Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0197, written 24 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jun 2022 |
|---|---|
| Reference | 2022-0197 |
| Deceased | Zsolt Kirjak |
| Coroner | Russell Caller |
| Coroner area | London Inner (West) |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | West London NHS Trust · Central and North West London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
GP”)
The Portland Practice, 16 Portland Road, London W11 4LA (“The
2. Central and North West London NHS Foundation Trust 350 Euston Rd, London NW1 3AX
(“CNWL Trust”)
3. Imperial College Health Care NHS Trust The Bays South Wharf Road St Mary's Hospital
London W2 1NY (“IHC Trust”)
4. West London NHS Trust 1 Armstrong Way, Southall UB2 4SD (“WL Trust”)
1
CORONER
I am Russell A Caller, HM Assistant Coroner, for the Coroner Area of Inner London West
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 14th March 2021 I commenced an investigation into the death of ZSOLT KIRJAK then aged
45. The investigation concluded at the end of the inquest on 17th June 2022. The Conclusion
of the Inquest was Suicide.
Medical Cause of Death
1 (a) Left Pneumothorax and Hemopericardium
1 (b) Stab wounds to the Chest.
4
CIRCUMSTANCES OF THE DEATH:
ZSOLT KIRJAK had been suffering with Tinnitus and lack of sleep for some considerable time
He tried to obtain health assistance from a number of Health Care Agencies including The GP,
CNWL Trust, IHC Trust and WL Trust. However, ZSOLT KIRJAK could not obtain the health care
he required.
Moreover, ZSOLT KIRJAK became nervous and very anxious and to each of the health
agencies he visited he said that he had attempted suicide previously and he still had suicide
ideation.
As a result on his not being able to resolve his medical and psychiatric issues on 14th March
2021 14 ZSOLT KIRJAK drove his car to
leading to his death.
5. CORONER’S CONCERN
During the course of the Inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
1. ZSOLT KIRJAK was found to have ended his life following a succession of emergency
presentations for persistent ENT symptoms and associated psychological distress
including acute suicidal thoughts.
2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete,
particularly with regards to his psychiatric history (including previous attempts at self
harm and the documented recent attempt by the patient to give himself a stroke),
substance use and medical history. Correspondingly, there was an insufficient risk
assessment that did not include or appraise the Patient’s risk factors for suicide. The
treatment plan prescribed did not manage the Patient’s risks.
3. There was a lack of enquiry by any of the clinicians who had seen the patient into the
Patient’s previous attempt to give himself a stroke and a subsequently acquired eye
injury. It is very unusual for a patient to attempt to give oneself a stroke and would
reasonably be expected to warrant a detailed assessment because it implies a high
degree of harm and lethality.
4. Though there was contact between the LPS clinician and the Patient’s wife, there is
no evidence as to whether the Patient’s wife was given the opportunity to contribute
to his clinical and risk assessments and corresponding management plan.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe each of you
respectively have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. I, the
Assistant Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
namely
of Littlemead, Lyndhurst Road, Mossley Hill, Liverpool, L18 8AU
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the Assistant Coroner, at the time of your response,
about the release or the publication of your response by the Chief Coroner.
9
24/06/2022
Russell Caller
HM Assistant Coroner
Inner West London
33 Tachbrook Street
London SW1V 2JR
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