Coroner blames ‘Mary Celeste’ wards for death of ex-doctor, 84

A RETIRED doctor died in hospital as a result of NHS failure to safely staff wards at weekends, a landmark inquest has found.

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

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

Just weeks ago experts and politicians renewed calls for NHS bosses to switch to a seven-day working rota.

Kidney consultant Dr Andrew Stein likened NHS hospitals at weekends to the ‘Mary Celeste’. Former Health Secretary Lord Lansley added: ‘We owe it to patients to provide the best possible care at weekends.’

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

On a ward that required five nurses, just three were available on the evening of his death in October last year. The nurse left to supervise Dr Gordon-Nesbitt’s ward was a student, not supposed to practise on her own.

The doctor responsible for overseeing the ward was not in the building and reachable only by phone.

Dr Gordon-Nesbitt was admitted to hospital on Thursday, October 21, with a bowel obstruction. It was a regular problem for him, following an operation to remove a tumour from his bowel two decades ago.

He had never required invasive treatment before and typically stayed in hospital until the swelling went down. This time he was fitted with a nasogastric tube, designed to drain fluid building up in his bowels through a tube fitted 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 out of the bowel.

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

Only when he vomited did nurses realise the danger. He quickly went into cardiac arrest and died.

His daughter Rebecca GordonNesbitt, 51, a health policy researcher of Sandwich, Kent, said: ‘He was in really good health for a man his age. This was an issue he’d dealt with for years and should not have killed him.

‘The hospital was low on staff in the first place but because it was the weekend this problem was made worse because there were fewer staff available to work. It was diabolical a student nurse was put in charge.

‘My father gave up 45 years of life working for the NHS. It is horrifying that he should die like this.’

The family’s solicitor, Frankie Rhodes, of lawyers Leigh Day, said: ‘If there had been more people on that shift, this could have been avoided.’

NHS figures show patients admitted to hospitals in England at weekends are 14 per cent more likely to die than those admitted midweek.

Last year, a major NHS-funded study found the ‘weekend effect’ was due entirely to those admitted on weekends being sicker than those admitted in the week. But experts say this does not hold up to scrutiny.

Peter Walsh, chief executive of charity Action Against Medical Accidents, said: ‘Staffing is particularly an issue at night and weekends, and this has been the case for years. It is about time it was addressed.’

Analysis found 86 consultants work in a typical hospital on an average Wednesday, but only 12 on a Sunday.

Sarah Shingler, Executive Chief Nursing and Midwifery Officer for East Kent Hospitals, said: ‘We apologise unreservedly to Mr GordonNesbitt’s family for the failings in his care. We fully accept the findings and conclusion of the coroner and have employed more nurses, increased leadership support on each shift and strengthened patient safety procedures on the ward.’

‘It was diabolical a student nurse was put in charge’