2025

Noted (AI summary) Total Security Services clarifies that its security officer was not employed as a first-aider and it's not contractually required by Tesco for security officers to provide first aid. The company expects its employees to follow their SIA licence training and will conduct monthly audits to ensure that all its employees continue to hold valid licences that have neither been revoked nor expired. Tesco will deliver "Appointed Person" training to approximately 30,000 UK store management colleagues starting December 1, 2025, with completion by February 28, 2026. This training will provide managers with the skills to relay information to Ambulance Control, follow their instructions, and administer basic first aid when directed. The Security Industry Authority (SIA) investigated the training and conduct of the security operative and Total Security Services Limited, and will consider regulatory action if necessary. They have also offered expert witness assistance to coroners in relevant inquests.

Noted (AI summary) NWAS acknowledges ineffective communication between GMP and NWAS but states GMP is taking action in relation to this and will be writing separately. Pennine Care NHS Foundation Trust has commissioned a review of the governance and decision-making around which type of learning review was commissioned and undertaken following Mr Hamid’s death, expected by the end of November 2025, after which decisions around changes to the assessment process may be implemented. Oldham Council acknowledges the coroner's concerns regarding the transportation of Mr. Hamid, but states that their AMHP service acted lawfully and with appropriate consideration. They state that safeguarding adults’ partners are working with Oldham Safeguarding Adults Board to consider whether a Safeguarding Adults Review (SAR) is required. Response was empty and couldn't be classified.

Noted (AI summary) The Department for Health and Social Care acknowledges the concerns and outlines the Government's commitment to improving urgent and emergency care, referencing the 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, as well as improvements to ambulance response and handover times. They do not describe specific actions taken or planned as a direct result of this case.

Noted (AI summary) NHS England has requested that all ICBs put in place integrated crisis text services, with delivery expected across all areas by Spring 2026. Greater Manchester ICB plans to implement commissioned crisis text services as part of crisis transformation, with a phased approach: a contracted service will be launched first, followed by a fully established service. The Department of Health and Social Care acknowledges concerns about the delayed rollout of crisis text support services, highlights existing mental health support initiatives, and notes that NHS England and Greater Manchester ICB are addressing the specific concerns raised.

Noted (AI summary) The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations.

Noted (AI summary) The Royal College of Psychiatrists will remind members to adhere to NICE guidelines when prescribing ADHD medication and will discuss the case at a webinar on prescribing errors. They also highlight existing guidelines and resources and mention the TIMESPAN consortium is developing consensus recommendations for ADHD patients with increased cardio-metabolic risks. The Department of Health and Social Care acknowledges the concerns raised and states that the MHRA publishes guidance, the BNF provides evidence-based information, and professional bodies and regulators hold prescribers to account.

Noted (AI summary) The nursing home acknowledges the report and states improvements have been ongoing since the incident. They refer to a CQC inspection report from January 2024 detailing actions taken since a previous inspection.