Boy, nine, died of sepsis after ‘miscommunication’ between hospital staff

There was “miscommunication” between medical staff when a young boy was sent home and died of sepsis days later, an inquest has heard.

Dylan Cope, from Newport, died on December 14 2022 of sepsis from a perforated appendix.

Gwent Coroner’s Court in Newport heard on Tuesday that a breakdown in communication between two medical staff meant that the nine-year-old did not get the senior review he should have had.

The review could have identified the appendicitis which ultimately led to him getting sepsis.

Dylan was initially taken to his GP on December 6, after experiencing pain.

His GP, Dr Amy Burton, suspected he had appendicitis and told his father, Laurence Cope to immediately take him to Grange Hospital in Cwmbran.

When he attended hospital, he tested positive for the flu and tenderness on his right-hand side – which would indicate appendicitis – but was not examined further.

Instead, he was discharged early on December 7, 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.

Dr Lianne Doherty, a paediatric registrar and the most senior member of staff on duty on December 6, said that she does not recall being told about the tenderness or concerns about Dylan’s appendix that evening.

She told Caroline Saunders, the senior coroner for Gwent, that she did not see Dylan herself but spoke with Samantha Hayden, a paediatric nurse practitioner about his case.

While Ms Hayden told a hearing on Monday that she had approached Dr Doherty asking for a senior review, the doctor said she believed she was asking for Dylan to be discharged.

“Samantha Hayden approached me in the corridor, she explained that she had seen a child who had tested positive for flu,” she said.

“I directly asked her, ‘do you want me to see (Dylan), or do you think he can go home?’

“Samantha Hayden said she was happy with him and prepared a discharge summary.”

She added: “There must have been a miscommunication.”

She also said she was not aware that Dylan had been sent to the department with abdominal pain or that he had tenderness in his right side and would have seen him if she had been.

Dr Doherty later found Dylan’s folder in the racks designated for patients needing a senior review and assumed it had been misplaced.

The coroner heard that folders had been repeatedly placed in the wrong location during that period, due to paediatrics being particularly busy.

She asked a senior nurse whether Dylan was still present on the ward, who found he was and that a discharge summary had been written by Ms Hayden with influenza listed.

Ms Hayden said on Monday that pre-writing a discharge summary was standard procedure and could be changed following a senior review.

Asked by Ms Saunders if she needed to call for help due to how busy it was, she said she did not but had done so on the previous night.

She said: “It was very busy, if there had been one clearly sick child who had presented, I would have called at that point (for help) because it would have divided my attention.”

She added: “That run of nights was the single busiest time I have ever worked in paediatrics. It was worse than Covid.

“The combination of Strep A and flu made it very challenging working conditions.”

The inquest continues on Wednesday.