NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board

Health and care · Integrated care board

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First report 12 Feb 2016•Latest report 13 Mar 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to NHS Bath and North East Somerset Clinical Commissioning Group, now represented here by NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board.

    Avon

    AI-generated summary

    Marcie Joan TADMAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marcie Joan Tadman died on 5 December 2017 at Royal United Hospital after admission with pneumonia and parapneumonic effusion. The report describes failures to recognise and manage sepsis, follow hospital procedures and protocols, communicate effectively, conduct proactive reviews, and make appropriate decisions. It also identifies the absence of a paediatric high dependency unit at the hospital as a concern.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of second consultant review on the paediatric ward

    Wider context from the report

    “• I heard from the independent expert Dr. Ninis that the only opportunity for Marcie to be picked up with fresh eyes would have been at another ward. I understand that this would be an opportunity for a Consultant to take a step back and review the notes, charts, PEWS and results; examine the patient and to make a plan. In Marcie’s case everyone agreed that all of the information was there in her records but no one carried out this exercise; there was and is no second word round on the paediatric ward at the RUH. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a paediatric High Dependency Unit facility

    Wider context from the report

    “• I was also made aware at the inquest that there is no High Dependency Unit (HDU) facility on the RUH paediatric ward for children in their care and this was something that they were hoping to provide but needed to create a business case to the Accountable Offices for BANES CCG for this. In Marcie’s case she should/would have been placed in such a unit had one been at the RUH at the time. ”
    Open source report

  2. Addressed to NHS Bath and North East Somerset Clinical Commissioning Group, now represented here by NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board.

    Avon

    AI-generated summary

    Mr. Terence Brooks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr. Terence Brooks, who was being treated for acute myeloid leukaemia, developed Legionella pneumophila pneumonia and died on 23 July 2015. The report raised concerns that the hospital misinterpreted microbiological testing, conducted its investigation on a false premise, and had no procedure for investigating the cause of a Legionella infection.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a procedure for investigating the cause of Legionella infection

    Wider context from the report

    “(4) The hospital, although responding promptly to the infection, had no procedure in place detailing how the investigation of the cause of a legionella infection should be undertaken. (5) The hospital should put in place an approved procedure for the investigation of any future outbreaks of Legionella infection should they occur. This procedure should describe and define clearly inter alia the nature, limitations and interpretation of the results of any microbiological testing undertaken. (6) The responsibility for putting such a procedure in place should be that of the Director of Infection Prevention and Control who, in drafting the procedure, should seek the support and guidance of appropriate professionals including Public Health England and the Health Safety Executive. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly interpret microbiological water-sample results and testing limitations

    Wider context from the report

    “(1) Those who conducted the investigation and root cause analysis on the part of the hospital did not appreciate that notwithstanding the absence of the specific subgroup of Legionella serotype 1 in the water samples from the ward as compared to samples from the deceased that this was not conclusive as to the ward not being the source of the infection. (2) There was a lack of understanding on the part of the hospital as to how to interpret the results of the microbiological analysis of the water samples and the limitations of testing including the meaning of any results obtained, the reliability which may be placed on those results and any conclusions which may be drawn from those results. (3) As a result of this lack of understanding the hospital misinterpreted the results and conducted their investigation and root cause analysis on a false premise which led them to conclude incorrectly that the William Budd ward was not the source of the Legionella infection. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026