Betsi Cadwaladr baby death probably preventable – coroner

The death of a nine-month-old baby boy from bacterial meningitis probably could have been prevented, a coroner has said.

Lucas Thomas Munslow from Flint, Flintshire, was taken to Glan Clwyd Hospital in Bodelwyddan, Denbighshire, by his parents on 17 May 2019 with a very high temperature and a squint.

He died the following evening.

John Gittins, senior coroner, recorded a narrative conclusion at Ruthin Coroner’s Court on Wednesday.

He said failure of hospital staff to properly check Lucas’s notes when he was referred to someone new was “poor practice”.

When he was initially taken to the hospital the emergency department did not think he was significantly ill and he was categorised as a yellow case, to be seen within an hour, rather than as orange case, seen within 10 minutes.

He was next seen at about 20:00 GMT by nurse practitioner Carol Stevenson, who noted that he had become “stiff and vacant” while in the waiting room, and had a squint.

He was referred to the paediatric unit, where he was examined four hours later.

The on-call doctor, Kayode-Awe Olugbemiga, noticed a red throat and diagnosed tonsillitis.

Dr Olugbemiga previously told the hearing there were no “red flags” indicating that anything more was wrong with him.

His senior, Dr Solabomi Alalade, also examined Lucas before his discharge and agreed with the diagnosis.

But by the next evening Lucas’s condition had significantly worsened and he was rushed back to hospital where attempts were made to resuscitate and stabilise him, and arrangements were made to transfer him to intensive care at Alder Hey Hospital in Liverpool.

He died from acute bacterial meningitis before the move could take place.

Mr Gittins said when Lucas was examined the night before his death, the doctor did not read the notes from the emergency department and so did not know about the squint.

He said that had he known, “he would have probably called for more observations”.

He said the failure to detect the bacterial infection was understandable, but it was “probable” further tests and appropriate treatment could have prevented its advancement.

He added that “the failure to give consideration to all the documented information… represented poor practice”.

“Investigations and treatment may have not prevented the development of meningitis which was likely already present in the emergency department on the 17th, but would have at the very least presented the greatest probability of a favourable outcome… it is probable his death could have been prevented,” he said.

In a statement, Lucas’s parents Kimberley and Nathan Munslow said an internal investigation carried out by Betsi Cadwaladr University Health Board originally concluded that there were no criticisms of the care provided to Lucas, but they did not accept the findings and “fought to get answers”.

They said they lost their their first born “in circumstances that could have been avoided” and had been left “deeply traumatised”.

“We welcome the coroner’s finding of the death of our son being preventable,” they said.

“We hope that this finding leads to key learnings at the trust.”

The family say they will now consider their options as to whether to pursue a claim against the trust for clinical negligence.

Betsi Cadwaladr health board’s executive medical director, Dr Nick Lyons, said they accepted the coroner’s findings.

He said: “We have already reviewed the circumstances surrounding Lucas’s treatment and identified where we can improve our diagnostic procedures in extremely rare cases such as this.

“However, we will look closely at the coroner’s comments from his finding of fact, to see if there are additional areas of learning which will help patients.”