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.