Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report

On 20th November 2020 I commenced an investigation into the death of Stanislaw Wieslaw ZIELINSKI. The investigation concluded on the 2nd June 2021 and the conclusion was one of Narrative: Died from 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 1a Cardiac arrest; 1b Pulmonary Embolism II fall from window on 20/10/2020 - subdural haematoma, multiple vertebral and rib fractures, prolonged immobilisation.

Stanislaw Wieslaw Zielinski reported symptoms of anxiety and insomnia to his GP from June 2020. He was not seen face to face but via telephone appointments. His mental health continued to deteriorate. His GP believed a referral had been made to mental health services. They did not have a record of receiving it. It was unclear why that referral was lost in the system. He self-referred to Healthy Minds and was triaged on 1st October. He was not written to until 15th October offering a telephone assessment. An appointment was made for 21st October 2020. He was prescribed mirtazapine, zopiclone and diazepam by the GP to address his anxiety and insomnia. They appeared to have little impact on him. His insomnia and anxiety increased.

On 20th October 2020 in the early hours of the morning, he fell from an upstairs window. He told his wife that he believed he was being chased and fell from the window. He was taken to Salford Royal Hospital where he was found to have suffered multiple rib and vertebrae fractures and a subdural haematoma. He was operated on for the spinal fractures. On 18th November 2020 he was transferred to Tameside General Hospital. In the early hours of the 19th November 2020, he had a significant cardiac arrest due to a pulmonary embolism and died on 19th November 2020 at Tameside General Hospital.

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.
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.