Hospital failed dehydration patient who died Dr Radcliffe said: "Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, a culture of assumption." Dr Radcliffe told the inquest she would write to the hospital about nurses involved in fluid management and sedation following Mr Gorny's treatment there. A post mortem examination revealed high sodium levels caused by dehydration had caused his death. Mr Gorny, a supermarket employee, from Balham, south London, had been sedated and put in a side room following his outburst. Staff nurse Adela Taaca, who was the senior nurse in Mr Gorny's ward on the night of May 27, previously told the inquest she did not take observations or ensure he took his medication. She said this was because she was mindful of his earlier behaviour, and that his brother, who was sitting next to his hospital bed, asked her to let him sleep as he was sedated. Shortly after her shift ended, Mr Gorny's condition deteriorated and despite frantic efforts to save his life for two-and-a-half hours, he was pronounced dead at 11.20am.