Patient safety

12.03.19

Two-year-old girl ‘would have survived’ if hospital’s guidelines had been followed in sepsis death

Systemic failures on the children’s ward of Bath’s major hospital led to the death of a young girl from sepsis, an inquest heard.

Dr Nelly Ninis said that if staff at the Royal United Hospital had followed their own guidelines then two-year-old Marcie Tadman would not have died.

Marcie was being treated for pneumonia on Bath hospital’s children’s ward but suffered a cardiac arrest in December 2017.

The father of the young girl, James Tadman, had taken her to the hospital’s emergency department the day before she died but described how hospital staff had seemed “unconcerned” when her condition deteriorated.

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Consultant general paediatrician Ninis wrote a report on behalf of Avon Coroner’s Court into Marcie Tadman’s care, and said her symptoms “should have been recognised from the moment she arrived at the hospital.”

She told the inquest that the toddler should have been sent to Bristol Children’s Hospital, stating: “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.”

The coroner’s court also heard that there was not an “ingrained” culture for doctors to test for sepsis.

Dr Ninis said that despite there being signs of sepsis present when her father took Marcie Tadman to the hospital, the sepsis screening tool was not completed.

Showing signs of respiratory failure, Ninis said Marcie was “very unwell” and was placed in a resuscitation bay.

Ninis also questioned the decision to then transfer her from the emergency department to the children’s ward which occurred during handovers, stating that “everything was in flux and bound to go wrong.”

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

She continued: “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 inquest continues.

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