Robert Tremble left a Queensland hospital with three unexplained spinal fractures, now a coroner is probing his death

Robert Tremble left a Queensland hospital with three unexplained spinal fractures, now a coroner is probing his death
  • PublishedSeptember 14, 2023

When Robyn Tremble admitted her 48-year-old son with Down syndrome to a Queensland hospital for a routine epileptic episode in December 2020, she believed he was in the safest han

But two days later when she went to visit Robert Tremble, she found him writhing in pain from a spinal injury with bruises on his back and a grazed knee.

She said his condition and manner was completely different to when she visited him at 5pm the day before.

He told her his nursing assistant at Caboolture Hospital had headbutted him.

“He was sitting in the chair like he’d had a stroke,” she said.

It was the start of six months of suffering that would result in Mr Tremble’s deterioration and eventual death.

His grief-stricken family thought the matter would be investigated, but an ABC investigation found a litany of failures by various Queensland government agencies.

An error-riddled police investigation and delays in co-operation by Metro North Health Service has left the family without answers for nearly three years.

In July, a Queensland coroner began to probe the death.

Two months on, Queensland Health has yet to provide the court with its evidence.

Spinal injuries trigger rapid decline

Hospital incident reports show four hospital staff witnessed the nursing assistant being “verbally aggressive and physically threatening” to Mr Tremble.

Handwritten progress notes provide a real-time account from another nurse who was on shift at the time of the confrontation who became “heavily concerned for this patient’s health and safety”.

When Robyn Tremble arrived to visit her son that morning, a doctor told her the nursing assistant had been sacked and would never work at Caboolture Hospital again.

Mr Tremble spent six days in hospital. 

Hospital records showed he was admitted due to an epileptic episode, that included an “unwitnessed fall”, but Mr Tremble’s family said he had not reported back pain at the time. 

A poster of Robert Tremble hangs on the door while his mum Robyn sits inside the bedroom
The family has faced two years of turmoil, after police dropped the investigation.(ABC News: Mark Leonardi)

Intimate home videos taken after leaving hospital show Mr Tremble explaining his injuries to his mother, who helped him be understood.

A scan ordered by his GP showed fractures to his T8, T9 and T10 vertebrae “likely in keeping with recent trauma.”

Hospital records showed Mr Tremble developed PTSD-like symptoms after the alleged attack and would wake in the night yelling “don’t hurt me”.

Hundreds of pages of medical records illustrate how his mobility and capacity deteriorated rapidly in the six months between the hospital admission and his death.

“We had to get him a wheelchair to push him around, then it got to the stage we couldn’t even get him into the wheelchair,” Robyn Tremble said.

“And then he stopped walking, and then he couldn’t sit up.”

He died at home on June 8, 2021.

The death certificate lists aspiration pneumonia as the primary cause of death. Thoracic spine fractures were a contributing factor.

Robert Tremble holds a Christmas gift.
Robert Tremble was happy and healthy five days before his admission.(Supplied)

Hospital took four months to cooperate with police

Police opened an assault occasioning bodily harm investigation in February 2021, and arranged a time for Mr Tremble to give a statement.

Police investigators interviewed Mr Tremble – who was visually impaired and had Down syndrome – alone.

A subsequent police report revealed “nil disclosures obtained due to limited capacity, he failed to disclose any details in relation to the alleged assault”.

Ms Tremble said the outcome would have been different had a support person been present.

The nursing assistant who allegedly threatened Mr Tremble refused to be interviewed by police.

A framed photo of Robert Tremble
Robert Tremble died six months after the alleged assault at Caboolture Hospital.(ABC News: Mark Leonardi)

In the four months it took for Metro North to co-operate with police, Mr Tremble died.

In mid-March 2021, a search warrant was executed on Caboolture Hospital.

Three months later the hospital told police the documents were available, but records showed there were still “numerous deficiencies”.

It was not until July 30 that the hospital handed a full brief of evidence, that identified witnesses, to police.

Robert Tremble holds family photos of her son Robert
Robert Tremble was admitted to hospital for a seizure on New Year’s Eve 2020. He left with three traumatic spinal fractures.(ABC News: Mark Leonardi)

Queensland police closed the investigation in August 2021, “due to death of victim”.

The lead investigator was about to go on leave.

Four days before Mr Tremble died, Robyn Tremble brought a complaint to the Health Ombudsman.

The office was provided with a brief of 18 pieces of evidence, including testimony, timelines and hospital records.

Hospital executive admits system failed patient

In a recorded meeting in July 2022, Metro North Chief Executive Jackie Hanson and Executive Director Michelle Gardner did not dispute the Tremble’s allegations of the incident.

“We actually accept your version of events,” Ms Hanson said in the recording.

“We’re not here to defend or challenge your story about Robert.”

She admitted the system failed Mr Tremble, but said nothing more could be done given the nursing assistant was employed through an agency.

“Because they’re an assistant in nursing, they’re not bound by the regulatory authority [AHPRA],” she said.

She described the alleged attacker as “clearly, a bad person”.

The executives urged the Trembles to contact police or the public advocate to make a human rights complaint.

Coroner probes death

Fed up with the system, the Tremble family wrote to Coroner Don MacKenzie in June.

Two and a half years after Robert was admitted to hospital, a Queensland Coroner began to probe the death.

He initiated a preliminary investigation in July but is waiting on police and hospital investigation records to decide whether to open a formal investigation.

Brian and Robyn Tremble reading a letter together
Brian and Robyn Tremble wrote to Police Minister Mark Ryan in 2021. They say their letter went unanswered.(ABC News: Mark Leonardi)

Queensland police has provided its records, but more than two months on, Queensland Health has yet to hand over its investigation material to the coroner.

Police and health ministers both aware

The Tremble family lived in Upper Caboolture — Police Minister Mark Ryan’s electorate – at the time of Robert’s death.

They wrote to Minister Ryan in February 2021 but said they never heard back

But Minister Ryan told the ABC his office did respond and referred the matter to the health minister who he said ordered Queensland Health to “urgently investigate.”

“I had met Robert on a number of occasions previously at local events and he was a lovely man,” the Police Minister’s statement read.

“It’s a tragedy what has happened to Robert and my condolences are with all who knew him.”

Yvette D’Ath, the health minister at the time, did not respond to the ABC’s questions.

‘The system let us down’

The Queensland Police Service did not respond to the ABC’s questions regarding the initial investigation.

Metro North Chief Executive Jackie Hanson did not respond to the ABC’s questions regarding Metro North’s response to the alleged attack, involvement in the police investigation, or comments made in the meeting with the family.

In a statement she wrote: “Any reported issue or complaint is investigated, and suitable action is taken … As this specific matter is currently before the coroner, it would be inappropriate for us to comment further. Patient safety and care is our highest priority.”

Robyn Tremble stands by a wooden cross in her backyard
Robert Tremble’s death certificate lists “aspiration pneumonia” as the primary cause of death. Thoracic spinal fractures were a contributing factor.(ABC News: Mark Leonardi)

Robyn Tremble hopes the new investigation gives the family peace.

“I just hope some justice will come out of it,” she said.

“He was neglected in the hospital and the system let him down and let us down.

“I’ve got no confidence in the hospital.”


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