Mohammed Akramuzzaman

Not Protectively Marked 

29 August 2024 

Dear HMC Hassell, 

Inquest into the death of Mohammed Akramuzzaman – PFD Response 

This  is  a  response  prepared  by  British  Transport  Police  (‘BTP’)  following  a  Regulation  28: 

Prevention of Future Deaths Report issued in the inquest of Mohammed Akramuzzaman.  

The Prevention of Future Death report identified 5 areas of concern for BTP as outlined below. 

1.  The officers left Mr Akramuzzaman after he had simply nodded that he was alright 

and shaken his head that he did not want medical treatment.  They never actually 

heard him speak.  They did not attempt to stand him up to see if he was able to 

support himself.  I appreciate that if Mr Akramuzzaman had mental capacity then he 

could not be forced to go to hospital, but it is difficult to see how he could have been 

assessed properly following just a nod and a shake of the head. 

2.  The three station officers (one PC and two PCSOs) who attended Mr Akramuzzaman 

told me that they had placed great reliance on hearing a BTP response officer  (one 

of three who had arrived just moments before the station officers) give an opinion 
over the radio that Mr Akramuzzaman was “coming round” after having taken drugs 

or alcohol.  However, the station officers were themselves very experienced, and 

should have formed their own view.   

3.  The officers also eventually accepted at inquest that it was impossible to decide so 

quickly that this was a drug comedown. 

4.  It must have been a very cold night (it was minus 4⁰C when he was found in the 

morning), but nobody went back to check on Mr Akramuzzaman later.  I appreciate 

that a decision had to be made about what action to take there and then.  But when I 

asked, BTP witnesses agreed that it would have been an easy matter for an officer on 

patrol later to check on a person in that situation.  No consideration was given to that 

British Transport Police 
West Gate House, Grace Street, Leeds LS1 2RP 
email 

Not Protectively Marked 

 
 
 
 
 
 
 
 by either of the PCSOs, by the PC, or by the sergeant who then took the decision to 

cancel the ambulance called earlier. 

5.  I was told that the BTP officers had reflected a lot about this incident in the time since, 

and had learnt a lot.  However, when giving their evidence they struck me as 

defensive, and they were unable to point to any specific learning or any changes in 
their procedures following Mr Akramuzzaman’s death.  Whilst I readily accepted that 

the officers had talked about Mr Akramuzzaman since his death, I did not gain the 

impression of a culture of learning. The sergeant told me that before the inquest, he 

had not known about the existence of ketoacidosis.  The officers reminded me that 

they are not healthcare professionals.  However, as I explained in court, I was not 

suggesting that they should have a particular understanding of ketoacidosis. Mr 

Akramuzzaman could have been suffering from any number of medical conditions.  

He could have sustained a subtle head injury.  He could have had diabetes (which, as 

it happens, can also result in ketoacidosis).  He could have had epilepsy.  The list 

goes on. Mr Akramuzzaman did not need the BTP officers to be doctors in order to 

survive this episode, but he was probably already confused when officers dealt with 

him, and he needed them to make an appropriate assessment and to take 

appropriate action as BTP officers. The sergeant told me that he thought learning 

should be undertaken by BTP at an organisational level. 

Following the death of Mr Akramuzzaman, BTP referred themselves to the IOPC. A decision 

was made that the IOPC would investigate the actions of the officers and the officers were still 

under investigation when the inquest was taking place. This may have been a factor in why 

the officers appeared to be defensive when giving evidence before you. 

The IOPC report provided the following recommendations for BTP. 

The IOPC recommends that the British Transport Police (BTP) should explore opportunities to 

raise  awareness  of  the  Vulnerability  Assessment  Framework  (VAF),  outside  of  the  Public 

Protection and Vulnerability training programme, to ensure that officers are made aware, and 

British Transport Police 
West Gate House, Grace Street, Leeds LS1 2RP 

 
 
 
 
 regularly reminded, of how and when this should be used in respect of safeguarding vulnerable 

individuals.  

In response to the IOPC  recommendations,  a force wide  bulletin  was circulated  on  19  July 

2024 to highlight the learnings identified as a result of this incident. This bulletin is exhibited to 

this response [EXHBIT 1].  

The safeguarding of the vulnerable is a key objective for BTP and we have opted out of the 
national programme ‘Right Care, right person’ due to the increased vulnerability of people on 
the rail network. We are currently promoting our own ‘Mental Health Crisis to Care’ programme 

in force and have eleven regional single points of contact pulling this activity together. A force 

wide update was circulated on 7 August 2024 to provide an update on Mental Health Crisis to 

Care. This update is exhibited to this response [EXHIBIT 2].  

Reflective practice has been provided to the officers involved in the incident. The officers have 

reviewed their understanding of BTP's safeguarding policy and legal powers under the Mental 

Capacity Act and Mental Health Act, and they have reflected on the comments made by the 

Coroner around making further checks on the male's welfare, which in hindsight would have 

required the ControlWorks log to have been left open. They have also reflected on their use of 

BWV and the importance of capturing everything. They have commented that they would look 

to be more persuasive in convincing subjects to get medical attention in future incidents. 

The reflective practice was also provided to the IOPC who gave feedback as follows.  

I would just like to feedback that the RPRP process here appears to have been very positive, 

with  both  individuals  demonstrating  genuine  reflection  and  positive  steps  to  develop  their 

understanding of issues that were relevant in this case, as well as things that would be done 

differently if faced with a similar situation to help prevent another tragic outcome.  

British Transport Police 
West Gate House, Grace Street, Leeds LS1 2RP 

 
 
 
 
 
  
 
 BTP trusts that this addresses the concerns of the coroner but if there is anything further that 

can assist, please do not hesitate to let us know.  

Yours sincerely, 

British Transport Police   

British Transport Police 
West Gate House, Grace Street, Leeds LS1 2RP 

 
 
 
 
 INNER NORTH LONDON CORONER COURT 

INQUEST OF MOHAMMED AKRAMUZZAMAN 

_______________________________________________________________________________________________ 

BTP PFD RESPONSE - EXHIBIT 1 

______________________________________________________________________________________________ 

 
 
 
 
 
 
 
 
 
 
 Mind the Gap: 19th July 2024 

Following the death of a man in January 2024, it was concluded at the coroner’s inquest that 
there was learning to be taken for BTP and we were issued with a Prevention of Future Deaths 
Regulation 28 notice. 

What happened 

The man had sadly passed away at a railway station from an alcohol related condition and 
hypothermia. He went into cardiac arrest having been outside all night in extremely cold 
conditions. Concern had been raised by a member of the public the previous evening and 
o*icers attended, but the man refused medical treatment and o*icers did not return. Medical 
care and a warmer environment could have saved his life. 

Learn from experience 

O*icers should always seek medical assistance from an approved medical professional as 
soon as reasonably practicable. O"icers should not cancel any ambulance called unless the 
need for medical assistance has been rescinded or a duty of care has been relinquished to 
someone else, for example a family member or friend meets the individual and arranges 
hospital transfer. 

If a delay is anticipated in the ambulance response and you’re advised by Ambulance Control 
that immediate transport to hospital is more appropriate, Police may use police vehicles to 
transport a person to hospital but only when authorised by the Force Incident Manager (FIM) 
and when the Control Works log has been endorsed. 

If there’s a suspected mental health related concern, o*icers should consult with the 
appropriate mental health pathway regarding options, one of which could be detention under 
section 136 of the Mental Health Act 1983 (England and Wales) or Section 297 of the Mental 
Health (Care and Treatment) Act 2003 (Scotland). For internal advice, contact our Vulnerability 
Unit. 

For further guidance on how to look beyond the obvious in relation to someone’s mental health, 
please take a look at the safe and well checks for police response by the College of Policing. 

 
  
  
  
  
  
  
  
  
 
 INNER NORTH LONDON CORONER COURT 

INQUEST OF MOHAMMED AKRAMUZZAMAN 

_______________________________________________________________________________________________ 

BTP PFD RESPONSE - EXHIBIT 2 

______________________________________________________________________________________________ 

 
 
 
 
 
 
 
 
 
 
 We’re progressing with our Mental Health Crisis 
to Care project 

The Mental Health Crisis to Care MHC2C project was formed to review our 
current vulnerability operating model and assess our response in attending 
mental health incidents. 

You’ve routinely told us that you spend long hours in emergency departments and places of 
safety, you receive mixed support when requiring tactical advice and that you’d benefit from 
additional training. Now the appropriate approvals are in place we’ll delivering a two year 
programme of change and investment to ensure we can support you more when dealing with 
mental health incidents, whilst maintaining our duty to protect those in crisis and minimising 
disruption to the railway. 

Over the next year you’ll start to see a difference in our Force Control rooms with the addition of 
Clinical Mental Health professionals within the Psychiatric Liaison Team (PLT) to enable specific 
patient advice, guidance and escalation assistance. The missing person portfolio will move from 
Public Protection to Public Contact with a revised policy and reduced to two categories (high or 
low risk). We’ll be adopting new technology to help aid Section 136 and Section 297 detentions 
which will improve the service for those in distress and will reduce the administrative burden for 
our officers by creating an improved handover mechanism, allowing for quicker handover times. 
To help develop you, look out for our new mental health and wellbeing training which will consist 
of new e-learning packages, a virtual hydra course, face to face inputs woven into our yearly first 
aid and personal safety training refreshers and webinars with the PLT. 

We’ll be reviewing the activity over the first year and with the assistance from our Analysis and 
Insight colleagues, we’ll assess our demand data to ensure there’s been an impact before then 
looking to progress even further, starting off with an interactive map of available Mental Health 
services. Based on the data we’ll look to expand triage vehicles of a Band 6 mental health 
practitioner and an officer to locations reporting the most demand. We’ll also lower the Harm 
Reduction (HaRT) criteria from four presentations to three in eight weeks to bolster prevention 
work and incorporate both clinical supervision and police staff with mental health expertise 
within HaRT. There’ll be more focus on training with hydra training made available for frontline 
rail colleagues and additional guidance for those attending Coroners court and ensuring they can 
access a network of SPOCs across England and Wales.  

Following the national launch of the Right Care Right Person model, the project team will 
continue to liaise with the National Police Chiefs' Council and College of Policing as well as our 
Home Office colleagues to build on our effective partnership working, contribute to the national 
agenda and raise awareness of our national jurisdiction.  

To effectively monitor our ongoing response to mental health incidents, the below SPOCs are 
now in place across the force. You can contact your local SPOC by email with any operational 
queries, good news stories, or new ways of working

28A recommendation and response record  

To 

Head of Professional Standards - British Transport Police (BTP)  

OFFICIAL 

Copied to 

British Transport Police Authority  

HM Coroner Mary Hassell 

Date sent 

13 August 2024  

Deadline for response  56 days after the date above – 8 October 2024 

Case name 

Euston Railway Station DSI  

Case type 

Independent 

Case reference 

2023/198295 

Recommendation from  Operations Manager 

Police case reference 

We have identified organisational learning for BTP and make the recommendation below under Paragraph 28A of Schedule 3 to 
the Police Reform Act 2002. 

You are required by law to respond, in writing to us by the deadline specified above (56 days from the date this recommendation 
has been sent to you) and should do so using this form. Paragraph 28B of Schedule 3 of the Police Reform Act sets out the 
requirements in relation to the response. 

Page 1 of 4 

 
 
 
 To be completed by recipient 

Details, to include 

a)  action to be taken,  
b)  reason for no action, or  
c)  reason not accepted 

OFFICIAL 

To be completed by IOPC 

Previously sent as 
a S10 
recommendation?  
Date sent 

 Yes 
 No 

Do you 
accept? 

 Yes 
 No 

Reference 

Recommendation 

2023/198295/1  The IOPC recommends 

that the British Transport 
Police (BTP) should 
explore opportunities to 
raise awareness of the 
Vulnerability 
Assessment Framework 
(VAF), outside of the 
Public Protection and 
Vulnerability training 
programme, to ensure 
that officers are made 
aware, and regularly 
reminded, of how and 
when this should be 
used in respect of 
safeguarding vulnerable 
individuals.  

This follows an IOPC 
investigation whereby a 
member of the public 
contacted police to report a 
concern for a man’s 
welfare outside Euston 
Railway Station. The call 

Page 2 of 4 

 
 
 
 
 
 was graded as requiring an 
emergency response and 
several officers attended. 
As a result of decisions 
made at the scene, no 
further action was taken 
and sadly the man later 
died. Evidence obtained 
during the investigation 
indicated that despite the 
officers having attended 
the training programme, 
they appeared unaware of 
the application of the VAF 
to help them assess the 
man and gather the 
appropriate information to 
inform their decision-
making. Spreading further 
awareness of the VAF, will 
help officers make better 
decisions about 
safeguarding when 
attending welfare 
incidents. In using the VAF 
in this instance, the officers 
would have likely 
recognised that the man 
was vulnerable, and action 
could have been taken to 
appropriately safeguard 
him.  

OFFICIAL 

Page 3 of 4 

 
 OFFICIAL 

On receipt of your response, we are required to publish it within 21 days and send a copy to any person who was sent the original 
recommendation (as listed above).  If you have any representations why this response should not be published, e.g. if it may 
prejudice ongoing proceedings, please let us know.  

When completed please return this form to: 

Page 4 of 4