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. 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

Call Centre 0161 342 8355

Date 28 September 2021

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.

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. Interim Chief Executive, NHSI, National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 27 October 2021

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:

.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.

Dear Ms Mutch, 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)