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A coroner launched a scathing attack on hospital staff today ruling that a patient who became so dehydrated that he rang 999 to beg for a drink of water died of neglect.

Kane Gorny, 22, called police in desperation after being denied lifesaving fluids.

But an inquest heard that staff at St George’s hospital in Tooting, South London, simply turned them away and sedated him.

Kane then died of thirst and, after a five-day inquest, deputy coroner Dr Shirley Radcliffe said he had been “undoubtedly let down by incompetence of staff, poor communication, a lack of leadership both medical and nursing, a culture of assumption, assuming others will do what you haven’t done or haven’t made explicitly clear needs to be done.”

Delivering a verdict that he died of neglect at the hands of medical staff, Dr Radcliffe told London’s Westminster coroner’s court that Kane’s death was caused by “a collective failure by a number of individuals, both medical and nursing.”

Kane had been admitted to the hospital for a routine hip operation but his medical condition was complicated by a brain tumour he had suffered the previous year.

It meant that his fluid intake had to be strictly monitored but he was left without water and his desperate pleas for help were ignored.

Dr Radcliffe said the catalogue of failures included “failure to administer essential medication, failure to consider organic causes for his behaviour, failure to understand his complex medical condition and a failure to conduct proper investigations.”

She added: “Kane was undoubtedly let down by incompetence of staff, poor communication, a lack of leadership both medical and nursing, a culture of assumption, assuming others will do what you haven’t done or haven’t made explicitly clear needs to be done.”

Concluding her narrative verdict, Dr Radcliffe said: “Kane Gorny died as a result of dehydration contributed to by neglect.”

She added: “There has undoubtedly been a failure and that failure has been gross.”

She also said the European Time Directive, which stipulates how long staff can stay on a particular shift, had been partly to blame for the lack of continuity in the care.

Earlier, while hearing final submissions, Dr Radcliffe said staff should have relied on their clinical judgement.

She said: “At some point you have to accept this is basic nurses and doctors stuff. It’s not rocket science. It’s basic stuff.”

(Image: PA)

Outside court, James Stevenson, solicitor for the Gorny family, said: “Kane was a well liked, adored and loving son, brother and friend who is sorely missed by all who knew him.

“The tragedy of his death is that he had fought and overcome terrible adversity at such a young age and was very much looking forward to a bright future.

“Having listened to the evidence over the last few days we, as a family, are devastated to hear of the number of missed opportunities to avert our son’s tragic death.

“We are pleased the coroner’s verdict recognises the number of systemic and individual failings in the basic level of care provided to Kane.”

Keen footballer Kane, of Balham, South London, had suffered a brain tumour in 2009 and had been admitted for the routine hip operation the following year.

As Mr Gorny became increasingly agitated, he called the police and his mother, civil servant Rita Cronin.

Mrs Cronin told the hearing: “He sounded really, really distressed. He said ‘they won’t give me anything to drink.’

“He also said ‘I’ve called the police.’ He said: ‘I’ve called the police you better get here quickly, they’re all standing around the bed getting their stories straight.’”

The inquest heard Ms Cronin immediately went to the hospital, where Kane was “confused and angry,” shouting at staff and behaving in an uncharacteristic abusive manner.

Despite expressing her concerns that he was not behaving normally, one doctor asked if he was “coming off booze” and another asked if he was “always like this.”

Failures in basic monitoring and communication meant doctors did not realise he was rapidly losing body fluids.

And specialists who had been treating Kane for a year had no idea he was rapidly deteriorating because they were not told he was there.

Kane was restrained by security guards and sedated with strong medication to calm him down.

When Mrs Cronin arrived at the hospital the following day she found him looking “delirious” with swollen lips and tongue.

She said she was ignored by locum doctors and was told everything was fine and it “wouldn’t do him any harm” to miss a dose of his medication.

When she eventually alerted a more senior member of staff, he began life-saving treatment but it was too late, the inquest was told.

Mrs Cronin said during her evidence: “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 out his drip back on him.

“Nobody’s done anything since he became aggressive.”

Following his death from dehydration, they were asked to help move his body so a nurse could put a clean sheet under his lifeless body.

The inquest heard the nurse asked: “Have you finished seeing your son yet? Can I bag him up now?”

Outside court, Dr Rosalind Given-Wilson, the medical director of St George’s Health Care NHS Trust, said they were “profoundly sorry”.

She said: “We deeply regret the death of Kane Gorny, and have apologised unreservedly to his family for the grief that this has caused.

“We provide safe high-quality healthcare services to over a million patients across south-west London every year, but it is clear that on this occasion our services fell short of expectation in a number of respects, and for this we are profoundly sorry.

“We have admitted civil liability for the failures in Kane’s care and we accept the coroner’s verdict.

“We have made changes to senior leadership on our wards and put a number of patient safety measures in place.”