A coroner has ruled that 22 year old Kane Gorny was the victim of a 'cascade' of medical failures that led to his death in 2009.

"Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, and a culture of assumption," coroner Shirley Radcliffe said.

Kane Gorny was suffering from diabetes and had also undergone treatment for a brain tumour. He had become increasingly distressed after he was deprived of vital medication he needed to retain his fluids, and had been sedated.

Dr Radcliffe said the case was marked by "simple incompetence" in her damning assessment of the care Mr Gorny received at St George's.

Kane's parents, Peter Gorny and Rita Cronin, have paid tribute to their son: "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.... we as a family are devastated to hear of the number of missed opportunties to avert our son's tragic death."



July 13, 2012