An eight-year-old boy was seeking help in a "broken system" after he died from undiagnosed meningitis, an inquest was told.
Logan Jones died on 19 November 2019 after a junior registrar at the Royal Gwent Hospital in Newport said he was not showing any signs of meningitis, such as a stiff neck or obvious light sensitivity.
Dr Alejandro Levin had four months of paediatric experience and "did not think it was necessary" to consult a more senior member of staff before discharging Logan.
Dr Levin suggested to keep Logan in hospital to monitor him, but the eight-year-old's mother decided to take him home and return if his condition worsened.
Senior coroner for Gwent, Caroline Saunders, said Logan was "completely failed" by the systems. However she struggled to determine whether his death was a direct result of his hospital experience or of natural causes.
The young boy from Monmouthshire had a complex medical history. He was born with a heart defect, learning difficulties and needed a tube to eat.
Michelle Allen described her son as a "very happy child" who enjoyed visiting Big Pit and Bristol Zoo.
She told the coroner that Logan first started feeling unwell with a headache and started vomiting on 15 November.
After calling the out-of-hours service the following day, Ms Allen was advised to take her son to A&E at Royal Gwent Hospital.
They arrived at 11am on 16 November where everything appeared normal. Logan was eventually seen at 2pm, but the inquest heard he should have been seen within an hour of arrival given his situation.
Dr Levin then examined Logan and concluded any problems were "most probably a viral illness". In his statement, he added, "no doctor wants to miss meningitis".
He made no record of Logan's examination, including the fact he did not have a stiff neck and there was no evidence that he checked to see if Logan was sensitive to light.
Dr Levin's decision was supported by consultant Edward Valentine as "[Logan] had been there for three hours and his vital signs hadn't changed".
After taking her son home, Ms Allen explained how Logan went "downhill" that night and took him to a GP.
Again, there were no symptoms of meningitis. Dr Gray said: "We have a traffic light system for meningitis and my assessment was that he didn't score very high on that at all. He was on the green, which is low risk."
Ms Allen took Logan back to the hospital, but decided to return home after seeing how "chaotic" the Child Assessment Unit was and being refused a bed for Logan to lie down on.
"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 died at around 4am with his medical cause of death recorded as pneumococcal meningitis.
Dr William Christian gave supporting evidence at the inquest. He said that Dr Levin gave "a very brief assessment for a child with complex needs".
He added that people with meningitis can deteriorate rapidly and he "could not say for definite" that the outcome would have been different for Logan.
The coroner told the inquest that Logan's mother knew her son "better than anyone".
Ms Saunders added: "Had Logan remained in hospital overnight his deterioration would have been [observed] and staff would have been offered an opportunity to save his life."
A statement made on behalf of Ms Allen, read by her representative, Andrew Collingbourne, said: "Logan was just eight years of age but had courageously battled complex medical conditions all his young life with a smile on his face.
"We will remember him with great love and affection and he will main close to us and in our hearts for the rest of our lives."
The inquest heard that changes had been made since 2019. Susan Dinsdale, assistant divisional nurse, said those who leave without being seen by medical staff are now called afterwards as standard practice.