Marcie Tadman died at Bath’s Royal United Hospital on December 5 after doctors failed to test her with a sepsis screening tool, Avon Coroner’s Court heard
A two-year-old girl said “OK, daddy” and looked into his eyes moments before she collapsed in front of him after contracting sepsis, an inquest has heard.
Marcie Tadman was taken to the Royal United Hospital in Bath after she was diagnosed with pneumonia.
The toddler was about to be transferred to the paediatric intensive care unit when she suffered a cardiac arrest.
Doctors tried to resuscitate Marcie, who lived with her family in Bath, but were unable to save her.
Avon Coroner’s Court heard Marcie died shortly before 6am on December 5 2017 having been taken to the hospital’s emergency department by her father James Tadman two days previously.
The inquest heard she had been suffering with a cough for a couple of weeks and her father had telephoned the out of hours GP service on the morning of December 2, who said she should see one of the doctors.
“Marcie was examined and I was told she had a viral infection,” Mr Tadman said.
“I was told to keep doing what I was doing and to keep her well hydrated and feed her and to keep up with the Calpol and she should improve in 48 hours but she would get worse before she got better.”
That night Marcie was regularly coughing as she slept and at 3.30am Mr Tadman got up to check on her.
He took her the hospital because he was concerned about her breathing.
“A male nurse told me she was suffering from a simple chest infection, possible pneumonia, and that antibiotics would be given and she would be right as rain,” he said.
She was taken to the children’s ward and given the antibiotics, and Mr Tadman was told his daughter would be able to go home in a couple of days.
Mr Tadman’s sister, Rachael Le Huray, went to visit her niece on the evening of December 4 and noticed the alarms on Marcie’s monitors kept going off.
“Before I left one of the last things James said to me was ‘don’t worry she’ll be fine’,” she said.
“I stroked her hair and said goodbye. That was the last time I saw her alive. She was dead eight hours later.”
Mr Tadman said he shared his sister’s concerns and questioned whether his daughter was getting sicker but was reassured the antibiotics would help.
He said he fell asleep and woke at 2am on December 5 to find Marcie had been sick again.
“I was starting to get concerned because Marcie was still talking to me and was generally responsive but she looked worse and very unwell,” he said.
“No-one else seemed concerned so that put me at ease.”
A consultant then entered the room and ordered her transfer to the intensive care unit.
“I explained to Marcie that everything was OK and they were going to go to another room,” he said.
“She looked at me and said ‘OK, daddy’. When the nurse finished giving the fluids Marcie looked at me, took one big breath and she looked straight into my eyes.
“I had hold of her other hand and was stroking it, telling her she was going to be OK, she just seemed to turn off when she exhaled and went limp.
“I really didn’t know what was going on. I looked at the nurse and she had a look of horror on her face and shouted ‘crash’.
“I couldn’t believe this was happening.”
He added: “They were attempting resuscitation and that hour and a half was most definitely the worst of my life.”
A doctor then came to see him to tell him they were going to stop resuscitation.
“It was all a bit of blur, I just couldn’t get my head around how we had got to this point when they had been telling me all day she was going to be fine,” he said.
“They couldn’t explain why there had been so little concern and why we had received so much reassurance and then she had died.”
A post-mortem examination found Marcie had died from a Group A Streptococcus infection with secondary pneumonia.
Dr Victoria Jacobs, who had examined Marcie at the out of hours GP service, told the court her notes of the appointment “could have been better” and she has since “hugely reflected” upon this.
A doctor who examined Marcie shortly after she was admitted to hospital told an inquest she did not screen Marcie for sepsis.
Dr Claire Verey who worked in the emergency department at Bath’s Royal United Hospital at the time said she did not use a sepsis screening tool.
Wiping away tears, she told an inquest Avon Coroner’s Court in Bristol: “My diagnosis was based purely on the Marcie I saw in front of me.
“In my mind, Marcie Tadman was definitely an unwell child in front of me.
“I reconciled all the observations I had in front of me with bacterial pneumonia. This is my only explanation for not doing all the sepsis tests.
“I cannot fully explain why sepsis didn’t pop up in my head. It’s just I genuinely felt that all the signs pointed to pneumonia.
“Rather than using the screening tool I used my own judgement looking at Marcie as she was in front of me.
“I apologise wholeheartedly for what happened to Marcie.”
Dr Verey told the inquest that, had Marcie been screened for sepsis, she should have been given IV antibiotics sooner, as sepsis guidelines dictate.
She said: “It can be very difficult to decide whether or not someone has sepsis. Sepsis is still quite rare in children.
Putting a drip into an adult is a relatively easy thing to do, but getting a drip into a child is not so straightforward.
“I know that thought crossed my mind at the time, and meant that I maybe didn’t get a drip in to start giving antibiotics perhaps as quickly as the sepsis guidelines dictated.”
She added: “The sepsis screening tool is designed to be quite a blunt tool, and it will pick up a lot of children who are far less ill than Marcie was and who maybe don’t need the full screening.
“Therefore rather than using the tool I used my judgement looking at Marcie as she was in front of me, and maybe that’s why she didn’t get the treatment.”
The inquest continues.