'Systemic failure' at Bath hospital led to girl's sepsis death

A systemic failure on a children's ward led to the death of a young girl from sepsis, an expert has told an inquest.

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

Marcie was being treated for pneumonia on the children's ward when she had a fatal cardiac arrest in December 2017.

Avon Coroner's Court heard doctors were treating her for pneumonia and had not considered sepsis.

Marcie's father James Tadman had taken her to the hospital's emergency department on 4 December - the day before she died - because she had a cough, a high temperature and had been vomiting.

Dr Ninis, a consultant general paediatrician, wrote a report on behalf of the Avon coroner into Marcie's care in the days before she died.

She told the inquest Marcie's symptoms "should have been recognised from the moment she arrived at the hospital" and she should have been sent to Bristol Children's Hospital.

"I think 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," Dr Ninis said.

Dr Ninis said the signs of sepsis were present when Mr Tadman took his daughter to hospital, but a sepsis screening tool was not completed.

Marcie was "very unwell" and put in a resuscitation bay where she was "grunting", which Dr Ninis said was a "sign of respiratory failure".

Dr Ninis said a decision to transfer Marcie from the emergency department to the children's ward was a "bit odd" because it had happened at a point in the day where handovers were happening between staff.

"Everything is in flux and is bound to go wrong," she said.

Dr Ninis also criticised the fact no-one took overall charge of Marcie's care.

"There was such a systemic failure here to manage a child with a serious illness," she said.

"Children with serious illnesses show you where all the failings are because they fall ill so quickly."

A post-mortem examination found Marcie had died from a Group A Streptococcus infection with secondary pneumonia.

The inquest continues.