Mason Logue · Prevention of Future Deaths report

On 30th October 2017 I commenced an investigation into the death of Mason Logue. The investigation concluded on the 22nd May 2019 and the conclusion was one of;
Narrative: Died a sudden and unexpected death for reasons that cannot be ascertained

The medical cause of death was unascertained

Mason Logue was born prematurely and was in a Neonatal Unit for 11 weeks after his birth. He had a complex medical history. On the 28th October 2017 he was in his mother's bed at their home address of ████████ Stockport. She awoke and found him unresponsive. A Post-Mortem Examination did not find a clear cause of death. There was no evidence of trauma contributing to the death of Mason.

The inquest heard that Mason was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU. His mother had previously been known to Family Services. There was limited evidence available of an integrated approach to care from the Local Authority, Tertiary Centre, Local Hospital and Community Health Professionals. As a result, information about his health was not shared between all health professionals. There was no overarching supportive care plan in place on discharge.

Furthermore, no one health professional had an overview of his health needs and ensuring that support was put in place and appointments were coordinated. There was no system for an allocated paediatrician to coordinate care where multiple paediatric specialists were involved.

During the course of the inquest, it was clear that the understanding of local health professionals about how information would be disseminated in accordance with MOUs and protocols was different from the tertiary centre. This meant that there were different views held between health professionals as to their roles and responsibilities.

There was a lack of understanding about the use and importance of Early Health Assessments amongst community health practitioners.

The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult. The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it.