Coroner rules toddler’s death was due to doctors’ failure to diagnose sepsis

Two-year-old Marcie Tadman died after suffering a cardiac arrest whilst being treated for pneumonia at the Royal United hospital (RUH) in Bath in December 2017.

Marcie had been suffering with a cough for a number of weeks when she developed a high temperature and began vomiting. Her father, James Tadman, took her to A&E at the RUH on 4 December. Doctors admitted Marcie to the children’s ward after suspecting pneumonia and she was given antibiotics, however the toddler’s condition deteriorated and she tragically died at around 6am on 5 December. A post mortem examination found she had died from ‘group-A streptococcus infection with secondary pneumonia’.

The senior coroner for the Avon area, Maria Voisin, has this week ruled that Marcie’s death was due to the gross failure of the doctors treating her at RUH, after they failed to diagnose sepsis.

Listing a number of failures by the hospital during the inquest at Avon Coroner's Court, Ms Voisin said:

“I consider that putting these basic failures together led to the gross failure to provide or perform any effective medical treatment [and] 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.”

Dr Nelly Ninis, an expert witness at the inquest, agreed that ‘systematic failures on the children’s ward’ led to her death and that doctors in the emergency department at RUH should have recognised the sepsis. She added that the toddler would not have died if staff had transferred her to a pediatric intensive care unit (ICU), in keeping with their own guidelines and those of the National Institute for Health and Care Excellence (NICE).

Hannah Bottomley, clinical negligence solicitor at Potter Rees Dolan, said:

Sepsis is thought to effect 25,000 children and results in more than 50,000 deaths each year. It is these shocking figures that have promoted the multiple campaigns encouraging treating doctors and nurses to “think sepsis” whenever presented with possible symptoms. The purpose behind these campaigns is that with earlier detection and treatment lives can be saved as here in the tragic case of Marcie Tadman. I cannot imagine what Marcie’s family have been put through following her death and whilst I imagine the findings of the Coroner may well carry some satisfaction that those treating Marcie will be held to account, the tragedy is heightened by the family knowing that will better care Marcie would not have died.

Read how we secured compensation for a young man in his 20s after a failure to diagnose resulted in loss of arm movement

Hannah Bottomley is a clinical negligence solicitor here at Potter Rees Dolan. Should you have any queries about clinical negligence issues, including failure to diagnose or sepsis claims, or indeed any other aspect of this article and wish to speak to Hannah or any other member of the team please contact us on 0161 237 5888 or email Hannah directly.