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. 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, aged eight, died in November from undiagnosed Meningitis. He was discharged from the hospital but had not been seen by a doctor.
The youngster was taken home after symptoms of the fatal disease were missed – as “staff could not cope”, it was said.
On Thursday, the coroner ruled that Logan, who was from Magor in Monmouthshire, might have survived if 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.
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.
Logan arrived at the hospital around 11 AM. He was triaged, and his vital signs were checked by both triage nurses and an ambulance crew.
Despite everything appearing normal, the inquest found that Logan should have been seen within an hour due to his circumstances. He was finally seen at 2 pm.
Logan was seen at the hospital by Dr Alejandro Levin. He is a junior paediatric registrar and has four months of experience.
The inquest was told by Dr Alejandro Levin that Logan did not show any signs of meningitis, such as stiff necks or 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”.
The doctor said that Logan was discharged by Dr Levin because Ms Allen offered to keep him in hospital. However, she agreed to take Logan home and bring him back if his condition deteriorated.
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.
Dr Gray stated that he couldn’t find any rash on Logan and that there wasn’t evidence of stiffness in his neck when he examined him at the inquest.
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 6.02 pm 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”.
Ms Allen stated that Logan was so desperate for a lie-down, and there was no end in sight, she decided to take Logan home.
Ms Allen said in her statement: “We got him to bed [at around 10.30 pm]. Logan said to me: ‘See you’ and I replied: ‘Love you’.
“I woke up at 3.50 am and decided to give Logan some water. He was lying there… He was lying there, I touched him and he became stiff. I began screaming.”
Logan was pronounced dead at around 4 am, 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 was 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”.
He said that Dr Levin hadn’t recorded that Logan had a stiff neck.
He also said that there was no record of him checking to see if Logan was sensitive.
In reference to November 18, Dr Christian stated that Logan would likely have been kept overnight if he had not been seen by a doctor.
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 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 2 pm was a “significant delay”. But she said that it didn’t impact 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 of 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.
According to the inquest, there had been changes since 2019, when paediatric services were centralized at the Grange Hospital in Cwmbran.