A Walthamstow bicycle courier died after an east London A&E discharged him without realising he had fractured his spine.
Robert Walaszkowski was sent to Queen’s Hospital in Romford with a serious head injury in October 2019 after running into a door at Goodmayes Hospital, where he was receiving mental health treatment.
Queen’s Hospital discharged him back to Goodmayes the next evening, his inquest heard, on the floor of a hired patient transport van, having failed to check his spine.
When he arrived back at Goodmayes unresponsive, staff immediately sent him back to A&E, where an urgent CT scan revealed the fracture that had been missed the first time.
Giving evidence at his inquest, neurosurgeon Dr Richard Mannion told jurors it is likely Robert would have survived if he had been diagnosed with neck injuries the first time he was admitted to the hospital.
Recording their conclusion on September 22, jurors said: “Robert’s neck was not cleared by paramedics, nor accident and emergency staff, and this failure to identify his injury meant that it was left unsupported.
“This led to further injury to the spinal cord and vertebral artery during the course of his care which ultimately led to a hypoxic brain injury [and] contributed to his death.”
The court also heard Queen’s staff gave Robert three times the maximum daily dose of the sedative Lorazepam, according to the hospital’s own policy, within 12 hours.
Accident and emergency expert Dr Francis Morris gave evidence that two of these three doses had “no medical reason”.
However, coroner Nadia Persaud was most concerned by the way Robert was sent back to Goodmayes Hospital, completely unsupported on the floor of a hired van.
Despite being unable to walk, Robert was placed on the floor without neck support during the 15-minute drive back to the mental health hospital.
Those receiving him back at Goodmayes discovered him on the floor of the van, with blue lips and unable to move his head.
The van was owned by Patient Transport UK, a company employed by G4S, who, in a letter to the court, argued he was transported in the “safest” way.
The letter read: “It is safest for [patients] to be at the lowest possible state, to eliminate as far as possible risk and to prevent a fall.”
The coroner said: “I have not received any investigation report from the company and the explanation about why sometimes patients are transported is not in my view an adequate response.
“I will be writing to the company about the way patients are transferred and how many other mental health patients would be transported on the floor.”
Robert never regained consciousness, but was kept on life support until his sister Dorota was able to travel from Poland to visit him at Queen’s Hospital, where he died on November 15, 2019.
Following the jury’s verdict, Dorota said: “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.”
Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), which runs Queen’s Hospital, said it has since refreshed staff on treating spinal injuries and how to check patients before discharge.
Clinical lead in emergency medicine, Dr Ignatius Postma, said the trust is getting a “massive staff increase”, in an effort to rely less on locum staff, who are not always aware of its practice and guidelines.
Despite this, the coroner asked the trust to review how it trains its locum and agency staff.
Jurors, who heard seven days of evidence, recorded a narrative conclusion of Robert’s death, noting it was “contributed to by neglect” at the A&E.
Matthew Trainer, Chief Executive, BHRUT, 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 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.”