THE family of a baby boy who died in “preventable” circumstances at Ysbyty Glan Clwyd say they “continue to suffer as we try to come to terms with our loss” following the inquest into his death.

Lucas Thomas Munslow, from Flint, was nine months old when he died of acute bacterial meningitis at the Bodelwyddan hospital aged nine months late on May 18, 2019.

Less than 24 hours earlier, his parents had been told by staff at the hospital that he had viral tonsillitis but was safe to return home.

After a full inquest, held in Ruthin on November 21 and 22, John Gittins, senior coroner for North Wales East and Central, said that “poor practice” had been exhibited by staff at the hospital.

Mr Gittins recorded a narrative conclusion after hearing at the inquest from various Glan Clwyd staff members who saw to Lucas, as well as paediatric experts.

Denbighshire Free Press: Lucas MunslowLucas Munslow (Image: Family handout)


Nine-month-old died on same day of discharge from Ysbyty Glan Clwyd

Baby’s death at Ysbyty Glan Clwyd was likely preventable, inquest concludes

A statement made on behalf of Lucas’ family read: “We lost Lucas, our first-born baby boy, in circumstances that could have been avoided.

“We have been left deeply traumatised by the death of Lucas and continue to suffer as we try to come to terms with our loss. We hope that this finding leads to key learnings at the trust.

“We will now consider their options as to whether to pursue a claim against the trust (for) clinical negligence.

“We thank the coroner, Mr John Gittins, and welcome his finding of the death of our son being preventable.”

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

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.

An internal investigation carried out by Betsi Cadwaladr University Health Board originally concluded that there were no criticisms of the care provided to Lucas. 

Kimberley and Nathan Munslow, Lucas’ parents, did not accept this conclusion.

The health board’s executive medical director, Dr Nick Lyons, said: “Firstly, I would like to offer my sincere and heartfelt condolences to Lucas’ parents and wider family, on behalf of the health board.

“We accept the coroner’s findings unreservedly and 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 in the future.”

Dr Simon Nadel, a consultant in paediatric intensive care, gave evidence at the inquest as an independent expert.

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.

He added 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.

Mr Gittins said at the conclusion of the inquest: “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.”