Leigh Day represents family of former NHS doctor who died of neglect in hospital
Findings of neglect in such cases are 'extremely rare'
Leading law firm Leigh Day has represented the family of Dr David Gordon-Nesbitt (pictured with his daughter, Rebecca), a former NHS consultant, who died in 2021 at Queen Elizabeth the Queen Mother Hospital in Margate, Kent. A coroner has concluded Dr Gordon-Nesbitt died as a result of neglect at the hospital.
The 84-year-old retired consultant paediatrician suffocated when his nasogastric tube was left closed following a standard procedure to address a bowel obstruction.
Dr Gordon-Nesbitt had been admitted to hospital on Thursday 21 October 2021 with a bowel obstruction – a recurrent issue which stemmed from an operation to remove a bowel tumour in the late 1990s.
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; however, when he returned to the ward, the tube was left spigotted, which meant digestive juices, combined with the dye, were not able to drain away. Instead, the fluid built up until the retired doctor vomited. His lungs filled with fluid, he developed sepsis, went into cardiac arrest and died.
North East Kent assistant coroner Catherine Wood 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.
The inquest heard on the night Dr Gordon-Nesbitt died, Saturday 23 October, there were three nurses on the ward – two agency staff and one newly qualified junior nurse, who was named as the nurse in charge. There was one doctor on call and one junior doctor available to help. There were 32 patients on the ward.
Wood said staffing levels contributed to the neglect. She has asked the East Kent Hospitals University NHS Foundation Trust to confirm the management team will investigate staffing, specifically what help the hospital site manager could have provided, within 14 days.
The coroner acknowledged the national shortage of NHS staff and said further support and supervision is required from the hospital site team, even if staffing levels are improved.
Dr Gordon-Nesbitt’s daughter, Rebecca Gordon-Nesbitt, 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 working 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 commented: “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.”
Rhodes instructed Louisa Brown of Serjeant’s Inn.
