The court also heard that Dylan’s father, Laurence Cope, phoned the NHS non-urgent 111 service days after his son was discharged, but waited two hours for his call to be answered.
An NHS 111 boss told the court that when the call was answered, the handler recorded the wrong information, which failed to trigger a 999 response.
Peter Brown, the head of 111 Operations at the time, said Laurence Cope made the phone call at 12:48 on 10 December, but his call was not answered until 14:49, a wait of more than two hours.
Mr Brown said the target to answer calls was 60 seconds.
“We were simply not achieving that,” he said, adding that on the day of Mr Cope’s call the service had received more than 9,000 calls – compared to the usual 4,000 – because of concern about Strep A.
He said the call volumes were “beyond anything” the service had previously seen.
The court heard that Mr Cope managed to speak to a call handler who recorded the wrong information.
The inquest heard that Mr Cope was asked, “is Dylan severely unwell?”, to which he responded that his son was “severely unwell”.
However, the call handler mistakenly recorded “no” in the system in response to that question.
Mr Brown said that if the call hander had recorded “yes”, it would have connected him to a 999 call handler.
He then said “a number of critical pieces of information” were not passed on to a 111 clinician by the call handler.
“That was an opportunity missed,” he said.
The court heard the call handler has since left the service.
Mr Brown said there had been changes to the 111 system since Dylan’s death, including replacing the computer system with a “modern, fit for purpose” system which now allows clinicians to view GP notes.
He said call handlers and clinicians had been retrained, and that the service had “done a lot of work” to answer more calls in a “timely fashion”.
The court also heard from Dr Yvette Cloette, clinical director in paediatrics at Aneurin Bevan University Health Board, who investigated Dylan’s treatment at the Grange Hospital.
She said “it was exceptionally busy” the night Dylan was admitted and that a colleague had felt “the system was unsafe” during that period.
She said the health board did not speak to Dylan’s parents as soon as they should have, and that she recognised that the nurse practitioner who saw Dylan did not read his GP notes.
She said sometimes there would be an hour or two delay until those notes were put on to the computer system, but she said it now goes directly on to the system.
Dr Cloete told the court that Dylan should not have been sent home.
“I know he was, but he was not meant to be sent home,” she said.
The inquest continues.
