A coroner in Newport has concluded that a nine-year-old boy’s death from sepsis was “contributed to by neglect” and “would have been avoided” if he had not been “erroneously discharged” from a hospital in Cwmbran, Torfaen. Dylan Cope went to A&E with a GP note indicating potential appendicitis, but the note was not read and the boy was sent home with information on flu after being diagnosed with that by doctors. Dylan died on 14 December, having been readmitted to hospital four days earlier. His death resulted from multi-organ dysfunction due to a perforated appendix.
The coroner, Caroline Saunders of Gwent, has recommended that Aneurin Bevan health board review the discharging of patients and improve the reading of GP notes by clinicians. Saunders stated that Dylan’s death would not have occurred if he had received “a senior review” whilst in hospital. Saunders said that clinicians were unaware the boy had a history of potential appendicitis because communications and observations had been “inadequate”.
Laurence, Dylan’s father, has claimed that his son’s death resulted from numerous opportunities being lost, saying “every one of those could have been a point where that might have saved his life, a missed opportunity”. Dylan’s mother, Corinne, added “there were so many failures…I think that is what is so alarming”.
The inquest heard that the department was “operating over capacity” and that GP referrals were not being printed off. Dr Nakul Gupta, a paediatric consultant from the health board argued clinician’s responsibilities extended to reading letters from GPs. The coroner did not feel the need to enact a regulation 28 report due to the measures taken by the health board following Dylan’s death
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