An eight-year-old boy who died after three doctors missed signs
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, saying the hospital was 'chaotic' with 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.
Three doctors missed 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 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 although Logan had perked up a little, the first responder advised her that she should take him to A&E at Royal Gwent Hospital.
At around 11am, Logan was triaged and had his vital signs observed by triage nurses and the ambulance crew. Though everything appeared normal when he was later seen at 2pm, Logan should have been seen within one hour due to his complex medical history.Dr Alejandro Levin, a junior registrar with four months of paediatric experience, saw Logan at the hospital and he told the inquest 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 'did not think it was necessary' to consult with a more senior colleague before discharging Logan.
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
Ms Allen was offered to keep Logan in hospital for observations, but 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 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, scoring him as 'low risk' for meningitis.
But Ms Allen remained concerned and Logan seemed unwell, he 'wasn't happy to send him home' so referred Logan to Royal Gwent Hospital's Child Assessment Unit (CAU), now named the Children's Emergency Assessment Unit.
When Ms Allen arrived at the CAU at 6.02pm, she described the scene as 'chaotic' and she knew she would be there 'for some time'.
She asked for a bed so Logan could lie down, but she claimed she was told it was not possible and to stay in the waiting area with her son.
Ms Allen said she asked for an indication of waiting times and was told by a member of staff that it was 'busy', so with no end in sight, she decided to take Logan 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.
When the coroner asked children's nurse Joanne Anslow whether it was safe in the CAU that evening, she replied: 'It wasn't safe.'
However, she said there had since been several improvements in the department 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'.
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'
It was heard that Dr Levin had not made a record that he had not found Logan to have a stiff neck or 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.
Ms Saunders said Logan not being seen by 2pm was a 'significant delay', but added that she didn't think this affected the overall outcome.
She also said 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 that Dr Levin, who only had four months paediatric experience, should have sought a 'more senior review'.
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, giving staff 'an opportunity to save his life'.
The inquest heard that changes had been made since 2019 as the paediatric services were 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 and people are advised not to leave without speaking to a nurse.
A spokesman for Aneurin Bevan University Health Board said: 'Our thoughts and deepest sympathy remain with the family of Logan and we're very sorry for the circumstances surrounding the care he received.
'The events surrounding Logan's death have been fully investigated through the Health Board's Serious Incident review process. Our investigation findings, actions and learning have been fully and openly shared with the family and the Gwent Coroner.
'The Health Board and its staff have fully contributed to the recent Inquest to help provide answers to the family and to assist the Coroner.
'The Health Board has undertaken comprehensive corrective actions to address the issues raised through our investigation, including a review of escalation protocols, further recruitment, staff training, and a move to the new Children's Emergency Assessment Unit at The Grange University Hospital in Cwmbran.'
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