Parents say docs ‘avoiding duty’ for dying of son, 9

The parents of a nine-year-old boy who died after being sent home from hospital with just painkillers for a sepsis infection have accused ‘shameful’ doctors of ‘deliberately avoiding responsibility’ for their role in his tragic death.

Laurence and Corinne Cope lamented the ‘chaotic and shambolic’ failures of Grange University Hospital in Cwmbran, Wales following an inquest into the death of their son, Dylan Cope.

A coroner speaking at Gwent Coroner’s Court on Friday found that their son had died from a gross failure of basic care after he was sent home from hospital in 2022 without a full review of suspicions he may have been suffering from appendicitis.

After senior coroner Caroline Saunders identified multiple ‘individual errors’ surrounding the ‘loving and sensitive’ boy’s death, Dylan’s heartbroken parents told reporters: ‘Making genuine errors is one thing but deliberately avoiding responsibility as a healthcare professional is shameful’.

‘Dylan was our youngest son, our little boy with his whole life ahead of him’ Corinne Cope said outside the court on Friday. ‘As family we have had to adjust to being four instead of five. Our circle is forever broken.’

‘Dylan is central to all of this. The magnitude of his loss of life has been overshadowed by others minimising and thwarting attempts to uncover the truth,’ she continued. ‘For our child to suffer and die from an easily treatable condition is unimaginable for most parents.

‘This is now our living nightmare and it does not end with the conclusion of this inquest.’ 

Grange University Hospital in Cwmbran was guilty of neglect when it sent young Dylan home from hospital with painkillers, the inquest ultimately ruled, some two years on from his death in December 2022.

The schoolboy, who was looking forward to hitting ‘double digits’ on his 10th birthday, died on December 14 2022 of septic shock and multiple organ failure.

He was found to have suffered a burst appendix which led to a sepsis infection spreading right through his body.  

The family GP had sent him to A&E at the Grange University Hospital in Cwmbran, South Wales, with suspected appendicitis on 6 Dec 2022 after he complained of ‘excruciating’ pain.

The doctor had written a note saying ‘query appendicitis’ which was not picked up by the hospital. 

‘The only person who seemed to get it spot on was the GP, and thereafter it seemed like everyone let him down,’ said Ms Cope. 

An inquest heard paediatric nurse practitioner Samantha Hayden’s examination of the schoolboy was ‘inadequate’ and Dr Lianne Doherty did not carry out a senior review before Dylan was discharged.

Senior Gwent Coroner Caroline Saunders said at the inquest: ‘There were a number of individual errors which resulted in Dylan being sent home from hospital when he should have remained. This amounted to a gross failure of basic care.’

In her summing up the coroner said the failure of Dylan to receive a senior review was due to a misunderstanding, not a system failure. 

Saunders recorded a narrative verdict saying Dylan was ‘erroneously discharged’, and identified he was ‘suffering from appendicitis’ when he first arrived at hospital.

She said: ‘His condition warranted further observation and assessment.

‘The effects of sepsis proved overwhelming. Dylan’s death would have been avoided if he had not been erroneously discharged from the Grange University Hospital.’

Aneurin Bevan health board admitted ‘full reponsibility’ for Dylan’s death, deeming the tragedy ‘a result of an organisational system failure’, and apologised. 

‘We are deeply sorry and remain fully committed to supporting the family in any way we can,’ it said in a statement. 

Laurence and Corinne, who have since campaigned to raise awareness of appendicitis and the symptoms of sepsis, wept as they heard their son died from a gross failure of basic care.

The couple said there were ‘numerous missed opportunities’ to save their ‘loving and unique’ son.

Corinne Cope said that they ‘appreciate the coroner’s findings’, noting that ‘from our own investigation we already felt Dylan’s death was preventable’.

‘During the inquest process we painfully learned that the Grange University Hospital, touted as a state-of-the-art super hospital, had what we saw as chaotic and shambolic processes that led to both extensive, systemic and human errors.’

Judging the system ‘broken and urgently in need of change’, Ms Cope said that they believed the internal investigation into Dylan’s death was ‘inadequate in critical areas’, which ‘added to our distress and in our view hindered the identification of key clinicians, key staff involved in Dylan’s first visit to the Children’s Emergency Assessment Unit’.

‘We believe one of these staff members to be a doctor who may not be honestly speaking about Dylan and Laurence that night,’ she continued.

‘We understand that no single person is entirely to blame for the multiple failures, but a true no-blame culture should still include accountability and learning.

‘Every individual must be responsible for their actions, regardless of whether their errors were accidental or unintentional.’

Ms Cope said that the inquest still did not address concerns brought by medical experts that Dylan’s treatment upon his return to hospital on December 10, four days before his death, were ‘suboptimal’ and that better care could have ‘improved his chances’.

‘There is no greater opportunity for learning than from a child’s preventable death,’ she said.

‘We appreciate that some measures have been implemented but remain deeply concerned that the health board have not demonstrated all of the necessary learning.

‘Many improvements were made only because of our persistent challenges which raises concerns for future learning and future patient safety.

‘We have had to fight for answers that to us were painfully obvious and we believe that we are not the only family who will have experienced this,’ she warned.

 ‘We feel that instead of being combative towards families during investigative process, the health board should have been focused on achieving adequate processes and clinical excellence.

‘If that had been their priority in the past we may not have been here today.

‘The system is broken and urgently needs change.’

Ms Cope said she believed ‘our agony’ during the ‘dark process’ was evident, and thanked those ‘who have shown compassion’ for their support throughout. 

Dylan was initially sent home from hospital with a leaflet on coughs and colds and his parents were advised to give him Calpol and Nurofen.

Four days later, on December 10, Dylan’s condition deteriorated and he was readmitted to the Grange Hospital and transferred to the University Hospital of Wales in Cardiff. 

Surgeons removed his perforated appendix but he went into cardiac arrest and died four days later when life support was withdrawn.

Dylan’s father Laurence Cope, said at the inquest his son was ‘loving, feisty and sensitive’ and nothing delighted him more than hearing Alexa say ‘free hugs available in the lounge’ when he would eagerly run to get one from a member of the family.

Mr Cope said none of the medics at the Grange Hospital identified themselves or gave their medical qualifications when they examined his son on 6 December 2022.

The father-of-three told the inquest in a written statement that he assumed Dylan was seen by a surgeon. He said: ‘He came across as senior in his role and was calm and confident in his demeanour.

‘Although calm, casual, relaxed and confident he remained professional as though he was seeing me and Dylan in a professional capacity. He seemed very sure of himself.’

Mr Cope said the doctor, who was in scrubs and a facemask, was in his 30s to 40s, slim to average build, tall and with a slight ‘foreign’ accent.

The medic told Mr Cope it was ‘highly unlikely’ Dylan’s abdominal pains were connected to his appendix but he could not remember him physically examining his poorly son.

The inquest, in Newport, heard the doctor who was never identified, told the family that Dylan had tested positive for Influenza A which was raging at the time.

The court heard Dylan complained of severe pain on the left side of his abdomen – the appendix is on the right.

Mr Cope added: ‘I was given a fact sheet for children with coughs and colds. I felt relieved and reassured that the medics all concluded it was not appendicitis.’

Dylan was given Calpol and Nurofen at home but became more lethargic on Saturday December 10. 

His worried parents called the emergency number on the discharge note they were given by the Grange University Hospital

After 19 attempts to get through a female call handler advised Mr Cope to call 111 for advice but he said she ‘did not seem concerned’.

The family was waiting for a call back from a doctor when Dylan started shouting about his leg pain.

Mr Cope said: ‘His legs had started to mottle – Corinne said it was either meningitis or sepsis. An ambulance would have taken too long – I drove him to A&E and an emergency team took over.

‘He was taken to the University Hospital of Wales and after an operation he was on life support.’

The inquest heard Dylan had severe septic shock and went into cardiac arrest.

Mr Cope said: ‘The doctors told us there was nothing more they should do for him, it was highly unlikely Dylan would survive.’

Life support was gradually withdrawn and Dylan died on December 14.

Dylan, the youngest of three children, was looking forward to playing a reindeer in his school Christmas play.

In a statement through their legal team his parents said: ‘Dylan was very loving and inquisitive with a quirky sense of humour.

‘He saw the beauty of life but also the injustice and was quick to make his views known.

‘His strength of character and fierce independence balanced with his softer, endearing, sensitive side were traits that made him rather unique.

‘On the day we were meant to be proudly watching Dylan in his school Christmas play dressed as a little reindeer, instead we watched him dying.

‘There is no doubt that Dylan would have grown up to do some very interesting things in his life, but we have been denied the opportunity of watching our son grow into a man and experiencing the joys of life with him.

‘Moreover, we are truly heartbroken for Dylan, that he will never get to experience the joys of life and the hopes and dreams he had.

‘Since Dylan’s death, our lives have become unrecognisable. We are filled with grief and shock that our little boy was taken so soon and in this way.

‘Our hearts ache for Dylan every millisecond and everything we see and do is through his eyes. Dylan’s absence is and will continue to be the undercurrent of our days until our final breath.’

Mr Cope, a web developer and his wife, a civil servant, are warning other parents of the dangers of sepsis which is more prevalent in the winter months when people are prone to viruses and infections.

They also want to raise awareness of appendicitis and the symptoms of sepsis, which is a reaction to an infection and happens when the immune system overreacts and starts to damage the body’s own tissues and organs.

Symptoms can be like those of flu and include severe breathlessness and a high fever.

The couple said: ‘We have been told sepsis in children is very rare, tragically we know Dylan is one of many to lose their life to this brutal killer.

‘There is much good work being done to help prevent deaths from sepsis and also improve outcomes for those recovering from sepsis but still a way to go.

‘We urge parents to always trust your instincts over anything else with your child, despite what you are told, if you feel something isn’t right it probably isn’t and be mindful that time may not be on your side.

‘Trust your instincts over anything else and seek urgent help.’

The couple thanked surgeons and staff at the University Hospital of Wales for trying to see their young son.

They said: ‘Obviously, we want nothing more than to be in the position to say we owe Dylan’s life to them but tragically, we are not. What we do owe them is our sincere thanks for doing their utmost to save him.’

The couple’s campaign has led to changes in sepsis awareness and a Sepsis Trust QR code is now printed on paediatric safety sheets in GP surgeries and hospitals.

The Welsh Government is currently working with the Sepsis Trust to produce a sepsis leaflet that will be distributed across Wales.

Dr Ron Daniels, Founder and Joint CEO of UK Sepsis Trust, said: ‘It’s every parent’s worst nightmare to lose a child and to look ahead to a lifetime of grief – Dylan reminds us that sepsis can strike any child at any time.

‘The UK Sepsis Trust is on a mission to empower parents to ‘just ask; could it be sepsis?’ if their child is deteriorating in the context of an infection and to encourage health professionals to listen – parents know their child better than anyone.’