13 Nov 2023 Igor Kacper SZALAPSKI · Prevention of Future Deaths report Inner North London
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Concerns raised 8 Failure to re-contact the crisis team after a concerning change in a resident’s condition View source Lack of policy on when to increase welfare checks View source Failure to undertake welfare checks at least once per shift View source Chaotic culture at the London Youth Hub View source Insufficient staff conversations with vulnerable residents View source Failure to engage sufficiently with partner agencies regarding residents’ care and welfare View source Failure of London Youth Hub staff to attend self-harm and suicide awareness training View source Lack of family contact details for young residents View source See 5 more concerns
Responses linked to these concerns
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AI-generated summary
Igor Kacper SZALAPSKI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Igor hanged himself in his room at a hostel for homeless young people on 30 April 2023. Concerns included failures to re-contact the crisis team after staff found him drowsy and incoherent, insufficient meaningful staff contact and welfare checks, inadequate engagement with partner agencies and family contact, a lack of self-harm and suicide awareness training, and a chaotic hostel culture.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Failure to re-contact the crisis team after a concerning change in a resident’s condition
Wider context from the report “1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold and wet, but did not re-contact the crisis team .
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.
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.
4. She also acknowledged that greater attempts should have been made by staff to engage with partner agencies regarding Igor’s care and welfare.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Lack of policy on when to increase welfare checks
Wider context from the report “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.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake welfare checks at least once per shift
Wider context from the report “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.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Chaotic culture at the London Youth Hub
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff conversations with vulnerable residents
Wider context from the report “1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold and wet, but did not re-contact the crisis team.
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 .
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 .
4. She also acknowledged that greater attempts should have been made by staff to engage with partner agencies regarding Igor’s care and welfare.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Failure to engage sufficiently with partner agencies regarding residents’ care and welfare
Wider context from the report “1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold and wet, but did not re-contact the crisis team.
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.
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.
4. She also acknowledged that greater attempts should have been made by staff to engage with partner agencies regarding Igor’s care and welfare .
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Failure of London Youth Hub staff to attend self-harm and suicide awareness training
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Depaul UK; that does not assign responsibility.
PFD Monitor interpretation Lack of family contact details for young residents
Wider context from the report “1. On 14 April 2023, staff found Igor outside, drowsy and incoherent, cold and wet, but did not re-contact the crisis team.
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.
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.
4. She also acknowledged that greater attempts should have been made by staff to engage with partner agencies regarding Igor’s care and welfare.
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 .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement organisational policies and procedures at the London Youth Hub in place of local Covid-hotel procedures.
Verbatim wording from the response “Following this incident, DePaul took quick action to address the concerns regarding the ‘chaotic’ feel of the service. This included:” Source location Response from DePaul
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen London Youth Hub management by appointing experienced service managers and placing the service under an experienced Area Director of Housing and Support.
Verbatim wording from the response “Following this incident, DePaul took quick action to address the concerns regarding the ‘chaotic’ feel of the service. This included:” Source location Response from DePaul
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide structured support sessions for London Youth Hub clients.
Verbatim wording from the response “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.” Source location Response from DePaul
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver self-harm and suicidal-ideation training to staff.
Verbatim wording from the response “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.”” Source location Response from DePaul
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an organisational welfare-check procedure defining routine and increased checks, authorisation, duration and recording requirements.
Verbatim wording from the response “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.”” Source location Response from DePaul
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead an internal investigation into missed welfare checks and take resulting employment action.
Verbatim wording from the response “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.” Source location Response from DePaul
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy experienced permanent and agency staff from other services to provide shifts, shadowing and buddying at the London Youth Hub.
Verbatim wording from the response “Following this incident, DePaul took quick action to address the concerns regarding the ‘chaotic’ feel of the service. This included:” Source location Response from DePaul
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relevant safeguarding referrals were for medical professionals to make; limited intervention was possible because the service was not a care provider.
Verbatim wording from the response “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.” Source location Response from DePaul
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Next-of-kin details are requested but not required, and visitor contact details are not recorded under data-protection procedures.
Verbatim wording from the response “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.” Source location Response from DePaul
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DePaul disputes that it failed to identify behavioural deterioration or raise concerns, citing referrals to mental-health services and safeguarding teams.
Verbatim wording from the response “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.” Source location Response from DePaul
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The claim that meaningful staff contact ended on 20 April is disputed because staff and partner agencies recorded regular subsequent interactions.
Verbatim wording from the response “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.” Source location Response from DePaul
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations