Dr David Gordon-Nesbitt was undergoing a standard operation that he had been through before (Picture: SWNS)

A retired doctor died because of a basic medical error on an understaffed NHS ward, an inquest has found.

Dr David Gordon-Nesbitt, who worked in the health service for 45 years, was admitted to Queen Elizabeth the Queen Mother Hospital, in Margate, Kent last October.

The 84-year-old needed an operation to remove a bowel obstruction, a simple procedure he had received previously to deal with legacy of a tumour removal in the 1990s.

As part of the surgery, Dr Gordon-Nesbitt had a nasogastric tube fitted to run from his nose into his stomach to drain digestive fluids.

It should have been unclamped when he was returned to the ward in order to prevent a dangerous build-up but was left closed.

The oversight caused his lungs to fill with fluid and he developed sepsis, went into cardiac arrest and died.

Later investigations revealed the hospital had just three nurses looking after 32 patients the night he died.

Two were agency staff and one was a newly-qualified junior nurse who was left in charge.

Dr Gordon-Nesbitt’s daughter Rebecca said ‘ultimate responsibility lies with the government’ (Picture: SWNS)

Assistant coroner Catherine Wood said not unclamping the tube was a gross failure, greater in magnitude than medical negligence.

She said it amounted to a failure of basic nursing clinical care, and removing it would have prevented Dr Gordon-Nesbitt’s death and saved or prolonged his life.

She added low staffing levels on the ward contributed to the consultant’s death.

Ms Wood asked the East Kent Hospitals Trust to confirm within 14 days that the management team will investigate staffing levels, specifically what help the hospital site manager could have offered.

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

Dr Gordon-Nesbitt’s daughter Rebecca, from Ramsgate, 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.’

East Kent Hospitals Trust said it ‘fully accepts’ the coroner’s findings.

It added: ‘We apologise unreservedly to Mr Gordon-Nesbitt’s family for the failings in his care.

‘Since the incident, we have employed more nurses, increased leadership support on each shift, and strengthened patient safety procedures on the ward.’

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On the night the dad died, there were only three nurses looking after 32 patients.