Igor Kacper SZALAPSKI · Prevention of Future Deaths report

On 15 May 2023, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Igor Szalapski, aged 18 years. The investigation concluded at the end of the inquest on 1 November 2023. I apologise for the delay in the provision of this report. At inquest, I made a determination of death by suicide.

Igor hanged himself in his room at the Depaul London Youth Hub (a hostel for homeless young people) on Sunday, 30 April 2023.

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.

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.

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.

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.

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.