We’re deeply sorry, RUH tells Marcie family

Inquest hears of failings in hospital care that led to tragic death of toddler

Bath’s Royal United Hospital says it is “deeply sorry” following a comprehensive investigation into the death of a two-year-old in its care.

Marcie Tadman, pictured, had been seen by seven doctors who were treating pneumonia as the main cause of her illness.

She then suffered a fatal cardiac arrest and a coroner criticised doctors’ “gross failure” in not diagnosing her with sepsis.

At the conclusion of the inquest into her death, on December 5 2017, senior Avon 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.

Speaking on behalf of the Royal United Hospitals Bath NHS Foundation Trust, its 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 both Marcie and her family down. This should never have happened.

“We owe it to Marcie’s family to demonstrate we have learned from their devastating loss and that we are doing everything we can to make sure a tragedy like this does not happen again.

“We have carried out a comprehensive investigation into the circumstances in the lead-up to Marcie’s death. The findings and the improvements we have made, and will continue to make, have been shared with her family and the coroner.

“This has been very distressing for everyone involved and our thoughts and sympathies remain with the family.”

Ms Voisin said: “I consider that putting these basic failures together led to the gross failure to provide or perform any effective medical treatment.

“I find that the gross failure has caused or significantly contributed to Marcie’s death.”

Ms Voisin also said she was “disturbed” by evidence given by witnesses of the extent of the “mis-remembering by those involved” in Marcie’s care.

Expert Dr Nelly Ninis told the inquest 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 (Nice), and transferred her to a

paediatric intensive care unit.

Marcie’s father, James Tadman, had taken her to the 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 outof-hours GP who had diagnosed a viral infection and told her father to give her Calpol.

Dr Ninis said: “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.”

The hearing heard there was not an “ingrained” culture to test for sepsis on the children’s ward.

Marcie 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.

Her 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 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.