Dear Ms Kearsley

Regulation 28 Report – Inquest Touching the Death of Masood Hamid

I write further to your Prevention of Future Deaths Report dated 20 August 2025, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Mr Hamid.

I am aware that you will share my response with Mr Hamid’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes.

Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. I am aware that no NWAS witnesses were present at the inquest hearing and that NWAS was not granted Interested Person status to the proceedings. However, by this letter I will address the concerns raised as far as I am able.
1. There was ineffective communication between GMP and NWAS between 21:28 hours and 23:45 which delayed the deployment of officers to assist NWAS staff with the transportation of the deceased. This delay meant a prolonged period of distress and agitation which contributed to the stress placed on the deceased. Following conclusion of the inquest, and upon receipt of your report, the care provided to Mr Hamid was retrospectively reviewed at the Trust’s CCRG (Complex Case Review Group) and PSEC (Patient Safety Events Committee) meetings which are attended by senior clinicians including the Trust’s Chief Consultant Paramedic. I have been advised that following the review no issues have been identified regarding the care provided by NWAS as part of that process. The actions of the crew were in accordance with the high standard of care that I would expect from my colleagues.

Due to the concerns you raised regarding communication with Greater Manchester Police (“GMP”), the Trust’s Mental Health Liaison Lead contacted GMP to review this further. There is a joint protocol in place between NWAS and GMP which contains Guidance on ‘Transporting Mental Health Patients’ which governs the way our respective organisations work together. I enclose a copy of the protocol for your consideration, and within section 4.5 it outlines the roles for NWAS staff in these types of circumstances, and also the role of GMP in terms of their A7

attendance to support NWAS when a patient is aggressive and/or violent.

Unfortunately, having liaised with GMP regarding Mr Hamid’s case, there is an acceptance that the individual Police decision to close the incident and not attend to support NWAS was incorrect on this occasion, and not in line with the agreed protocol. I understand GMP are taking action in relation to this and will be writing to you further in that regard.

In any event I wish to assure you that NWAS and GMP work very closely together, and we pride ourselves on the effective communication that is in place between our organisations. Some of the ways in which we can demonstrate this is by the twice daily meetings in place between GMP and NWAS duty managers to ensure there is open dialogues around call logs and any concerns that may arise. NWAS attend the Regional Police Forums where RCRP (Right Care Right Patient) is regularly discussed. GMP are also undertaking training within the control room at NWAS to ensure they fully understand the service with a view to constantly drive improvements to learn from incidents.

Having reviewed the timeline of events in relation to Mr Hamid, it is the Trust’s view that there was good communication in place between NWAS and GMP, but unfortunately an individual incorrect decision was made on this occasion.

I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, .

Dear Ms Kearsley,

RE: Inquest touching on the death of Masood Hamid

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust (PCFT) and the issuing of a Prevention of Future Deaths Notice (Regulation
28), arising from the inquest into the death of Masood Hamid. May I take this opportunity to extend my own condolences to the family of Mr Hamid and apologise that you had to raise concerns relating to the services he accessed prior to his sad death. The Trust sets out its response to the points below raised by HMC’s as areas of concern:
1. There was a lack of planning or consideration between all those involved is his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital. This is full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.

Our Head of Quality for Oldham spoke directly with the practitioner involved in Mr Hamid’s care, who in their witness statement identified it would have been beneficial for Mr Hamid to be transferred within working hours. This was due to the care home staff who worked during the day having a good relationship with Mr Hamid and the knowledge and skills to be able to calm him in situations that may cause him distress.

The member of staff reflected on this and identified that he did not share this information directly with the Approved Mental Health Professional (AMHP) Service. They felt that in future, they would endeavour to ensure this type of personal information was shared. From a system perspective, there are robust mechanisms in place surrounding patient flow in which information like this can

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be shared more easily, as part of the regular bed management meetings, which are held every day, at three different intervals. As you know, the responsibility for conveyance when a bed is identified lies with the Local Authority, so the Trust cannot always influence decision making within this area. We will, however, ensure information sharing does take place to assist decision making which is patient centred and considerate of known needs or requirements.

Our Head of Quality has also met with colleagues from Oldham Local Authority to discuss this further. She requested that the Local Authority team review their AMHP referral form so that additional useful information, particularly around conveyance, is included on the document for their consideration. Again, we are not able to enforce this, but it is hoped that this recommendation is recognised as a positive step to ensure the patient and their needs are at the centre of this process.

Following review and discussion with Oldham Local Authority, it is not believed that the inclusion of this information would have changed the decision made to transfer Mr Hamid from the care home to hospital. This was because Mr Hamid was detained under Section 2 of the Mental Health Act as he presented as a risk to other people, including residents and colleagues within the care home. Mr Hamid had presented as a risk that day to others and it was only later in the day that he had appeared to have calmed with the use of PRN medications.

There was a duty of care to all staff and other residents in the care home and the risk posed to others needed to be acted on and taken seriously. The trajectory at the time of the Local Authority arranging conveyance of the patient to hospital via ambulance from North West Ambulance Service (NWAS) was 5-8 hours, which was anticipated to have been within working hours. Unfortunately, due to the pressures on NWAS services on that day, the timeframe for the availability of an ambulance to transfer Mr Hamid to hospital exceeded that trajectory, and this subsequently fell outside of working hours.

Since Mr Hamid’s inquest concluded, there has been a Safeguarding Adult Review commissioned by the Oldham Safeguarding Adult Partnership. Pennine Care NHS Foundation Trust will be participating in that review and will continue to fully engage with that process and act upon any learning identified as part of the review. This is ongoing at the point of sharing this letter with you.

The Trust has also completed a trust wide patient safety data analysis using sixteen separate data sets. From this, the new updated Patient Safety Incident Response Framework (PSIRF) priorities have been identified, and these have now been confirmed and ratified. One of which is physical health – deteriorating patient. The Trust now has an improvement work stream looking at the deteriorating patient which will report to our Trust Board on a regular basis. Mr Hamid’s case is an incident that was categorised within the incident dataset as physical health – deteriorating patient.

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As part of this workstream a thematic review has been commissioned through the Physical Health Steering Group. All incidents with a deterioration in condition cause code over the last 18 months will be included within the thematic review. That thematic analysis will then feed through the Deteriorating Patient Best Practice Group, which in turn will feed back into the Physical Health Steering Group. Once analysis is complete, themes and trends with be identified with associated recommendations and action being set from the results to ensure that learning is captured. This will in turn inform improvement work within this area leading to a reduction in this type of patient safety incident.

There is also a risk identified in the Trust’s Risk Register in relation to recognising and escalating a deteriorating patient within a mental health trust and that risk is fed through the Deteriorating Patient Best Practice Group. The risk score is informed by the findings of the patient safety data analysis and understanding of controls and actions to reduce the score will be further determined by the thematic review and associated improvement initiatives which can be undertaken. The Physical Health Steering Group oversees all risks aligned to the workstreams, and their understanding of progress against identified actions will form part of the reports into our quality governance structures.

2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act
1983. As a result, the findings of the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent future deaths.

Since you identified the above concern, further analysis and reflection was undertaken in the Trust’s Central Safety Summit. This was focused on the decision to undertake a SWARM Huddle, of its conclusion and closure, opposed to the commissioning of a further learning review, such as a Patient Safety Iincident Investigation (PSII). As part of these discussions the Trust’s PSIRF Policy was consulted which indicates that a PSII should be undertaken for ‘Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care.’ At the time of Mr Hamid’s death, there was nothing to show following the completion of the learning review that Mr Hamid’s death was linked to any problems in relation to the care provided to Mr Hamid from the Trust.

At the time of Mr Hamid’s death, and when the SWARM Huddle was completed and progressed through our approval processes, some of the information that became apparent in inquest disclosure and subsequent evidence heard during the hearing was not known. As a consequence, the Executive Director of Nursing, Quality and AHP’s has commissioned a review of the governance and decision making around which type learning review was commissioned and undertaken following Mr Hamid’s sad death. This is being undertaken by the Head of Quality in our Tameside and Glossop Care Hub. This is to ensure this is considered independently of the Care Hub and Network in which the incident took place. As

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part of this process, terms of reference have been set including to assess the quality of the SWARM information and conclusion/ actions, and the assessment of the governance process of the SWARM sign off.

It is possible that consideration of a change in process in how we assess if learning reviews are still effective in identifying learning when more information is made available, could be implemented. A decision around this will be made once we have an outcome from the review, which is expected by the end of November
2025. I would be happy to share the outcome of this review and any associated recommendations and actions that are identified once these are available.

I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again.

Dear Sarah Re: Death of Masood Hamid - Date of Birth - 20 July 1944 - Ref: 23556816 Regulation 28 report to prevent future deaths notice Thank you for making Oldham Council aware of the Corners concerns regarding the risk of future deaths arising from the inquest of Masood Hamid. We would like to offer our assurance that Oldham Council’s Adult Social Care Directorate have given full consideration to the coroners’ concern that: “There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital. This is in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues”. As Oldham Council Adult Social Care Directorate was not asked to provide evidence at the inquest of Mr Hamid, we would like to provide information and assurance to the coroner regarding our contact with Mr Hamid in December 2024 and the practice of our Approved Mental Health Professionals (AMHP) service in the chronology below. Chronology
• Oldham Council coordinated a Mental Health Act Assessment on 18th December 2024, to consider Mr Hamid’s circumstances, as required under section 13 of the Mental Health Act 1983.

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• The section 12 medical recommendations were for the patient to be admitted to hospital under section 2 of the Mental Health Act 1983, for further assessment relating to the presenting mental disorder. The Approved Mental Health Professional’s decision agreed that Mr Hamid required admission to hospital for assessment under Section 2.

• There were no acute mental health beds available at this time, and no private beds available, and so an application under the Mental Health Act could not be made.

• Whilst awaiting a bed being identified, there was an appropriate interim safety plan for the patient to remain in the care setting at Shawside which was put into place.

• An acute bed became available on 23rd December 2024, and the patient was appropriately reviewed, in accordance with the Mental Helath Act and Statutory Guidance.

• An application was made for admission to hospital under Section 2, and conveyance was requested via the Integrated Care Board commissioned Northwest Ambulance Service, with a projected lead time of 5-8 hours.

• Mr Hamids conveyance was appropriately planned, and patient welfare was appropriately considered by the AMHP, including giving due consideration that there had been a significant delay of 5 days in admission due to bed availability. It was, therefore not considered appropriate to leave the patient in the setting unnecessarily any longer, due to the level of reported distress, and potential risk to staff and other residents.

• With regard to the timing of the patient transport, Oldham Council has no influence or control over the operational capacity of Northwest Ambulance Service. Patient transportation must occur at the earliest possible opportunity that suitable patient transport resource is available.

• In reviewing our records, we have found that Oldham Council’s AMHP service acted lawfully and with appropriate consideration of the patient welfare and when requesting conveyance for Mr Hamid.

Oldham Council would like to offer further assurances to the coroner in relation to this matter as follows: Consideration of individual welfare and minimising distress are central to the practice of Oldham Council’s Approved Mental Health Professionals’ service. Oldham Council recorded a safeguarding concern in December 2024 following the death of Mr Hamid and worked closely with Greater Manchester Police to understand the circumstances of Mr Hamid’s death and determine if further action was required by safeguarding partners to safeguard others.

Following the concerns raised by the coroner, safeguarding adults’ partners in Oldham are working with Oldham Safeguarding Adults Board to share information in relation to their involvement with Mr Hamid and to consider whether a Safeguarding Adults Review (SAR) is required. Oldham Council will participate fully in extracting and implementing any learning and recommendations from this process should a statutory SAR proceed.

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I trust this provides you with the information requested.

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