NHS could have saved life of boy who died from sepsis, coroner rules

Dylan Cope
Dylan Cope's mother described him as 'a little boy with his whole life ahead of him' - Nigel Iskander

The NHS could have saved the life of a nine-year-old boy who died from sepsis after he was misdiagnosed, a coroner has ruled.

Dylan Cope was sent home from the Grange Hospital in Cwmbran in December 2022 after being diagnosed with influenza and given a leaflet with advice about coughs and colds.

He died just over a week later at the University Hospital of Wales in Cardiff from sepsis.

Caroline Saunders, the Gwent Coroner, recorded a narrative conclusion, saying there had been a “gross failure of basic care”.

She added: “His death was contributed to by neglect.”

The inquest had examined whether Dylan’s appendicitis, which led to sepsis, could or should have been picked up earlier.

The court was told that after falling ill, the boy saw his GP who suspected he had appendicitis and advised him to go immediately to the Grange Hospital.

While there, Dylan was seen by a paediatric nurse practitioner, who noted he had indicated the pain was mainly on his left-hand side, away from the appendix. Tests also showed he had influenza.

A breakdown in communication between two medical staff meant Dylan was not reviewed by a senior doctor and he was later discharged.

Speaking after the inquest, Dylan’s mother Corinne Cope said her family believed he should not have died.

“We appreciate the coroner’s findings,” she said. “From our own investigations we already felt that Dylan’s death was preventable.

“During the inquest process, we’ve 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.

“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 accept responsibility for their actions, regardless of whether their errors were accidental or unintentional.”

‘Easily treatable condition’

Mrs Cope, from Newport, added: “Dylan was our youngest son, a little boy with his whole life ahead of him.

“As a family, we have to adjust to being four instead of five; our circle is forever broken. This pain will last our entire lives, not just through this hearing.

“Dylan is central to all of this. The magnitude of losing his life has often been overshadowed by others minimising and thwarting attempts to uncover the truth.

“For our child to suffer and die from an easily treatable condition is unimaginable for most parents. This is now our living nightmare.”

‘Tragic circumstances’

A spokesman for Aneurin Bevan University Health Board, which runs the Grange Hospital, said: “We are truly heartbroken and our thoughts and deepest sympathies remain with Dylan’s parents and his whole family.

“No parent should have to go through losing a child in such circumstances. We are all truly devastated.

“Senior members of the health board have met with the family in person to apologise for the tragic circumstances leading to the loss of their beloved son.”

He added: “The health board fully recognise that no apology will ever make up for the pain and suffering the family have experienced in losing Dylan.

“Dylan’s tragic death was a result of an organisational system failure that occurred in a department whilst under extreme pressure, with twice the number of patients normally attending, and was not attributable to any individual member of staff.

“The health board takes full responsibility for what happened to Dylan. We are deeply sorry and remain fully committed to supporting the family in any way we can.”