Kane Gorny inquest: medics did not check pulse for 24 hours Dr Victoria Agunloye, one of the doctors on duty in the ward, checked his vital signs on the morning of May 28 and found he had a high pulse and felt warm. His pulse had rocketed to 186bpm and his blood pressure was 'extremely low', the inquest was told. "I would assume a patient who was heavily sedated would need regular observations, at least hourly, I would be worried about neurology and maintaining their airwaves," said Dr Agunloye. Deputy Coroner Dr Shirley Radcliffe asked what she thought when she realised no observations had been made for almost a day, and she replied: "I was very surprised. But no concerns were raised by the nurses in the morning of the 28th. Mr Gorny was shut off in a side room after violently lashing out at nurses when they would not give him more glasses of water to drink. Student nurse Joanna Lewin said: "What I didn't understand was he was asking for more water when it was still by him, it was almost like he wanted to ensure he didn't run out." Dr Agunloye said she knew Mr Gorny was suffering from diabetes insipidus, a disease which can bring on bouts of paranoia and aggression if not adequately medicated and his fluid levels drop. But she claimed not to have thought of his condition when trying to work out why Mr Gorny was lashing out at nurses and refusing to be assessed, in the afternoon of May 27. "I was quite a junior doctor at the time, and I did not think of that," she said. I wasn't thinking his behaviour was accounted to the diabetes insipidus, I had heard from the nurses that his behaviour wasn't unusual. She added that although she was on duty, she believed she was not the doctor in charge of Mr Gorny's care, and it was her colleague's responsibility to thoroughly read his notes and assess the care being given. "The truth is, if it had been my patient, I would have seen him before I went home that night," she said. Mr Gorny, a Waitrose employee of Balham, south London, was sedated after his outburst and put in a side-room, but he did not come round until the next morning. Nurse Rechard Beharry, who had overall charge of Holdsworth ward where Mr Gorny was being treated, learned of the patient's dangerously high sodium levels in his blood the night before he died. He took a call from the laboratory, and immediately phoned for on call doctor Konstantinos Karras to come and treat him. But Dr Karras said he was too busy with patients in Accident and Emergency. Mr Beharry claimed Dr Karras had promised to visit the ward later in the evening, and he informed the nurse caring from Mr Gorny about the sodium test results. "I just phoned the doctor on call and related to him the results," he said. He told me he was busy and he would come and see the patient. But Dr Karras told the hearing he made no such promise, and expected the nurses to find a different doctor to assess Mr Gorny. Mr Beharry also claimed to have told Dr Karras who the patient was, an assertion denied by the doctor. No doctor came that evening and Mr Beharry knocked off work at 8.30pm without doing anything else to get a doctor to examine Mr Gorny. Mr Beharry told the inquest he saw Mr Gorny in the morning of May 28, and describe him as "chatting with doctors, nice and calm." But Dr Agunloye said she spotted something was seriously wrong at around 9am, and frantic attempts to resuscitate Mr Gorny were made. He died that morning, having not had his vital medication for three days while in hospital.