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...