Investigating harm with humanity - practical guidance for NHS investigators, clinical teams and legal representatives (by Corinne Cope)

Summary

In December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”.

This guidance has been developed by Dylan's mum Corinne Cope, following her lived experience as a bereaved mother.

Corinne says: "Multiple investigations failed to provide clear answers or accountability, causing significant secondary harm; an issue increasingly recognised among harmed patients, bereaved families, and healthcare staff."

Corinne's guidance aims to support NHS investigators and system leaders to strengthen the quality and humanity of investigations, ensuring ownership, reflection, and sustained learning.