“ZSOLT KIRJAK was found to have ended his life following a succession of emergency…”
Dated 24 Jun 2022, from the coroner for Inner West London. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 22 Sep 2022, after the 56 days for replies had ended (19 Aug 2022). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated24 Jun 2022
- Deadline19 Aug 2022
- Published on judiciary.uk22 Sep 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Portland Practice | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 22 Sep 2022, after the 56 days for replies had ended (19 Aug 2022). These dates can’t tell us whether a reply was due before it went online. |
| Central and North West London NHS Foundation Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 22 Sep 2022, after the 56 days for replies had ended (19 Aug 2022). These dates can’t tell us whether a reply was due before it went online. |
| Imperial College health Care NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 22 Sep 2022, after the 56 days for replies had ended (19 Aug 2022). These dates can’t tell us whether a reply was due before it went online. |
| West London NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 22 Sep 2022, after the 56 days for replies had ended (19 Aug 2022). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
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.
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, 2022-0197
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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