Naeem Ahmed

Minister of State 
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

HM Coroner Rachael Griffin   
Dorset 

11 August 2026 

Dear Rachael, 

Thank you for the Regulation 28 report of 24 June 2026 about the death of Naeem Ahmed. 

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ahmed’s 
death, and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The report raises concerns about disposal of medicines and lack of joined up systems to 
show the cumulative workload of clinicians undertaking both NHS and private clinical work.  

In considering your report, officials within the Department of Health and Social Care made 
enquiries with NHS England and concluded that the concerns you have raised are more 
appropriately addressed by NHS England directly. The matters relating to the disposal of 
medicines are operational issues that fall within NHS England's remit. This includes 
responsibility for coordinating the regional response. Accordingly, NHS England is best 
placed to respond to these aspects of your correspondence. I am advised that NHS 
England will therefore provide you with a full and comprehensive response to the 
operational concerns you have raised. 

On staff working patterns, employers have a duty of care to balance the demands of 
providing continuous care with consideration for staff rights and wellbeing. The national 
terms and conditions of employment for consultants provide safeguards related to working 
patterns which go beyond the minimum legal requirements established by the Working 
Time Regulations. As set out in their contract of employment, a consultant is expected to 
inform their employer of any private practice work they are undertaking to ensure safe 
working hours and shift patterns are maintained within their job plan. 

The Government also expects employers across the NHS to have their own arrangements 
in place for supporting their staff, including occupational health provision and employee 
support programmes.  On a national level, NHS England has made available additional 
support including emotional and psychological health and wellbeing support and in 2023, 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 published a strategy to grow occupational health and wellbeing, setting out a roadmap for 
the NHS and partner organisations to work together to develop and invest in occupational 
health and wellbeing services for NHS staff over the next 5 years. For those NHS staff in 
need of specialist mental health support, including doctors, they can access the National 
Staff Mental Health Treatment Service (provided by NHS Practitioner Health), a national 
support service for staff with more complex mental health needs brought about by serious 
issues such as trauma or addiction.  

I hope this response is helpful 

Yours sincerely,  

MINISTER OF STATE

Ms Rachel Clare Griffin  
HM Senior Coroner  
Coroner’s Office for the County of Dorset  
BCP Civic Cente 
Bourne Avenue  
Bournemouth  
BH2 6DY 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

17th August 2026  

Dear Ms Griffin,  

Re: Regulation 28 Report to Prevent Future Deaths – Naeem Ahmed who died 
on 21 June 2025 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated  24th 
June 2026 concerning the death of Dr Naeem Ahmed on 21st June 2025. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Dr Ahmed’s family and loved ones. NHS England is keen to 
assure  the  family  and  yourself  that  the  concerns  raised  have  been  listened  to  and 
reflected upon.   

Your Report raised the following concerns:  

1.  Depending on the methods adopted by hospitals in England and Wales when 
disposing of unused liquids in sharps bin, there is a risk that the liquids could 
be used and lead to fatal consequences.  

2.  There is no legal requirement for doctors to notify NHS Trusts of their private 
work patterns or notify private providers of their NHS work patterns which can 
result in continuous periods of working without rest which could put both patient 
and doctors’ lives at risk. 

1.  The process for the disposal of drugs in Trusts 

NHS England recognises the risk of obsolete controlled drugs being recovered from 
sharps  bins,  whether  from  discarded  syringes  or  where  their  contents  have  been 
squirted  into  them.  NHS  England  has  previously  reminded  organisations  and 
individuals of the need to render obsolete controlled drugs irrecoverable as part of any 
disposal process, as is now the case in Poole hospital with the use of gels in sharps 
bins.  

The National Controlled Drugs Accountable Officer (CDAO) function will address this 
matter again at an upcoming national learning event on 22nd September 2026. We will 
remind  designated  bodies  of  their  obligations  under  both  the  misuse  of  drugs  and 
health and safety legislation which require that controlled drugs are securely disposed 
of and not ordinarily capable of being accessed accidentally or deliberately.  

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 In  addition,  we  recognise  the  risk  to  colleagues’  health  and  wellbeing  where  life 
stresses,  including  any  associated  with  work,  may  increase  their  risk  of  misusing 
controlled drugs where they have access to them. 

We routinely remind organisations and colleagues of the need to ensure that there is 
adequate support for their employees especially those working in potentially stressed 
and/or traumatic clinical environments.  

NHS  England  will  also  raise  this  case  with  the  Care  Quality  Commission  as  the 
medicines  governance  component  of  their  inspection  will  include  the  disposal  of 
controlled drugs in operating departments.  

2.  Doctor’s  working  patterns  and  requirements  to  inform  of  other  NHS  and 

private work  

NHS England would expect doctors to declare and review their full scope of practice 
to their appraiser, for the purpose of licensing and revalidation. This forms part of their 
appraisal which is shared with their Responsible Officer  (RO) which should include 
appraisal  of any  work they  are  undertaking,  including  the  location and  frequency of 
any  work.  This  includes  any  private  work  they  are  undertaking.  As  Dr  Ahmed  was 
working in secondary care their RO would be a senior clinician (typically the Medical 
Director) of their main clinical employer, which is usually their NHS Trust where they 
have their substantive NHS contract. 

The European Working Time Directive (EWTD) is an EU initiative to prevent employers 
from  requiring  their  workforce  to  work  excessively  long  hours,  with  implications  for 
health  and  safety.  The  UK  version  of  the EWTD  is  also  known  as  the  Working 
Time Regulations (WTR). Post Brexit the UK remains bound by core rules originating 
from the European Union's law, but under domestic UK legislation rather than direct 
EU authority. 

The WTR, which implements the EWTD in law, came into force on 1 October 1998, 
with full compliance by 2009. These safeguards are particularly relevant to workers in 
the health service: 

•  a limit of an average of 48 hours worked per week, over a reference period 
•  a limit of 8 hours worked in every 24-hour period for night work 
•  a weekly rest period of 24 hours every week 
•  an entitlement to 11 hours consecutive rest per day 
•  an  entitlement  to  a  minimum  20-minute  rest  break  where  the  working  day  is 

longer than 6 hours 

•  a requirement on the employer to keep records of hours worked. However,  it 
is still possible for doctors to work longer hours by signing an opt-out clause. 

It is not possible to opt out of the rest requirements, so doctors still need to ensure 
they take the necessary breaks, and their employer still needs to monitor the hours 
they work. NHS England therefore expects doctors to declare their full scope of work, 
including any additional work undertaken for other employers, to their Clinical Director 

 
 
 
 
 
 
 or line manager, to ensure compliance with the WTR for the safety of both the doctor, 
and for the patients they treat.   

Regional Response 

NHS England’s South West regional colleagues have been in contact with the South 
West CDAO who has informed us that the following actions have been taken:  

•  They  have  written  to  South  West  CDAOs  (South  West  NHS  Trusts, 
Independent Hospitals, Hospices) regarding the learning around the  disposal 
of medicines.  

•  They have also shared the report with South West Integrated Care Board (ICB) 

Pharmacy Leads for their awareness.  

•  They have raised the issue at a recent National CDAO network meeting and 
shared  this  learning  with  regional  NHS  England  CDAO  colleagues  (England 
only).  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of  Dr 
Ahmed, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England