Joshua Edwards

{+5 3/4le.W/as / as

meee CITY COUNCIL

03 DEC 2018

Highways & Transportation
3” Floor
St George House

Mr K McLoughlin
Office of the Senior Coroner
ner’s Office and Court
Ss Northgate ee 40 Great George Street
Leeds
efi
Wakefield (et 3DL

WF1 3BS
Contact:
Tel: 0113 378 7590

Ref; KM/CS/1753/17

Date: 30 November 2018

Dear Mr McLoughlin,

Inquest touching the death of Joshua Lee EDWARDS (deceased)
Regulation 28 report to prevent future deaths

| refer to your letter of 2 October 2018 enclosing your report under paragraph 7, schedule 5, of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)

Regulations 2013.

The concerns raised within that report and my responses are set out below in the order within
your report.

(1) The ambulance despatched to the scene encountered roads closed for the Leeds "10K
run that day. It then navigated a route around the course, thus encountering a delay in
reaching the casualty. The Police Officers at the scene telephoned three times to ask where
the ambulance was but this did not result in the situation being escalated in the control room
at Yorkshire Ambulance Service.

For clarification the event on the day in question was the Leeds Half Marathon. Following the
events of that day, Sunday 14" May 2017 the Ambulance Service undertook a full review of the
circumstances surrounding their response. The review took a particular focus on their response
during events when the most direct route to an emergency may be subject to road closures,
That review resulted in a number of learning points, all of which have now been implemented.

They included:

1. Education provided to the Emergency Medical Director community with regard to Police
Calls and the correct information being taken from Police call-handlers.

Continued..

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2. Process in place to ensure that estimated time of arrival calls are highlighted to the
relevant persons within the Emergency Operations Centre.

3. The Emergency Medical Director Standard Operating Procedure duplicate call process
has been re-circulated and reinforced to all Emergency Medical Directors.

(2) Evidence taken at the Inquest indicated that ambulance crews were unclear as to
whether they were entitled to cross ‘road closure’ signs in an emergency. Clarification of the
Ambulance Service authority to do so in an emergency has been given, but has not yet been
circulated to all ambulance crews. This needs to be done on the morning of such events.
Ambulance crews should be reminded of this power by way of a refresher briefing. Similar
considerations arise in relation to the Fire and Rescue Service.

In addition to the actions taken in response to (1) above the Ambulance Service have taken the
following actions:

1. A process has been put in place for managing information on planned events, event road
closures and who to contact for advice and help if needed.

2. Dynamically controlled access zones to be set for major events and maintained
independently from the other dispatch bays in the Emergency Operations Centre.

These actions taken by the Ambulance Service provide a more secure outcome than simply
briefing the Ambulance crews on the morning of the event. Ambulance crews may become
available to respond to emergencies during shift changes or brought to the location from outside
of the area at short notice. Individual response direction from the Emergency Operations Centre
will ensure that crews are informed of the most appropriate response at the time in a more
holistic way.

West Yorkshire Fire and Rescue Service (WYFRS) crews/control are aware that road closures
can be compromised and events stopped for emergency purposes. This is WYFRS
default/standard practice for all events, unless WYFRS resilience team instigates a command
structure for a bespoke response procedure. As a result the Fire Service have suggested that a
briefing for staff of this procedure before every event is not required. The Fire Service have
agreed to publish an Operational Policy Information Document (OPID) to reiterate and confirm
the procedures for WYFRS staff.

(3) in the preparation for such public events, the organisers should be required to brief their
Marshalls that at specified crossing points, the event may require to be halted momentarily to
allow emergency response vehicles to cross. In short, that an emergency may take
precedence. Participants in the event should also be forewarned of the possibility of this
occurring.

Every major event such as the half-marathon and Leeds 10k run includes an Event
Management Plan which sets out the process for emergency responses, emergency vehicle
access and the training of Marshalls. Emergency routes are agreed with emergency services
during the planning for each event. Specific locations to cross the routes are designated. These
are used wherever possible. Other locations can be used under the control of Event Control. All
road closure points are staffed with marshals capable of assisting access and halting events in
the case of an emergency.

Continued..

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The YAS Controller in Event Control, as employed by not just the half marathon organisers but
most organisers of major events in Leeds, will also be briefed to ensure that communications
between Event Control and Ambulance Control are fully operational.

(4) Road closure signs at such designated crossing points should be replaced by signs
indicating ‘Access to emergency vehicles only' or equivalent wording.

Road closure signs during events are placed for the safety of event participants and road users
alike. In the current climate of vehicle incursion we would not seek to weaken their prohibition of
vehicles by allowing anyone to confuse or misinterpret the message to suggest that any form of
access is permitted. In doing so there will always be road users who interpret the signs to their
advantage. In discussions with emergency services and traffic regulation colleagues | feel it is
preferable to maintain the road closure signing as it is set out in the Traffic Signs Regulations
and General Directions legislation and take other measures such as those described above.
This will provide authority to those who legitimately need access in a controlled way. This will
ensure that any delays to genuine emergencies are minimised and the safety of event
participants is not compromised.

In addition to the above | would like to assure you that we take the safety of all participants in
events in Leeds and the surrounding district extremely seriously. The council hosts a joint
emergency services/council Safety Advisory Group on a regular basis. The Safety Advisory
Group promotes the clarity of roles and responsibilities relevant to events within the groups
remit, and works to create a consistent, coordinated, multi-agency approach to event planning
and management. In line with their responsibilities, the events of 14°" May 2017 have been
discussed at length at this group and reassurance has been sought from alll parties that the
learning from this event has been actioned and changes have been made.

The council is clear that the Safety Advisory Group has a vital role to play in the event planning
stage to ensure that organisers:

e Ensure that emergency services procedures are clear and well communicated with all
stakeholders.
¢ Make sure that marshals are well briefed around emergency protocol.

e Effectively communicate with event participants around the potential for the most
appropriate course of action being taken in the event of an emergency.

Whilst some road closures are inevitable with the events in the city, we are also continually
reviewing these to make sure they are appropriate, kept to a minimum and are as safe as
possible.

Yours Sincerely

Head of Highways Infrastructure

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