United Kingdom

Boy, eight, who died after THREE doctors missed signs of meningitis was 'failed' by hospital staff

An eight-year-old boy who died after three doctors missed signs of undiagnosed meningitis was 'completely failed' by hospital staff at an 'unsafe' children's unit, an inquest was told.

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

His mother Michelle Allen, who described Logan as a 'very happy child', took her son home before he was seen as she said the hospital was 'chaotic' and there was nowhere for her unwell son to lie down.

Just hours later at 3.50am, the youngster died at home, with his medical cause of death recorded as pneumococcal meningitis, despite three doctors missing signs of the illness, the inquest heard.

The eight-year-old 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.

A children's nurse told the inquest that the conditions at Royal Gwent Hospital's Child Assessment Unit were not 'safe' on the evening of November 18, when Logan was at the unit.

Senior coroner for Gwent, Caroline Saunders, said Logan was seeking care within a 'broken system' and that his mother's decision to take him home was the 'lesser of two evils'.

Ms Saunders said Logan was 'completely failed' by hospital staff but added that she couldn't determine whether his experience directly contributed to his death and therefore recorded a conclusion of natural causes.

Logan Jones (pictured), from Magor, Monmouthshire, died on November 19, 2019, after he left the Royal Gwent Hospital in Newport, South Wales, without being seen by a doctor

The inquest heard a statement from Logan's mother, Ms Allen, who said Logan loved Peppa Pig and also enjoyed day trips to Big Pit and Bristol Zoo.

The devastated mother said Logan was was 'surrounded by affection' at school, was very close to his sister and loved fashion and music.

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

The next day, she called the out-of-hours service and said although Logan had perked up a little, the first responder advised her that she should still take him to A&E at Royal Gwent Hospital. 

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 complex medical history. He was eventually seen at 2pm.

Dr Alejandro Levin, a junior registrar with four months of paediatric experience, saw Logan at the hospital and 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 that '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'.

His mother Michelle Allen took Logan home from Royal Gwent Hospital (pictured) before he was seen as she said the hospital was 'chaotic' and there was nowhere for him to lie down

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 he quickly 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 added: '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.'

But Ms Allen remained concerned and Logan seemed unwell, he 'wasn't happy to send him home' so referred Logan to hospital.

When Ms Allen arrived at Royal Gwent Hospital, 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 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 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 evidence from several health care staff linked to the CAU at Royal Gwent Hospital 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.

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 heard.

Dr William Christian, who was at the inquest to give supporting evidence, said he believed Dr Levin's notes gave 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. 

Dr Christian said if Logan had been seen by a doctor when he should have been, he would have likely been kept overnight.

But he added that meningitis can deteriorate very quickly and that he 'could not say for definite' that the outcome would have been different for Logan.

The coroner told the inquest that Logan's mother knew her son 'better than anyone'.

Senior coroner for Gwent, Caroline Saunders, said Logan was seeking care within a 'broken system' and that his mother's decision to take him home was the 'lesser of two evils'

Ms Saunders 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', but added that she didn't think this affected the overall outcome.

Ms Saunders also said that 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.

Ms Saunders 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.' 

Ms Saunders said Logan arrived at Royal Gwent Hospital while the children's unit was 'extremely busy', adding that the 'staff could not cope' and 'the environment was not safe'.

Ms Saunders 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.'

The coroner said she believed from the evidence that if Logan had been seen when he should have been, his complex medical needs would have been given more consideration and he would possibly have been kept in overnight.

Ms Saunders 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.'

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 [University] Health Board insert 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 University 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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