Hospital staff under fire following inquest into three-year-old's death (From Wandsworth Guardian)

St George's Hospital staff under fire following inquest into three-year-old's death

2:30pm Wednesday 24th October 2012 in News By Alexandra Rucki

Hospital staff have come under fire at a council meeting after an inquest into the death of a three-year-old found "gross failures" were made.

At a public meeting held at Lambeth Town Hall last night St George's Hospital staff were accused of failing to learn from mistakes following the death of Kane Gorny, 22, of Weir Road, Balham on May 28, 2009.

An inquest in July heard staff failed to give him water even after he asked for it even though he needed regular medication to keep hydrated after undergoing surgery for a brain tumour.

He died the next day.

A report submitted to Lambeth council said George's Healthcare NHS Trust had updated handover systems, held medication safety sessions and developed a more thorough observation chart since his death.

Councillor Edward Davie, who chaired the health and adult services scrutiny committee, said staff were still found to have made "gross failures" by a coroner at an inquest held in September into the death of Isla Taylor, 3, in the hospital in June last year.

This was more than two years after Mr Gorny's death.

Ros Wilson, medical director, explained the case was different to Kane Gorny and they were working on improving communication systems.

Yvonne Connolly, head of patient safety, said: "One of the difficult things about communication, it is not an exact science, improving systems is difficult.

"Particularly in terms of the hand over in shift and in between teams. I think one of the things that Kane Gorny has done is made us realise how we can become safer."

Alison Robertson, chief nurse, said open forums for staff have proved to be successful for staff to learn from mistakes.

She said: "We did make sure we used the inquest to talk to staff about patient safety, we held an open forum.

"A lot of staff were upset about what they heard and read about in the papers. We ran four of these sessions, they found it useful to use. It is about trying to build up that two way communication."

Councillors also discussed the need for a whistle-blowing culture, where it is acceptable for colleagues to challenge each other.