Dear Coroner Hassell

Re: London Borough of Islington response to the Regulation 28 Prevention of future death report (3 June 2025) into the death of Pellumb Olaj

Firstly, we would like to reiterate our deepest condolences, and those of the Council, to the family of Mr Olaj.

In order to provide a clear and substantive response to the PFD report, we consider that it will assist the Chief Coroner to set out some background, including a synopsis of some procedural matters at the hearing, as well as to explain evidence that could have been given, if so permitted, during the hearing.

Inquest hearing

Prior to the Inquest Islington Council asked if the Coroner was seeking a written statement from any Council officer, but was advised by the Coroner’s Office that it was not required. The Coroner did not, therefore, have the benefit of detailed evidence in relation to local authority housing provision and/or housing management. Only oral evidence was therefore available at the hearing. However, the oral evidence permitted during the hearing was significantly and unexpectedly limited.

Representatives from Islington Council at the inquest hearing comprised three Islington Council officers (the Assistant Director for Housing Needs, the Assistant Director for Housing Management, and an Income Recovery Officer), and Counsel for Islington. All three Islington Council officers were listed in the witness list provided by the Coroner’s Officer the day before the hearing. During the hearing, oral evidence was provided by two of the three Council Officers in attendance. However, the Coroner unanticipatedly decided not to call the third council officer, the Assistant Director for Housing Management, thereby significantly limiting the evidence provided. The Assistant Director for Housing Management, had she given oral evidence, would have been able to speak to the management changes (as further described below).

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Islington Council only became an Interested Person at the start of the inquest hearing. It became evident at the outset of the hearing that there was an apparent assumption from the Coroner that Islington Council was an Interested Person. This assumption was corrected by Counsel for Islington, who was asked to immediately confirm whether Islington Council wished to become an Interested Person. Prior to that interaction, there was no previous indication that it would have been in any way appropriate for Islington Council to become an Interested Person.

Chronology

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.

Action taken since Mr Olaj’s death

There are a number of procedural changes that Islington has implemented/is implementing. Some of these were already in progress prior to the death of Mr Olaj. Despite the impetus of these actions not being related to the death of Mr Olaj, the aims of the actions are such that they can be identified as addressing concerns arising out of his death. For other actions identified, the impetus behind the change was Mr Olaj’s death.

Actions that were already in progress – for existing tenants

A re-organisation of the Housing Management Service.

The service redesign includes:

i. A single point of contact for residents to raise concerns with a named and directly contactable housing officer. The aim is to ensure that the tenancy team is more accessible to residents.

ii. Smaller patch sizes. Officers are to be allocated patch sizes of up to 600 properties per senior housing officer (reduced from up to 1,400). The aim is that this will enable more proactive and less reactive contact to residents with live issues. Additionally, it will allow for officers to be able to provide a more dedicated period to each of the tenants, building positive professional relations.

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

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including known vulnerabilities. On the audit form itself, it is stated: “By completing this form, we can better understand the needs and concerns of our residents and take appropriate action to address any issues that may arise.” A copy of the audit form appears at pages 3 – 20 of the appendix to this response.

The restructure report was completed on 7 August 2024 and updated on 23 September 2024. Tenancy audits commenced on 9 June 2025. Implementation of the new structure commences 4 August 2025.

It is anticipated that all of the above changes will work to improve the service for all residents. Existing tenants experiencing mental health and other challenges will be more easily identified and therefore supported appropriately.

Actions that were already in progress – for new tenants

A re-organisation of the Housing Needs Service.

It had been identified that the internal process from an applicant applying as homeless, through to being offered a secure tenancy, was fractured, due to the different teams involved. It was considered that this process could be made more streamlined, allowing for all the officers involved in the process to sit within one larger team. Accordingly, a number of functions delivered by officers within Housing Management (Targeted Duty Manager, Targeted Duty Team, Principal Tenancy Officer, and Targeted Duty Team Tenancy Officer), were shifted across to Housing Needs. Therefore, in practice, all the steps from applying as homeless through to the sign up of a new tenancy now fall within a single service. This allows for information regarding applicants, including any potential mental health or other needs, to be more easily shared throughout the process.

It is anticipated that the above organisational changes will work to improve the service for all new tenants. As the officers will now all be working within one service, it is expected that the needs of all new tenants, including those with mental health and other challenges, will be known to all officers engaged during the process, such that they can be taken into account throughout, including when an offer of accommodation is made. The re-organisation will also result in all the officers dealing with the case, from the initial date of application, through to the sign up of the new tenancy, having access to the same database.

The report establishing these organisational changes is dated 6 August 2024. Implementation of the new structure commenced on 1 April 2025 and concluded on 2 June 2025.

Actions that have been initiated since Mr Olaj’s death - for existing tenants

Changes to IT systems.

Currently, the Housing Needs Service and the Housing Management Service use a single database with access to two modules that are inaccessible to one another. Prior to the inquest, it was identified that allowing access to the two modules for both services would ensure that information obtained by the Housing Needs Service during the homelessness application process

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is more easily accessible to the Tenancy Management service. This change will allow for officers within the Housing Management service to access records developed during the application process. Once the change is implemented, officers within the Housing Management Service will be able to check the computer system to locate information about a tenant’s medical history, such that there is a continued awareness of issues that were of previous and possibly ongoing concern.

This issue was first discussed with Islington Council’s Digital Services team prior to the inquest. A meeting was subsequently arranged, which took place on 15 July 2025. The Digital Services team are now looking into how this request can be developed into reality. Whilst the implementation of this proposed change has yet to materialise, the issue had been identified and raised with Digital Services following the death of Mr Olaj and prior to the inquest hearing.

Actions that have been initiated since Mr Olaj’s death - for new tenants

i. New procedure for specialist psychiatric advice.

A new procedure has been identified and now implemented, regarding the requirement for specialist psychiatric evidence to be obtained where it becomes apparent during the homelessness application process that an applicant has a mental health condition and/or has previously attempted to end their life. This new procedure was identified and proposed wording discussed with the Legal Team on 7 May 2025. The procedure was subsequently finalised and implemented on 10 July 2025. Whilst implementation of the procedure postdates the inquest hearing, the identification of the procedure and an intention to implement such would have been explained at the hearing, should the opportunity have arisen. A copy of the finalised procedure appears at pages 21 – 22 of the appendix to this response.

ii. Amended internal form.

Amendments to an internal form have now been implemented. The form is used to gather information about a homeless applicant’s needs and determine the type of housing to be offered to the individual to enable the Council to discharge its housing duty under the Housing Act.

The amendments made to the form are to explicitly highlight any medical needs encompassing either the physical and/or mental health needs of any person/s in the household that is to be rehoused. This information along with other information within the form is considered holistically by the housing officer before an offer of social housing is made to the individual.

Whilst the introduction of the amended form postdates the inquest hearing, identification of the changes planned were first discussed on 7 May 2025. This would have been explained at the hearing, should the opportunity have arisen. A copy of the amended form appears at pages 23 – 29 of the appendix to this response.

Conclusion

We trust that the information in this response provides some reassurance to the Chief Coroner that Islington Council does indeed take its responsibilities as a social landlord seriously and that

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any mental health and other needs of new and existing tenants is considered when allocating accommodation and thereafter.

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.

The information and evidence set out in this response was available at the inquest hearing and would have been heard by way of oral evidence, had the opportunity been provided. It is somewhat unfortunate that there was no opportunity at the inquest hearing for any of this information to be shared. It is possible that, had it been provided, the matters of concern raised by the Coroner in the PFD report would have been addressed.