Care failures revealed as coroner condemns doctors over death of two-year-old
A coroner has criticised doctors for their “gross failure” in not diagnosing a two-year-old girl with sepsis – ruling neglect contributed to her death.
Marcie Tadman was being treated for pneumonia at the Royal United Hospital in Bath when she suffered a fatal cardiac arrest on December 5 2017.
The toddler had been seen by seven doctors who were treating the pneumonia as the main cause of her illness and had not considered sepsis, Avon Coroner’s Court heard.
Coroner Maria Voisin listed a range of failings by the hospital and recorded a conclusion that Marcie died from natural causes contributed to by neglect.
“I consider that putting these basic failures together led to the gross failure to provide or perform any effective medical treatment,” she said.
“I find that the gross failure has caused or significantly contributed to Marcie’s death.”
Ms Voisin also said she was “disturbed” by some of the evidence given by witnesses of the extent of the “miss-remembering by those involved” in Marcie’s care.
Expert Dr Nelly Ninis told the inquest that systemic failures on the children’s ward led to Marcie’s death.
She said Marcie would not have died had staff 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.
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 – but the sepsis screening tool was not completed.
Three days before her death, Marcie had been seen by an out-of-hours GP who had diagnosed a viral infection and told her father to give her Calpol.
Dr Ninis said: “There was such as 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.”
The hearing heard there was not an “ingrained” culture to test for sepsis on the children’s ward.
The little girl was seen by a doctor on the afternoon before her death, but not reviewed again for 11-and-a-half hours.
She was about to be transferred to the intensive care unit when she suffered a fatal cardiac arrest.
He father told the inquest: “I explained to Marcie that everything was okay and they were going to go to another room.
“She looked at me and said, ‘Okay, Daddy’. When the nurse finished giving the fluids Marcie looked at me, took one big breath and she looked straight into my eyes.
“I had hold of her other hand and was stroking it, telling her she was going to be okay, she just seemed to turn off when she exhaled and went limp.”
A post-mortem examination found Marcie, who lived in Bath with her family, had died from a Group A Streptococcus infection with secondary pneumonia.
Speaking afterwards, Marcie’s father spoke of the “hell” his family has gone through since her death.
Marcie died just a few months after her mother Lindsay passed away, having been diagnosed with cancer.
“As you can all appreciate, my family and I have been through hell and no words can adequately describe how we are feeling,” Mr Tadman said.
“We have lost a very beautiful, caring little girl whose smile would light up any room and melt any heart.
“We put our trust in the Royal United Hospital, assuming that our little girl would be getting the very best card but tragically that was not the case.
“The hospital’s own internal investigation has identified a number of failings and these have been described by one expert as ‘systemic’ in nature.”
He added: “We can only hope that lessons have been learnt and that every child that receives treatment at the hospital in the future will be better protected.
“The only crumb of comfort I can take from the impossible situation I find myself facing is that Marcie has been reunited with her Mummy, my wife, who sadly lost her fight against cancer in July 2017.”
Trust medical director Dr Bernie Marden said: “We are deeply sorry for the shortfalls in Marcie’s care.
“We failed to appreciate the gravity of her illness and in doing so we let down both Marcie and her family. This should never have happened.
“We owe it to Marcie’s family to demonstrate we learnt from their devastating loss and we are doing everything we can to make sure tragedies like this do not happen again.”
LIST OF CARE FAILURES RELATING TO TREATMENT OF SEPSIS VICTIM
As part of her closing remarks, Avon Coroner Maria Voisin listed the failures she found in the care Marcie Tadman received at the Royal United Hospital in Bath.
– There was no sepsis screening in the emergency department
– Marcie was transferred before treatment could be completed
– Marcie was a critical unwell child and she should not have been taken from the resus area to the ward
– The handover from the emergency department to the ward was ineffective
– She was not considered with the same urgency after this move
– Once on the ward, the sepsis sticker in the nursing notes was not seen and actioned by any member of staff
– The sepsis screening was not communicated to staff and was not actioned by staff
– A new Paediatric Early Warning System (PEWS) chart was started on the ward and vital information from the emergency department was not seen
– The emergency department PEWS chart and records should have been looked at by staff on the ward
– The morning handover was ineffective
– After the morning handover, she was not deemed to be urgent and was not seen by the consultant until 9.50am
– The abnormal blood gas result was known at 9.50am, but no action was taken and it should have been
– Sepsis should have been considered and diagnosed at this time
– The pleural effusion protocol was not followed and Marcie was never discussed with Bristol in relation to its management and it should have been
– There was a delay in starting her antibiotics, which were in fact started four hours and 35 minutes after she arrived at hospital
– Bristol was not contacted after the ultrasound result was known
– Communication failure when the blood results were known
– Once the blood gas results were known not communicating them with the local specialist unit for discussion and transfer to the local intensive care unit
– No handover at lunchtime which would have allowed an opportunity for Marcie to be reviewed
– Failure to record the sepsis and follow the protocol when it was considered at 2.30pm
– Not setting up a high dependency unit area to manage Marcie after 2.30pm
– Not recording the examination after the fluid bolus
– Not repeating the blood gas test after the fluid bolus
– Failure by consultant to step back and look at the bigger picture, assess Marcie, make a plan and collectively communicate that plan
– Not following hospital protocols and procedures by any staff
– Not contacting the nurse in charge when the PEWS were two
– Not recording the proper fluid balance
– Inadequate levels of observation by the nursing staff
– Not recording nursing concerns when the PEWS, especially at around 2.30pm when clinical concerns were raised
– A totally ineffective handover at 5pm with medical staff
– Doctors not aware that Marcie was made “a watcher” by nurses on the night shift
– The nurse in charge of the night shift had considered sepsis at 7.30pm, but did not review Marcie or follow the hospital procedures or take any steps at all
– The nurse should not have reset the perimeters on the equipment recording the observations of her heart rate so that it did not alarm
– The nurse in charge of the night shift did not review Marcie when she was aware the PEWS were three
– The doctor should not have altered the oxygen levels for Marcie without seeing her
– The handover at 8.30pm with medical staff was inadequate and did not reflect Marcie’s actual condition
– Night shift nurses did not contact a doctor for a review at 10pm or midnight when the PEWS were three
– No medical review of Marcie for 11-and-a-half hours after she was last seen before the 5pm handover.
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