Man died of dehydration in hospital due to staff failures

In a narrative verdict, Deputy coroner Dr Shirley Radcliffe said that Mr Gorny had died from dehydration contributed to by neglect.

Dr Radcliffe said: “Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, a culture of assumption.”

The inquest had previously heard that Kane Gorny died of thirst after medical staff failed to give him vital medication and carry out proper checks.

Westminster Coroner’s Court heard how a catalogue of errors by staff at St George’s Hospital led to the death of Mr Gorny, who had already successfully beaten a brain tumour, but was admitted to hospital for a hip replacement operation after steroids to treat his illness had weakened his hips.

Surgery was performed on the 22-year-old without notes being fully consulted, and nurses admitted they failed to take observations or ensure he took medication which would have helped him retain his fluids.

Mr Gorny had become so dehydrated and delirious, causing him to become violent, that he called police begging for a drink. He died of dehydration on May 28, 2009.

The deputy coroner told the inquest she would write to the hospital about nurses involved in fluid management and sedation following Mr Gorny’s treatment at St George’s.

Missed opportunities

Speaking outside court today, James Stevenson, the solicitor for Mr Gorny’s family said they were “devastated by the number of missed opportunities” to prevent his death. With Mr Gorny’s mother standing beside him, Mr Stevenson said: “Kane was a well-liked, adoring and loving son, brother and friend.”

The errors began with his arrival at the hospital, on May 25, 2009. Staff failed to tell his endocrinologist that he was there for the operation, despite advice to do so.

Mr Gorny, a trainee locksmith and keen footballer, needed hormone medication to control fluid levels in his body.

They then failed to give him his tablets, despite repeated reminders by him and his family, and failed to act despite abnormally high sodium levels in his blood.

When orthopaedic specialist Phillip Stott went to operate, he did so without due care the inquest heard. He said: “I had a quick flick through the notes but didn’t read them properly and then went into surgery. One of the errors is you get into assuming other people have done that as part of a team. My role was just the operation, I thought that had all been sorted out and assumed everything had been put in place.”

After the operation, Paul Gillespie, a consultant, said that he had tried to calm Mr Gorny down after he became violent and threw a beaker of urine at him.

When Mr Stott was called in, he again failed to read his notes which would have explained that Mr Gorny was prone to violence because of his rare diabetic condition and dehydration. Instead, he ordered for him to be sedated, and Mr Gorny was put into a side room without an intravenous drip. Mr Stott told the inquest he had not issued instructions for the drop because he had assumed nurses would know to do this.

In the side room, staff nurse Adela Taaca, the senior nurse on the ward, failed to take observations.

“I should have given the medication but at that time I felt that Kane needed more rest because earlier on he was very aggresstive and disruptive,” she said.

Forcibly restrained

As he became delirious, the inquest heard, he began calling his mother, Rita Cronin, and told her he had called the police. When she later arrived, she found he had been held down by a security guard.

Later, she described how the alarm was only raised an hour before his death when a doctor on rounds entered his room and realised how serious his condition was.

She said: “He walked straight in, took one look at him and called to everyone, ‘Get in here quick!’ That’s when it dawned on me – he’s not had any medication, no observations, no fluids, nobody has given him a drink, nobody has done anything from yesterday.”

Fighting back tears, she described the moment she was allowed to see his body after he was pronounced dead three days after his admission.

“He was lying flat on his back and he had tubes, and there was iodine or something on the bed,” she said. “But he was dead. He was already dead. I felt sick.”

Following media coverage of the inquest, Miles Scott, the chief executive of St George’s NHS Trust, apologised, admitting that he had died because staff failed to care for him properly.

On a message posted on his blog, he said: “Kane was admitted for an operation in 2009 with complex medical needs and we failed to care for him as we should have.

“Sadly he died as a result. I would like to apologise again on behalf of the trust for this failure in our duty of care and to say that we have taken action to protect other patients. When things do go wrong, it is vital that we learn from them and adapt our approach to make sure we do not repeat our mistakes.”