Driven to his ward on the floor of a caged van

A detained mental health patient with an uncleared spinal injury was taken to his ward lying on the floor of a secure van, and died a month later.

What happened

Robert Walaszkowski, 35, was detained at Goodmayes Hospital under section 2 of the Mental Health Act on 18 October 2019 with suspected psychosis. In the early hours of the next day he ran at a locked door and lost consciousness.

London Ambulance Service took him to Queen’s Hospital in Romford without immobilising his neck. At A&E he was given three doses of 4 mg of lorazepam in 12 hours; the trust’s protocol allowed 4 mg in 24. No cervical spine scan was done.

At 23:48 on 19 October he was discharged in a private patient transport van, booked because he was detained. He could not weight bear, sit up or hold his head upright. He was placed on the floor of the caged section, with no seatbelt or securing point. His partner and the support worker said the vehicle was unsuitable. Fifteen to twenty minutes later he was found unresponsive and in respiratory arrest at Goodmayes. A CT scan showed spinal fractures. He died on 15 November 2019.

The outcome

An inquest before Nadia Persaud, area coroner for East London, concluded on 22 September 2021. The jury found the original head and neck injury was the trigger: his neck had not been cleared by paramedics or A&E staff, so it was left unsupported, and further injury to the spinal cord and vertebral artery during his care led to hypoxic brain injury. His death was contributed to by neglect.

The coroner issued a Regulation 28 report, reference 2021-0325, to Patient Transport UK Ltd, copied to the CQC, the London Ambulance Service and the trusts involved. No prosecution is recorded.

What went wrong

Nobody cleared the neck, at either stage. The paramedics did not immobilise it and A&E did not scan it, so he was discharged into a vehicle with nothing to support his head.

The transfer was arranged around his legal status rather than his body. A secure van was booked because he was detained, and the floor was used because there was nowhere else. The coroner found that floor transport of detained patients appeared to be accepted practice, and that the company had not reviewed it.

What it teaches

Detention decides the paperwork. It does not decide the vehicle. A patient who cannot sit up needs a stretcher and a clinician, and “no seatbelt, no securing point” is a reason to refuse the journey.

Sedation and reduced consciousness make positioning and monitoring more important, not less. Protocol arithmetic is easy to lose when the bed is the floor of a van.

Two people said the van was unsuitable and the journey went ahead. A crew that cannot stop a transfer cannot act on what it sees.

Questions for the room

He could not hold his head upright. What should the crew have done before the doors closed?
You are the A&E clinician. What must be recorded before a head-injured patient leaves without spinal imaging?
The coroner found floor transport was accepted practice. What would let a crew say no?

Evidence and limits

Confidence: confirmed. The Regulation 28 report and the family’s solicitors’ release were both read and agree on the sequence, doses and neglect finding.

The sources differ on one detail: the record says he ran head first into the door, the précis says he ran towards it and lost consciousness. The page says he ran at the door.

Proceedings concluded on 22 September 2021. Walaszkowski is named because the open reporting names him. No member of staff is named.

Our physical interventions training covers safe holding, positioning and the monitoring that has to go with both.

Sources

Reviewed 20 October 2026.