Zsolt Kirjak

On 14th March 2021 I commenced an investigation into the death of ZSOLT KIRJAK then aged
45. The investigation concluded at the end of the inquest on 17th June 2022. The Conclusion of the Inquest was Suicide. Medical Cause of Death 1 (a) Left Pneumothorax and Hemopericardium 1 (b) Stab wounds to the Chest. CIRCUMSTANCES OF THE DEATH: ZSOLT KIRJAK had been suffering with Tinnitus and lack of sleep for some considerable time He tried to obtain health assistance from a number of Health Care Agencies including The GP, CNWL Trust, IHC Trust and WL Trust. However, ZSOLT KIRJAK could not obtain the health care he required. Moreover, ZSOLT KIRJAK became nervous and very anxious and to each of the health agencies he visited he said that he had attempted suicide previously and he still had suicide ideation. As a result on his not being able to resolve his medical and psychiatric issues on 14th March 2021 14 ZSOLT KIRJAK drove his car to leading to his death.

5. CORONER’S CONCERN During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:
1. ZSOLT KIRJAK was found to have ended his life following a succession of emergency presentations for persistent ENT symptoms and associated psychological distress including acute suicidal thoughts.

2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, particularly 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.

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.

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.

1. ZSOLT KIRJAK was found to have ended his life following a succession of emergency presentations for persistent ENT symptoms and associated psychological distress including acute suicidal thoughts.

2. The Psychiatric assessment 4 (four) days prior to the Patient’s death was incomplete, particularly 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.

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.

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.