Igor Szalapski

REGULATION 29: RESPONSE TO PREVENTION OF FUTURE DEATHS REPORT 

RELATING TO THE INQUEST TOUCHING THE DEATH OF IGOR KACPER SZALAPSKI (DATE OF DEATH 

30.04.23) 

1. 

Introduction 

1.1  This Report is drafted on behalf DePaul UK by their instructed solicitors, rradar of  Platform, 

Suite 4B, New Station St, Leeds LS1 4JB the contents of which have been approved by 

  (Chief  executive  officer)  -  DePaul  UK).  The  Report  is  signed  and  dated  by 

as authorised by the Board of Trustees of DePaul. 

1.2  This Report is made in response to the Prevention of Future Deaths Report (“PFD”) dated 13 

November  2023  which  was  issued  following  the  Inquest  into  the  death  of  IGOR  KACPER 

SZALAPSKI  (‘Mr  Szalapski’)  who  sadly  died  on  30  April  2023  whilst  staying  as  an 

accommodation client at the London Youth Hub (“the LYH”), Holly Park, Islington.   

1.3  This Report is drafted in accordance with Regulation 29 and the Chief Coroner’s Guidance No. 

5 ‘Reports to Prevent Future Deaths’, specifically paragraphs 44 and 45. 

1.4  The Inquest took place on 1 November 2023, the Coroner concluded that Mr Szalapski died 

by suicide.  

1.5  DePaul was not afforded Interested Party (IP) Status prior to or during the Inquest.  To the date 

of writing this Report, DePaul are not an IP, despite a PFD Report being made against them. 

1.6  Both DePaul and rradar solicitors made numerous attempts to ascertain whether DePaul were 

IP’s and request what information was required.  These requests were not responded to prior 

to  the  Inquest.  Depaul  did  not  have  the  benefit  of  any  opportunity  to  review  the  Inquest 

Bundle and despite repeated requests, the Coroner’s Office did not confirm what information 

was required from them in advance of the hearing. This subsequently led to criticism in the 

PFD. It is disappointing that DePaul did not have the opportunity to provide information and 

address His Majesty’s Coroner’s concerns directly as they would have been able to with the 

benefit of having had sight of the Inquest Bundle and confirmation as to what information was 

being requested from them, had they been granted IP status.  

1 

 
 
 
 
 
 
 
 
 1.7  rradar solicitors have instructed a third- party transcription company to provide a transcript of 

the recording of Inquest provided by the Coroner’s Office. This document is appended to the 

Report in compliance with the Chief Coroner’s Guidance No.4 Recordings. 

2.  Background  

2.1  The LYH is a 26-bed accommodation service for 18- to 24-year-olds currently sleeping rough, 

and those at imminent risk of rough sleeping in London.  

2.2  The Hub is lead-managed by Depaul UK with support Workers from New Horizon Youth Centre 

assisting guests to move on from the Hub into suitable accommodation. It is supported by the 

Greater London Authority. Partner agencies and statutory services refer young people into the 

project. 

2.3  The LYH provides emergency accommodation. The aim is for most young people to stay for to 

up 56 days, during which time they will receive personalised, holistic support from the delivery 

partners Depaul UK and New Horizon Youth Centre. Some young people may stay for shorter 

periods (such as those for whom there are clear and immediately available accommodation 

options)  and  others  longer  (such  as  where  immigration  status  is  unclear,  and  a  legal 

intervention is required). Whilst staying at the Youth Hub, young people are  provided with 

essential items such as toiletries, food and travel support. 24-hour staff on- site assist with 

referrals to specialist organisations, for example substance use or health organisations.  

2.4  DePaul  UK  is  not  regulated  by  the  Care  Quality  Commission  (CQC).  DePaul  is  a  registered 

Charity and  is  therefore  regulated  by  the  Charity  Commission.  The London  Youth Hub as  a 

project delivered by Depaul UK is not regulated by the CQC either.  

2.5  Mr Szalapski was 18 years old and had been referred to the service by the Hounslow Street 

Outreach Team on 24 January 2023. He moved into the service on the 25 January 2023. 

3.  The PFD Report 

3.1  In the PFD report, there are several inaccuracies which are addressed by DePaul as follows: 

3.1.1  At page 2 of the PFD His Majesty’s Coroner states; 

“I heard evidence at inquest that Depaul conducted an internal investigation into Igor’s 

death. The fact of the report was not disclosed to my office in advance of the inquest as it 

should have been, and I did not see it until it was mentioned in evidence at the inquest.” 

DePaul had provided information to the police regarding the Internal Investigation Report. 

This is detailed in the MG11 of 

 as “NMH/5 – Internal Investigation Report 

from  Depaul”.  There  was  ongoing  correspondence  between  the  police  and  DePaul 

2 

 
 
 
 
 regarding  service  of  this  document  and  therefore  the  police  were  well  aware  of  it’s 

existence and that it was intended by DePaul to serve this as part of their investigation. 

DePaul  would  have  expected  that  this  information  be  sent  to  the  Coroner.  In 

 email to 

 dated 9 August 2023 at 15:03, 

DePaul confirmed they would serve the log and internal investigation requested by the 

police but that “Due to the nature of these documents they need further redaction but will 

be with you no later than 25th August.” Representations were subsequently made to the 

police that because of the nature of their DPA request, it would be beneficial if the Coroner 

requested the documents as it would then not need to be redacted in terms of the third 

party  information  it  contained.  The  Coroner  should  therefore  have  been  aware  of  its 

existence, which is contrary to the statements made at the Inquest. Further DePaul and 

rradar  solicitors  attempted  on  numerous  occasions  (including  12.10.23,  13.10.23, 

16.10.23, 20.10.23), to contact the Coroner’s office to clarify the position both regarding 

Interested  Persons  Status,  and  to  request  confirmation  as  to  what  information  and/  or 

documentation  was  required  prior  to  attending  the  Inquest.  These  requests  were  not 

responded to.   

It is therefore factually incorrect that His Majesty’s Coroner stated, “You didn’t offer this, 

you didn’t mention it existed… you do not volunteer all of the material that you have in 

relation to that, and, and, and frankly one way of looking at it is that you’re trying to hide 

your 

investigation.”  DePaul  did  mention  the 

investigation  report  at 

length 

in 

communications with the police, confirmed they were happy to provide this subject to 

redaction  or  any  DPA  requirements,  alternatively  would  be  happy  to  assist  should  a 

request come from the Coroner. DePaul are of the view that they went above and beyond 

what  may  be  considered  reasonable  in  requesting  information  regarding  what    was 

required, this was heard in the evidence of Nicola Harwood at 01:00:00 of the recording 

where  she  stated  “I  was  initially  contacted  2  -  3  weeks  ago  with  the  request  for  a 

statement,  and  I  asked  for  clarity  about  what  that  statement  should  cover  and  what 

additional records that should cover.” 

3.1.2  DePaul  is  not  regulated  by  the  CQC.  DePaul  are  therefore  confused  as  to  why  the  PFD 

Report  has  been  shared  with  the  CQC.  DePaul  are  in  fact  a  registered  charity  and  in 

accordance with their regulatory obligations, have kept the Charity Commission updated 

throughout  this  matter,  including  sharing  the  PFD  Report.  This  report  and  associated 

action plan will also be shared with the Charity Commission.  

3 

 
 
 
 3.1.3  DePaul UK is not a registered provider of care with the CQC – this is because they do not 

provide personal care or nursing care in any of their services across England.  The Youth 

Hub operates out of a building (280 Holly Park) that is owned by West London Mission. 

West London Mission are registered with the CQC, and had delivered a substance misuse 

service  called  ‘The  Haven’  from  the  building  until  September  2021.  Depaul  UK  began 

operating  homelessness  provision  in  November  2022  from  that  building.  Haven  and 

DePaul are in no way connected. The only connection between West London Mission and 

Depaul UK is that of landlord / tenant.  

3.1.4  An  error  was  made  early  on  in  the  investigation  by  the  police,  who  believed  that  Mr 

Szalapski  lived  at  ‘the  Haven’  and  that  the  service  was  still  operational.  This  reference 

entered the Inquest via the initial police reports which were in fact incorrect. 

 confirmed some confusion at the Inquest as per the transcript. 

3.1.5  At every point in the process DePaul have declared both verbally and in writing that Depaul 

UK and the LYH is not a registered care service or CQC registered, however the mistake 

was  promulgated  throughout  the  correspondence  for  the  inquest-  including  being 

referenced in the families own statement. 

3.1.6  DePaul clearly stated;  

i. 

ii. 

iii. 

iv. 

verbally to the police 

via  email  (12  October  2023)  to  the  Coroner’s  Office,  and  verbally  by 

 to the Coroner’s Office in a telephone conversation. 

in DePaul’s written statement; and  

in the verbal evidence from the Director of Services at the inquest, that DePaul UK 

and the London Youth Hub are not CQC registered, going as far as to ask via email, 

to the Coroner’s Office, to remove every reference to CQC for the avoidance of all 

doubt. 

3.1.7  Despite all of the above attempts to correctly inform, there has been continued confusion 

from the police and the Coroner’s Office that the service was a substance misuse centre, 

known as ‘the Haven’. As clarified to both parties, that was a previous organisation that 

ceased in 2021 and had no involvement with Depaul UK. 

3.2  Matters of Concern (“the Matters”)  

His Majesty’s Coroner raised the following Matters: 

3.2.1  Concern 1: 

4 

 
 
 
 
 
 On 28 March 2023, Igor refused to get out of the shower. Hostel staff took various 

actions, including calling the crisis team. The crisis team decided that Igor did not 

need daily visits, but told staff to call back if there was any change or further 

concern.  

1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold 

and wet, but did not re-contact the crisis team.  

Response 

DePaul accept that there is no record on their client management system of the 

Mental  Health  Crisis  Team  having  been  contacted  by  DePaul  following  the 

recorded  incident  on  14  April  2023.    HM  Coroner’s  above  statement  does  not 

represent  the  full  facts.  The  Crisis  Team  had  been  contacted  and  subsequently 

visited Igor on the 29 March 2023 in response to an Incident Safeguarding and 

Near Miss report (ISN) on 28 March 2023. Staff had been alerted to Mr Szalapski 

flooding  the  bathroom  during  a  very  long  shower  (2  hours)  in  an  effort  to  kill 

himself through electrocution. At this point the Crisis Team response (as recorded 

on the ISN) was: 

 “Crisis Team met with IS 29.03.2023 

 They have concluded that the above events are due to excessive drug use, his lack 

of medication may have impacted him, but predominately his drug use. IS stated 

to the Crisis Team he plans on continuing to take amphetamines and cannabis. He 

does not want any support. Crisis do not feel they need to come daily to see IS. 

They had advised we contact them again if we are concerned for IS mental health”.  

In any case, on 14 April 2023 contact was made by 

 the Manager at 

LYH with  Mr  Szalapski’s  GP  in order that they  could  discuss  his  medication and 

confirm when this was last prescribed. It was agreed between 

 and 

the GP that the GP would call back on 15 April 2023. The ISN record evidences this 

under the ‘actions taken’ section following the incident and states as follows: 

“

 spoke with the Doctors surgery  

IS was issued a months’ worth of Duloxetine and Quetiapine on the 28.03.2023.  

5 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 IS has used up all this medication in around 17 days.  

The doctor is calling Saffron tomorrow to discuss his medication and what we can 

do moving forward.” 

DePaul  submit  that  they  had  contacted  the  medical  professionals  (the  GP)  and 

previously  the  Crisis  Team  it  was  for  them  to  make  the  relevant  safeguarding 

referrals if in their medical opinion, this was required.  DePaul spoke to numerous 

professionals  on  numerous  occasions,  referred  him  to  the  Crisis  Team  who 

referenced his drug problems, DePaul referred him to drug agencies and he would 

not engage with these. DePaul referred him to safeguarding and also to the GP. 

Safeguarding referrals were also made to Islington and to Hounslow.  As DePaul 

were not a Care provider, they were limited in what they could do to progress any 

intervention with such organisations. 

“It  was  heard  during  the  Inquest  that 

  of  the  Hanley  Primary  Care 

Centre had in fact called Saffron Allan, Service Manager at 11.02 on the 15th April 

2023 (a Saturday). The GP gave a detailed statement regarding their conversation. 

It was heard in evidence that Saffron gave a full history and reiterated to the GP 

that LYH was not an appropriate place for Mr Szalapski and 

 advised 

DePaul  to  contact  the  crisis  service,  police,  social  services  and  A  and  E  for 

assessment.  

DePaul have since reviewed their internal communications and confirm that an 

email trail between the Manager and the Youth Hub Team at 18.04 at 11.36 states 

as follows: 

“Following on from a conversation with I.S GP we have been advised in the event 

of an episode re-occurring to call the Police and request a Section 136 under the 

Mental Health Act. 

The GP has stopped all medication for I.S due to him mis-managing his meds and 

misusing various substances and alcohol.  

Please  remember  this  is  the  only  course  of  action  to  be  taken  in  the  event  of 

another psychotic episode. There are no other routes or remedies. 

6 

 
 
 
 
 
 
 
 Meanwhile he is attending Court 20.04.2023 and  we are discussing his housing 

with Hounslow Council as a more suitable and permanent arrangement for him.” 

The above suggests 

 may only have advised DePaul to contact other 

services if a further event took place. The GP’s advice post- dates the advice of the 

Crisis Team and therefore it is reasonable to assume that this later advice should 

take priority. In any case, if DePaul had been granted IP status this matter could 

have been investigated further and the witness cross examined as rradar would 

expect the GP to make such referrals himself if he had such safeguarding concerns, 

rather than put the responsibility on another organisation. 

On  In-form  (DePaul’s  client  management  system)  a  call  was  recorded  as  taking 

place at 10.30 am on 15 April 2023 as follows;  

“GP called 

 - Manager Saturday a.m to discuss and review IS's case. The 

doctor said that due to his high mental health needs, IS should be living in higher 

needs accommodation. He also said that if IS becomes a danger to himself or/and 

others we should call the police as they can act and detain under the Mental Health 

Act Section 136. Another option is to call Crisis mental health team, depending on 

the  situation.  Regarding  his  medication,  the  doctor  said  that  IS  wouldn't  be 

prescribed new medication for the foreseeable future as he used 28 days worth of 

medication in 14 days and also because he has declined substance misuse support 

which was offered to him after we learned he is taking methamphetamine, crystal 

meths and other substances.”   

On 17 April 2023, DePaul emailed Hounslow Substance Use Service which outlined 

the incident, the steps taken with the GP and asked for an update on moving him 

on  and  the  concerns  around  his  safety.    This  is  outlined  in  DePaul’s  Incident 

safeguarding  or  near  miss  report  (DePaul’s  internal  incident  management 

reporting system). This was in response to the Substance Use team stating on 14 

April  that  there  was  no  immediate  availability  for  alternative  accommodation. 

DePaul  continue  to  struggle,  much  like  many  other  organisations,  to  find  such 

higher  needs  accommodation  even  though  as  with  Mr  Szalapski,  the  local 

7 

 
 
 
 
 
 
 
 authority  with  a  duty  towards  him  had  accepted  their  responsibility,  nothing 

suitable was available. 

DePaul  have  since the  date of  the Inquest,  located  email correspondence from 

Saffron Allen. On 18 April 2023 at 11:36, she sent correspondence to colleagues 

at DePaul stating: 

“Following on from a conversation with I.S GP we have been advised in the event 

of an episode re-occurring to call the Police and request a Section 136 under the 

Mental Health Act. 

The GP has stopped all medication for I.S due to him mis-managing his meds and 

misusing various substances and alcohol.  

Please  remember  this  is  the  only  course  of  action  to  be  taken  in  the  event  of 

another psychotic episode. There are no other routes or remedies.” 

This suggests that DePaul employees did as advised by the medical professionals 

dealing with Mr Szalapski and also questions the decision for a PFD to be made on 

this issue. 

Meanwhile he is attending Court 20.04.2023 and we are discussing his housing 

with Hounslow Council as a more suitable and permanent arrangement for him. 

There is no evidence on In-format that the Crisis team were updated of the 14 

April incident, however other steps were taken as detailed above.  Nevertheless, 

DePaul accept that as per their safeguarding policy (in the section on self-harm 

and suicide); 

“Staff  must  support  clients  to  access  suitable  professional  support  to  help  keep 

them safe... In most instances this would involve a referral to other agencies or 

health professionals to provide additional support and management strategies to 

the individual and/or the team.” 

8 

 
 
 
 
  
  
 
  
 
 
 In the absence of a record on In-form relating to referrals post the 14 April 2023 

ISN, along with the staff who were present at the time leaving employment with 

DePaul, they cannot confirm such safeguarding referrals were made. 

DePaul are reviewing how actions relating to ISNs is captured in In-form to ensure 

that ISN actions and comments are quantifiable and monitorable. 

3.2.2  Concern 2:  

“Igor was a vulnerable young man, recently homeless, but the last time that any 

member of staff had a meaningful conversation with him was on 20 April 2023, ten 

days before he died.” 

Response: 

Staff from DePaul had regular contact with Mr Szalapski. According to In-form – which 

does not capture every interaction he had with staff, there were over 112 recorded 

contacts with him during his time at the service The client contact record on 20 April 

2023 refers to a discussion with him about the court case in relation to an injunction 

his family had taken out against him. On 21 April 2023, staff met with him to discuss 

his housing options his drug use, the reasons for staff checking on him (he reported 

he felt ‘babied’ at the Youth Hub in response to increased checks on him), and his 

relationships with other clients at the service. These were relayed at the Inquest in 

the  evidence  of 

,  as  more “Structured  Support”  interactions  rather 

than check- ins. However, the Coroner has interpreted them as the only conversations 

that were held with Mr Szalapski in the run up to his death. This is incorrect as both 

Depaul staff and staff from other agencies had regular conversations with Mr Szalapski 

and spoke warmly about him. In addition, New Horizons (DePaul’s delivery partner) 

also worked closely with Mr Szalapski recording referrals to a number of agencies as 

follows:  

‘29/03/2023  

⦁ 

Contact to Phoenix Futures to request substance misuse support for IS. IS 

declined to engage with them.  

04/04/2023  

⦁ 

Hounslow Housing Options to alert them of IS case.  

9 

 
 
 
 
 
 
 
 06/04/2023  

⦁ 

⦁ 

Hounslow again. Duty to Refer was made.  

St Mungo’s to note previous chasing from Saffron at Depaul. Asked for 

transfer to Staging Post to be agreed.  

13/04/2023  

⦁ 

Phone assessment between IS and Hounslow to identify options. Hounslow 

due to follow up.  

21/04/2023  

⦁ 

⦁ 

Followed up with St Mungos to request Staging Post transfer again 

24/04/2023  

IS attended further assessment with Hounslow and New Horizon. Hounslow 

due to make referral to St Mungo’s.  

26/04/2023  

⦁ 

St Mungo’s carried out zoom assessment with IS.  

28/04/2023  

⦁ 

AG followed up with St Mungo’s – said it was likely IS would be accepted into 

one of their projects, needed to confirm with a manager and would respond 

to New Horizon by 2nd May.’ 

The  Operations  Director  (

)  at  New  Horizon  confirmed  that  the  above 

records are all sourced from New Horizon’s In-Form system and one note regarding 

the Phoenix referral, was obtained from their email system. 

In addition, there are daily records for most days between the 14 April 2023 incident 

and his death on 30 April 2023, where staff recorded seeing him or checking in with 

him. This includes references to him being seen with other clients in the communal 

spaces,  but  also  refers  to  him  making  complaints  about  ‘feeling  babied’,  having  no 

money, and his poor physical or mental health. 

There are no further ISNs or updated risk assessments after the 14 April 2023 incident 

regarding any of these exchanges, and there are no other records of escalations or 

reports  to  external  agencies  other  than  the  GP  and  the  substance  misuse  team 

detailed above, which is what is expected.  

However, it is important to note the nature and context of the service in relation to 

support.  The  LYH  model  was  born out  of  the  emergency  hotel  initiative  during  the 

pandemic. The purpose of the service is to provide emergency housing for up to 56 

10 

 
 
 
 
 
 
 
 
 
 days, during which time the clients will ‘receive personalised, holistic support from 

the delivery partners Depaul UK and New Horizon Youth Centre’. It is not supported 

accommodation and therefore does not specify the frequency of support sessions to 

clients, recognising the short-term nature of their stay, and the focus of the provision 

on moving them on to longer term accommodation. There is the expectation however 

of general, broader support in place for clients from partner agencies and statutory 

services. 

During the transition from emergency hotel provision, as the client’s needs (higher 

risk referrals than expected) and length of stay have evolved, DePaul recognise that 

regular structured support sessions were beneficial for clients and staff – rather than 

more informal support- based interactions.  

The LYH now has structured sessions in place. 

3.2.3  Concern 3: 

“The Depaul executive director of services recognised at inquest that there should have 

been more staff conversation with Igor throughout his time at the London Youth Hub.” 

Response: 

  (Executive  Director  of  Services)  was  called  to  the  Inquest  to  give 

evidence.  She  did  not  directly  work  with  the  Mr  Szalapski  or  the  staff  team,  and 

therefore the information given in her statement and testimony was based on what 

was recorded on In-form. 

It is recognised that the quality of record keeping at the LYH was not of the standard 

expected – an example being the conversation between the GP and the Manager on 

15 April 2023, that was heard at the inquest, varied in how it was recorded by both 

parties. This, however does cast doubt on which is the accurate version of events. In 

addition, the staff model was based on the model used across the emergency covid 

hotel  provision  where  Agency  Security  staff  worked  alongside  single  cover  support 

provision.  The  staff  at  the  hub  at  the  time  of  Igor’s  death  were  either  new  or 

temporary staff following an extremely challenging period of staff recruitment across 

the  voluntary  sector.  Induction,  training  and  support  for  the  staff  team  was  not  as 

detailed as it should have been, with reliance on temporary staff in the absence of 

recruited permanent staff. Temporary staff do not have access to In-form, and do not 

11 

 
 
 
 
 
 always attend or engage with DePaul’s full training offer (due to the temporary nature 

of roles). This means it is difficult to conclude whether the In- form records reflect the 

team’s full interactions with Mr Szalapski. 

Following  the  incident,  staff  and  management  did  share  their  interactions  with  Mr 

Szalapski,  with 

  (ED  of  Services).    They  spoke  clearly  with  warmth 

about him and shared details of their conversations. It is 

 view that 

there were regular conversations with him, but this was not always recorded on In- 

form. As the Executive Director of Services, 

 could only go from the 

formal reports on In- form. Had the team directly working with him been called to give 

evidence  too,  she  is  confident  they  would  more  accurately  paint  a  picture  of  the 

relationship staff had with him and be able to detail the conversations that took place. 

3.2.4  Concern 4: 

“She  also  acknowledged  that  greater  attempts  should  have  been  made  by  staff  to 

engage with partner agencies regarding Igor’s care and welfare.” 

Response: 

In-form shows that during his stay at the Youth Hub, contacts were made with; 

• EASL for a mental health assessment (24.02.2023) 

• Islington Housing Benefit (throughout stay) 

• Crisis Mental Health Team (28.03.2023 – who informed DePaul that Mr Szalapski, 

was receiving support from the community mental health team) 

•  Consultant  Psychiatrist  (28.03.2023  and  30.03.2023  reiterating  more  suitable 

accommodation should be found for IS) 

• GP’s at Hanley Road Surgery as per the statements at Inquest (throughout his stay) 

• Islington Safeguarding team (28.03.2023) 

• Better Lives substance Use service (this was refused by Mr Szalapski on 30.03.2023) 

•  Hounslow  Substance  Misuse  team,  regarding  accommodation  options  (later 

deemed to be too high risk for options 17.04.2023). 

• New Horizons – DePaul’s partner in the delivery of the London Youth Hub focused 

on his housing move on. DePaul’s records show that they referred him to as per the 

above paragraph 3.2.2; 

12 

 
 
 
 
 
 •  LB  Hounslow,  highlighting  ‘a  significant  deterioration  in  his  mental  health  and 

behaviour’ (06.04.2023) 

•  Staging  Post/St  Mungo’s  (Emergency  accommodation  transfer  request)  as  above 

(06.04.2023) 

They  also  shared  that  referrals  for  long-term  accommodation  were  explored  with 

Cooperative Housing and Aves Housing, but neither could be progressed due to the 

risk around IS’ support needs increasing. 

However, whilst referrals were made, and risks shared, it is clear that more could have 

been done professionally to disagree with or challenge the external advice regarding 

his housing situation and wider support needs. In addition, all agencies working with 

him should have been informed when there was a change in his mental health. 

3.2.5  Concern 5: 

“Igor was only 18 years old and his father did visit him, but the hostel did not have any 

contact details for his family.” 

Response: 

DePaul  request  next  of  kin  details  for  all  our  clients,  when  they  move  into  their 

services however it is not a condition or requirement of accommodation and given 

the  family  relationship  history  of  many  of  their  clients,  it  is  unsurprising  that  they 

choose not to provide this information. 

DePaul’s Data Protection policy outlines it may be necessary to share information with 

other agencies and organisations – this is related to safeguarding concerns – and they 

are clear with clients about this. 

Where clients have visitors, they record their time and date of visit, and their name 

but do not record their contact details. This in line with data protection procedures. 

When a serious incident occurs, and next of kin do need to be notified,  they share 

relevant information that they may hold with the police and the police are required 

to contact the next of kin. In this case, the police agreed to notify the family. This was 

confirmed by the police at the Inquest.  

3.2.6  Concern 6:  

“I heard evidence at inquest that Depaul conducted an internal investigation into Igor’s 

death. The fact of the report was not disclosed to my office in advance of the inquest 

13 

 
 
 
 
 
 as it should have been, and I did not see it until it was mentioned in evidence at the 

inquest. However, I have read the report since. It went into some detail and identified 

that,  when  Igor  was  found  at  6.25pm,  no  staff  member  had  undertaken  a  welfare 

check of him since half past midnight, whereas there should have been at least one 

per shift. I was told at inquest that staff were disciplined about this after Igor’s death.”  

Response: 

DePaul UK are committed to sharing information to enable wider understanding and 

learning. Both DePaul and DePaul’s legal advisers (rradar) were proactive in asking the 

Coroner’s  Office  for  clarity  on  what  to  share  and  to  what  extent,  on  a  number  of 

occasions  and  received  no  response  from  the  Coroner’s  Office.  Without  a  doubt 

DePaul  would  have  shared  whatever  was  required.  To  summarise  DePaul’s 

communications; 

i. 

On 11 October DePaul received a request for a statement for the Coroner’s 

Office,  stating  “The  coroner  requires  reports  from  staff  dealing  with  Mr 

Szalapski's stay at the Haven and details any treatment that he had there”. In 

response to this request, 

 spoke on the phone with the officer 

asking for clarity on the parameters of the statement, and what evidence we 

should provide as part of this. 

 explained the volume of client 

records they hold, and the clarity they needed in line with data protection. 

Advice was to email with request. 

ii. 

On 12 October, 

 emailed the Coroner’s Office following up on 

the  conversation  above,  asking;  “What  information  do  you  need  in  the 

statement – your initial request below refers to any treatment he had. Is there 

anything else you need covering or is it solely what Depaul do at the Youth 

Hub, and information regarding treatments?” 

iii. 

On  13  October,  the  coroner’s  office  responded  to  state  “The  coroner  has 

reviewed the file and feels she has everything required for the inquest so no 

need for a further report. However, she requires you to attend the inquest to 

give evidence”. This statement has  undoubtedly added to the confusion on 

the part of DePaul. 

iv. 

On 16 October, 

 replied to state “Many thanks for sharing this. 

Do you have any details regarding the parameters of what I might be asked 

14 

 
 
 
 about,  or  indeed  what  evidence  I  may  need  to  consider  bringing?“  No 

response was received. 

v. 

vi. 

Whilst a statement was not required DePaul, voluntarily decided to provide 

one, to ensure they were as transparent and prepared as possible.  

They  also  sought  legal  advice  from  rradar  on  both  preparation  for  the 

statement and for attending the Inquest as a witness. On 25 October 2023, 

rradar advised that it was unclear whether DePaul were an Interested Party 

or not, and they contacted the Coroner’s Office on a number of occasions as 

follows: 

- 

i. 

ii. 

Email dated Wednesday 25 October 2023 at 14:28 hrs; and 

Email dated Thursday 26 October 2023 at 15:13 hrs 

Further  to  the  above,  rradar  attempted  to  call  the  Coroner’s  Office  on  the 

following dates: 

iii. 

iv. 

v. 

25 October 2023 x 2 calls at 14:46 

25 October 2023 at 14:40 

27 October 2023 at 13:41 

All of the above 6 attempts to make contact with the Coroner’s office were 

unanswered and no response was provided to rradar. 

Following the immediate aftermath of the incident, DePaul learned that Mr Szalapski 

had not been seen for 18 hours. They would have expected staff to check on him on 

every shift as a minimum. Furthermore, they learned a local management decision 

had been made to complete these checks more frequently due to his deteriorating 

mental health. However, staff on shift reported different understanding of this, and 

routine or increased checks were either not actioned or not recorded. 

DePaul immediately led an internal investigation with the staff on shift at the time, 

and as a result of that investigation, two staff members failed their probation and are 

no longer employed by DePaul UK. 

15 

 
 
 
 
 
 
 Whilst it is  unlikely  that  his  death could have  been  prevented by  Depaul UK,  there 

could have been more dignity in the way he was found, and the timing of  this. He 

should have been seen or checked on by each shift and this did not happen. 

3.2.7  Concern 7: 

“At the time of Igor’s death, there was no national policy on when to increase welfare 

checks. I was told that there is now national guidance.  

Response: 

As  part  of  the  investigation  DePaul  recognised  that  there  was  a  lack  of  clarity  on 

welfare checks. There was no organisational policy on this, and local management was 

trusted to make decisions based on their experience.  

DePaul have now developed an organisational procedure on welfare checks (as part 

of safeguarding policy) that captures  what routine checks are,  and when increased 

checks may be put in place (including by who, for how long, and how to record this) 

to  ensure  staff  and  managers  are  clear.  Through  the  incident  and  safeguarding 

procedures,  designated  safeguarding  officers  have  been  clear  on  parameters 

surrounding  increased  checks  (i.e  temporary,  and  with  external  specialist  advice  in 

place). 

3.2.8  Concern 8: 

“The Depaul investigation also identified that staff at the London Youth Hub had not 

attended  self-harm  and  suicide  awareness  training.  I  heard  that  training  has  now 

increased and is mandatory. The report described the culture at the London Youth Hub 

as chaotic.” 

Response: 

The  clients  of  Depaul  services  are  increasingly  presenting  on  referral  with  higher 

mental  health  support  needs  than  they  have  experienced  in  the  past.  As  they  see 

increased  mental  health  challenges  for  people  experiencing  homelessness, 

coupled  with  limited  external  specialist  resources  available  to  them,  they  are 

seeking to address this. Considering this, DePaul developed training in self-harm  and 

suicidal ideation, and to date, 186 staff have attended this training. 

16 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Following this incident, DePaul took quick action to address the concerns regarding 

the ‘chaotic’ feel of the service. This included; 

-  

-  

-  

Change in management, drawing on experienced London service managers 

Change  in  leadership,  with  the  service  being  overseen  by  our  experienced 

Area Director of Housing and Support. 

Staff (permanent and agency) from other services, experienced in the  

application of Depaul policies and procedures working shifts at the hub,  

providing shadowing and buddying opportunities. 

-  

Organisational policies and procedures implemented, rather than local  

procedures in place (that had related to the Covid hotels rather than  

supported housing). 

-  

Thresholds  to  access  and  enter  supported  accommodation  have  increased, 

along  with  increased  pressures  and  demand  on  emergency,  health,  social 

care, housing and support services across the board. 

4  Measures already in place prior to Mr Szalapski's death  

As an organisation providing housing and support to people experiencing homelessness, there 

are organisational procedures in place that relate to this case. They include;  

-  Organisational Safeguarding Policy  

- 

- 

Incident near miss and safeguarding procedure 

Support Planning Policy 

-  Mental Health Strategy  

Operationally DePaul requires room checks and housing management security checks, which aim to 

ensure the health and safety of clients.  

DePaul also works in close partnership with expert and specialist providers to complement the housing 

and  support  they  offer.  Their  staff  are  not  specialists  in  wider  support  needs,  and  therefore  seek 

technical advice from these organisations on specific issues clients may face. These include – but are 

not  exhaustive  –  working  with  local  authority  teams  (social  workers,  safeguarding  teams,  housing 

teams)  and  with  specialist  Mental  Health  providers,  substance  use  organisations,  family  support  / 

relationship organisations.  

In relation to the ISN process, fortnightly senior review of ISN's meeting has been in place for some 

years. 

17 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 

Action taken or to be taken, whether in response to the report or otherwise, and the timetable 

for it, or it must explain why no action is proposed (Regulation 29(3)). 

5.2  DePaul attach as an appendix to this document, their action plan. This was finalised and put 

in place by DePaul on 1 December 2023. The Action Plan is monitored at a high level through 

the Executive Team Meeting and Services Committee at DePaul 

6 

Conclusion  

6.2  The safety of DePaul’s clients remains of the utmost importance to them. All those who knew 

Mr Szalapski were saddened and shocked upon learning of the event of his death. 

6.3  DePaul  wishes  to  pass  on  their  sincere  condolences  to  the  family  of  Mr  Szalapski.  DePaul 

hopes  this  response  provides  the  Coroner  and  the  family  with  the  appropriate  level  of 

assurance  that  as  a  Charity  they  have  dealt  with  the  concerns  highlighted  within  the  PFD 

report. 

6.4  DePaul acknowledges that this was a tragic event and whilst rare within DePaul’s services, 

has resulted in reflections and learning which have shown that Mr Szalapski was failed by a 

number of services. 

6.5  The Youth Hub provided  temporary  emergency shelter for him  – a better alternative than 

rough sleeping – but not supported or specialist accommodation. He had complex high needs, 

that  the  Youth  Hub  was  not  able  to  provide.  His  housing  needs  were  raised  by  both  New 

Horizon (responsible for the  housing move on) and Depaul who advocated that the Youth 

Hub was not able to meet his needs.  

6.6  However, despite acknowledging the nature of the service (26 clients, with limited staff cover, 

all in temporary emergency accommodation) the quality of service he received within the 

LYH was still not the quality he should have had. The immediate aftermath of the incident 

addressed this through formal HR processes with individuals, disciplinary action and a full 

internal  investigation.   However,  wider  learnings  show that  DePaul  could have done  more 

notably on; 

6.6.1 

Identifying  smaller  changes  in  behaviour  /  interactions,  and  seeing  them  as  a 

deterioration in mental health and ensuring these were acted upon by the relevant 

agencies 

6.6.2  Making continued escalation and referrals to housing teams, mental health teams and 

to safeguarding teams. 

18 

 
 
 
 6.6.3  Ensuring  staff  were  well  inducted,  trained,  managed  and  supported  to  provide 

effective support within the service (including the recording of those interactions on 

In-form). 

6.7  More broadly, following this incident DePaul quickly undertook a number of HR investigations 

and  broader  service  changes  and  improvements.  Whilst  this  was  necessary  to  ensure  the 

safety  and  wellbeing  of  other  clients,  this  meant  DePaul  did  not  in  parallel  complete  an 

individual case review into the support Mr Szalapski received. DePaul will, going forwards, 

ensure  following  serious  incidents,  that  individual  case  reviews  continue  alongside  wider 

organisational reviews. 

6.8  On process there are a number of points DePaul challenge within the PFD; 

i. That Depaul UK withheld / failed to provide supporting evidence to the Coroner 

ii. That Depaul UK is CQC registered and a care provider 

iii. That Depaul UK should have contacted the next of kin rather than the police. 

These points are addressed above.  

6.9  Though DePaul have reflected following this incident and put in place the above measures 

and action plan, as discussed at 3.2.1, DePaul raised issues of a deterioration in mental health 

with the Crisis Team and were told that it was a substance use issue not a mental health issue. 

This is after he had expressed an intention to take his own life through electrocution in the 

shower. The GP refused to prescribe his medication given that he had taken 4 weeks supply 

in  14  days  (as  detailed  at  paragraph  3.2.1).  DePaul  did  identify  changes  in  behaviour  and 

raised those concerns with the appropriate mental health services and safeguarding. 

Signed:……

………. 

 (CEO)(for and on behalf of DePaul UK) 

Dated: ………31.01.2023……………………………….. 

19