Stanislaw Zielinski

From Gilian Keegan 
Minister of State for Care and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

Alison Mutch  
HM Senior Coroner, Manchester South 
Coroner’s Court   
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Ms Mutch, 

19 November 2021 

Thank you for your letter of 24 August 2021 to Sajid Javid about the death of 
Stanislaw Zielinski.  I am replying as Minister with responsibility for mental health 
and am grateful for the additional time in which to do so.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mr 
Zielinski’s death, and I offer my sincere condolences to his family and loved ones. 
The circumstances your report describes are very concerning and I am grateful to 
you for bringing these matters to my attention.  

I would like to acknowledge that general practice teams have worked tirelessly 
during the COVID-19 pandemic response, remaining open throughout and providing 
both face-to-face, and remote consultations.  

In response to the pandemic, general practice teams rapidly changed how they 
provided support and delivered services to their populations, with a focus on triage 
and remote (telephone and online) consultations, so that they can see as many 
patients as possible, while minimising risk of infection from COVID-19 for patients 
and staff.  This approach was necessary to enable practices to manage demand and 
prioritise the most urgent cases and helped to navigate patients to the right services 
or healthcare professional at the right time.  The quality of care must remain the 
same high standard regardless of whether the appointment is in person or remote. 

Throughout the pandemic, NHS England and NHS Improvement (NHSEI) provided 
guidance to general practice and continually updated standard operating procedures 
to ensure that changing services could operate safely.  NHSEI set out clear 
expectations that general practices offer face to face appointments alongside remote 
appointments (telephone and online), and that clinical appropriateness and patient 
preference should be taken into account to determine the most appropriate 
consultation method.  NHSEI has also supported general practices in how best to 

 
 
 
 communicate with their population on how to access services.  Further details on 
guidance and standard operating procedures can be found on the NHSEI website.  

General practices have been providing remote consultations to patients by telephone 
for many years to help patients access care and clinical advice quickly and 
conveniently.  There are existing skills in the workforce when it comes to telephone 
consultations and telephone consultations are part of general practice training 
schemes.  NHSEI has worked with professional and regulatory bodies, voluntary, 
community and social enterprise sector and patient organisations to support the safe 
and effective use of remote consultations guided by the principle of the interests and 
preferences of the patient.   

A number of resources have been developed1 to support general practices with good 
practice principles in maintaining professional vigilance and identifying concerns 
around safety and safeguarding when using remote consultations.  The resources 
highlight the importance of ensuring patient safety, shared decision making, and 
patients’ needs are paramount.   

The Department and NHSEI continue to support general practices, as we emerge 
from the pandemic, to maintain and improve access to care for patients - on 14 
October 2021, the Government and NHSEI published Our plan for improving access 
for patients and supporting general practice2. The plan includes investment of 
£250million in a Winter Access Fund to improve the access to GP practice services.   

With regard to the second concern raised within your report, I note that the NHS 
Long Term Plan will see an additional £2.3billion funding invested in mental health 
services from 2019/20 – 2023/24, around £1.3billion of which is for the adult 
community, crisis and acute mental health services to help people get quicker 
access to the care they need and prevent avoidable deterioration and hospital 
admission. 

My officials understand from NHSEI that Mr Zielinski’s referral to local Improving 
Access to Psychological Therapies, and offer of a first appointment were within the 
expected national timeframes. 

While emerging from the crisis period resulting from Covid-19, the Department 
continues to monitor the impact of the pandemic and adjust policy and investment 
priorities where necessary.  As part of the Government’s commitment to build back 
better, we have published our Mental Health Recovery Action Plan3, backed by an 
additional £500million for this financial year, to ensure that the right support is in 
place.  The plan aims to respond to the impact of the pandemic on the mental health 
of the public, specifically targeting groups which have been most affected including 
those with severe mental illness, young people, and frontline staff.  

1 See Annex 1  
2 https://www.england.nhs.uk/coronavirus/publication/our-plan-for-improving-access-for-patients-and-
supporting-general-practice/  
3 https://www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-recovery-action-
plan  

 
 
  
 
 
 
 
 
 
 
 As part of this investment, we have committed to accelerate key commitments in the 
NHS Long Term Plan, including:  

•  £79million to expand support in Children and Young People’s Mental Health 

Services;  

•  £110million to expand Adult Mental Health Services including Psychological 

Therapies, implementing the Community mental health framework, investment 
in Crisis services and maintain the delivery of the 24/7 urgent crisis lines 
stood up earlier in the pandemic, as well as additional investment in suicide 
prevention programmes; and  

•  £111million committed to grow the mental health workforce to deliver 

these ambitious commitments.  

This is in addition to the £2.3billion additional funding a year we are investing in 
mental health services by 2023/24. 

The NHS worked hard to keep mental health services open during the first peak of 
the COVID-19 pandemic, using technology where needed but also face to face 
appointments where appropriate.  All mental health trusts established 24/7 urgent 
mental health helplines where people experiencing a mental health crisis can access 
support and advice.  

Talking therapies continue to be made available remotely so people can access help 
safely from home and the NHS will work to ensure the option of face to face support 
is provided to people with serious mental health illnesses across all ages where it is 
clinically safe to do so. 

You may also wish to note that in July 2021, NHSEI announced a consultation on the 
potential to introduce five new waiting time standards, including to community based 
mental health and crisis services4.  The consultation closed on 1 September 2021, 
and NHSEI is analysing the consultation responses which will inform a 
recommendation to Government in due course on whether and how to implement 
any proposed new standards. 

I hope this response is helpful. 

GILLIAN KEEGAN 
Minister of State for Care and Mental Health 

4 https://www.england.nhs.uk/2021/07/nhs-england-proposes-new-mental-health-access-standards/  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex 1  

Resources to support general practice remote consultations 

•  Remote versus face-to-face: which to use and when? (Royal College of 

General Practitioners) 

•  Principles for supporting high quality consultations by video in general 
practice during COVID-19 (Royal College of General Practitioners and 
NHSEI) 

•  How to conduct written online consultations with patients in primary care 

(British Medical Journal) 

•  Key principles for intimate clinical assessments undertaken remotely in 

response to COVID-19 (NHSEI) 

•  Clinical safety risk templates to support general practice in mitigating risks 
associated with the implementation of digitally supported triage, online and 
video consultations 

•  Advice on how to establish a remote ‘total triage’ model in general practice 
using online consultations and e-resource on remote total triage model in 
general practice (NHSEI) 

•  Supporting practice staff with a Total Digital Triage model for online 

consultations and Admin Crib Sheet 

•  Top 10 tips for COVID-19 telephone consultations (Royal College of General 

Practitioners)  

•  Guidance for general practice on confidential enquiry questions for domestic 

abuse during a remote consultation (NHSEI and IRISI)

Interim Chief Executive, NHSI, 
National Medical Director 
NHS England & NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

27 October 2021 

Ms Alison Mutch,  
Senior Coroner 
Coroner Area of Greater Manchester South 
1 Mount Tabor Street,  
Stockport  
SK1 3AG 

By e-mail coroners.office@stockport.gov.uk 

Dear Ms Mutch, 

Re: Regulation 28 Report to Prevent Future Deaths – Stanislaw Wieslaw Zielinski on 
19 November 2020.  

Thank you for your Regulation 28 Report dated 24 August 2021 concerning the death of 
Stanislaw Zielinski on 19 November 2020. Firstly, I would like to express my deep 
condolences to Mr Zielinski’s family.  

The regulation 28 report concludes Mr Zielinski’s death was a result of a pulmonary 
embolism following hospitalisation and an operation for complications of a fall which 
occurred whilst suffering from insomnia and anxiety. The medical cause of death was of  
1a Cardiac arrest;  
1b Pulmonary Embolism II fall from window on 20/10/2020 - subdural haematoma, multiple 
vertebral and rib fractures, prolonged immobilisation. 

Following the inquest you raised concerns in your Regulation 28 Report to NHS England 
regarding:  

The inquest heard that due to Covid 19 and the restrictions and challenges that this 
presented to the health services the way in which care was delivered to Mr Zielinski was 
significantly impacted. In particular: 

1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of

telephone consultations. The inquest heard that he and his family struggled to
communicate with the GP to explain his deteriorating health position as a result of how
his GP practice was delivering health care. The inquest heard evidence that as a
consequence his deteriorating picture was not fully understood by his GP and he was
additional anxious as a result of an inability to express his concerns in person.

Since the advent of the Covid-19 pandemic general practice has been delivering health care 
services according the national General Practice in the Context of Coronavirus Standard 
Operating Procedure that has been regularly updated. This national guidance was in force at 
the time of Mr Zielinski’s death. The aim of this Standard Operating Procedure was to ensure 
general practice was able to provide health care to patients in a safe environment, limiting 
the opportunity of Covid-19 infections in staff and patients while reducing the number of 
absences either by infections or self-isolation. 

NHS England and NHS Improvement 

 As the pandemic developed and circumstances changed locally and nationally, The General 
Practice in the Context of Coronavirus Standard Operating Procedure evolved to state that 
general practices should be open for delivery of face to face care, whilst triaging patients 
remotely in advance where possible, using remote consultations where appropriate. Where 
clinically appropriate patients will be seen face to face within general practice. Guidance for 
this can be found here: 
https://webarchive.nationalarchives.gov.uk/ukgwa/20201231113250/https:/www.england.nhs
.uk/coronavirus/publication/managing-coronavirus-covid-19-in-general-practice-sop/ 

2.  Mental health services were experiencing delays due to operating under the constraints 
of Covid and staffing issues. As a result there was a delay in offering him support which 
would have assisted him. The inquest heard that the existing challenges pre Covid for 
mental health services had been exacerbated by Covid due to an increased need for 
their services in part as a result of the impact on mental health of isolation during 
lockdown.  

Mr Zielinski self-referred to the Tameside and Glossop Improving Access to Psychological 
Therapies (IAPT) Services and was triaged on 01 October 2020. He was subsequently sent 
an appointment letter on 15 October 2020 and offered a first appointment for 21 October 
2020. The National timeframes for response for IAPT services are that 75% of all referrals 
commence treatment within 6 weeks and 95% within 18 weeks. Mr Zielinski’s referral and 
subsequent appointment were within the stated, and expected, national timeframes and the 
standard expectations of service delivery. 

Please find below details of information provided (in a letter) to all people who self-refer to 
Healthy Minds – I can also confirm that this was sent to Mr Zielinski – it does also clarify that 
Healthy Minds is not an Urgent Response Service and that if the person feels they need to 
access help urgently, they should utilise one of the numbers listed below. The Urgent Care 
Helpline is run by staff from Pennine Care NHSFT, who would have access to details of his 
contacts with mental Health Services. 

Services Identified in the letter 

Mental Health Helpline 0800 014 9995 24 hours a day, 7 days a week - Our mental health 
helpline is here to support our service users and carers of all ages 

Your GP - either in telephone or in person 

The Samaritans - Freephone 116 123 - Talk to them anytime you like, in your own way, and 
off the record about whatever is getting to you. You can also email jo@samaritans.org 

NHS walk in centres - a GP led walk in centre for treatment of minor ailments without an 
appointment. Locally these are open 8 am to 8 pm 7 days a week 

Urgent Treatment Centre (UTC) - A new Urgent Treatment Centre (UTC) opened on 29th 
April 2019 at Tameside Hospital site (next to A&E). The new centre replaces the existing 
Walk in Centre (WIC) at Ashton Primary Care Centre. Initially people with an urgent need will 
be able to see support at the Urgent Treatment Centre (UTC) by walking in between 9 am - 
9 pm 7 days a week 

Emergency Social Services (Tameside) 0161 342 2222 Outside of normal office hours. 
The 'normal office hours' are 8.30 am - 5 pm Monday to Wednesday, 8.30 am - 4.30 pm 
Thursday and 8.30 - 4 pm Friday - Call in the event of an unexpected major problem within 
the home or family 

 
 
 
 
 Emergency Social Services (Derbyshire) 01629 532 600 5 pm - 9 am Monday to Friday 
and 24 hours per day during weekends and bank holidays. This service is available for the 
public and agencies to access a range of social care staff for adults or children in need of 
social care  

Silverline - 0800 470 8090. Free helpline 24 hours a day 365 days a year. For people over 
55 years for people who are feeling lonely, want to share their worries, having difficulty 
sleeping and for practical enquiries 

Papyrus 0800 068 4141 or text 07786 209 697. For young people up to the age of 35 (Mon 
– Fri 10 am - 10 pm, Weekends 2 pm - 10 pm and bank holidays 2 pm - 5 pm). Can also 
email pat@papyrus-uk.org 

CALM (for males) 0800 58 58 58 or call using the web-chat at www.thecalmzone.net (5 pm 
till midnight) 

SANE 0300 304 7000 - a national, out of hours Mental Health helpline offering specialist 
emotional support to anyone affected by mental illness, including friends, family's and 
carers. Open every day of the year from 16.30 - 22.30 

SHOUT It's a new national service open 24/7 for anyone in crisis. You simply text 'shout' to 
85258 and then you will be connected with trained individual who will help you to reach a 
calmer, safer place and think about where you can get future and on going support should 
you need it. The service has been set up as part of Princes William and Harry's mental 
health initiative to get people talking when they need help. You can check out the service 
here: www.giveusashout.org 

Thank you for bringing these important patient safety issues to my attention and please do 
not hesitate to contact me should you need any further information. 

Yours sincerely, 

Interim Chief Executive, NHSI & 
National Medical Director

Via email:-  
manchestersouthcoroners@stockport.gov.uk 

Alison Mutch OBE 
HM Senior Coroner 

CHIEF EXECUTIVE 

Chief Executive, Tameside MBC 
and Accountable Officer, Tameside & Glossop CCG 
Tameside One, Market Place, Ashton under Lyne, 
OL6 6BH 

www.tameside.gov.uk 

Call Centre            0161 342 8355 

Date  

 28 September 2021

Dear Ms Mutch 

Re: Mr Stanislaw Wieslaw Zielinski - Regulation 28 Report to Prevent Future Deaths 

Further  to  your  letter,  dated  24  August  2021,  regarding  the  tragic  case  of  Mr  Stanislaw  Wieslaw 
Zielinski please find my response outlined below. 

The untimely death of a person is distressing for their family and any others affected by their death 
and  loss,  and  all  the  more  so  if  there  is  any  belief  that  but  for  the  actions  of  any  organisation  it 
could have been avoided.    

I would like to record my sincere condolences to the family of Mr Zielinski for their loss, and I hope 
through this process they can obtain some closure. 

The  matters  of  concern  raised  in  the  Regulation  28  Report  to  Prevent  Future  Deaths  were  as 
follows: 

1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of
telephone  consultations.    The  inquest  heard  that  he  and  his  family  struggled  to
communicate with the GP to explain his deteriorating health position as a result of how his
GP  practice  was  delivering  health  care.    The  inquest  heard  evidence  that  as  a
consequence  his  deteriorating  picture  was  not  fully  understood  by  his  GP  and  he  was
additionally anxious as a result of an inability to express his concerns in person.

2. Mental health services were experiencing delays due to operating under the constraints of
Covid  and  staffing  issues.    As  a  result  there  was  a  delay  in  offering  him  support,  which
would  have  assisted  him.    The  inquest  heard  that  the  existing  challenges  pre  Covid  for
mental health services had been exacerbated by Covid due to an increased need for their
services in part as a result of the impact on mental health of isolation during lockdown.

Since  the  advent  of  the  Covid-19  pandemic,  general  practice  has  been  delivering  health  care 
services  in  line  with  the  national  General  Practice  in  the  Context  of  Coronavirus  Standard 
Operating Procedure that has been regularly updated alongside British Medical Association (BMA) 
and Royal College of General Practitioners (RCGP) guidance.  This national guidance was in force 
at the time of Mr Zielinski’s death.  

 
                  
 
 
 
 
 
 
 
 The aim of this Standard Operating Procedure was to ensure general practice was able to provide 
health care to patients in a safe environment, limiting the opportunity of Covid-19 infections in staff 
and patients while reducing the number of absences either by infections or self-isolation. 

As  the  pandemic  developed  and  circumstances  changed  locally  and  nationally,  the  General 
Practice in the Context of Coronavirus Standard Operating Procedure evolved to state that general 
practice  should  be  open  for  delivery  of  face  to  face  care,  whilst  triaging  patients  remotely  in 
advance where possible and using remote consultations where clinically appropriate. 

Between  January  2020  and  July  2021  Tameside  and  Glossop  general  practices  have  delivered 
1,803,362  appointments,  this  includes  1,038,069  (or  57.56%)  face  to  face  appointment  and  728 
649 (40.40%) telephone consultations. 

In July  2021  there  were  104,827 GP  appointments  in Tameside  and  Glossop  –  62,717 (59.83%) 
were face to face, 40 156 (38.30%) were by telephone with 1828 (1.7%) home visits. 

Pre-pandemic Tameside and Glossop GPs were seeing approximately 84% of patients face to face 
and approximately 12.5% patients via telephone appointments.  This blended model of access is in 
line with previous RCGP guidance which suggests that approximately 50% of appointments in the 
‘new normal’ could be digital.  Recognition of individual practice patient demographics and patient 
engagement  regarding  a  blended  model  is  however  essential.    Tameside  and  Glossop  general 
practices  are  seeing  the  same,  or  more,  numbers  of  patients  on  a  month  as  they  were  pre-
pandemic through this blended approach.  

In the  latest  national  GP  Patient  Survey  80%  of Tameside  and Glossop respondents  stated their 
experience  of  Tameside  and  Glossop  practices  was  good  or  very  good.    This  is  close  to  the 
national average of 83%. 

The current national guidance states that practices should still triage all patients, and while Covid-
19  remains  a  risk,  a  balance  is  required  to  ensure  the  safety  of  staff  in  general  practice,  while 
ensuring  that  patients  are  still  having  consultations.    This  blended  approach  has  seen  more 
appointments in Tameside and Glossop taking place face to face than remotely.  

Returning  delivery  of  general  practice  to  levels  seen  before  the  pandemic  has  been  a  gradual 
process involving responding to different waves of the pandemic as it has evolved and asking both 
patients  and  service  providers  to  continually  adapt.    As  part  of  this  approach  Tameside  and 
Glossop  CCG  has  undertaken  two  Building  Back  General  Practice  Surveys,  which  provided  a 
snapshot  of  general  practice  delivery  at  July  2020  and  April  2021.    Following  these  surveys 
discussions  were  held  with  practices  to  ensure  consistency  of  delivery  of  care  across  Tameside 
and Glossop. 

However, regardless of these positive figures we are aware that this blended approach may not be 
appropriate  for  all  patients  and  are  greatly  concerned  about  potential  inequalities  of  access, 
including  digital  exclusion.   Where  clinically  appropriate,  patients  will  be  seen face  to  face  within 
general practice and to support those who may be digitally excluded we have established a digital 
wellbeing project that is providing those patients referred into it with hardware and training on how 
to access services online. 

This work commenced with a general practice appointment booking survey in July 2021 to better 
understand  how  each  individual  practice  manages  its  appointment  booking  system.    t  is  at  the 
discretion  of  each  practice,  outside  of  commissioners’  direction,  as  to  how  they  manage 
appointment  booking.    From this  survey  a  best  practice  booking guidance  has  been  created  and 
was shared in August 2021 with all practices. 

Work  is  also  ongoing to understand  negative patient  experiences  of  primary  care  so that  we can 
mitigate  and  reduce  similar  incidents  going  forward  by  sharing  the  learning  across  all  general 
practices  within  Tameside  and  Glossop.    This  work  involves  reviewing  appointment  data  on  a 

 
 
 
 
 
 
 
 
 
 
 monthly  basis  in conjunction  with any  feedback from  patients  highlighting  poor  experiences.   We 
then have conversations with practices regarding those poor experiences to support learning and 
improvement across all general practice within Tameside and Glossop.  As such we encourage all 
patients  to  share  their  experiences  –  positive  as  well  as  negative  –  to  reduce  any  inequality  of 
access. 

As  part  of  the  planned  update  to  Locally  Commissioned  Services,  delivered  by  general  practice, 
and to further  support  practice  reflection  on  whether  each individual  practice has  the  appropriate 
blend  of face  to face  and telephone  consultations for  their  individual  patient  lists, from  1  October 
2021,  practices  will  survey  their  patients  and  clinicians  every  six  months  to  understand  how  both 
parties experience delivering primary care during the ongoing and evolving pandemic. 
Tameside  and  Glossop  CCG  has  been  working  to  improve  patient  experience  and  access 
throughout  the  pandemic  and  will  implement  an  action  plan  as  part  of  this  work  that  will  also 
respond to the concerns raised by this Prevention of Future Deaths letter. Due to the nature of the 
available  data  this  will  be  a  rolling,  ongoing  action  plan  involving  continual  review  of  data  and 
experiences.  The action plan consists of the following: 

1.  Appointment booking survey in July 2021 and best practice guidance produced and shared 

with practices in August 2021 

2.  Review appointment data each month. 
3.  Review patient experience feedback each month 
4.  Individual conversations with practices with negative feedback after monthly reviews 
5.  Individual practice patient surveys every six months from October 2021 
6.  Individual practice clinician survey in October 2021 
7.  Sharing learning across Tameside and Glossop practices 
8.  Patient  Experience  Workshop  with  practice  managers  in  October  2021  with  the  learning 

subsequently shared with Tameside and Glossop practices 

Mr  Zielinski  self-referred  to  the  Tameside  and  Glossop  Improving  Access  to  Psychological 
Therapies  (IAPT)  Service  and  was  triaged  on  01  October  2020.    He  was  subsequently  sent  an 
appointment letter on 15 October 2020 and offered a first appointment for 21 October 2020.  The 
national  timeframes  for  response  for  IAPT  services  are  that  75%  of  all  referrals  commence 
treatment within 6 weeks and 95% within 18 weeks.  While Mr Zielinski’s referral and subsequent 
appointment  were  within  the  stated,  and expected,  national timeframes it  is  regretful  that this  did 
not meet Mr Zielinski’s needs at the time.  Tameside and Glossop CCG will work with the provider 
to  ensure  access  times  are  optimised  for  all  trying  to  access  support  during  these  challenging 
times. 

The  Covid-19  pandemic  is  constantly  evolving  and  all  health  care  settings  are  evolving  with  it, 
adapting to each changed circumstance to deliver health care services safely for both patients and 
those  working  within  the  health  and  social  care  system.    Tameside  and  Glossop  currently  have 
high  rates  of  covid  transmission  in  the  community  and  this  needs  to  be  taken  into  account  in 
ensuring all health services are able to safely deliver care to patients.Tameside and Glossop CCG 
shall continue to develop and support safe ways of working alongside its providers, learning from 
all adverse events. 

Nonetheless, whilst the CCG seeks to raise and maintain high standards it has no legal powers to 
determine  how  such  consultations  are  undertaken.    The  contract  with  GPs  –  which  is  negotiated 
nationally  and  which  the  CCG  isn’t  actually  a  party  to  –  doesn’t  allow  for  specifying  how 
consultations are delivered.  At best the CCG can share data, share best practice and share any 
negative  feedback  with  practices  to  understand  why  it  has  been  received  and  encouraging 
changes that may want to consider to improve patient care and/or lived experience. 

 
 
 
 
 
 
 
 
 
 I hope that we have provided you with the necessary assurances in relation to your concerns and 
explained the legal framework within which we are operating. 

Please contact me if you require any further information or if I can assist further in any way.   

Yours sincerely 

Chief Executive, Tameside MBC/Accountable Officer, Tameside & Glossop CCG