Man died of dehydration after “cascade” of staff failures

BMJ 2012; 345 doi: (Published 13 July 2012) Cite this as: BMJ 2012;345:e4807
  1. Zosia Kmietowicz
  1. 1London

A series of medical and management failures by doctors and nurses led to the death from dehydration of a man who was recovering from a routine hip operation, a coroner has ruled.

Kane Gorny, 22, became so desperate for water that he called the emergency number 999 from his hospital bed the day before he died in May 2009 at St George’s Hospital in Tooting, south London.

At the inquest the deputy coroner Shirley Radcliffe said that “a cascade of individual failures had led to an incredibly tragic outcome.” She recorded a narrative verdict saying that Gorny had died from dehydration contributed to by neglect.

Radcliffe said, “Kane …

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