How hundreds of patients are dying of thirst in hospital: The story of a 22-year-old who died in hospital from dehydration shocked Britain. But his tragedy is horrifyingly common
02:08 GMT, 24 July 2012
The reports last week of Kane Gorny’s final hours beggared belief.
The 22-year-old had been admitted to one of the UK’s top teaching hospitals for hip replacement surgery, but within three days he’d died of thirst, after medical staff ignored both his pleas for water and the symptoms of dehydration that experts say are ‘easy to recognise’.
When Kane, in desperation, rang 999 on his mobile, a policeman who responded to his call witnessed him shouting repeatedly to the nursing staff: ‘Can I have some water’
Victim: Kane Gorny and his mother Rota Cronin. The 22-year-old had been admitted to one of the UK's top teaching hospitals for hip replacement surgery, but within three days he'd died of thirst
Kane had a form of diabetes that hampered his body’s ability to retain fluid.
Yet the response of doctors and nurses on the ward was to sedate him, without giving him intravenous fluids or monitoring him as he lay unconscious.
The inquest into Kane’s death in May 2009 at St George’s Hospital, Tooting, in South London, has caused an outcry.
First and foremost, there has been widespread condemnation of the extraordinary inhumanity of staff who refused water to a dying man left immobile and unable to get out of bed as a result of surgery.
Equally alarming, however, is that these healthcare professionals failed to recognise the symptoms of dehydration, or to appreciate the significance of his desire for water.
Instead, according to the coroner, nurses ‘felt he had a fixation with water’.
The story has appalled health campaigners.
‘What on earth do they teach nurses and doctors today if not the fundamental importance of keeping patients hydrated’ says Roger Goss, co-director of Patient Concern.
‘It’s completely unbelievable that the dangers of dehydration — known to every mother — are not being inculcated in the nursing profession.
'Every health professional should be making it a top priority to keep patients properly hydrated.’
Worryingly, Kane’s tragic death is an extreme example of a far more widespread problem: patients simply aren’t getting enough water.
‘We’re all aware of the importance of drinking plenty of water, as it’s essential to digestion, absorption of nutrients and the elimination of toxins and wastes,’ says dietician Rick Wilson of the British Dietetic Association.
‘Yet healthcare staff too often ignore the huge importance of hydration for hospital patients.
‘Hospitals today are hot, dry buildings where people can become dehydrated quickly anyway.
‘Add to that the fact that many patients are recovering from surgery that is frequently preceded by several hours of “nil by mouth”; they may have multiple disorders affecting hydration levels; or they may be confused, unwell or physically unable to sit up and help themselves to a drink.’
Without water, even a healthy person’s body starts to feel the effects within hours, especially in hot weather.
Rita Cronin and Peter Gorny, the parents of Kane Gorny. The inquest into their son's death in May 2009 at St George's Hospital, Tooting, in South London, has caused an outcry
‘The risk of becoming dehydrated is actually no greater for sick people, but the consequences are likely to be more serious,’ says Dr Tim Bowling, a gastroenterologist and nutritional expert.
Even moderate dehydration, characterised by a dry mouth, headache, dizziness on standing up and passing more concentrated urine, causes severe problems for hospital patients.
It is linked to pressure ulcers, which can develop in a matter of hours once the padding over bony points starts to shrink.
It also raises the risk of falls caused by low blood pressure and confusion, and of urinary tract infections. It also means blood clots are more likely to form, because lack of fluid makes the blood thick and sticky.
All these are potentially dangerous and hugely expensive complications of drinking too little water.
Meanwhile, severe dehydration — signs include confusion, incoherence, nausea and vomiting — is a leading contributory factor in acute kidney injury (previously known as acute kidney failure).
This is a ‘predictable and avoidable emergency diagnosis that should never occur’ according to a report by the National Confidential Enquiry into Patient Outcomes and Death published in 2009.
Yet acute kidney injury affects one in five people admitted to hospital, with five in 100 in-patients developing acute kidney failure that can lead to permanent damage to the kidneys and eventually to death.
The disease costs the Health Service 500 million a year — which is more than lung and skin cancer together.
‘Dehydration is a huge problem that significantly increases a patient’s risk of dying in hospital,’ says Dr Mark Thomas, a nephrologist at Heart of England NHS Foundation Trust.
Dehydration was a contributory factor in the deaths of 816 hospital patients in England and Wales in 2009, according to the Office for National Statistics — ‘a terrible indictment of the NHS’, said Katherine Murphy of the Patients’ Association.
A Royal College of Nursing report, Water For Health, published five years ago, warned ‘dehydration can cause rapid deterioration requiring complex, costly and invasive clinical interventions, with many patients suffering devastating long-term outcomes, resulting in loss of independence and dignity’.
While hospital food is often in the news, water is a more critical problem, says Dr Bowling, because ‘the effects of dehydration have much quicker manifestations than malnutrition’.
In recognition of this problem, the National Institute for Clinical Excellence (NICE) is to issue its first hydration guidelines next year.
So how is it that something as fundamental as ensuring that patients are getting enough fluid is going wrong
Far more common in hospitals is a failure to understand that patients may need help to drink their glass of water
Much of the blame for dehydration problems has been laid at the door of Britain’s 300,000 healthcare assistants, who are largely untrained and therefore unaware of patients’ needs, while ‘too posh to wash’ nurses with degrees see themselves as overly qualified to get involved with the everyday needs of patients.
Yet such a blame game ignores the widespread ignorance of senior staff.
‘For sure, healthcare assistants need better training, but so do doctors, especially junior doctors, and nurses,’ says Dr Bowling.
While it may be rare for hospital patients to be left without water jugs, far more common is a failure to understand that patients may need help to drink that water.
‘We’ve all seen committed, caring staff putting the water in the jug and even pouring the water into a cup when the patient is not able to drink it,’ says dietitian Rick Wilson.
At extra risk of dehydration are infants, whose low body weight makes them sensitive to even small amounts of fluid loss, and older people who don’t feel thirst as keenly or are too poorly to manage a water jug beside their bed.
Such people may even deliberately avoid drinks, fearing they will need a bedpan later on.
Those recovering from surgery can also be at risk — often simply because they don’t like to ask for help.
Rachel Berryman, 32, a personal assistant from Grimbsy, had to spend several days lying flat on her back after spinal surgery to combat chronic back pain, and recalls having to rely entirely on visitors to get a drink.
‘I quickly found the nurses were not going to offer me a sip of water — though they’d always help if I rang the bell and asked them to hold the cup up to my mouth.
‘But as a very independent person, I hated doing that.
‘I found it easier to put up with being thirsty until a visitor arrived — and luckily for me, I had lots of visitors.’
One important way of assessing hydration is by estimating the amount of fluid consumed against a measurement of urine produced.
This should be carried out on a daily basis and is a vital part of healthcare, says Dr Bowling. But it’s an inexact science that can be neglected, alongside the recognition of relevant symptoms.
And blaming poorly trained healthcare assistants simply isn’t good enough. Dr Claire Chambers, senior lecturer in health and life sciences at Oxford Brookes University, says the key to avoiding dehydration is a culture where every healthcare professional cares about their patients getting enough to drink.
‘There’s nothing wrong with devolving responsibility for monitoring hydration to healthcare assistants,’ she says.
‘What’s dangerous is the tick-box mentality where particular targets are focused on to the detriment of others.’
What’s so frustrating is that the symptoms of dehydration should be very easy to spot.
First and foremost is the feeling of being thirsty: people who complain about being thirsty ‘are already dehydrated’, points out the recent Royal College of Nursing report.
Other symptoms are also obvious to the trained eye, says Dr Bowling, such as low blood pressure, dry tongue, low urine output and deteriorating kidney function (shown by a blood test).
‘Unfortunately, the education of nurses and doctors in this regard has always been poor and there is a clear need for this to be improved,’ he says.
The desperate need for this was graphically illustrated by the inquest of 19-month-old Harry Connolly held in Northampton in April 2012.
The toddler had acute kidney failure which caused him to die of dehydration — after twice being sent home by doctors at Northampton General Hospital and a third time by a GP employed by an out-of-hours service, South East Health, in April 2011.
On the day before his death, Harry’s grandmother became concerned that the toddler had ‘sunken eyes’ — one of NICE’s ‘red flag’ signs of clinical dehydration in children under five.
Yet her concerns were dismissed by the out-of-hours GP, who said the boy was not dehydrated and did not need to go to hospital. Tragically, Harry was found dead in his cot the next morning.
Such terrible failures of care point to the need for ‘a monumental initiative to shift attitudes’, according to the British Dietetic Association, which supports the call for better awareness of dehydration among healthcare professionals.
‘Educating staff to recognise the symptoms of dehydration must be the first step to good hydration behaviour,’ says dietician Dr Aisla Brotherton, who is helping to launch a new training module on hydration for NHS staff.
Dr Thomas says the key to better care is more careful monitoring of at-risk patients.
‘Perhaps they need to have red jugs on their bedside table so that all staff, and indeed visitors, can ensure that everything possible is done to keep their hydration levels high.’
Another practice being introduced in a handful of trusts is ‘intentional rounding’, where nurses, rather than simply responding when patients ask for help, carry out regular ward rounds on an hourly or two-hourly basis, including questioning patients about whether they want a drink.
‘It’s about nurses ensuring that patients are safe, rather than assuming they are safe,’ says Annette Bartley of the Health Foundation.
A further contribution to ending dehydration is the Hydrant, a water bottle with a straw that can be used by anyone, even those with restricted hand movement, enabling them to drink any time they want.
It was developed five years ago by Mark Moran, an endurance athlete who woke up after a back operation and found he couldn’t get a drink.
Now two hospitals, Stoke Mandeville in Aylesbury and Great Western Hospitals NHS Foundation Trust in Swindon, provide the Hydrants for patients — with evidence showing a significant increase in hydration levels and a dramatic reduction in dehydration-related disorders including urinary tract infections and falls.
Mark Moran says what haunts him is the knowledge that the simple bottle could have saved Kane Gorny’s life.
‘He was able to use his mobile phone to call the police — which means he could certainly have helped himself to water without troubling the nurses at all.’
SIX WAYS TO KEEP YOUR LOVED ONE SAFE
How much you need to drink daily varies according to the heat and levels of activity.
‘For most people, two to three pints of fluid is sufficient,’ says Dr Mark Thomas, a kidney specialist at the Heart of England Foundation Trust.
1. The danger signs of dehydration include dry mouth, low blood pressure, dizziness and confusion. If you notice these, bring it to the attention of a nurse or doctor. You can also ask the doctor or nurse if he or she can find a moment to explain the hydration measurements that should be on the chart at the end of the bed.
2. Always offer to pour or help someone to a drink when you are visiting them in hospital. Bear in mind that older people especially may not notice that they are thirsty.
3. Ensure water is fresh and looks palatable — perhaps by adding a few slices of lemon or orange or ice cubes. Or bring in a favourite soft drink.
4. Some patients worry about needing the loo — or a bedpan — more frequently. Reassure them that evidence shows increased fluid intake does not increase frequency of passing urine.
5. Buy a Hydrant — an easy-to-use water bottle with a straw that can be hooked onto a hospital bed (12.95 from hydrateforhealth.co.uk) .
6. Rarely, for health reasons, a doctor may advise that your relative needs to restrict fluid intake.