Recurring concern

Unreliable police and ambulance coordination for patient transport assistance

Pin Get email alerts Request correction

First reported 28 Feb 2025•Latest report 20 Aug 2025

Definition

What this concern includes

Includes failures in the bounded police–ambulance process for coordinating patient transport assistance, including communication, responsibility allocation, requests for police support, transport arrangements and escalation when assistance is needed.

Not included

  • Excludes generic inter-agency communication failures where police and ambulance transport assistance is not the shared safety condition.
  • Excludes ambulance dispatch, response-capacity and hospital-handover failures that do not concern coordination of transport assistance.
  • Excludes failures in the clinical assessment or treatment of a patient after transport assistance has been reliably arranged.
  • Excludes routine patient transport or transport failures involving neither police assistance nor the same coordinated police–ambulance transport process.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2025–2025

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Greater Manchester Police1
North West Ambulance Service NHS Trust1
Oldham Borough Council1
Pennine Care NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester North

    AI-generated summary

    Masood Hamid · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Ineffective communication between police and ambulance services during transport assistance

    Wider context from the report

    “3. 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. ”

    Source location

    Masood Hamid · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver the developed mental-health protocol briefing to all frontline officers force-wide.

    Verbatim wording from the response

    “• 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.”

    Source location

    Response from Greater Manchester Police
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce daily operational huddles between GMP dispatch managers and NWAS managers to improve real-time coordination.

    Verbatim wording from the response

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

    Source location

    Response from Greater Manchester Police
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct ongoing knowledge-sharing visits between FCCO staff and NWAS control rooms, with designated SPOCs cascading learning.

    Verbatim wording from the response

    “• 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.”

    Source location

    Response from Greater Manchester Police
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NWAS disputes that communication was ineffective, stating communication was good and the delay resulted from an individual incorrect police decision.

    Verbatim wording from the response

    “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.”

    Source location

    Response from North West Ambulance Service NHS Trust
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing NWAS-GMP protocols and established communication arrangements are presented as effective for managing cooperation and transport of mental health patients.

    Verbatim wording from the response

    “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”

    Source location

    Response from North West Ambulance Service NHS Trust
    Page 1 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    GMP is responsible for addressing the incorrect individual police decision not to attend and support NWAS.

    Verbatim wording from the response

    “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.”

    Source location

    Response from North West Ambulance Service NHS Trust
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communication between GMP and NWAS occurred and was constructive, disputing the concern that communication was ineffective.

    Verbatim wording from the response

    “Following careful consideration of your Regulation 28 report, I 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.”

    Source location

    Response from Greater Manchester Police
    Page 1 · response
    Published 1 September 2025

    Open published response
  2. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to share information about ambulance delays between police and ambulance services

    Wider context from the report

    “2) Information Sharing There is a concern also about how information was shared between the police and ambulance service. Both police officers said that, had they been aware of the extent of ambulance delays, they may have considered other options, notably, conveying Lachlan to hospital in a police car. I am writing separately to SWAST and Devon & Cornwall Police in this regard and you do not need to address this concern. ”

    Source location

    Lachlan Charles Campbell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The South Western Ambulance Service NHS Foundation Trust is responsible for addressing information-sharing concerns raised in the report.

    Verbatim wording from the response

    “The report raises concerns over emergency service pressures, including ambulance response times and handover delays, and information sharing between police and ambulance emergency services. I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that the South Western Ambulance Service NHS Foundation Trust is also writing to you separately to address the matters of concern you have raised for them which include the issues with information sharing.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 4 March 2025

    Open published response
Back to top

Data last updated 7 September 2026