Nine-year-old Dylan Cope died of sepsis after doctors and nurses missed GP note warning of appendicitis

Doctors and nurses missed a GP note warning of a suspected appendicitis that led to the death of a nine-year-old boy, an inquest was told. Dylan Cope passed away in December 2022 after suffering sepsis.

The youngster, from Newport, South Wales, was taken to the Grange Hospital in Cwmbran, Torfaen, on December 6. A note from his doctor read, “query appendicitis”, but was not read - because the department was too busy.

Staff on duty at the hospital that night said GP referrals - including notes - were not being printed out and included in patients' notes as staff were overwhelmed.

After that visit, Dylan was readmitted to hospital on December 10, and passed away on December 14 after suffering septic shock, with multi-organ disfunction caused by a perforated appendix.

At the inquest, Dr Singh, a consultant paediatric surgeon from Nottingham University Hospital, gave expert evidence at the inquest and said the GP note which identified appendicitis and referenced Dylan “guarding” the right side of his abdomen - an indication of the condition. He said the information was "very, very significant" and that clinicians should have ruled out appendicitis before moving on to other diagnoses.

The inquest was also told the children’s emergency assessment unit at the hospital was “operating well over capacity” the night Dylan was admitted. A nurse practitioner said they believed the youngster was going to be seen by a registrar, which did not happen.

If he had been referred to a surgeon that night, it was likely an appendectomy would have been carried out and he would have been kept in hospital, he said, which may ultimately have saved his life.

The court was also told Dylan’s heart rate increased while in hospital. Dr Singh said: "This was a very significant finding which should have alerted for him to be admitted. In septic shock every minute counts."

In expert evidence Dr Simon Nadel, a consultant paediatric intensivist at St Mary’s Hospital in London, said he believed "Dylan had appendicitis when he presented on December 6".

Dylan's father, Laurence Cope, called NHS 111 days after his son was discharged, but waited two hours for his call to be answered. When he did get through, the inquest heard the operator did not trigger a 999 response as they recorded incorrect information, said Peter Brown, head of 111 Operations at the time.

He said "a number of critical pieces of information" were not passed on to a 111 clinician, which had led to changes in the system since, meaning clinicians can view GP notes.

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

Colleagues felt, due to the high volume of patients that night, the department "was unsafe", she said, and that the health board did not speak to Dylan’s parents as soon as they should have, and that the nurse practitioner who saw Dylan did not read his GP notes.

Dr Cloete told the court that Dylan should not have been sent home. "I know he was, but he was not meant to be sent home," she said.

The inquest continues.