Hospital's failure to identify neck injury 'contributed' to courier's death, inquest finds
Josh Mellor, Local Democracy Reporter
- Credit: Courtesy of family
A bicycle courier died after Queen’s Hospital staff discharged him without realising he had fractured his spine, an inquest heard.
Robert Walaszkowski, from Waltham Forest, died in November 2019 of complications from an injury he sustained a month earlier by running into a door at mental health facility Goodmayes Hospital.
Jurors were told by expert neurosurgeon Dr Richard Mannion that Robert would likely have survived had he been diagnosed with neck injuries when he was first admitted.
In October 2019, Robert was taken by ambulance to Queen's in Romford.
But the following evening, the inquest heard he was discharged back to Goodmayes on the floor of a hired patient transport van, Queen’s staff having failed to check his spine.
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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.
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.
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“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 inquest 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.
Despite being unable to walk, the inquest heard Robert was placed on the floor of a hired van without neck support during the 15-minute drive back to the hospital.
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.”
Ms Persaud 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, 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.
“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, told the Ilford Recorder it had learned from its internal investigation and had implemented improvements.
These include training staff on treating spine injuries and how to check patients before discharge, targeted teaching on the use of tranquilisers, and the implementation electronic observation recording which automatically calculates and sends alerts when a patient is deteriorating.
Matthew Trainer, Chief Executive at BHRUT, said the trust was "extremely sorry" that Robert "did not receive the high level of care he should have been able to expect".
He added that the trust had also been working on safer patient transfer and co-ordinating with North East London Foundation Trust to ensure that their Emergency Department staff were able to provide appropriate care to people with sever mental illness.
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, Ms Persaud 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.