'Gross failures' in Marcie Tadman sepsis death
A two-year-old girl died from sepsis because of major failings in the way she was cared for by medics, an inquest has found.
Marcie Tadman suffered a fatal cardiac arrest at the Royal United Hospital in Bath on 5 December 2017, a day after being admitted with pneumonia.
The inquest heard seven doctors who treated her had not considered sepsis.
Avon Coroner Maria Voisin concluded Marcie died from natural causes contributed to by neglect.
Ms Voisin said there had been a range of failings by the hospital: "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 included 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."
Marcie's father James Tadman had taken her to the hospital's emergency department the previous day because she had a cough, a 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 said she should have Calpol.
During the hearing, expert Dr Nelly Ninis said: "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 (National Institute for Health and Care Excellence) guidelines that were not followed."
Speaking afterwards, Mr Tadman spoke of the "hell" his family has gone through since her death.
Marcie died just a few months after her mother Lindsay passed away, having been diagnosed with cancer.
"My family and I have been through hell and no words can adequately describe how we are feeling," Mr Tadman said.
"We put our trust in the Royal United Hospital, assuming our little girl would get the very best care but tragically that was not the case.
"The hospital's own internal investigation has identified a number of failings and these have been described by one expert as 'systemic'."
He continued: "We can only hope that... every child that receives treatment at the hospital in the future will be better protected.
"The only crumb of comfort I can take from the impossible situation I find myself facing is that Marcie has been reunited with her Mummy, my wife, who sadly lost her fight against cancer in July 2017."
The hospital trust's medical director has apologised to Marcie's family.