Nurse haunted by tragedy of Marcie
Inquest hears how carer voiced strong concerns to doctors
A nurse caring for a little girl who suddenly collapsed and died from sepsis keeps asking herself whether she could have done more, an inquest heard.
Marcie Tadman had been admitted to the Royal United Hospital in Bath after being diagnosed with pneumonia. The two-year-old was about to be transferred to the intensive care unit when she had a fatal cardiac arrest, Avon Coroner’s Court heard. Staff nurse Kay Edwards, who was caring for Marcie on the day she was admitted, said she had expressed concerns to doctors but keeps wondering whether she could have been “more forceful”. In a statement read to the court, Ms Edwards said: “I continue to think about Marcie and her family. “I remember Marcie’s father thanked me for doing everything for Marcie as I was leaving at the end of my shift. “I continuously ask myself whether I did do everything and whether I could have been more forceful in expressing my concerns. “At the time I was reassured by the doctors, who told me that they had a diagnosis to explain Marcie’s condition and whilst there was a need to keep a close eye on her and her condition, she was not a patient about whom they were unduly worried.” Marcie’s father, James Tadman, had taken her to the emergency department in the early hours of December 3 2017, because she had been suffering with a cough for two weeks and had developed a high temperature and vomiting. Doctors decided to admit the girl to the children’s ward after suspecting she was suffering from pneumonia. Ms Edwards had just started a 12-hour day shift when Marcie came on to the ward, and as part of initial checks she and colleague Clare Best completed a sepsis assessment which was “indicative of possible sepsis risk”. Ms Best paged twice for a doctor, but by the time she finished her shift at 8am the doctor had not arrived. Later that morning a doctor examined Marcie and inserted a cannula into her arm for the administration of antibiotics, which were given at 10.15am. The inquest heard that at 2pm Ms Edwards requested a medical review because she was concerned about Marcie’s heart and respiratory rates, which was carried out. At 5pm Ms Edwards spoke to a consultant because there had been no change in her condition “but no change in her treatment was asked for” and “the antibiotics should be given time to work”. At 6.30pm she spoke to a registrar about her concerns for Marcie. “I was told to continue current care and reduce the amount of oxygen in the nasal cannula if it was causing discomfort,” Ms Edwards said. “At this time high flow oxygen and high dependency care was suggested by me, but it was decided this was not needed at this time but would be considered if she could not maintain saturation levels. “I don’t think I specifically asked the doctor to review Marcie but I believed this would be done shortly. “I thought this because I made it clear I was concerned and because I had stated that her paediatric early warning score was three, which required medical review.” Marcie, who lived with her family in Bath, died shortly before 6am on December 5 2017. A post-mortem examination found Marcie had died from a Group A Streptococcus infection with secondary pneumonia. The inquest continues.
Marcie’s father thanked me for doing everything for Marcie as I was leaving at the end of my shift. Staff nurse Kay Edwards