THE death of a nine-month-old baby at Ysbyty Glan Clwyd less than 24 hours after he had been discharged from the hospital was probably preventable, an inquest concluded.

Lucas Thomas Munslow, from Flint, died at the Bodelwyddan hospital late on May 18, 2019, after his parents had been told almost 24 hours earlier that he had viral tonsillitis but was safe to return home.

After a full inquest into his death, held in Ruthin yesterday and today (November 21 and 22), John Gittins, senior coroner for North Wales East and Central, recorded a narrative conclusion.

Mr Gittins provided a medical cause of death of acute bacterial meningitis, adding that “poor practice” had been exhibited by staff at the hospital.

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The inquest heard about concerns regarding diagnosis and care in Lucas’ case, with his parents, Nathan and Kimberley, stating he was discharged early on May 18 without “proper consultation”.

Yesterday, the inquest was told that, three days prior to his death, Lucas was taken to visit his GP, Dr Suganya Prabhaker, at The Laurels Surgery in Flint, who concluded that he likely had a viral infection.

Mr Gittins said in his conclusion that all of the actions taken and advice given by Dr Prabhaker, who had seen Lucas a number of the times already in 2019, were “entirely reasonable and appropriate”.

Lucas’ temperature had risen as high as 39°C, and his heart rate beyond 150bpm, and when his parents took him to Glan Clwyd on May 17, they waited several hours before being seen to by Dr Kayode-Awe Olugbemiga, then a senior house officer.

Dr Olugbemiga said he believed Lucas had viral tonsillitis, given his tonsils were red when he inspected them, and did not detect any other “red flags” when reviewing him.

After Dr Solabomi Alalade, a colleague of Dr Olugbemiga’s, agreed with his diagnosis when he requested a second opinion, Lucas was discharged shortly after midnight on May 18.

He had earlier been recorded by other members of staff as having squints in his eyes, but both Dr Alalade and Dr Olugbemiga were not aware of this.

They each told the inquest that, if they had been, their course of action would have been different.

Lucas returned to Glan Clwyd late that afternoon after his parents said he “went stiff” and was “staring into space”, but his condition deteriorated and he was pronounced dead at 11.50pm.

Dr George Kokai, a pathologist at Alder Hey Children's Hospital, found evidence of bacterial infection and meningitis when undertaking Lucas’ post-mortem examination.

At today’s hearing, Dr Simon Nadel, a consultant in paediatric intensive care, gave evidence as an independent expert.

Dr Nadel said that pneumococcal meningitis, which the inquest was previously told Lucas had developed, is an “insidious” disease with varying symptoms and ongoing fevers, and which can be difficult to diagnose.

Having filed a report on Lucas’ case, Dr Nadel said he believed Lucas had developed a fever in the lead-up to his death, so it was likely that, in the preceding two to three days, he had pneumococcal bacteria in his blood.

It is also likely, Dr Nadel said, that he already had meningitis when he presented to Glan Clwyd’s emergency department on May 17, the day before his death.

But he added that there were “worrying” features about Lucas at that time, such as abnormal movements, and the probable onset of a new squint.

He also agreed with an assumption made by Dr Carol Stevenson, who saw to Lucas on May 17 at Glan Clwyd, that Lucas had displayed signs of febrile convulsion (fever often from infection occurring in young, healthy children).

Dr Nadel said earlier antibiotic treatment for Lucas “would have made a difference”, or decreased the severity of his illness, albeit added that pneumococcal meningitis is nonetheless a disease with a typically “bad outcome”.

Of those diagnosed with it, he said, roughly 20 per cent will normally die, and 30 to 50 per cent will have neurological abnormalities if they recover.

That many of the typical signs of pneumococcal meningitis were not present in Lucas, such as a rash, suggested to Dr Nadel that the outcome in his case may have been better if he had been given antibiotics sooner.

There were “red flags” in Lucas’ presentation, he said, that should have warranted further investigation – such as probable febrile convulsion and a squint, together with high fever.

Babies less than a year old do not often present with “classic symptoms” of meningitis, Dr Nadel said.

He disagreed with the working diagnosis of viral tonsillitis, adding that, on balance, Lucas likely would have survived if given more appropriate treatment sooner.

Concluding, Mr Gittins said: “The failure to give consideration to all available information, including the documented episodes in the emergency department, represented poor practice.

“It’s a combination of the high temperature, febrile convulsion and squint which ought to have been red flag markers warranting further investigation.

“Although such investigations and treatment may not have prevented the development of meningitis, as this was likely already present in the emergency department on May 17, it would, at the very least, have provided the greatest possibility of a favourable outcome.

“In this respect, it is probable that his death was preventable.”