Rajkiran acted for Robert Walaszkowski’s family in a 7-day Article 2 jury inquest which concluded with a finding of neglect.

Robert was a fit 35-year old who was sectioned due to psychosis. On his first day at the mental health hospital he ran headfirst into a door and suffered a spinal fracture. He was taken to the ED department and discharged back to the mental health hospital around 19 hours later. However he was immediately return to ED in a critical condition. He never awoke and died weeks later from a hypoxic brain injury.

The jury found several failures amounting to neglect, including: (1) a failure by the paramedics to examine Robert’s neck (2) an inadequate handover of information between the paramedics and the ED staff (3) a failure by the ED consultant to take a proper history, do a proper examination and order a CT scan of Robert’s neck (4) excessive administration of lorazepam (5) insufficient observations (6) discharging Robert without reviewing him (7) failure to escalate a raised NEWS score and (8) allowing Robert to travel in an unsuitable vehicle.

The court’s neurosurgical expert said that, when Robert first arrived at hospital, he could move all his arms and legs and probably hadn’t suffered a severe spinal cord injury. He said that a combination of four factors led to Robert suffering a severe hypoxic brain injury including the large doses of lorazepam and his position in the back of the van which would have made it harder for him to breathe.

Evidence emerged at the inquest which suggested that the private transport company had a practice of placing sedated mental health patients on the floor of secure transport vehicles, and as a result the Coroner stated she would write a Prevention of Future Deaths report. She also indicated she would write a letter to the London Ambulance Service regarding other concerns.

Kiran was instructed by Nandi Jordan of Leigh Day (see here). The inquest was reported in the local press (see here) and the Hospital Trust have released a statement.