Kane Gorny, 22, died in May 2009 of dehydration while under the care of St George’s Hospital staff. It was heard at the inquest at Westminster Coroner’s Court that a post-mortem examination found dehydration caused high sodium levels to lead to his death.
It was reported by the BBC that Mr Gorny had previously overcome a brain tumour, but due to taking steroid medication he had suffered weakening of his bones and was, prior to his death in hospital, undergoing a routine hip replacement at St George’s Hospital in Tooting.
In the report it was stated that Mr Gorny was suffering from diabetes insipidus, which leaves the kidneys unable to conserve water. On the day of Mr Gorny’s death he was incredibly thirsty, but the inquest heard that nurses refused to give him water, as the nurses had become ‘blinkered’ to his care due to his aggressive behaviour, which had been a result of the treatment he had received for his brain tumour.
The inquest heard that Mr Gorny became so thirsty that he called 999 and when the police attended they were turned away. It was further heard, that a nurse failed to give him his diabetes medication. Deputy Coroner, Dr Shirley Radcliffe said that “the staff nurse was out of her depth and should have sought help from her seniors.”Dr Radcliffe found that: "Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, a culture of assumption" and that “a cascade of errors had lead to his death”.
It is reported by the BBC, that St George’s Health Care NHS Trust have admitted civil liability for the failures in Kane’s care. Dr Rosalind Given-Wilson, the medical director of St George's Health Care NHS Trust, said it was "profoundly sorry".
A spokeswoman for the Department of Health is reported to have said "We want to introduce patient-led inspections and put regular nursing rounds in place to check that patients are always comfortable, properly fed and hydrated, and treated with dignity and respect."
Kane’s case highlights the pressures placed upon junior members of staff and the terrible consequences that it can lead to.
By clinical negligence specialist, Anne Marie Cassidy