PFD report

Pellumb Olaj · Prevention of Future Deaths report

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Issued 3 Jun 2025•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to account for relevant suicide risk history in housing decisions
  2. Lack of a mapped process for accounting for suicide risk history for new and existing tenants
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Use an amended homelessness assessment form that explicitly records household physical and mental health needs before accommodation offers.

    Stated by London Borough of IslingtonStated completedThe respondent said that this action was complete when they made their response on 12 June 2025.
  2. Action

    Require specialist psychiatric evidence during homelessness applications when an applicant has a mental health condition or prior suicide attempt.

    Stated by London Borough of IslingtonStated completedThe respondent said that this action was complete when they made their response on 12 June 2025.
  3. Action

    Investigate development of shared access between Housing Needs and Housing Management database modules.

    Stated by London Borough of IslingtonStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    No concerns about the sixth-floor location were raised, and accommodation suitability could have been reviewed at any time thereafter.

    Stated by London Borough of IslingtonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to account for relevant suicide risk history in housing decisions

Wider context from the report

“Mr Olaj had paranoid schizophrenia and had attempted to kill himself in the past, including by trying to jump from a high window on more than one occasion, but Islington Council failed to take that into account in 2020 when housing him in a sixth floor property. I heard at inquest that, in preparing for inquest (not immediately following Mr Olaj’s death), Islington has now recognised the need to take such matters into account, but I am not clear that it has mapped a way to do this for new and existing tenants. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a mapped process for accounting for suicide risk history for new and existing tenants

Wider context from the report

“Mr Olaj had paranoid schizophrenia and had attempted to kill himself in the past, including by trying to jump from a high window on more than one occasion, but Islington Council failed to take that into account in 2020 when housing him in a sixth floor property. I heard at inquest that, in preparing for inquest (not immediately following Mr Olaj’s death), Islington has now recognised the need to take such matters into account, but I am not clear that it has mapped a way to do this for new and existing tenants. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Use an amended homelessness assessment form that explicitly records household physical and mental health needs before accommodation offers.

Verbatim wording from the response

“ii. Amended internal form.”

Source location

Response from Islington Council
Page 4 · response
Published 12 June 2025

Open published response

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

Require specialist psychiatric evidence during homelessness applications when an applicant has a mental health condition or prior suicide attempt.

Verbatim wording from the response

“i. New procedure for specialist psychiatric advice.”

Source location

Response from Islington Council
Page 4 · response
Published 12 June 2025

Open published response

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

Investigate development of shared access between Housing Needs and Housing Management database modules.

Verbatim wording from the response

“Changes to IT systems.”

Source location

Response from Islington Council
Page 3 · response
Published 12 June 2025

Open published response

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

Operate a unified Housing Needs service covering homelessness applications through new-tenancy sign-up, with shared applicant information and database access.

Verbatim wording from the response

“A re-organisation of the Housing Needs Service.”

Source location

Response from Islington Council
Page 3 · response
Published 12 June 2025

Open published response

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

Conduct tenancy audits for all tenants and leaseholders within three years to identify vulnerabilities and enable support or referrals.

Verbatim wording from the response

“iii. A strategy within the new structure for the named officer to complete effective tenancy audits, with all tenants and leaseholders (approximately 36,000 residents) being visited within three years. This will allow for vulnerable tenants to be identified, enabling appropriate support and referrals to be made. Prioritisation of audits is based on a number of data points”

Source location

Response from Islington Council
Page 2 · response
Published 12 June 2025

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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

No concerns about the sixth-floor location were raised, and accommodation suitability could have been reviewed at any time thereafter.

Verbatim wording from the response

“We have attached to this letter an appendix of documents. At pages 1 and 2 of the appendix appears a chronology of events which summarises pertinent details from prior to the offer of accommodation being made, until beyond Mr Olaj’s death. At no point either around the time of the offer of accommodation being made, nor subsequently, were any concerns raised to Islington by anyone, including Mr Olaj’s treating primary care physician, psychiatrist and specialist occupational therapist, about the location of his home on the 6th floor. Importantly, a review of its suitability could have been requested at any time in the years thereafter. As said by ████████ at the hearing, when she reviewed Mr Olaj in June 2022, he indicated that he was happy with his flat, and seeing his children.”

Source location

Response from Islington Council
Page 2 · response
Published 12 June 2025

Open published response

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

Limited availability of ground- and first-floor council accommodation restricts the ability to provide lower-floor homes to every applicant requiring them.

Verbatim wording from the response

“It does also seem prudent to highlight that the availability of Council accommodation is extremely limited, especially accommodation on the ground and first floor. Some applicants and tenants with physical disabilities may not be able to physically access accommodation that is above the ground floor and their needs must also be considered when suitable accommodation does become available.”

Source location

Response from Islington Council
Page 5 · response
Published 12 June 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Implement a housing management redesign with named resident contacts and smaller officer patches.

    Stated by London Borough of IslingtonStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2025.

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 a housing management redesign with named resident contacts and smaller officer patches.

Verbatim wording from the response

“A re-organisation of the Housing Management Service.”

Source location

Response from Islington Council
Page 2 · response
Published 12 June 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026