Inquest hears ‘systemic failure’ to blame for death of two-year-old from sepsis

Systemic failures on a children’s ward led to the death of a two-year-old girl from sepsis, an expert has told an inquest into her death.

Dr Nelly Ninis said Marcie Tadman should not have died had staff at the Royal United Hospital in Bath followed their own guidelines, as well as those from the National Institute for Health and Care Excellence, and transferred her to a paediatric intensive care unit.

The toddler was being treated for pneumonia on the children’s ward when she suffered a fatal cardiac arrest on the morning of December 5 2017.

The inquest at Avon Coroner’s Court heard doctors were treating the pneumonia as the main cause of the two-year-old’s illness and had not considered sepsis.

Marcie’s father James Tadman had taken her to the hospital’s emergency department the previous day because she had a cough, a high temperature and had been vomiting.

Dr Ninis, a consultant general paediatrician, wrote a report on behalf of the Avon Coroner into Marcie’s care in the days before she died.

She said every winter children fell ill with similar symptoms to Marcie and sepsis should have been considered with a paediatrician seeing her in the emergency department.

“My conclusions are that this should have been recognised from the moment she arrived at the hospital,” she told the court.

“She should have been sent to Bristol within a few hours and had much more prompt antibiotics and resuscitation.

“I think if this process had been in place, she would have had a stormy time in the intensive care unit, but I think she would have survived.”

Dr Ninis said the signs of sepsis were present when Mr Tadman took his daughter to hospital, but the sepsis screening tool was not completed.

“On the morning she was taken to hospital she was clearly systemically inflamed,” she said.

“What starts as a contained infection becomes a multi-organ condition.

“In order to reverse this process, there has to be a multi-pronged attack.

“In Marcie’s particular case when she came to the hospital she was very unwell and was put in the resuscitation bay.

“She was severely tachycardiac and was grunting which is a sign of respiratory failure.”

Dr Ninis said that by 10am Marcie should have been receiving fluids and resuscitation.

“The notes show she remained unresuscitated all day,” she said.

She said doctors had recognised Marcie had an empyema, a collection of fluid on the lungs, and should have been sent to Bristol Children’s Hospital for specialist treatment.

“It’s a real mistake not to refer for drainage,” she said.

Dr Ninis described the decision to transfer Marcie from the emergency department to the children’s ward as a “bit odd”.

“Everyone in resus is aware there is a sick child and the timing of the move was also very unfortunate because its handover time.

“Everything is in flux and is bound to go wrong,” she said.

“It feels like no one took charge of this little girl and had a look at the overall picture.

“I think moving her from resus was an error and the timing unfortunate.

“Everything was there to tell the team that she needed to go to intensive care and resuscitation, but the decision was made to give her antibiotics and monitor.”

Dr Ninis also criticised the failure on the ward for anyone to take overall charge of Marcie’s care.

“I was struck how everybody had done a little bit but no one had done the whole thing,” she said.

“Before handover the most senior doctors on the ward should have reviewed her before handing over.

“You cannot hand over a patient if you have only seen them once in the morning.”

She said she found it “unusual” that no one went to see Marcie after the 5pm handover.

“You have to work in a unit where you question what you have done.

“It’s healthy and it is not seen as criticism,” she said.

“Had the evening team done this they would have seen her not looking well and could have referred her to Bristol and they could have resuscitated her.

“There is a limit to how long you can stay in septic shock.

“Marcie was in unresuscitated shock for the entire day and not only were her antibiotics delayed, they were inadequate as well.”

Dr Ninis added: “There was such a systemic failure here to manage a child with a serious illness.

“Children with serious illnesses show you where all the failings are because they fall ill so quickly.

“The hospital policies are well written and had they been used they would have been enough and there were Nice guidelines that were not followed.

“It was so remarkable, the lack of attention to detail, one does have to wonder if this is a common feature in this unit.”

A post-mortem examination found Marcie had died from a Group A Streptococcus infection with secondary pneumonia.

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