24 Jun 2022 ZSOLT KIRJAK · Prevention of Future Deaths report Inner West London
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Concerns raised 5 Insufficient suicide risk assessment View source Lack of enquiry into previous self-harm and associated injury View source Incomplete psychiatric assessment View source Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning View source Failure of treatment planning to manage patient risks View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
ZSOLT KIRJAK · 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
ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.
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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient suicide risk assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially 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.
” 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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of enquiry into previous self-harm and associated injury
Wider context from the report “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.
” 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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete psychiatric assessment
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially 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.
” 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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the patient's wife an opportunity to contribute to clinical and risk assessments and management planning
Wider context from the report “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 .
” 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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of treatment planning to manage patient risks
Wider context from the report “2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, partially 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.
” Open source report
Concerns raised 2 Insufficient out-of-hours mental health/Crisis staffing View source Failure to provide timely Discharge Summaries to GPs View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Natalie Zara HUNTER · 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
Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.
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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient out-of-hours mental health/Crisis staffing
Wider context from the report “5. During the course of the live evidence I heard from ████████, Service Manager for Community Mental Health Services at the Isle of Wight NHS Trust, in connection with the lack of sufficient numbers of out-of-hours mental health or Crisis staff which are available across the Isle of Wight . His evidence (which has since been supplemented by up-to-date figures), was that the team currently comprises of 11.1 full-time equivalent Band 6 mental health staff members, but it really requires 15.74 full-time equivalent appropriately qualified staff members which would necessitate 4.64 full-time equivalent additional staff to be funded and recruited in order to be able to offer a full and effective service.
6. The evidence was that there are currently insufficient funds in order for a full complement of out-of-hours mental health/Crisis staff to be deployed which is affecting the way in which the Mental Health service operates and delivers care to those who need it out-of-hours.
7. Accordingly, I have concerns that those who are vulnerable with mental health issues and who need to be seen out-of-hours are currently not in receipt of an adequately staffed out-of-hours mental health provision .
” 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 Imperial College Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely Discharge Summaries to GPs
Wider context from the report “1. Natalie HUNTER’s GP, ████████ gave live evidence about Miss HUNTER’s 18 previous serious attempts to take her life. During the course of his evidence he referred to the lack of Discharge Summaries from the Isle of Wight NHS Trust . He said it is not uncommon for a Discharge Summary not to be sent to a GP’s practice by the IOW NHS Trust, or if it is sent, for it to be sent very late after the patient has been discharged from the Trust .
2. ████████ raised concerns about this as the Discharge Summary should contain details of why the patient was admitted; what care they received during their time at the IOW NHS Trust; what medication they were prescribed, and whether such medication was intended to be continued; and whether there were going to require ongoing care/treatment as a result of this admission/treatment.
3. If no Discharge Summary is received , it has a big impact on the care that GPs are able to offer to their patients and the continuity of care which is needed, particularly in relation to mental health input.
4. On several occasions, ████████ had been unaware of the nature of the admissions (which were almost all linked to her serious suicidal attempts) – and significantly the ongoing risk of further attempts on Miss HUNTER’s life as he had either not received a Discharge Summary or had received it too late for it to have any meaningful input into Miss HUNTER’s care .
” Open source report
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Addressed to St Mary'S Hospital NHS Trust, now represented here by Imperial College Healthcare NHS Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations