Kane Gorny, 22, pictured with his mother Rita, needed drugs to regulate his hormone levels after successfully beating brain cancer |
-Nurses forgot to give Kane Gorny his medication and he became so delirious he called 999
-His mother said she spent hours trying to convince staff he needed attention but was told he was alright
-Alarm finally raised an hour before his death when a doctor realised how serious his condition was
A young patient who died of dehydration at a leading teaching hospital phoned police from his bed because he was so thirsty, an inquest heard yesterday.
Officers arrived at Kane Gorny's bedside, but were told by nurses that he was in a confused state and were sent away.
The keen footballer and runner, 22, died of dehydration a few hours later.
A coroner had such grave concerns about the case that she referred it to police.
Yesterday an inquest was told how Mr Gorny died after blunders and neglect by 'lazy and careless' medical staff at St George's Hospital in Tooting, South London.
His mother Rita Cronin, a civil servant told Westminster Coroner's Court that staff tutted at her and repeatedly refused to listen to her concerns that her son hadn't been given vital medication.
At one point he became so desperate and upset that staff sedated and restrained him – and on the night before his death, his mother said, he was not checked on by medical staff, despite being in a room on his own.
Following his death, a nurse allegedly inquired whether the family, from Balham, South-West London, was 'finished' and asked a matron in front of them whether she could 'bag him up'.
Mr Gorny, who worked in Waitrose and was training to be a locksmith and shoe repairer, had survived a malignant brain tumour in 2008.
The cancer affected his pituitary gland, which controls the body's mechanisms, such as fluid levels. Part of his treatment included a course of steroids to regulate the fluid levels in his body. These drugs, however, weakened his bones and he was in hospital for a routine hip replacement.
Doctors told him that, without regular medication to control his fluid levels, he would die.
When he arrived at hospital for the hip operation, nurses assured the family they would give him his medication and said: 'Don't worry, he's in good hands – we'll look after him.'
But, despite the repeated reminders and insistence by both Mr Gorny and his family, staff failed to give him the tablets and he became severely dehydrated after being refused water.
In an interview with the Daily Mail in 2010, Miss Cronin said of the nurses who treated him: 'They were lazy, careless and hadn't bothered to check his charts and see his medication was essential. He was totally dependent on the nurses to help him and they totally betrayed him.'
Yesterday Miss Cronin told the inquest she received a distressed phone call from her son on May 27, 2009, in which he told her he'd called the police because he was so desperate for a drink.
She then went to the hospital where she found him 'confused and angry', shouting at staff and behaving in an uncharacteristically abusive manner.
Despite this, one doctor asked if he was 'coming off the booze' and another asked if he was 'always like this'. Miss Cronin said: 'He sounded really, really distressed. He said "They won't give me anything to drink". 'He also said "I've called the police. You better get here quickly: they're all standing around the bed getting their stories straight".'
When Miss Cronin arrived, she recalled: 'They weren't doing anything. They seemed out of their depth. It felt like the two locum doctors were nervous about calling anyone more senior than them.'
The inquest heard Mr Gorny was restrained by security guards and sedated with strong medication to calm him down. Later, he was put into a side room and left alone.
Miss Cronin said she sat in his room for three hours the night before he died without a single nurse checking on him or giving him vital medicine.
She said she told a nurse who walked past the room that Mr Gorny had not had his medication. When Miss Cronin volunteered to return to the hospital should he wake, another nurse allegedly told her: 'You don't need to do that. If he makes noise, I'll close the door and then he won't wake everyone up.'
She added: 'I later realised that her comment was unbelievable but I was so distraught that it didn't register.'
The morning of her son's death, May 28, 2009, Miss Cronin arrived at the hospital early to find him delirious with swollen lips and a swollen tongue.
She recalled: 'I then heard three nurses outside his room and I said: "There's something wrong with my son. He doesn't look right."
'The nurse said to me "He had a good night. There's nothing wrong with him and he's just had breakfast and a chat with us."
'I thought: "How could he have had breakfast? There's no evidence (of breakfast)."
'The nurse carried on her handover then I interrupted again and said: “He's not right.”
'The other nurse then tutted and said: "She's already told you he had a good night." And with that the three of them walked off.'
Miss Cronin said she then noticed that her son hadn't been given his medication because the packet was still on the table by his bed.
She told the locum doctor about her concerns, but the doctor said it wouldn't do him any harm.
A doctor doing the rounds then checked on Mr Gorny. Miss Cronin said: 'He took one look at him then he started calling to everyone “Get in there quickly”.
'It suddenly dawned on me he hasn't had his medication, hasn't had his bloods done, nobody's given him a drink, nobody's bothered to put his drip back on him.
'Nobody's done anything since yesterday afternoon when he became aggressive.'
She said there was a 'flurry of activity' and everyone 'had a very sad look on their face' as they battled to save her son's life. Miss Cronin said: 'The main doctor came out and you could tell he was really angry. He said: “You need to go and see your son. He's dying.”
The couple then found their son lying in blood and fluid-soaked sheets and a nurse came in and asked them to help her to change them. The same nurse later came into the matron's office and asked whether they were 'finished', adding: 'Can I bag him up?'
The death certificate said Mr Gorny died of a 'water deficit' and 'hypernatraemia' – a medical term for dehydration.
Mr Gorny had radiotherapy and chemotherapy following his diagnosis of brain cancer. He was eventually given the all-clear and led a normal life until his mother noticed he was having trouble with his hip.
As he waited for the surgery, his life started to return to normal.
'He was out and about like everybody else,' said Miss Cronin yesterday.
'I always used to make him take his tablets for the next morning, just in case he stayed at a friend's house – and he knew the importance of his medication. We all did.
'He was starting to enjoy his life again, even though he had pains in his hip. He was upset he was having a hip replacement - he was worried he would be in a wheelchair when he was 50.'
Nurses at the hospital were said to have been offered counselling as a result of Mr Gorny's death.
The inquest continues. The case is still being considered by the Crown Prosecution Service.
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