Boy died of sepsis after important GP note missed

A nine-year-old boy died from sepsis after doctors and nurses missed a "significant" GP note, an inquest heard.

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

The senior doctor on shift that night said GP referrals were not being printed off and put into patient’s notes because of how busy the department was.

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

Dylan was readmitted to hospital on 10 December, and died on 14 December from septic shock, with multi-organ disfunction caused by a perforated appendix.

Dr Singh, a consultant paediatric surgeon from Nottingham University Hospital, said the GP note which identified appendicitis and referenced Dylan “guarding” the right side of his abdomen were important.

“That was a very, very significant piece of information," he said.

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

The court heard the children’s emergency assessment unit at the Grange Hospital was “operating well over capacity” 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 take place.

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

The court was 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."

The inquest was read expert evidence from Dr Simon Nadel, a consultant paediatric intensivist at St Mary’s hospital London.

He said: “In my opinion on the balance of probabilities Dylan had appendicitis when he presented on 6 December."

He said it was his opinion Dylan “would have died whatever treatment was initiated”, when he represented at hospital.

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

He said, when Dylan was readmitted to hospital the chances of him surviving was “50% or less”.

Call handler mistakes

The court also heard that Dylan’s father, Laurence Cope, phoned the NHS non-urgent 111 service days after his son was discharged, but waited two hours for his call to be answered.

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

Peter Brown, the head of 111 Operations at the time, said Laurence Cope made the phone call at 12:48 on 10 December, but his call was not answered until 14:49, a wait of more than two hours.

Mr Brown said the target to answer calls was 60 seconds.

“We were simply not achieving that,” he said, adding that on the day of Mr Cope’s call the service had received more than 9,000 calls – compared to the usual 4,000 – because of concern about Strep A.

He said the call volumes were “beyond anything” the service had previously seen.

The court heard that Mr Cope managed to speak to a call handler who recorded the wrong information.

The inquest heard that Mr Cope was asked, “is Dylan severely unwell?”, to which he responded that his son was “severely unwell”.

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

Mr Brown said that if the call hander had recorded “yes”, it would have connected him to a 999 call handler.

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

“That was an opportunity missed,” he said.

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

Mr Brown said there had been changes to the 111 system since Dylan’s death, including replacing the computer 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 that the service had “done a lot of work” to answer more calls in a “timely fashion”.

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.

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

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

She said sometimes there would be an hour or two delay until those notes were put on to the computer system, but she said it now goes directly on to the system.

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.