Masood Hamid

Corporate Legal Services
Trust Headquarters
225 Old Street
Ashton Under Lyne
Lancashire
OL6 7SF

15 October 2025 

Private & Confidential 
Joanne Kearsley 
HM Senior Coroner 
HM Coroner's Court 
Newgate House 
Newgate  
Rochdale  
OL16 1AT 

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  

A34 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 
The  Physical  Health  Steering  Group  oversees  all  risks  aligned 
workstreams,  and  their  understanding  of  progress  against  identified  actions  will 
form part of the reports into our quality governance structures.  

to 

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  

A36 
 
 
 
 
 
 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.  

Yours sincerely 

Chief Executive   

A37

GREATER MANCHESTER

>POLICE

Chief Constable

Joanne Kearsley
Senior Coroner
Manchester North

Via email

9" October 2025
Dear HMC Kearsley
Re: Regulation 28 report following the death of Masood Hamid

Thank you for your report dated 20" August 2025 in respect of the death of Masood Hamid pursuant
paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013.

Following careful consideration of your Regulation 28 report, | provide the following formal response
regarding the concerns raised. The primary issue identified relates to the alleged ineffective
communication between Greater Manchester Police (GMP) and Northwest Ambulance Service
(NWAS) between 21:28 and 23:45 hours on 23 December 2024, which is understood to have
delayed the deployment of police officers to assist NWAS staff with the transportation of Mr Hamid.

Prior to the inquest, it was known that a call had been made to NWAS, though evidence of the
second call could not be located at that stage. A subsequent review of all content held by GMP
relating to Mr Hamid on the evening in question has been carried out and the record of call located.
The difficulty in locating the second call was due to the Record of Contact not being linked to the
initial call, just referenced within. This review confirms that communication did take place between
GMP and NWAS and that the communication was constructive. The following chronology outlines
the key events:

° 21:28 — GMP received a call from NWAS requesting police assistance with an 80-year-old
male who was verbally and physically aggressive. The individual was detained under
Section 2 of the Mental Health Act. NWAS staff were in proximity to the patient but reported
increasing difficulty in managing the situation. A Grade 2 incident log was created, and a
THRIVE risk assessment was appended. It is noted that NWAS did not clearly specify the
support required, and the call handler did not seek further clarification.

° 21:48— A District Sergeant updated the log, stating that police attendance was not
appropriate given the care home setting and the presumption that staff were trained to
manage such behaviour. The dispatcher contacted NWAS to relay this decision, and NWAS
updated their own log accordingly. The dispatcher requested the sergeant to complete a
THRIVE assessment before closing the log.

e 22:37 — The District Sergeant appended the THRIVE assessment, and the log was closed.

° 23:28— NWAS recontacted GMP to request police assistance regarding an earlier incident.
An advanced practitioner advised that a patient, recently assessed by an Approved Mental
Health Professional and detained under Section 2, was exhibiting physical and verbal
aggression, preventing safe transport to hospital. Crew contact details were provided.
GMP'’s dispatch supervisor liaised directly with the crew, reopened the original incident log,

and at 23:55, deployed an officer to the care home. NWAS clearly outlined the rationale for
police involvement, enabling GMP to identify a defined policing role in support of partner
agencies and allocate appropriate resources.

Organisational Learning and Improvements

While communication between GMP and NWAS was present, the review identified areas for
improvement. The following actions have been taken:

Training for District Officers: A briefing item has been developed by GMP’s Prevention
Branch for all frontline officers. This includes guidance on the Northwest Regional Mental
Health Capacity Act Joint Protocol 2023, specifically regarding police support to NWAS in
restraining or transporting patients lacking capacity and requiring emergency treatment.
This will be delivered force wide imminently.

RCRP Escalation Process: GMP recirculated the district escalation process to reinforce
supervisors’ responsibilities when reversing deployment decisions. Supervisors must
record their rationale via a THRIVE assessment and seek ratification from a dispatch
supervisor. Closure of incidents must include re-contacting the original informant and
providing appropriate signposting.

FCCO Review: A Force Contact Centre Operations (FCCO) review was conducted to
assess incident demand, governance, and service delivery. One key outcome will be the
implementation of a mandatory action field in Contro/Works to ensure victim contact and
officer arrival are recorded prior to incident closure, which is expected to be finalised soon
— pending final costing and related details with third party suppliers. Standardised training
on deployment and THRIVE was mandated and completed by all district Chief Inspectors
and Inspectors (who cascaded the training) by 18 July 2025.

Strengthening GMP-NWAS Collaboration

GMP has undertaken several initiatives to enhance communication and partnership with NWAS:

Weekly Strategic Meetings: Regular meetings between FCCO and NWAS Senior
Leadership Teams have been established to share feedback and address concerns.
Performance Meetings: NWAS now participates in GMP’s weekly performance meetings
to share case studies and learning.

Daily Operational Huddles: Daily briefings between GMP dispatch managers and NWAS
managers have been introduced to improve real-time coordination.

Knowledge-Sharing Visits: Since 14 July 2025, GMP FCCO staff have been visiting
NWAS control rooms to foster mutual understanding and collaboration. These visits include
first and second-line leaders, with designated SPOCs responsible for cascading learning
across teams.

Conclusion

| trust this report demonstrates the thorough review undertaken and the significant steps
implemented to improve GMP’s response to mental health incidents and enhance our working
relationship with NWAS. GMP remains committed to continuous improvement and ensuring that our
service delivery meets the highest standards of public safety and care.

Yours sincerel

Ao

Ms Joanne Kearsley  
Deputy Chief Coroner 
Manchester North Coroners Court  

By Email Only  

13 October 2025 

Dear Ms Kearsley 

LADYBRIDGE HALL 
399 Chorley New Road 
Bolton 
BL1 5DD 

nwas.nhs.uk 

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 

Headquarters: 

Ladybridge Hall, 399 Chorley New Road, Bolton BL1 5DD 

Delivering the right care, 
at the right time, 
in the right place; 
every time. 

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, 

.  

Yours sincerely 

Chief Executive 

A8

06.10.25 

Adult Social Care 

Oldham Council 

Spindles Shopping Centre 

George Street 

Oldham 

OL1 1HD 

Sarah Royle 
Coroner's Officer 
HM Coroner's Court,  

Floors 2 & 3, Newgate House,  

Newgate,  

Rochdale, OL16 1AT 

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.  

Yours sincerely,  

Interim Deputy Director of Adult Social Care.  

A33