Deputy coroner Dr Shirley Radcliffe has said in an inquest that a "cascade" of medical failures resulted in the death of a patient at St George's hospital in London.
Kane Gorny, 22 died in the St George's hospital in Tooting, south London due to dehydration because he was not given medication to him retain fluids by staff at the hospital. The supermarket employee, from Balham, south London, was suffering from diabetes insipidus but the staff was unaware of his condition.
The condition had caused him to be aggressive towards eh medical staff. The staff faced his aggressive behavior a day earlier and said he had a "fixation" with water. He called the police claiming he has been assaulted by security guards. When the police arrived he asked them if he looked thirsty and wanted them to examine his tongue. The police officers left because he was unhurt.
Dr Radcliffe said that "a cascade of individual failures had led to an incredibly tragic outcome. Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, and a culture of assumption."
She also said that in the inquest that the errors included no monitoring of Mr Gorny’s fluid after his operation, failure to administer essential medication and a lack of understanding by doctors about his medical needs.
Dr Radcliffe has said that she will write to the hospital about nurses involved in fluid management and sedation following Gorny's treatment.
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.”
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