Jan Michael RACIBORSKI · Prevention of Future Deaths report

On 09 February 2024 I commenced an investigation into the death of Jan Michael RACIBORSKI aged 62. The investigation concluded at the end of the inquest on 10 January 2025. The conclusion of the inquest was that:

On the 5th February 2024 Jan Michael Raciborski died at his home address in Caversham after he hung himself. He had suffered with mental health issues for the majority of his life which, along with the impact of a brain injury resulting from an historic attempt to end his life, significantly affected his mood and decision making processes.

Mr Raciborski suffered from depression and a brain injury for many years. This led to a complex presentation and he was under the care and treatment of the South Oxon Adult Mental Health Team (AMHT) from 2022. He had previously been sectioned, spent time as a voluntary patient and the mental health services had had involvement on and off over the past 40 years.

The AMHT worked closely with Mr Raciborski and he had both a care co-ordinator and support worker, as well as involvement with further staff members. He had many contacts with them during his final period of care.

He had a history of impulsive actions and intermittent suicidal thoughts. In August 2023 his condition deteriorated before then improving. In November 2023 this happened again and this presentation was in keeping with a pattern over the years.

In January 2024 he had a fleeting thought of suicide and was assessed by a mental health team in London. He subsequently had contact with his local AMHT. He remained distressed over the following days until he was found deceased on the 5th February 2024.

None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assessment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not causative factor.

However my concern is that the failure to properly record the details of a risk assessment can lead to inadequate information sharing and the possibility of someone who relies upon the records gaining the wrong impression. In addition it does not allow the adequacy of the risk assessments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations.