Kane Gorny died due to neglect of hospital staff, coroner rules
A hospital patient died due to neglect of hospital staff, a coroner ruled today.
Kane Gorny, 22, of Weir Road, Balham, died of dehydration in St George’s Hospital after medical staff neglected to give him a drink.
Mr Gorny needed regular medication to keep hydrated after undergoing surgery for a brain tumour.
He was sent to St George's Hospital, Tooting, for a hip replacement after steroids affected the bone, but died three days after the routine operation on May 28.
During the inquest, Westminster Coroner’s Court heard the trainee locksmith was so thirsty he called police from his hospital bed in a confused state.
Coroner Dr Shirley Radcliffe said: “A cascade of individual failures has lead to an incredibly tragic outcome.
“Kane was undoubtedly let down by incompetence of staff, poor communication, a lack of leadership, and a culture of assumption.”
She recorded a narrative verdict of death by dehydration, contributed by neglect of those caring for him.
She said: “He was not able to provide fluids by himself. There’s understandably been a failure to do this and that failure has been gross.
“There was a failure of doctors to understand his complex medical condition. Therefore Kane died from dehydration caused by neglect.”
Dr Radcliffe criticised doctors and nurses for a culture of “it’s not my patient, not my responsibility” and noted the amount of assumptions about his care that were made.
She also said his care was blinkered by a belief he was acting aggressively because of his brain tumour operation, and staff failed to look into “organic causes”.
The court heard a number of measures have been taken by the trust to combat it happening again, with the chief executive of St George’s NHS Trust, Miles Scott, apologising for Mr Gorny’s death on his blog.
Earlier this week he wrote: "When things do go wrong, it is vital that we learn from them and adapt our approach to make sure we do not repeat our mistakes."
Kane’s mother, Rita Cronin, broke down in tears while the coroner gave her condolences to the family.
Outside the court, solicitor James Stevenson, representing the family, said they were devastated by the number of missed opportunities that could have saved his life.
He said: “Kane was a well-liked, adoring and loving son, brother, and friend.”