An eight-year-old boy with a complex medical history died of undiagnosed meningitis after he was "completely failed" by his medical care leading up to his death, an inquest was told.

Logan Jones, of Blenheim Park in Magor, Monmouthshire, died on November 19, 2019, after he left the Royal Gwent Hospital in Newport without being seen by a doctor.

Logan was born with a heart defect and a genetic condition known as Chromosome 14 which meant he had learning difficulties and required feeding by tube. Senior coroner for Gwent, Caroline Saunders, said Logan was seeking care within a "broken system" and that his mum's decision to take him home before he was seen as the "lesser of two evils".

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The inquest heard a statement read out by Ms Saunders from Logan's mother Michelle Allen. She described her son as being a "very happy child" who was "surrounded by affection" at his school. She said Logan loved Peppa Pig and also enjoyed day trips to Big Pit and Bristol Zoo. He was also very close to his sister and loved fashion and music.

In her statement Ms Allen described how Logan first started feeling unwell on November 15, 2019. She said he had a headache, felt lethargic, and vomited. 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.

On arrival at around 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.

As painful as these proceedings are for those who have lost a loved one the lessons that can be learned from inquests can go a long way to saving others’ lives.

The press has a legal right to attend inquests and has a responsibility to report on them as part of their duty to uphold the principle of open justice.

It’s a journalist’s duty to make sure the public understands the reasons why someone has died and to make sure their deaths are not kept secret. An inquest report can also clear up any rumours or suspicion surrounding a person’s death.

But, most importantly of all, an inquest report can draw attention to circumstances which may stop further deaths from happening.

Should journalists shy away from attending inquests then an entire arm of the judicial system is not held to account.

Inquests can often prompt a wider discussion on serious issues, the most recent of these being mental health and suicide.

Editors actively ask and encourage reporters to speak to the family and friends of a person who is the subject of an inquest. Their contributions help us create a clearer picture of the person who died and also provides the opportunity to pay tribute to their loved one.

Often families do not wish to speak to the press and of course that decision has to be respected. However, as has been seen by many powerful media campaigns, the input of a person’s family and friends can make all the difference in helping to save others.

Without the attendance of the press at inquests questions will remain unanswered and lives will be lost.

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". This decision was supported by consultant Edward Valentine in his evidence because "[Logan] had been there for three hours and his vital signs hadn't changed".

Though Dr Levin said 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.

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".

She said: "I asked for a bed as Logan was wanting to lie down, which he could not do in the waiting room. [I was] told he could not, he would have to stay in the waiting area...as Logan was wanting to lie down and the department was chaotic."

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 the coroner asked children's nurse Joanne Anslow whether it was safe that evening she replied: "It wasn’t safe." However she said there had since been several improvements in the department, now named the Children's Emergency Assessment Unit, which made it easier to manage including more available nurses and improved shift patterns.

The inquest heard how nurses were aware Ms Allen was considering taking her son home and that normal practice is that parents should be advised to wait until they're seen.

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."

Logan Jones' family outside Newport Coroners' Court with mum Michelle Allen on the furthest right
Logan Jones' family outside Newport Coroners' Court with mum Michelle Allen on the furthest right

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.

A statement made on behalf of Ms Allen read by her representative, Andrew Collingbourne, said: "Logan, our beautiful boy, was cruelly taken from us on November 19, 2019. He was just eight years of age but had courageously battled complex medical conditions all his young life with a smile on his face.

"Logan was a very happy child with an infectious chuckle and a sunny disposition. Logan loved dressing up, wearing designer clothes including Hugo Boss. He also enjoyed his iPad and music.

"We sincerely hope his death was not in vain and Aneurin Bevan health board inset policies to insure children with complex medical needs are prioritised when presenting at the hospital and receive the professional healthcare required. We will remember him with great love and affection and he will main close to us and in our hearts for the rest of our lives."

The inquest heard that changes had been made since 2019 as paediatric services had been centralised at the new Grange Hospital in Cwmbran.

Susan Dinsdale, assistant divisional nurse, said leaflets were now handed to people who came to the unit. She said people are advised not to leave without speaking to a nurse. People who leave without being seen are now phone called as standard practice, she said, as it was previously just "good practice" to do so.

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