Masood Hamid

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.