Robert was a beloved bike courier (Credit: Leigh Day)
Robert Walaszkowski, 35, died a month after being discharged with a spinal injury that had initially not been detected by the hospital’s A&E department.
He was first detained at Goodmayes Hospital with suspected psychosis on 18 October 2019. In the early hours of the following day, he ran head-first into a door and lost consciousness.
London Ambulance Service workers did not suspect he had a spinal injury and Robert was taken to Queen’s Hospital A&E without having his neck immobilised. No examination of his spine was carried out even though one is required.
Robert was also given three doses of 4mg of Lorazepam within 12 hours although under Queen’s own protocol for the drug the maximum dose is 4mg within 24 hours.
A care worker from Goodmayes placed him on the floor of a van and took him back to the mental health unit shortly before midnight on the same day. He was transported without a seatbelt or safety harness.
Robert was unconscious when he arrived at Goodmayes. He was given CPR and taken back to Queen’s A&E, where he arrived at 2 am and an urgent CT scan revealed the spinal fractures.
The 35-year-old died on 15 November 2019 with the cause of death given as bronchopneumonia, hypoxic brain injury, and traumatic injury to the cervical spine and right vertebral artery.
Matthew Trainer, chief executive of Queen’s and King George hospitals, said: “Mr. Walaszkowski did not receive the high level of care he should have been able to expect when brought to our hospital, and we are extremely sorry about this.
“We have learned from our internal investigation and made a number of improvements. These include; further training on recognising and treating cervical spine injuries; targeted teaching sessions on the use of tranquilisation drugs in patients, and we are implementing electronic observation recording which automatically calculates and sends alerts when a patient is deteriorating.
“Another key area we have been working on is safer patient transfers, ensuring observations are carried out, and where necessary acted on, before discharge.
“We are also working with NELFT to make sure that our Emergency Department staff are able to provide appropriate physical care to people who have severe mental illness.”
Following the conclusion of the inquest, Robert’s sister Dorota said: “Robert was a beloved son to my parents, my best friend, and brother. He was the only uncle to my son and was a caring uncle to our older brother’s daughter.
“Robert was loved by his many friends in Poland and in London and particularly in the bike courier community where they have established an annual bike race in his memory.
“It’s been almost two years since Robert’s death but the pain and the anger that my parents and I feel has not faded. Hearing the awful circumstances of his care and treatment has caused further anguish. I have now sadly discovered how many people failed in their basic care of my adored older brother.
“My brother was vulnerable because of his mental state, and this was a reason for healthcare staff to be vigilant and careful with his treatment, but critically, they were not. Because he was judged to be mentally unwell the professionals failed to give him the basic medical care and attention he needed, and as a result he sadly died.
“No day has passed that I haven’t thought about my brother, I cannot make peace with what has happened to him, especially now it is clear that he probably would have recovered from his spinal fracture if basic tests and investigations had been carried out.”
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