Man dies from serious spinal injury after staff mistake it for mental health issue

A MAN has died from a serious spinal injury after hospital staff mistook it for a mental health issue, an inquest has heard.

Robert Walaszkowski was taken into custody at a North East London mental health unit. His family said that he was in a “vulnerable condition”.

Robert Walaszkowski was taken to Queen's Hospital in Romford after running into a door


Robert Walaszkowski was taken to Queen’s Hospital in Romford after running into a doorCredit: Central Recorder

He was staying at the unit in October 2019 and it was during this time that he ran into a door.

Staff determined that he didn’t have a spinal injury so an ambulance was dispatched. Instead, he was taken to Queen’s Hospital Romford with a suspected brain injury.

An inquest ruled that Mr Walaszkowski died of bronchopneumonia, hypoxic brain injury and traumatic injury to cervical spine and right vertebral artery on November 15 2019, the Health Service Journal reported.

He was not examined for spinal problems despite his appearance to the ambulance staff.

Just one day later, Mr Walazkowski was discharged from A&E and was taken back to the mental health unit at Goodmayes Hospital.

He was taken to the hospital on the ground in a private vehicle.

Inquest heard that he was unresponsive when he arrived and that he ‘never quite’ regained consciousness.

The jury found that Walaszkowski died from neglect.

Matthew Trainer, chief executive of BHR University Hospitals NHS Trust, stated that Mr Walaszkowski didn’t receive the care he deserved when he was admitted to our hospital. We are deeply sorry for this.

“We have learned from our internal investigation and made a number of improvements. These improvements include further training in recognising cervical spine injuries and teaching sessions on the use of tranquilization drugs in patients. We are also implementing electronic observation record which automatically calculates and sends alarms when a patient’s condition is declining.

“Another key area we have been working on is safer patient transfers, ensuring observations are carried out, and where necessary acted on, before discharge.”

He stated that they would also collaborate with local services to ensure that the emergency department staff can provide the appropriate care for those suffering from severe mental illness.

The family lawyer for Mr Walaskowski said that the loss of his life was tragic.


Leigh Day solicitor Nandi Jordan added: “What happened to Robert was heart-breaking and horrendous.

“The most basic checks and procedures were not undertaken; Robert was then sedated and transported in a dangerous manner and in a state of reduced consciousness because of the drugs which had been prescribed for him.”

She said that Robert died from a broken spine, no seatbelt, and of course no spinal protection.

“We heard at the inquest that Robert’s condition was incorrectly attributed to his mental health condition and because of this, it was not recognised that he had suffered from a spinal fracture and that his condition was deteriorating; it is appalling that Robert’s life was cut short for this reason”, she said.

His family stated that Mr Walaskowski’s mental condition meant that healthcare staff should have been more vigilant.

Dorota, his sister, added that Walaskowski was mentally unwell and that professionals failed to provide him with the necessary medical care. He died as a result.   

“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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