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 and the 22-year-old even phoned police from his hospital bed because 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” as she recorded a narrative verdict at Westminster Coroner’s Court.
“Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, a culture of assumption,” she said, adding that 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 on May 28 2009.
Mr Gorny, whose earlier treatment for a brain tumour had left him prone to violent outbursts, was suffering from diabetes insipidus, which had caused him to be aggressive towards nurses. As a result, the supermarket worker, from Balham, south London, was sedated and put in a side room.
He was undergoing a hip replacement after life-saving steroids had weakened his bones and the hearing heard medical staff were “blinkered” by previous incidents after he complained of being thirsty.
In his desperation he called police, claiming he had been assaulted by security guards. But nurses said Mr Gorny had a “fixation” with water and the officers took no further action.
Staff nurse Adela Taaca, who was the senior nurse in Mr Gorny's ward on the night of May 27, told the inquest she did not take observations because of his earlier behaviour, and this brother, who was sitting next to his hospital bed, had asked her to let him sleep.
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 NHS Trust, said: “We deeply regret the death of Kane Gorny and have apologised unreservedly to his family for the grief this has caused.”