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Hospital failed dehydration patient


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.”


Readers' comments (42)

  • Anonymous

    This is another bad story, which did not get a favourable 'review' on Radio 4 this morning. And it is interesting that R4 invited the RCN to comment, and the RCN wouldn't put up someone to speak. That tends to sour the public's opinion of the nursing profession.

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  • What a sad, sad story.

    Hope all involved have managed to recover a little from the huge trauma of this terrible case.

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  • aggression and zero tolerance often seem to be the 'norm' in modern day services of all kinds instead of investigation of the underlying causes and attempting to find solutions to problems. The onus for any problems which may have triggered the aggressive behaviour are shifted onto the service user.

    Staff need better training to deal with these situations, as well as being capable of observation and identifying clinical symptoms in the above case. if aggression becomes out of control and poses a risk they should be able to mobilise back up support who have more expertise in handling aggression (which should always be available in the same way a crash team is for cardiac arrest).

    Aggression is often exacerbated by needs not being identified and adequately met, many of which, as above should not be beyond the capabilities and skills of qualified staff.

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  • michael stone

    Anonymous | 13-Jul-2012 12:03 pm

    Some time ago, I posted comments along those lines re 'zero tolerance' and 'perspective issues': my comments were not universally well received.

    It is interesting, that coroners are either lawyers or doctors, and this one was I think (from her title) a doctor - her rather scathing comments, might have something to do with a clinical judgement about the level of clinical competence involved.

    It is difficult if patients are aggressive, and it is difficult if staffing numbers are less than ideal - but there do seem to have been a lot of potential warning signs here, which if acted on differently would have prevented this.

    And, as always, whenever this type of thing happens, it will get picked up, reported in the media (after simplification of the story) and it does nothing for the reputation of the NHS and clinicians.

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  • A culture of assumption seems to be prevalent amongst healthcare professionals. We are professionals with a huge body of knowledge. We lead healthcare. When we begin a shift it is essential that info rmation is communicated professionally. No assumptions should be made. We as professionals should be ashamed that a patient died due to assumptions.

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  • all down to record keeping,if the patient brother wanted him to sleep,the fact that he was taking ADH, warrants a strict fluid balance chart,the brothers request should of been refused. Nurses should document,fluids offered,fluids refused ect. Surely on a endocrin ward,fluid charts are a must. On the briliant neuro unit in the same Hosp,the confused SAH patients,if they didn't get their 3 litres input,God help the nurses. The case is sad and ruins great care that is carried out at SGH.

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  • DH Agent - as if ! | 13-Jul-2012 3:40 pm

    Anonymous | 13-Jul-2012 12:03 pm

    Firstly I could not careless if my comments about 'zero tolerance' are not well received. this is my personal perception and experience of it in the medical field as well as in other service provision.

    as to your comments of the clinical management of aggressive patients, it is vital to look for possible causes, study the notes, check lab reports and above all communicate about them without making any assumptions. I rather think you have no experience in this area.

    No matter what the staffing levels were, this case was totally mismanaged for which there is no excuse.

    As far as coroners go, in the UK, they have medical or legal qualifications and must have practised in either of those fields, unless it has recently changed which I very much doubt, and according to the press in this case the coroner was a medical doctor.

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  • A very complex and upsetting case, with a lot more to it than first appears. Heads will roll, just hope they are the right ones.

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  • I listened to a discussion on the radio about this sad case and heard the usual question, 'why aren't nurses caring any more?'. As a practising RN and former nurse educator, I cringed because this is not the point. The previous comments all identify the issues here- increasingly challenging patients are managed with increasingly fewer nurses. I don't know all the facts of this case so I am 'assuming', however, what I see and experience out there are shifts filled with patients needing complex care which is often delivered to the aggressive or dementia-affected and delivered under time pressures not least because of the mountain of paperwork which must be completed.Staffing levels often just cover the 'normal' shift, not shifts with the added difficulties of confused or aggressive patients. Let me add now that I completed my (hospital) training in 1982 and times were not rosier then. We didn't care more or less in my opinion,we just didn't have the pressures that are placed on us now. What really makes me despair is the blame placed on so-called 'uncaring nurses' and the absence of responsibility taken by management for the inadequacies of some hospital environments. No nurse wants something like this to happen. No nurse goes into a poorly paid job with undesirable work conditions without genuinely wanting to care for his or her patients. It is time that the real reasons for adverse events such as these to be examined. It is also time to ensure that nurses who are brave enough to admit they are out of their depth are supported with additional training and mentoring.

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  • You all seem to be missing the point. This 22 year old man was admitted for a THR a very rare procedure to undertake for one so young. His previous medical history involved treatment for a brain tumour which had left him dependent on hormone replacement therapy to maintain his electrolyte balance.

    It would appear that no one appreciated what a high risk was posed to this young man who was to undergo major surgery.

    When neglect and ignorance on the part of Nurses and Doctors resulted in this man's sodium levels reaching dangerous heights NOTHING was done!

    A Sodium level of (as reported in the press) 164 is a life threatening EMERGENCY! A nurse apparently made some ineffectual attempt to secure medical help for the patient then went off duty ! It would seem that the Nurses who then took over this patients care did nothing further to secure assistance for this desperately sick patient.

    There is no excuse to be made in this case the patient was failed by Nurses who failed to adhere to the NMC's Code of Practise and by Doctors who failed to meet the requirements of the GMC's Guide to Good Medical Practise.

    But it gets worse ! A decision was made to sedate this patient, he was placed in a side room and (again as reported) ignored. He was apparently given no fluids and was not observed overnight. In the morning he was eventually discovered to be dangerously ill with a pulse rate in the 180's.

    This is just the latest in a string of disasters involving for example elderly people being given sub-optimal care, the closure of a home for people with learning difficulties because of abuse (10 staff charged by police) , the miscalculation of narcotic medication resulting in two babies being overdosed , Police are still investigating the deaths of Severn babies and recently there has been controversy over the use of the Liverpool Care Pathway.

    All of these issues has resulted in significant media interest and a growing level of anxiety and loss of confidence amongst the general public about "their" NHS

    Now is the time for all Registered Nurses to question not only their own practise but that of their colleagues. Bad practice and ignorance Must be driven out of the profession.

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