PFD report

Marcie Joan TADMAN · Prevention of Future Deaths report

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Issued 13 Mar 2019•Avon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of second consultant review on the paediatric ward
    Part of recurring concern: Delays in consultant review of patients
  2. Unavailability of a paediatric High Dependency Unit facility
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Share a briefing paper with commissioners detailing staffing, equipment and ward redesign requirements for paediatric critical care.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Delivery of the proposed Paediatric Critical Care Unit and twice-daily ward rounds depends on commissioners supporting the plans and funding.

    Stated by Royal United Hospitals Bath NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Delays in consultant review of patients.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share a briefing paper with commissioners detailing staffing, equipment and ward redesign requirements for paediatric critical care.

Verbatim wording from the response

“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:”

Source location

2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Delivery of the proposed Paediatric Critical Care Unit and twice-daily ward rounds depends on commissioners supporting the plans and funding.

Verbatim wording from the response

“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”

Source location

2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A second consultant ward round cannot be delivered immediately because it depends on establishing a Paediatric Critical Care Unit.

Verbatim wording from the response

“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.”

Source location

2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Continue reviewing other actions and improvements identified during the inquest.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. 2

    Improve paediatric ward handover documentation to increase children’s safety.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue reviewing other actions and improvements identified during the inquest.

Verbatim wording from the response

“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.”

Source location

2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve paediatric ward handover documentation to increase children’s safety.

Verbatim wording from the response

“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.”

Source location

2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026