Coroner says understaffed wards to blame for the death of retired doctor, 84

A retired doctor died in hospital due to the NHS’s failure to safely staff wards at weekends, a landmark study has found.

Dr. David Gordon-Nesbitt, 84, died on a Saturday night after suffocation at Queen Elizabeth The Queen Mother Hospital in Maidstone, Kent.

A coroner concluded last week that his death could have been prevented if there were more staff on the ward.

Just weeks ago, experts and politicians repeated the call for NHS bosses to switch to a seven-day work schedule.

Kidney consultant Dr Andrew Stein compared NHS hospitals over the weekend to the ‘Mary Celeste’. Former Health Secretary Lord Lansley added: “We owe it to patients to provide the best possible care over the weekend.”

North East Kent coroner Catherine Wood found that Dr Gordon-Nesbitt, a former pediatrician at the hospital who worked in the NHS for 45 years, died after serious failure by the hospital to staff the ward, which she said amounted to medical negligence.

A Retired Doctor Died In Hospital As The Nhs Failed To Safely Staff Wards Over The Weekend, An Inquest Has Found (Photo: Dr David Gordon Nesbitt With Daughter Rebecca)

A retired doctor died in hospital as the NHS failed to safely staff wards over the weekend, an inquest has found (Photo: Dr David Gordon Nesbitt with daughter Rebecca)

On a ward that required five nurses, only three were available on the evening of his death in October last year. The nurse who had left to oversee Dr. Gordon-Nesbitt’s ward was a student and was not allowed to practice alone.

The doctor responsible for supervising the ward was not in the building and could only be reached by telephone.

Dr. Gordon-Nesbitt was admitted to hospital on Thursday October 21 with an intestinal obstruction. It was a regular problem for him, after surgery to remove a tumor from his gut two decades ago.

He had never required invasive treatment before and usually stayed in the hospital until the swelling subsided. This time he was fitted with a nasogastric tube, designed to drain fluids that accumulate in his intestines through a tube in the nose.

But after Dr Gordon-Nesbitt returned from an X-ray on Saturday, October 23, nurses failed to open the valve on the tube to allow the fluid to drain from the intestine.

As a result, his stomach filled with fluid to the point where he began to choke on its contents.

It wasn’t until he vomited that nurses realized the danger. He soon went into cardiac arrest and died.

Drug prices are skyrocketing

Patients are at risk of running out of medicine this Christmas due to price hikes faced by pharmacists.

Wholesale prices for commonly used drugs, including migraine medications and steroids, have skyrocketed in recent months, chemists say, sometimes increasing more than fourfold.

But the amount that high street pharmacies are reimbursed by the NHS has lagged.

Now more and more pharmacies are running out of stock, but are not buying anymore, saying that this would soon put them out of business. Dr. Leyla Hannbeck, managing director of the Association of Independent Multiple Pharmacies, said: ‘The average pharmacy risks losing tens of thousands of pounds a month if it continues to buy these medicines.’

Drug makers say raw material shortages and the energy crisis have driven up production costs.

A spokesman for the Ministry of Health and Social Care said that work is being carried out at a rapid pace on the revision of the advantageous price agreement.

His daughter Rebecca Gordon-Nesbitt, 51, a health policy researcher from Sandwich, Kent, said: ‘He was in very good health for a man of his age. This was an issue he had been dealing with for years and should not have killed him.

“The hospital was initially short staffed, but as it was the weekend this problem was exacerbated as fewer staff were available to work. It was diabolical that a student nurse was put in charge.

‘My father gave up 45 years of his life working for the NHS. It’s horrible that he has to die like this.’

The family’s lawyer, Frankie Rhodes, of lawyers Leigh Day, said: “If more people had been on that service, this could have been avoided.”

NHS figures show that patients admitted to hospitals in England over the weekend are 14 per cent more likely to die than those admitted during the week.

Last year, a large NHS-funded study found that the ‘weekend effect’ was entirely due to those admitted at the weekend being sicker than those admitted during the week. But experts say this doesn’t hold up to close scrutiny.

Peter Walsh, CEO of charity Action Against Medical Accidents, said: ‘Staffing is a particular problem at night and weekends, and has been for many years. It’s about time it was addressed.’

Analysis showed that on Wednesday there are an average of 86 consultants working in a typical hospital, but only 12 on Sunday.

Sarah Shingler, Executive Chief Nursing and Midwifery Officer for East Kent Hospitals, said: ‘We apologize unreservedly to Mr Gordon-Nesbitt’s family for the shortcomings in his care. We fully accept the coroner’s findings and conclusions and have increased the number of nurses employed, increased leadership support at each service and strengthened patient safety procedures in the ward.”

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