parents thought was a stomach bug.

After Dylan began to experience severe pain, his parents took him to his GP, Dr Amy Burton, who suspected he had appendicitis.

Ms Burton advised he go immediately to the Grange Hospital and she called ahead with her diagnosis.

While there, Dylan was seen by Samantha Hayden, a paediatric nurse practitioner for the Aneurin Bevan Health Board.

The inquest heard that while Ms Hayden had been aware that his GP had seen Dylan, Dr Burton’s diagnosis was not passed on and she did not follow up the notes.

Ms Hayden said this was normal because she did not want to be led by the GP’s assessment, taking a thorough history and examination for herself.

She also described that day as having been “exceptionally busy”.

Addressing Ms Saunders, she said she did not recall Dylan or his father expressing concern about the severity of pain the young boy was experiencing and that he seemed to be walking fine, but this was not noted in her notes.

The coroner said she was “concerned” by elements of Ms Hayden’s statement to the inquest.

Her notes said that Dylan had a tenderness on the right-hand side of his body – which would indicate appendicitis – but it was not documented in her statement to the coroner’s court.

Instead, the nurse said Dylan had indicated the pain was mainly on his left-hand side, away from the appendix.

Tests also showed that he had influenza.

She also said she had not ruled out appendicitis despite her listing influenza as her diagnosis in the preliminary discharge notes.

Ms Hayden said she had sought a senior review for Dylan, to check her assessment.

The court heard that a man wearing scrubs later saw Dylan but he did not introduce himself, with Mr Cope assuming he was a surgeon.

Asked if she has been given more training about notekeeping since the incident, Ms Hayden said she had not received formal training but was told that her documentation needs “improving”, which she said she has now done by recording all conversations with senior staff.

Peter Bassett, a staff nurse at the hospital for 20 years, said he had been told to discharge Dylan by a junior doctor on the ward.

Mr Bassett said he was unable to identify the doctor who gave him the order, with many of them being new and wearing face coverings at the time.

Asked whether he had checked to see whether the senior review had been carried out, he told the coroner he believed it had been done.

He said: “I didn’t check because I was given the discharge papers and that is only done after a review.

“I assumed at some point with that hour and a half that’s what happened.”

The also court heard that the health board has already made changes to its practices.

While patients were previously sent home only with a leaflet for the diagnosis, they are now also sent home with one for the presenting complaint, meaning Dylan would now be sent home with one for appendicitis as well.

The inquest continues.