Logan Jones, from Magor, Monmouthshire, was taken home after symptoms of the fatal disease were missed and died in the night, when he was found “stiff” by his “screaming” mother
Image: Michelle Allen)
A young boy with a complex medical history was “completely failed” by the care given in the run-up to his death, an inquest heard.
Logan Jones, eight, died from undiagnosed meningitis after leaving hospital without being seen by a doctor in November 2019.
The youngster was taken home after symptoms of the fatal disease were missed – as “staff could not cope”, it was said.
And a coroner ruled on Thursday that Logan, from Magor, Monmouthshire, may have survived if he had been kept in overnight.
An inquest into his death heard a statement from his mother Michelle Allen, reports WalesOnline.
She described her son as being a “very happy child” who was “surrounded by affection” at his school.
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Ms Allen described how Logan first started feeling unwell on November 15, 2019.
She said she called the out of hours service on November 16 and that although he perked up a little the first responder advised her that she should still take him to A&E at the Royal Gwent Hospital.
On arrival at roughly 11am Logan was triaged and had his vital signs observed by triage nurses as well as by the ambulance crew.
Though everything appeared normal, the inquest heard how Logan should have been seen within one hour considering his situation. However he was finally seen at 2pm.
Dr Alejandro Levin, a junior registrar with four months paediatric experience, then saw Logan at hospital.
He told the inquest that Logan was not showing any key symptoms of meningitis such as a stiff neck or obvious light sensitivity.
He said “no doctor wants to miss meningitis” but concluded at the time Logan’s problems were “most probably a viral illness”.
Dr Levin said he did not consult with a more senior colleague before discharging Logan as he “did not think it was necessary”.
He added that Ms Allen was offered to keep Logan in hospital for further observations she took him home and agreed to bring him back if his condition worsened, the inquest heard.
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In her statement Ms Allen said Logan seemed to perk up briefly, but that on the night of Sunday into Monday he went “downhill” so she took him to see his GP, Dr Andrew Gray.
Appearing at the inquest Dr Gray said on examining Logan he could not find a rash and that there was no evidence of a stiff neck.
He said: “We have a traffic light system for meningitis and my assessment was that he didn’t score very high on that at all. He was on the green, which is low risk.”
However, because Ms Allen was concerned and Logan seemed unwell, he “wasn’t happy to send him home” so referred Logan to the Royal Gwent.
When Ms Allen arrived at the Royal Gwent at what was then the Child Assessment Unit (CAU) at 6.02pm she described the scene as “chaotic” and she knew she would be there “for some time”.
Ms Allen also said she asked for an indication of how long they might have to wait and was informed by a member of staff that it was “busy”.
She said because Logan was so desperate to lie down and with no end in sight she decided to take him home.
Ms Allen said in her statement: “We got him to bed [at around 10.30pm]. Logan said to me: ‘See you’ and I replied: ‘Love you’.
“I woke up at 3.50am and decided to give Logan some water. He was lying there… I touched him, he was stiff, and I started screaming.”
Logan was pronounced dead at around 4am, with his medical cause of death recorded as pneumococcal meningitis.
The inquest then heard evidence from several health care staff linked to the CAU at the Royal Gwent who recalled it being “extremely busy” that evening.
When coroner Caroline Saunders asked children’s nurse Joanne Anslow whether it was safe that evening she replied: “It wasn’t safe.”
The inquest then heard from Dr William Christian who was there to give supporting evidence.
He said after seeing notes written by Dr Levin he believed he had given a “very brief assessment for a child with complex needs”.
It was heard that Dr Levin had not made a record that he had not found Logan to have a stiff neck.
It was also heard that there was no sign on record that he had checked to see if Logan was sensitive to light.
Speaking of November 18 Dr Christian said if Logan had been seen by a doctor when he should have been he would have likely been kept overnight.
However he said meningitis can deteriorate very quickly and that he “could not say for definite” that the outcome would have been different for Logan.
Concluding the hearing, Ms Saunders said Logan’s mother knew her son “better than anyone”.
The coroner said: “When Logan became unwell on November 15 she recognised the need to seek medical advice and and contacted the out of hours [service]… On arrival to hospital on November 16 Logan was triaged and had his vital signs monitored by the ambulance crew and triage nurses.
“These observations were normal.”
She said Logan not being seen by 2pm was a “significant delay”. However that she didn’t think this affected the overall outcome.
She continued to say Dr Levin should have recorded any findings or non-findings relating to whether Logan had a stiff neck or sensitivity to light, describing it as “inconceivable” that he did not record the results.
She added: “Dr Levin should have also discussed Logan with a senior colleague. He also had only four months paediatric experience. A more senior review should have been sought.”
After a “thorough examination” by Dr Gray on November 18 Ms Saunders said Logan arrived at the Royal Gwent while the children’s unit was “extremely busy”, adding that the “staff could not cope” and “the environment was not safe”.
She said she accepted it was Logan’s mother’s decision to take him home, adding: “I can understand it felt like the lesser of two evils.”
Ms Saunders said she believed from the evidence that if Logan had been seen when he should have been seen his complex medical needs would have been given more consideration and he would possibly have been kept in overnight.
She added: “Had Logan remained in hospital overnight his deterioration would have been [observed] and staff would have been offered an opportunity to save his life.”
She said Logan was “completely failed” but that she couldn’t determine whether his experience directly contributed to his death and therefore recorded a conclusion of natural causes.
The inquest heard that changes had been made since 2019 as paediatric services had been centralised at the new Grange Hospital in Cwmbran.