Tearful doctor apologises to parents of toddler who died of sepsis after she failed to screen for killer infection
A BABY girl died of sepsis after a doctor failed to detect the killer infection, an inquest has heard.
Little Marcie Tadman was taken to hospital by her dad James, 40, after he noticed she was suffering from rattling, "raspy" breathing.
Medics reassured the family, diagnosing the two-year-old with a chest infection and prescribing her antibiotics.
But 24 hours later the toddler died, of Group A streptococcal infections, sepsis and pneumonia.
Wiping away tears doctor apologised to Marcie's family
A doctor who examined Marcie after she was admitted to Bath's Royal United Hospital told an inquest she did not screen the toddler for sepsis.
Dr Claire Verey who worked in the emergency department, 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.
"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.''
Had sepsis tool been used antibiotics would've been given earlier
Had Marcie been screened for sepsis, Dr Verey told the inquest 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."
It started with a nasty cough
The inquest heard that James had initially raised concern for his daughter with out-of-hours GP Dr Victoria Jacobs on December 2, 2017.
In a phonecall between James and Dr Jacobs, he told her that Marcie had been unwell with a cough for "two or three days", but that her cold and cough had worsened.
The worried dad said Marcie was "coughing up phlegm" and that her "chest sounded rattly", and that she had been running a fever of 39C.
Dr Jacobs had a consultation with Marcie later that day which she said lasted just under 20 minutes.
She said: "Her dad told me he had been worried about her breathing overnight. He said it was very noisy, rapid and laboured.
The signs of sepsis in kids under five
SEPSIS is a serious complication of an infection.
Without quick treatment it can cause multiple organ failure, and death.
In kids under five, symptoms include:
- mottled, bluish or pale skin
- lethargy, it's hard to wake them up
- abnormally cold to touch
- breathing very fast
- rash that doesn't fade when you press it
- fit or convulsions
If your child shows any of these signs go straight to A&E or call 999.
For more information, see the information page.
"I examined her chest, and found that there was lots of transmitted upper airway noises. The top of her chest was very noisy to listen to.
"There was no wheezing, no rattling noises. She seemed quite settled.
"Her fever had also come down from 39 to 37.5, and she was eating and drinking a little bit.
"I made the decision that Marcie was suffering from an upper respiratory tract infection.
''I remember weighing Marcie and advising on paracetamol and ibuprofen doses based on her weight.''
Dr Jacobs admitted that she had not recorded Marcie's respiratory rate, and added: "I'm very regretful that I did not make my documentation clearer.
"This is something I have since hugely reflected on."
Marcie's condition deteriorated
But James said her condition worsened over the weekend.
He said that, on December 4, Marcie "continued coughing regularly throughout the day and night".
"When she stopped coughing at about 3am I got up to check on her. Marcie was awake and listless.
''She seemed lethargic, and hadn't jumped up to be picked up like she usually would," said James.
"I gathered her up and took her to A&E at Royal United Hospital."
'They told me not to worry'
Marcie's father James claimed that, when he rushed his young daughter to Royal United Hospital staff there "did not seem very urgent".
In a statement James said: "Doctors and nurses kept coming in and out throughout the day, and they all said there was nothing to worry about.
"They said we'd be back home in two days. They told me not to worry."
James said that, once at the hospital, he was told that Marcie had a "simple" chest infection, which could be easily treated in 24-48 hours with a course of antibiotics.
But he said: "A bit of time went by, and I wondered why the antibiotics were not given straight away, as I felt her condition was not getting any better, and that was what she needed.
"The first staff member we came across there was a male, and he did not seem very urgent.
"As I was explaining to him what had happened, Marcie was sick on me.
"I was told she would be admitted and stay overnight.
''I asked again where the antibiotics were, and was told, 'You are being transferred to the children's ward, they will be administered there'."
Toddler suffered cardiac arrest in early hours
But James said the antibiotics had still not been given - six hours after they arrived at the hospital And James said that the last hour and a half of Marcie's life was "most definitely the worst time of my life so far".
He said that he and Marcie had fallen asleep late in the evening on December 4 - but he was awoken around 2am by a heart monitor alarm going off beside Marcie's bed.
He said: "Marcie had been sick again and pulled her oxygen mask away and pulled the IV line out of her arm.
"I was a bit annoyed as the nurses told me they would keep an eye on her. Then I remember the consultant, Mr Webb, coming in and saying, "Why is this child still here and not in ICU?".
"I panicked a bit and asked "Why the hell should she be in ICU?"
"As they started to move her, Marcie looked at me, looked straight into my eyes, and took one big breath.
"Then she seemed to turn off as she exhaled and went limp."
James said that staff began attempt to resuscitate Marcie, which he said went on for "so long".
But at 5.59am, Mr Webb told him they were going to stop - and Marcie was pronounced dead.
James added: "I just couldn't get my head around how this happened when all day we were told she was going to be fine. I was in shock."
Only eight hours earlier, James had said to his sister, Rachael Le Huray, "don't worry Rach, she'll be fine".
More on SEPSIS
Dr Verey said to Marcie's family at her inquest: "There's definitely lessons been learnt.
"Paediatric sepsis is a difficult area, but it's getting far better trained.
"You have to be more cautious with everything you do with a child, which is why making a diagnosis of sepsis can be so much more difficult.
"At the time I examined Marcie, the onus was more on finding an infection.
";But now, the onus is much more along the line of, "Does this child have sepsis?", Dr Verey said.
The inquest continues.
We pay for your stories! Email us at [email protected] or call 0207 782 4368. You can WhatsApp us on 07810 791 502. We pay for videos too. Click here to upload yours