6 months ago
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A nine-year-old boy died from sepsis after doctors and nurses missed a "significant" GP note, an inquest heard.
Dylan Cope, from Newport was taken to the Grange Hospital in Cwmbran on 6 December 2022 after his GP advised, “query appendicitis”, but this note was not read.
The senior doctor on shift that night said GP referrals were not being printed off and put into patient’s notes because of how busy the department was.
Dylan was readmitted on 10 December, and died on 14 December from septic shock, with multi-organ disfunction caused by a perforated appendix.
Dr Singh, consultant paediatric surgeon from Nottingham University Hospital, said the GP note which identified appendicitis and referenced Dylan “guarding” the right side of his abdomen were important.
“That was a very, very significant piece of information," he said.
Dr Singh explained that clinicians should rule out appendicitis, “by all possible means” before moving on to other diagnoses.
The court heard the children’s emergency assessment unit at the Grange Hospital was “operating well over capacity” the night Dylan was admitted.
The court heard from a nurse practitioner who believed Dylan was going to be seen by a registrar, but this did not take place.
Dr Singh said that if Dylan had been referred to a surgeon that night, a surgeon would have diagnosed appendicitis and kept him in hospital.
The court was told Dylan’s heart rate increased whilst in hospital.
Dr Singh said: “This was a very significant finding which should have alerted for him to be admitted.
“In septic shock every minute counts."
The inquest was read expert evidence from Dr Simon Nadel, a consultant paediatric intensivist at St Mary’s hospital London.
He said: “In my opinion on the balance of probabilities Dylan had appendicitis when he presented on 6 December."
He said it was his opinion Dylan “would have died whatever treatment was initiated”, when he represented at hospital.
The inquest continues.
