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Retired paediatrician died as a result of neglect at Queen Elizabeth the Queen Mother Hospital, Kent

A former NHS consultant died as a result of neglect on a ward at Queen Elizabeth the Queen Mother Hospital in Margate, Kent, a coroner concluded.

Posted on 05 December 2022

Dr David Gordon-Nesbitt, an 84-year-old retired consultant paediatrician, suffocated when his nasogastric tube was left closed following a standard procedure to address a bowel obstruction.

Dr David Gordon-Nesbitt
Dr David Gordon-Nesbitt

North East Kent Assistant Coroner Catherine Wood said the neglect was a basic element of care and not specialist treatment. The nasogastric tube should have been unclamped so that fluid building up in Dr Gordon-Nesbitt’s stomach could drain away. Instead, the fluid built up until the retired doctor vomited. His lungs filled with fluid, and he developed sepsis, went into cardiac arrest and died.

The inquest heard that on the night Dr Gordon-Nesbitt died, Saturday October 23, 2021, there were only three nurses on the ward, two agency staff and one newly qualified junior nurse who was named as the nurse in charge. There were 32 patients on the ward.

There was one doctor on call and one junior doctor available to help.

The coroner said the staffing levels contributed to the neglect.

She has asked the East Kent Hospitals University NHS Foundation Trust to confirm that the management team will investigate staffing, specifically what help the hospital site manager could have provided, within 14 days.

Acknowledging the national shortage of NHS staff, the coroner said further support and supervision is required from the hospital site team, even if staffing levels are improved.

Dr Gordon-Nesbitt was admitted to the hospital on Thursday 21 October with a bowel obstruction. The issue had recurred on several occasions following an operation to remove a tumour from his bowel in the late 1980s.

On previous occasions, Dr Gordon-Nesbitt had been kept in hospital under observation until the issue resolved. An oral dye, which showed the blockage on an x-ray, would have helped to reduce the swelling by absorbing water from the bowel.

This time, as was usual, he was fitted with the nasogastric tube. The tube was spigotted – clamped – when he was sent for an x-ray on Saturday 23 October, but, when he returned to the ward, the tube was left spigotted, with the result that digestive juices, combined with the dye, were not able to drain away.

The coroner said the failure to unclamp the tube was a gross failure, greater in magnitude than mere medical negligence. It was not a failure of a complex sophisticated medical procedure, but of basic nursing clinical care.

She said the removal of the spigot would have prevented Dr Gordon-Nesbitt’s death, saving or prolonging his life.

Rebecca Gordon-Nesbitt and Dr David Gordon-Nesbitt

His daughter Rebecca Gordon-Nesbitt, of Ramsgate, Kent, pictured above with her father, said:

“Dad was in really good health for a man his age. This was an issue he'd dealt with for years, and it should not have killed him.

"On the weekend Dad died, there were too few experienced nursing staff available to work, and a dreadful mistake was made in his care.

"My father gave 45 years of his working life to the NHS. It is horrifying that he should die like this.

"Ultimate responsibility lies with the government for underfunding the NHS and for withdrawing the nursing bursary.”

Rebecca was represented by Leigh Day medical negligence solicitor Frankie Rhodes, who said:

“A finding of neglect in a case such as this is extremely rare; the bar for such a conclusion in an inquest is very high, but the coroner was clear that there was sufficient evidence for this and that all of the tests were met.

"Dr David Gordon-Nesbitt would not have died if his nasogastric tube had been unclamped on that Saturday in Queen Elizabeth the Queen Mother Hospital. The coroner found that the shortage of staff on the ward contributed to the circumstances that led to the doctor’s death.

"It was a privilege to represent Dr Gordon-Nesbitt’s family, support them at the inquest and secure this result.”

Frankie Rhodes instructed Louisa Brown from Serjeant’s Inn.

Frankie Rhodes
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Frankie Rhodes

Frankie Rhodes is a senior associate solicitor in the medical negligence department.

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