Robert arrived back at Goodmayes unresponsive and was rapidly sent back to Queen’s, where an urgent CT scan revealed spine fractures that were missed the first time. Sadly, he remained unconscious until his death a month later.
After the inquest, Robert’s sister Dorota said she has not gone a day without thinking about her brother and that she “cannot make peace with what happened to him”.
She said: “My brother was vulnerable because of his mental state and this was a reason to be vigilant and careful with his treatment. [The hospital] failed to give him the basic medical care and attention he needed.
“Robert was a beloved son to my parents, my best friend and brother. He was loved by his many friends in Poland and London and particularly in the bike courier community, where they have established an annual bike race in his memory.
“Hearing the awful circumstances of his treatment has caused further anguish but I am very grateful to the coroner for her detailed investigation of Robert’s case, and I am grateful to the jury for their careful deliberation.”
Robert was sent to Queen’s Hospital A&E with a suspected head injury, after running head-first into a locked door at Goodmayes Hospital while suffering from an acute mental health crisis.
The jury previously heard from doctor Joe McCarthy, working on the ward when Robert was admitted, that a patient like him would normally be seen by a junior doctor on arrival but that “there were no juniors on that day”.
He added: “I didn’t get the opportunity to sit down with him and conduct a mental health examination. This was my last day working on the ward before moving on to a different ward and I was handing over.”
The court also heard Robert was given three times the maximum daily dose of the sedative Lorazepam, as outlined by the hospital’s own policy, within just 12 hours of arriving at A&E.
The next evening he was sent away propped up on the floor of a privately hired patient transport vehicle, in a scene his friend Natasha remembered as “horrendous”.
In a statement read to court, she wrote: “[Staff at Queen’s] put him in a wheelchair and tied him around the chest with a blanket to keep him in, as he was falling out. His arms were drooping and his legs weren’t moving.
“The transport was a people carrier with a caged area in the back. They put him on the floor with his head against the seat, his head was hanging forward.
“I asked the driver ‘shouldn’t he be in the ambulance?’ He replied ‘I didn’t book the van’. As it drove off I heard [Robert] crying out and wailing ‘no’.
“I couldn’t believe how he was just propped on the floor, while he was travelling no one could assist him. The van he was travelling in was not appropriate for his condition.”
Robert, who his sister previously described as a “gentle giant” who “would talk with homeless people for hours”, died on 15th November, 2019.
His post-mortem determined his cause of death was bronchopneumonia, a brain injury and multiple spine injuries.
At the inquest’s conclusion on 22nd September, the jury returned a narrative verdict of his death and found it was “contributed to by neglect”.
Following the publication of this article, the chief executive for the NHS trust that runs Queen’s Hospital, Matthew Trainer, said it was “extremely sorry” Robert “did not receive the high level of care he should have been able to expect”.
He said the trust has “learned from [its] internal investigation and made a number of improvements”, including further training for staff on spine injuries and use of sedatives.
He added: “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.”