1. ITV Report

Bath toddler’s sepsis death caused by doctors’ ‘gross failure’

Marcie Tadman. Credit: Tadman family

A two-year-old girl died from "neglect" after the "gross failure" of doctors who did not diagnose sepsis, a coroner has ruled.

Marcie Tadman was being treated for pneumonia at the Royal United Hospital in Bath when she suffered a fatal cardiac arrest on the morning of December 5, 2017.

She had been seen by seven doctors who were treating the pneumonia as the main cause of the toddler's illness and had not considered sepsis.

Senior coroner for the Avon area Maria Voisin listed a range of failings by the hospital and recorded a conclusion 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.

The gross failures to follow proper or routine procedures and protocols including standard monitoring.

There was a serious deterioration in Marcie's condition and staff caring for her should have realised the need for action in all the circumstances. I find that the gross failure has caused or significantly contributed to Marcie's death.

– Senior coroner Maria Voisin

Expert Dr Nelly Ninis told the inquest at Avon Coroner's Court 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, to transfer her to a paediatric intensive care unit.

Marcie suffered a cardiac arrest while at the Royal United Hospital in Bath. Credit: Tadman family

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.

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.

– Dr Nelly Ninis

During the week-long inquest, doctors told Ms Voisin there was not an "ingrained" culture to test for sepsis on the children's ward.

A post-mortem examination found Marcie, who lived in Bath with her family, had died from a Group A Streptococcus infection with secondary pneumonia.

Trust medical director Dr Bernie Marden apologised to Marcie's family.

I want to say sorry. As an organisation, we recognise the responsibilities we hold and we feel we let Marcie down and we let you down as a family.

– Dr Bernie Marden