Neglect by medical staff led to a man dying of dehydration in a hospital bed, a coroner has ruled.
Medical staff at St George’s Hospital in Tooting, south London, did not give Kane Gorny vital medication to help him retain fluids.
The 22-year-old, who was a keen sportsman, even phoned police from his hospital bed as he was so desperate for a glass of water, the inquest heard.
Deputy Coroner Dr Shirley Radcliffe told the hearing “a cascade of individual failures has lead to an incredibly tragic outcome”.
She recorded a narrative verdict at Westminster Coroner’s court and said 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.”
Dr Radcliffe told the inquest she would write to the hospital about nurses involved in fluid management and sedation following Mr Gorny’s treatment there.
A post mortem examination revealed high sodium levels caused by dehydration had caused his death.
Mr Gorny was suffering from diabetes insipidus, a condition which caused him to be aggressive towards nurses on 27 May 2009, the day before he died.
Mr Gorny, a supermarket employee, from Balham, south London, had been sedated and put in a side room following his outburst.
Staff nurse Adela Taaca, who was the senior nurse in Mr Gorny’s ward on the night of 27 May, previously told the inquest she did not take observations or ensure he took his medication.
She said this was because she was mindful of his earlier behaviour, and that his brother, who was sitting next to his hospital bed, asked her to let him sleep as he was sedated.
Shortly after her shift ended, Mr Gorny’s condition deteriorated and despite frantic efforts to save his life for two-and-a-half hours, he was pronounced dead at 11.20am.
Dr Ros Given-Wilson, medical director at St George’s Healthcare Trust, said: “We deeply regret the death of Kane Gorny and have apologised unreservedly to his family for the grief this has caused.
“We provide safe, high-quality healthcare services to over one million patients across south west London every year, but it is clear that the care we provided on this occasion fell short of expectation in a number of respects and for this we are profoundly sorry.
“We have admitted civil liability for the failures in Kane’s care and we fully accept the coroner’s verdict.
“Since Kane died in 2009, we have made changes to senior leadership on our wards and put a number of patient safety measures in place.”
Dr Radcliffe said a “crescendo of small failings” had contributed to Mr Gorny’s death, including a failure to involve the hospital’s endocrinology team in his care, to monitor his fluid balance and to administer essential medication.
Dr Radcliffe said staff nurse Sharon Gibbs, who was caring for Mr Gorny during his violent outbursts on 27 May, was “out of her depth” and should have had senior help.
A Department of Health spokeswoman 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.
“All hospitals need to ensure they are focusing on what matters to patients and getting the simple things, as well as the clinically technical decisions, right.”