Joshua Smith

Sir Alan Massey KCB CBE
Chief Executive
3/30 Spring Place

os 105 ial Road

Maritime & Southampton
$015 1EG

Coastguard United Kingdom

Agency

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Tony Brown LLM | oe Sel Bet

HM Senior Coroner
North Northumberland

147 Church Street Our ref: AM/2016/03
Berwick-on-Tweed 3 February 2017
TD15 1EE

Dear Mr Brown

Thank you for your Regulation 28 report detailing the tragic circumstance in which
Joshua Smith lost his life. We wish to convey our condolences once again at this
tragic loss of life.

Regarding the matters of concern, Her Majesty's Coastguard (HMCG) has noted the
North East Ambulance Communications system limitation surrounding the inability to
‘play back’ live 999 calls. We have also reviewed our own systems, and updated
guidance has been issued and training packages modified.

As to the issue of Joint Emergency Service Interoperability (JESIP), we can report
significant progress has been achieved in the wake of this incident. All
Coastguard tactical commanders attend JESIP courses, and strategic level
commanders attend the Multi-Agency ‘Gold’ course, known as ‘MAGIC’. Every
Coastguard officer completes online training in JESIP as part of their basic training.

Since early 2016, the Maritime and Coastguard Agency (MCA), of which HMCG is a
part, assumed responsibility for the provision of all UK-based Search and Rescue
(SAR) aviation. These airframes are all equipped with Airwave radios specifically to
enhance interoperability with other services in all emergency response operations.

Also since early 2016, HMCG has established an additional 18 full-time senior officer
roles throughout the UK’s coastal regions to further enhance its capability and
engagement within Local Resilience Fora and with emergency service partners. We

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also conduct exercises and joint planning with the latter to improve mutual familiarity
and habits of cooperation.

Most recently, we took a further positive step in securing an HMCG seat on the
National Interoperability Board, as well as appointing a full-time Head of Resilience
within the Coastguard HQ structure.

| hope that these developments in the MCA give you an assurance of our intent to
learn from the tragic events of 2015 and improve our interoperability and routine liaison
with other emergency service partners.

Yours sincerely

Sir Alan Massey
Chief Executive

PREVENTING PROTECTING RESPONDING

Northumberland County Council

Our Ref: PH/JG

Your Ref:

Northumberland

Fire and Rescue Service
Mr Tony Brown LLM Service Headquarters
HM Senior Coroner West Hartford Business Park
North Northumberland a GE | Cramlington

| Se WWileld | Northumberland
17 Church Street : ae { NE23 3UP
Berwick upon Tweed i Telephone 01670 621114
TD15 1EE i | Mobile 07702 072022
Sait sSw: Fax 01670 714602

http://fire.northumberland.gov.uk

Chief Fire Officer
Paul Hedley

9" February 2017

Dear Mr Brown

Regulation 28 Report dated 2nd December 2016
Joshua Harry Smith Inquest 4th November 2016

As part of the operational debrief of the tragic events of 4th April 2015, and as a result of
the HM Coroner's investigation culminating in the inquest of Joshua Harry Smith on 4th
November 2016, Northumberland Fire and Rescue Service (NFRS) would like to provide
the following narrative in response to Section 7 of the Regulation 28: Report To Prevent
Future Deaths dated 2nd December 2016.

We would like to state at the outset that NFRS have been very supportive of the national
development of the Joint Emergency Services Interoperability Programme (JESIP)
which has produced much needed practical guidance to help improve multi-agency
response. The Joint Doctrine: Interoperability Framework sets out a standard approach
to multi-agency working, along with training and awareness products for organisations to
train their staff. Together with our North East blue light partners in Northumbria Police
and North East Ambulance Service (NEAS) we have committed to implementing and
embedding the joint working principles and models.

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Although the call handling and initial mobilising for the incident were not undertaken by
NFRS Fire Control personnel, steps have been taken to confirm, and reaffirm, the
procedures which would be applied within our Fire Control in the event of NFRS
receiving a similar 999 call. Our policy is for any emergency call to be ‘dual monitored’
as it is being taken by a duty supervisory manager to reduce the risk of a mobilisation
error, incorrect information being relayed to responding crews or an incorrect address
being recorded. As an additional confidence and assurance measure, NFRS have
adopted a policy of instigating an immediate review of the call by someone other than
the call handler whenever a call has been placed by a confirmed or suspected, missing
person. NFRS have also reviewed the control procedure when using Enhanced
Information Service Emergency Calls (EISEC) which allows Fire Control to pinpoint
mobile phone signals within a specific area. We have confirmed that Fire Control would
follow normal procedure and mobilise to this area even if the target zone covered part of
the sea or water area.

Since the events of 4th April, NFRS has instigated a full review of our water rescue
standard operating procedure (SOP) to ensure that the content remains appropriate and
relevant. We have ensured that salient operational protocols applicable to the incident
have also been re-emphasised and we have ensured that all recommendations
emanating from the operational debrief have been actioned across the service and all
operational personnel. NFRS missing persons protocols and procedures stipulate that
under normal circumstances Police colleagues hold primacy for the co-ordination and
management of a missing persons search with fire and ambulance services assuming
the primacy role dependent upon whether there was a subsequent requirement fora
rescues / recovery or medical treatment. It may be of interest that these arrangements
will be reviewed and confirmed due to the current development of the Local Resilience
Forum (LRF) Missing Persons and Search Coordination of which NFRS, Northumbria
Police and North East Ambulance Service (NEAS) are statutory partners.

In order to provide assurance with regard to the issues you have identified within
Section 5 ‘Coroner's Concerns' of your report it is incumbent upon us to review our
existing JESIP arrangements, consider their current effectiveness and engage with our
blue light partners to collaboratively identify revisions and enhancements that can be
applied. NFRS is committed to continual improvement with regard to operational
response and incident command and it is our intention to continue to develop and
embed our JESIP training with a clear commitment that it will be more focused at
operational firefighter and initial supervisory manager level. NFRS have released a
range of learning and development materials across the service to support personnel
already trained and have imbedded maintenance programmes established via the
competence framework. Front line operational personnel are scheduled to be trained
from February 2017. Personnel already trained to the JESIP principles include:

Civil Contingencies Team;

All NFRS flexi duty officers at middle and senior levels;

All Fire Control staff;

NFRS supervisory managers via Continuous Professional Development Days;

JESIP principles are embedded across all NFRS incident command courses and
incident command maintenance programmes.

/continued...

As part of our ongoing internal JESIP training we will liaise with Northumbria Police and
NEAS colleagues to ensure they are clear about the content and context of the front line
training we will deliver, and to ensure that it is consistent and complementary to the
training being provided at the same operational levels within our emergency partner
services. Our intention is to agree with partners on the implementation of a joint task
and finish working group to develop a joint inter-service action plan to address the
concerns raised during your inquest. It is our intention, in collaboration and discussion
with our ‘blue light’ partners, to seek to establish this group by 1% April 2017. To assist
with the facilitation of the group NFRS would like to nominate Station Manager
Station Manager has extensive experience delivering incident
command_at_all levels during a secondment to the Fire Service College. Station
‘Manager is also our JESIP single point of contact and has been integral in
developing NFRS JESIP structures.

In order to ensure that operational response and effectiveness to any future missing
person incident is optimised, we would look to include colleagues from HM Coastguard
and Northumberland search and rescue teams and in the confirmation of JESIP
principles across agencies and the delivery and execution of local joint exercising and
training. The inclusion of HM Coastguard as an attendee at the Northumbria Local
Resilience Forum and Emergency Services Liaison sub-group should assist in the
delivery of these proposals.

We would anticipate that some of the deliverable outcomes of that process will be;

e Confirmation of JESIP principles across all agencies

e Affirmation of the application of JESIP principles at Operational, Tactical and
Strategic levels

e Confirmation of agency primacy in missing persons cases

e Development of a ‘front-line’ joint exercising plan to compliment joint
exercising arrangements at tactical and strategic levels

e Reaffirm commitment to JESIP at regional forums such as Northumbria Local
Resilience Forum (LRF) and Emergency Services Liaison Group (ESLG)

e ach service to review, and if necessary revise, their existing JESIP delivery
plans.

To provide the required assurance and confidence that NFRS and partners have taken
the necessary steps to mitigate the potential risk of a reoccurrence of the issues
highlighted within your Regulation 28 report you may wish to be provided with a copy of
any jointly produced action plan for your review. | would be happy to facilitate this with
the agreement of our partners in due course.

Should you wish discuss the content of this letter to provide further detail and context,
please do not hesitate to contact me at your convenience

Yours sincerely

Paul Hedley
Chief Fire Officer

NORTHUMBRIA

Proud to Protect

porbie

Private and Confidential

Mr Tony Brown

HM Senior Coroner for North ;
Northumberland eS /
17 Church Street ——
Berwick upon Tweed

Northumberland

TD15 1EE

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13 February 2017

Dear Mr Brown

Inquest into the death of Joshua Harry Smith (Deceased)
Regulation 28 Report to Prevent Future Deaths

We are writing further to your Regulation 28 Report for the Prevention of Future Deaths dated 2
December 2016 and issued following the Inquest into the death of Joshua Harry Smith, which was
held between 31 October 2016 and 3 November 2016 at Berwick upon Tweed Coroner's Court.

On 6 January 2017 a multi-agency meeting took place in order to discuss the concerns you identified,
and also to conduct a formal debrief. At the request of the agencies, Northumberland National Park
Mountain Rescue were also in attendance, which offered the added benefit of their specific
knowledge in matters of Search and Rescue.

This is a joint response, sent by North East Ambulance Service NHS Foundation Trust and
Northumbria Police. Thank you for granting the agencies an extended period of time to consider your
report. We understand that Northumberland Fire and Rescue Service and HM Coastguard are
providing separate responses.

We will address each point you have raised in your matters of concern below:

Communication with the Caller

As identified in your Report, Joshua mentioned his location in the initial phases of the call, but this
was not heard by the Call Handler until later, when the call was replayed.

A number of questions asked by the Call Handler were of the “closed” type, which limited the
opportunity for Joshua to be more specific about his location. The nature of the questions posed by
the Call Handler may be explained by the fact the NHS Pathways telephone triage system in use by
the North East Ambulance Service requires Call Handlers to ask closed questions in order to identify
the nature of the medical complaint and provide the most accurate ambulance response. Failure to
follow NHS Pathways may lead to increased clinical risk and, ultimately, potentially unsafe calls.

Northumbria, Durham and Cleveland Police Call Handlers are trained to the THRIVE standard.
THRIVE (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) is a risk assessment tool
which assists call handlers to assess the nature of the emergency response required. The tool
enables operatives to decide whether it may be necessary for another agency to become involved.
Police Call Handlers are also trained in the use of the National Decision Making Model (NDM), which
is a dynamic decision making tool.

Such training ensures that risk to callers, and the appropriate level of response, is at the forefront of a
Call Handler's mind. Within the remit of the ambulance service, however, the main consideration is
the clinical aspect, as the principle reason for contacting an ambulance is a medical emergency,

With the above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways
licence requirements and maintain focus on the clinical complaint. However, in order to enhance the
skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers
that would alert them to the need for other emergency services, as a result of joint work with Police
colleagues, a specific THRIVE training program for NEAS has been devised with commencement of
delivery in March 2017. This further training will ensure that there is, so far as possible, a consistency
of response between Control Room staff across agencies. Furthermore, NEAS operational staff have
received training in NDM and Joint Emergency Services Interoperability Programme (JESIP)
principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period.

Whilst the above training is being rolled out, in order to enhance the Trust ability to respond
appropriately to incidents of a similar nature, a suitably trained “Dispatch Supervisor” rol,e has been
introduced to take over from the Duty Manager and deal specifically with this type of emergency.

Communication between Agencies

As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of
Call Handler training therefore, the presence of the Tactical Advisor will ensure that (1) the
appropriate tactical response is made (dispatch of the HART team, for example, being a matter raised
in your Report), and a decision regarding the appropriateness of this response is_made more quickly
and (2) communication between agencies is improved. This very point was discussed at length during
the meeting and the consensus reached was that in incidents of this nature, early communication with
HMCG would be a priority. This approach is also reflected in the updated “Control action following 999
calls to water incidents” procedure in use at NEAS. The Group were also informed of further training
that NEAS HART operatives are conducting around incidents in or near water.

HM Coroner may be aware that inter-agency training already takes place. For example, North/South
“Blue Light’ Working Groups are already in existence and meet regularly. In relation to JESIP,
training between police, ambulance and fire services currently takes place. Our organisations remain
fully supportive of the approaches of the Joint Doctrine; Interoperability Framework and continue to
work and train with our other emergency service colleagues. During our debrief meeting the agencies
present considered that it would also be appropriate for HM Coastguard to receive JESIP training and
to attend emergency response exercises more frequently in general. This is particularly the case as
JESIP does envisage the involvement of HM Coastguard where appropriate.

Further positive discussion revolved around the type and level of information required by HMCG to
equip them with the necessary details to make, an informed decision relating to their level of
involvement and provide the necessary specialised support.

The consensus was that the priority should always be to instigate effective inter-agency
communication and set up a command and control centre where all the information can be funnelled
and shared in an efficient and proactive way.

An important point that was highlighted was the need to ensure that safeguarding concerns are also
taken into relevant consideration in similar incidents.

Furthermore, our organisations work under a Joint Operating Procedure alongside Durham
Constabulary and Cleveland Police. The aim being to provide information to police officers, police
staff and partners in respect of the medical care options that is available through NEAS and the NHS.
The procedure provides guidance to staff on what action to take in the event of clinical care not being
available. The procedure also informs NEAS of the powers and responsibilities the police service has
in response to incidents involving medical matters. This joint procedure enables our staff to directly
contact our respective control rooms to seek advice and assistance whilst relaying information directly
from the scene.

Use of Technology

Your report identifies the fact that Joshua’s location could not be Clearly identified using his mobile
phone. As you are aware, the topography of the area (on or near cliffs) made triangulation difficult.
Northumberland National Park Mountain Rescue have advised other agencies of a further software
tool available to them, SARLOCK, which enables a text message to be sent to a missing person’s
phone. If the phone is a smartphone, the missing person is then able to click on the message and,
using the internet, the smartphone provides Mountain Rescue with its location. Although this system
cannot be independently utilised by other agencies, Mountain Rescue teams are able to distribute a
notification of the casualty’s whereabouts to all partner agencies upon notification of an incident to
them. Serious consideration is being given to the relevance of sourcing expert advice from Mountain
Rescue and the considerable benefits that could derive from the utilisation of this software. Although
it is not possible to say whether this would have helped in Joshua’s case, the potential benefits are
clear for all to see.

The multi-agency meeting also identified that whilst the new Coastguard helicopter has Airwave
capability (the standard communication system utilised by land based agencies), HM Coastguard
currently only have limited access to the Airwave system. HM Coastguard are currently giving
consideration to improving their Airwave capability, in order to facilitate communication between
agencies.

NEAS Procedures

As previously mentioned, in addition to the actions referred to above; NEAS have also finalised their
revised procedure in respect of responding to a 999 call to water based incident. This new procedure
(attached) has been considered by other partner agencies and has been approved.

The agencies sincerely hope that the update contained within this letter will reassure both yourself

and Joshua’s family that lessons have been learned from this incident, and that efforts will continue to
be made to prevent such a tragic incident occurring again.

Yours faithfully

Yvonne Ormston Steve Ashman

Chief Executive Chief Constable
Ambulance Headquarters Northumbria Police Force
Bernicia House Headquarters,

The Waterfront Middle Engine Lane,
Goldcrest Way Wallsend,

Newburn Riverside Tyne & Wear,

Newcastle upon Tyne NE28 9NT

NE15 8NY