Friday, 13 July 2012

If There's Naming And Shaming To Be Done...

...aren't we missing someone?
Kane Gorny dies following basic errors by doctors and nurses. The staff included:
SIMON BRIDLE: Consultant orthopaedic surgeon in charge of his care who failed to monitor him. When Mr Gorny became agitated, Bridle sent a more junior doctor rather than attending himself. He then failed to follow up the incident or check on his patient’s welfare.
ADELA TAACA: Nurse in charge of his care the night before he died. She failed to give him vital medication or carry out important observations because she did not want to wake him in case he became aggressive. Taaca also ‘forgot’ to tell a doctor to check his high sodium levels, despite them being the highest she had ever encountered. She was demoted to a healthcare assistant and is being investigated by the Nursing and Midwifery Council.
PHILIP STOTT: Surgeon who operated on Mr Gorny but failed to read his medical notes. He arranged for the patient to be sedated, removed his drip and then left without linking his behaviour to his medical condition. Instead, Stott asked Miss Cronin whether Mr Gorny was on drugs. He told the hearing: ‘I didn’t follow it up. I should have done but I didn’t . . . I just went home.’
VICTORIA AGUNLOYE: Locum junior doctor who dismissed the concerns of Mr Gorny’s mother moments before his death. She said she knew Mr Gorny was suffering from a rare condition called diabetes insipidus, but failed to link this to his behaviour. She claimed she did not check on the patient when his mother asked her to on the morning of his death because he was not her patient.
SHARON GIBBS: Nurse who failed to monitor Mr Gorny’s fluid levels after he was sedated. She admitted she had not recorded that his drip had been taken out and lost track of his water output, leaving boxes on his fluid balance chart empty. She also failed to link his aggressive behaviour to the fact he had not been given his medication, despite knowing about his condition.
ERLINDA EDWARDS: Nurse who carried out pre-operative checks on Mr Gorny but failed to highlight his condition to other staff. She also neglected to detail his medication and the fact that he suffered from diabetes insipidus on a ‘communication’ sheet. This meant other medical staff were unaware of his condition as none of them wanted to read through his substantial medical records.
DR KONSTANTINOS KARRAS: On-call doctor who was told by a nurse that Mr Gorny had very high sodium levels and was asked to attend, but failed to do so. He also failed to pass the concern on to the night on-call doctor. He blamed the target-driven culture for preventing him from seeing Mr Gorny.
POORIA HOSSEINI: Junior locum doctor who failed to investigate the real cause of Mr Gorny’s behaviour shortly before he was sedated. He said that this was because Mr Gorny was Agunloye’s patient. She said he was Dr Hosseini’s patient. He left for the evening without chasing up the blood test results which may have provided an explanation for Mr Gorny’s behaviour.
Yes, their names deserve to live in infamy (because, god knows, it's unlikely to affect their careers; one - Taaca - has been selected as the sacrificial victim and will have to endure demotion, for a while). But there are others involved who deserve a share of the blame:
A police officer told the five-day hearing that Mr Gorny had twice shouted: ‘Nurse, can I have some water?’ and was ignored by all the medical staff present.
Pity he didn't have the strength to take someone hostage; that unnamed police officer would have brought him the water personally (hell, would have ordered him a takeaway curry too!) rather than file the observation away for the future coroner's inquest...


Woman on a Raft said...

The police should be making a criminal investigation in to this, not a pair of footballers squabbling.

The use of sedation was not in the patient's interest; it was an assault carried out for the purposes of the hospital staff and was no more supportable than sticking him in a sack to shut him up.

There is a criminal case to answer.

Anonymous said...

It seems that in the medical world too, responsibility is like water - it tends to find the lowest possible level. In this case, the career of a nurse has been destroyed, probably deservedly, but she should not be the only one. Every single one of those named, plus the director of the hospital should be charged with manslaughter. If it can be done for the railways and other organisations, why not the NHS?

Robert the Biker said...

Surely with all the no win no fee sharks about (and I openly admit to using one due to my buggered leg) this blokes mum should not be able to move for ambulance chasers.
All these super quacks will have malpractice insurance as a matter of course, so it becomes an exercise between large firms

Clarissa said...

And, if I'm not being to heartless to suggest it, the family?

Whilst I'm not saying that they should have been by his side 24/7, wasn't one of them checking on him at least once a day?

Did his mother give - or at least try to give - him water when she arrived at the hospital? If not, then why not? If she was stopped from doing so by the staff then they deserve even more opprobrium then they have already received. If she did manage to give him some then was it already too late?

Caring for sick relatives is something we British have become very adept at passing off on to other people rather than doing it ourselves.

MrAngry61 said...

IMO the morals of the tale are
1) Never rely on the NHS &
2) Don't get labelled as a troublemaker by the NHS

Seemingly none of the staff were prepared to do their jobs and risk 'confronting' him. They were prepared to literally drug him up and let him die.

And none of them appear to have shown any contrition after the event.

Woman on a Raft said...

Clarrisa: I understand the point but it would be relevant in a home-care situation, not a hospital.

Kane Gorny was entitled to competent care in the very expensive facility for which we have all paid. He was entitled to that whether or not he had family, whether or not he was on talking terms with them, indeed, whether or not they were standing in the room at the time. They are not the qualified staff and are under no obligation to substitute their judgment for that of the medical staff. In fact, to do so would lay them open to possible legal intervention from the hospital.

The responsibility lies with the medics and cannot even be shuffled off on to the administrators; not, this time, on to the hospital management. They don't have the legal standing to interfere in medical decisions and this was a set of decisions not to carry out the required medical steps. It was, at best, negligent but whether it constituted gross negligence manslaughter is another question.

Nurses have the responsibility for patients, doctors for diagnosis. It's not a new thing; it has become elaborated in the past 64 years but the principle is clear. Instead, each one in that cascade abandoned their own responsibility and poured the errors down to the junior staff, increasingly unable to cope with them although - note - even the most junior staff are trained and are supposed to be caring for the patient, not making life simple for themselves.

Access to medical treatment does not, and should not, rely on whether you have family nearby.

The reports make it clear that the family were frantically questioning the medical judgment minutes before he died and the staff are criticised for ignoring what they were pointing out. Presumably they will now be living with the pain of not having having risked legal action.

They do not deserve to be blamed for this and are not in any way responsible.

Lynne said...

This makes you question the quality of the training clinical staff receive. It's beyond belief that most of the cretins involved in this case missed vital symptoms. That goes double for the uber-cretins who didn't miss them but failed to pass them on.

They are unfit to practice. I hope the family sue them into oblivion so the people who killed Kane Gorny with jobworthy negligence can't harm anyone else.

Noggin the Nogu said...


It really should have sunk in by now, and not be 'beyond belief' - the NHS is staffed by considerable numbers of under qualified, unintelligent drones who respond only to tick-box type training and work methods, whose ability to carry out an efficient, effective solution to a blatantly obvious is quite simply non existent.

It does not require a medical degree to see that a man with a swollen tongue who is begging for water and whose charts indicate he has had none for several days is dehydrated.

This is not a rare exception, sadly. Theses staggering levels of incompetence, laziness and ineptitude are par for the course when you allow a hospital to run along exactly the same lines a British Leyland car plant on a Friday afternoon.

Lynne said...

Noggin, I was being rhetorical, not literal.

bodo said...

The poor guy was begging for water, in all the reporting I haven't read just *why*no one gave him a drink.
This is manslaughter at least, possibly even murder - did the staff decide to "do a Shipman" and play God.
The truly nightmarish aspect of this case is that the police turned up and accepted the word of those who were killing him that all was well. They then sedated him, did they not want him making any more desperate 999 calls? It would be interesting to know if they confiscated his phone.

bodo said...

I noticed neither the hospital nor the Royal College of Nurses were prepared to be interviewed on radio this morning.
When there's something affecting nurses pay or conditions you can't keep the RCN away from the TV cameras, but when it's a matter of patient welfare... they are nowhere to be seen. Says a lot about modern nursing attitudes.

Anonymous said...

Nice little dig at the police in the last paragraph Julia.I would have been disappointed otherwise.
I assume you would be happy for me to patrol the wards handing out water and medicine against medical advice?

blueknight said...

i agree with WOAR and Jaded.
Just imagine the furore if the Police had let a prisoner die of thirst.

Anonymous said...

Shurely shome mishtake ?

The NHS is the envy of the world, according the losers over at the Guardian.

JuliaM said...

"The police should be making a criminal investigation in to this, not a pair of footballers squabbling. "

Well, now they've lost that one, maybe they'll have time... :/

" If it can be done for the railways and other organisations, why not the NHS?"

IS it done 'for the railways'? I don't think train crash survivors would agree!

"Caring for sick relatives is something we British have become very adept at passing off on to other people rather than doing it ourselves."

I think they did what they could, as WoaR points out. And it shouldn't be up to sick people to ensure they have living relatives!

JuliaM said...

"This makes you question the quality of the training clinical staff receive."

And the initial selection process....

"I assume you would be happy for me to patrol the wards handing out water and medicine against medical advice?"

Merely contrasting the solicitude shown to villains with the box-ticking shown here. Who really do the police work for, again?

Shaun said...

Prosecute them for manslaughter. That will see everyone else lift their game, regardless of the result, because long, public court-cases are very unpleasant.