Source · Prevention of Future Deaths

Marcie Tadman

Ref: 2019-0118 Date: 1 Apr 2019 Coroner: Maria Voisin Area: Avon Responses identified: 1 / 2 View PDF

No specific matters of concern were detailed in the provided text.

Date 1 Apr 2019
56-day deadline 4 Aug 2019 est.
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
No specific matters of concern were detailed in the provided text.

Responses

1 respondent
Royal United Hospitals Bath NHS Trust NHS / Health Body
28 May 2019 PDF
Action Planned

The Trust shared a briefing paper with its commissioners detailing what would be required to deliver paediatric critical care, including an additional evening ward round, and is aiming to deliver twice daily consultant ward rounds and paediatric high dependency care by Winter 2019. (AI summary)

View full response
Dear Madam Marcie Joan Tadman - Response to Regulation 28 Report

Please see the Royal United Hospitals Bath NHS Foundation Trust’s response to the Regulation 28 Report issued on 1st April 2019.

1) There is no second consultant ward round on the Paediatric Ward

The Trust has identified that an additional consultant evening session (4 hours) would be required each day to enable it to deliver a second ward round which would not only encompass new admissions but any patient about whom a concern had been raised, including patients receiving critical care. This is not a change in practice that the Trust has been able to deliver immediately. The ability to do this is directly linked to the provision of a Paediatric Critical Care Unit and therefore the plans outlined below presented to the commissioners take clear account of a second ward round being integral to this development.

As the Learned Coroner also raised concern about the lack of a permanent paediatric High Dependency Unit (referred to here as Paediatric Critical Care), the Trust has, on 21st May 2019, shared a briefing paper with its commissioners, detailing what would be required to deliver paediatric critical care. This sets out a requirement to do the following:

1. Increase in medical staffing to provide an additional evening ward round.
2. Increase in nursing staffing to ensure rota can provide a 0.5:1 ratio for a Paediatric Critical Care Unit.
3. Invest in additional equipment, eg monitoring.
4. Redesign the ward to establish a fit for purpose Paediatric Critical Care Unit on the children’s ward.

If the Trust’s Commissioners are satisfied with the Trust’s proposals, the RUH are aiming to deliver not only twice daily consultant ward rounds, but paediatric high dependency care by Winter 2019. The position of the Commissioners will be set out in their response to the Regulation 28 Report forwarded to them, however, if they HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Directors Office Royal United Hospital Combe Park Bath BA1 3NG

Tel: 01225 824032

… … were not in a position to support the Trust’s paediatric critical care plans, the Trust would still be looking for additional funding to support twice daily consultant ward rounds.

The RUH would like to offer its assurances that it continues to review the other actions and improvements identified during this tragic inquest and it is satisfied that the improvements already made to matters such as handover documentation have increased the safety of the children on the paediatric ward.

The Trust is willing to provide a further update in relation to the progress that has been made concerning twice daily consultant ward rounds and the creation of a critical care unit in six months’ time, if that would provide additional reassurance to the Court and Marcie’s family.

We trust that this response offers you sufficient assurances in relation to our actions following the Inquest into this tragic case.

Report sections

Investigation and inquest
On 04/07/2018 commenced an investigation into the death of Marcie Joan TADMAN: The investigation concluded at the end of the inquest 12th March 2019. The conclusion of the inquest was Natural Causes Contributed to by Neglect
Circumstances of the death
Marcie Tadman died on Sth December 2017 at Royal United Hospital, Combe Park, Bath. She had been admitted to hospital on 4th December 2017 with pneumonia and parapneumonic effusion: She was not referred to the regional unit for treatment of this condition. She had sepsis and there was a failure to recognise and to manage and/or treat sepsis There were failures to follow the procedures and protocols set nationally or by the hospital. The communication each and every time when discussing Marcie between members of the team was unsatisfactory: All handovers failed to take the opportunity to review Marcie with fresh eyes. The combination of: poor communication between all staff caring for Marcie; the failure to follow any hospital protocols; the lack of proactive review and poor decision making came together to contribute to her death_ The medical cause of death: 1a Disseminated group A streptococcal infection including empyema, bronchopneumonia and pyelonephritis Telephone 01275 461920 Email AvonCoronersTeam@bristol gcsx-gov.uk Website www.avon-coroner.com The Coroner'$ Court, Old Weston Road, Flax Bourton, BS48 1UL and
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Copies sent to
coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL 28th may

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Report details

Reference
2019-0118
Date of report
1 April 2019
Coroner
Maria Voisin
Coroner area
Avon

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Aug 2019 (estimated).

Sent to

Banes Clinical Commissioning Group
Royal United Hospital, Bath

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