“Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April…”

The coroner’s concerns

1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security and general observations the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation. An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient. Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented, in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy. In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation. At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient, or from physically entering a patient’s room to check the environment, and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations. 2 For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2015-0465

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0