A former NHS consultant died as a result of neglect on a short-staffed hospital ward, an inquest has found.

Dr David Gordon-Nesbitt suffocated when a drainage tube was left closed following a standard operation at the QEQM in Margate to remove a bowel obstruction.

An inquest into the death of the 84-year-old heard he died after inhaling stomach fluid in his lungs following a mistake on an understaffed ward.

The East Kent Hospitals Trust has accepted the coroner's findings and apologised to Dr Gordon-Nesbitt's family.

The retired consultant paediatrician was admitted to the QEQM on Thursday, October 21.

He was suffering from a bowel obstruction that had recurred a number of times following an operation to remove a tumour from his bowel in the late 1990s.

As with previous occasions, he was kept in hospital under observation until the issue resolved.

An oral dye, which showed the blockage on an x-ray, was given to reduce the swelling by absorbing water from the bowel.

During the standard operation, he had been fitted with a nasogastric tube – a very thin tube that runs through the nose and into the stomach, to remove stomach fluid and the dye.

The tube was spigotted – clamped – when he was sent for an x-ray on Saturday, October 23.

But when he returned to the ward the tube was left spigotted, with the result that digestive juices and the dye were not able to drain away.

Instead, the fluid built up until the retired doctor vomited. His lungs filled with fluid, and he developed sepsis, went into cardiac arrest and died.

His cause of death was given as aspiration pneumonia, caused by an acute small bowel obstruction as part of a recurrent adhesion-related small bowel obstruction.

In the background, ischaemic heart disease and a previous subarachnoid haemorrhage were noted.

Giving a narrative conclusion with a negligence rider, Assistant Coroner Catherine Wood said the failure to unclamp the tube was a gross failure, greater in magnitude than medical negligence.

She said it was not a failure of a complex sophisticated medical procedure, but of basic nursing clinical care.

The coroner said the removal of the spigot would have prevented Dr Gordon-Nesbitt’s death, saving or prolonging his life.

She added that low staffing levels on the ward also contributed to the circumstances surrounding the incident.

On the night Dr Gordon-Nesbitt died there were only three nurses on the ward, two agency staff and one newly-qualified junior nurse who was named as the nurse in charge.

Additionally, there was one doctor on call and one junior doctor available to help on a ward with 32 patients.

Ms Wood asked the East Kent Hospitals Trust – which also runs the William Harvey in Ashford – to confirm that the management team will investigate staffing levels within 14 days.

Acknowledging the national shortage of NHS staff, Ms Wood added that further support and supervision is required from the hospital site team, even if staffing levels are improved.

"This was an issue he'd dealt with for years, and it should not have killed him"

Dr Gordon-Nesbitt's daughter Rebecca, of Ramsgate, said her father had been "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," she added.

"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.”

Sarah Shingler, Executive Chief Nursing and Midwifery Officer for East Kent Hospitals, said the trust "fully accepts" the finding and conclusion of the inquest.

“We apologise unreservedly to Mr Gordon-Nesbitt’s family for the failings in his care," she added.

“[Since the incident], we have employed more nurses, increased leadership support on each shift, and strengthened patient safety procedures on the ward.”