A two-year-old girl died as a result of neglect following a gross failure by doctors to diagnose sepsis, a coroner has ruled. Marcie Tadman was treated for pneumonia at the Royal United Hospital in Bath and was seen by seven doctors before she died after a cardiac arrest.
Senior coroner for the Avon area, Maria Voisin, recorded a conclusion that Marcie died from natural causes contributed to by neglect. She stated that basic failures led to a gross failure to provide effective medical treatment and to follow proper procedures, including standard monitoring. The coroner found that the serious deterioration in Marcie's condition should have been recognised and that the gross failure significantly contributed to her death.
Marcie's father, James Tadman, told the inquest that staff had reassured him all day that she would be fine. He said he could not understand why there had been so little concern. An expert witness, Dr Nelly Ninis, told the inquest that systemic failures on the children's ward led to Marcie's death. She said Marcie would have survived if staff had followed guidelines and transferred her to a paediatric intensive care unit.
Dr Fran Hofmann, a registrar, admitted she had thought about sepsis but did not share her concerns with others. She left the hospital at 5pm on 4 December 2017, believing Marcie would be reviewed immediately by the evening team, but that did not happen. Dr Ron Daniels, chief executive of the UK Sepsis Trust, said the case highlighted the devastating consequences when healthcare professionals do not 'think sepsis' and called for adherence to protocol.
Marcie died shortly before 6am on 5 December 2017. A postmortem examination found she died from a group-A streptococcus infection with secondary pneumonia. Her father said the hospital 'let my little girl down with such tragic consequences' and hoped lessons had been learned.
