'Breakdown in communication' led to boy being discharged from hospital days before he died

A "breakdown in communication" led to a nine-year-old boy being discharged from hospital without a face-to-face assessment by a doctor just days before he died from sepsis, an inquest has heard.

Dylan Cope, from Newport, had been taken to the Grange Hospital in Cwmbran on December 6, 2022, after his GP referred him for abdominal pain.

He was released in the early hours of the following day, but within days his symptoms dramatically worsened and he was rushed back to hospital. After days in intensive care, his official cause of death on December 14 was given as septic shock from a perforated appendix.

An inquest into his death is being held at Gwent Coroner's Court in Newport, with the opening day hearing that paediatric nurse practitioner Samantha Hayden, who made the initial assessment of Dylan's condition on December 6, had not read his GP's hospital referral.

Dylan tested positive for influenza A while in hospital on the night of December 6 and a discharge note was preemptively prepared by Miss Hayden.

She previously told the inquest it was her expectation that details would be changed and added to if required following a senior review by a doctor, which did not take place.

On the second day of the inquest on Tuesday, the senior clinician on shift on December 6, Dr Lianne Doherty, gave evidence.

Dr Doherty told the court she had been approached by Miss Hayden shortly before 11pm, where she was told Dylan had tested positive for flu.

The inquest heard it was her understanding that flu-like symptoms were why Dylan had been brought to hospital. Dr Doherty said she was not told about his severe abdominal pains outlined in the GP's referral.

Dr Doherty told the court from the witness box: "I knew that we were in a danger spot because it was very busy so I asked her if I needed to see him.

"[Miss Hayden] told me she had prepared his discharge form so it was my understanding that she did not need me to see him”."

Dr Doherty told the court this was "clearly a breakdown in communication" between her and Miss Hayden.

Dr Doherty gave the inquest a picture of how busy their department was on the night in question. The night previous to December 6, there had been 90 patients in the children's assessment unit, equating to four times its capacity.

Dr Doherty explained that "where it is thought to be dangerous because there are too many children to see", the senior clinician is encouraged to call for help from additional doctors.

The senior coroner for Gwent, Caroline Saunders, asked the doctor: "Did it ever get to that point on the night of December 6/7?"

Dr Doherty said: "No, but it did on previous nights to that night… [On December 6th] it was very busy and if there had been one clearly very sick child then I would have called for more help because it would have divided my attention."

Dr Doherty was asked what would have been different if she had been made aware of Dylan's GP referral, which included details of vomiting and severe abdominal pain in the days leading up to his admission to hospital.

Dr Doherty said if she had been aware of all his symptoms, including pain in his lower right abdomen (where the appendix is located), that would have automatically triggered a senior review by a doctor.

Dr Doherty told the court: "I had worked with Samantha (Hayden, paediatric nurse practitioner) for a long time and I trusted her judgement. She had proven herself to be a very good clinician."

When the doctor found Dylan's notes in the pile of cases which require senior review by a doctor after Miss Hayden had finished her shift, she asked another colleague whether Dylan was still in the department.

Dr Doherty said if she knew about the pain in his right abdomen, she would have requested a blood test for Dylan, and potentially sought advice from a surgeon in the department.

Questioned by the lawyer for the family, Miss Jo Moore, Dr Doherty was asked how unusual it was for the department to be as busy as it was in the week that Dylan was taken to the Grange Hospital.

Dr Doherty said: “That run of nights was the single busiest I have ever experienced. Strep A and flu made it very challenging working conditions."

She said notes being put in the wrong place had been happening “fairly frequently” and "several patients" were taken home by their parents that week before getting a senior review because of delays to being seen.

As part of her evidence, Dr Doherty added that she had never seen a child with appendicitis present with pain in the lower left part of their abdomen - as Dylan did - and therefore it did not ring any alarm bells.

But questioned by the coroner about whether all the other pieces of information she potentially had available to her - including the GP's referral and Dylan's medical observations - would have contributed to a broader picture of concern, Dr Doherty replied: "Yes".

The court also heard evidence from Dr Nakul Gupta, a consultant paediatrician at Aneurin Bevan University Health Board. He told the court that it is "good practice” for hospital staff to read the GP's referrals as part of the initial assessment.

Dr Gupta said doctors and nurses always take into account the reasons for why the child was sent to hospital, but often children end up with a different diagnosis to what they were initially admitted with.

But he accepted that in Dylan's case, the fact his GP had noticed some "guarding" in his right iliac fossa - which is a key identifying symptom of appendicitis - was important information.

Asked by the coroner if the appendicitis could potentially have been identified if Dylan had been kept in hospital for further observations after December 6, Dr Gupta said: "Yes, it is possible".

The court heard that various changes have been made in the department since Dylan's death, including improved information for patients and their families when they are discharged.

He said changes have also been made to the process of senior review by doctors, which now means foundation training level doctors must seek a face-to-face senior review before one of their patients is discharged.

The inquest is due to last five days in total.

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