Robert Cobbina

London Ambulance Service NHS

NHS Trust

Executive Office

Headquarters
2 ri
Assistant Coroner Mr Xavier Mooyaart 20 Wate Taden
Southwark Coroners Court SE18SD
1 Tennis Street Tel: 0207 783 2004
Southwark Fax: 0207 783 2009
SE1 1YD
www.londonambulance.nhs.uk
Your Ref: 02922-2018
Our Ref: 5429
14 August 2019
Dear Mr Mooyaart,

Regulation 28: Prevention of Future Deaths Report for Robert Cobbina

Thank you for your Regulation 28 Report dated 25 June 2019. | would like to take this
opportunity at the outset of my letter to offer my condolences to Mr Robert Cobbina’s family.

Thank you for informing the London Ambulance Service NHS Trust (LAS) of the concerns you
identified at the inquest into Mr Cobbina’s death, which took place on 10 June 2019. We
welcome the opportunity to investigate your concerns and learn from this incident. If we had
been given earlier notification of the inquest and participation in the proceedings it is possible
that the LAS would have addressed not only the concerns you have raised in this Regulation
28 Report but also questions from the family by way of documentation and live witnesses.

The matters of concern you raised at the inquest is as follows:

1. Neither the caller nor the passer-by who continued the call with the emergency control
room were prompted to request the coastguard or other waterborne assistance despite
making it clear that the emergency related to a Person in the river. Whilst itis understood
that each service can subsequently involve other services as required, the concern
arises that there was a potentially significant delay in involving the appropriate assets
which would have been avoided at the point of triage.

The dispatch of resources in any category of cali is detailed in Operational Policy-
Emergency Operations Centre (EOC) Management of Complex Incidents Procedure
(OP61). OP61 sets out the fact that The Maritime Coastguard Agency (MCA) is responsible
for the coordination of incidents on the River Thames and the Royal National Lifeboat
Institute (RNLI) undertakes the search and rescue of patients.

OP61 states:

e The MCA must be informed of all calls involving the Thames, their banks and piers
where the rescue of persons or vessels are involved. The Metropolitan Police
Service (MPS) and London Fire Brigade (LFB) also have dedicated resources
working on the Thames and may be requested as appropriate, but this must not
prevent the MCA from being informed as they have primacy over the rescue of
patients.

On 2 November 2018 at 11.36am the LAS received a call from the patient's wife informing
the call handler that she found her husband’s clothes and shoes near the River Thames by
a bench. As soon as the call handler had sufficient information from the caller including a
delayed confirmation of the location they made a note on the call log. At 11.57am the
dispatcher sent a message to the MPS via the CAD link system informing them that both
the MPS and coastguard were required. The CAD link system is designed to provide a
messaging system between the LAS and MPS to request attendance and provide updates
in a speedy manner.

The dispatcher failed to follow this policy as they did not inform the coastguard directly.
Upon review of this incident it has become apparent that the procedure within OP61 needs
to be reviewed to eradicate any ambiguity and the individual dispatcher and all staff working
within EOC will be reminded of the correct procedure for informing the MCA.

Before receiving this Regulation 28 Report a meeting was already diarised between the LAS
and MCA which took place on 17 July 2019 and it was agreed that the LAS would remind
all staff of the current process for informing MCA within OP61 and to work closely to achieve
a more streamlined collaborative working agreement.

2. Neither the caller nor the passer-by were prompted to identify existing signage placed
along the riverfront providing a coastguard location reference to enable a swift and
precise arrival on scene.

The use of the coastguard signage along the River Thames was discussed at the meeting on
17 July 2019 and it was confirmed by MCA that coastguard signage is only specific to the
Greenwich stretch of the Thames path. We have reflected upon whether we should make it
mandatory for call handlers to request the coastguard signage from the caller. However, we
have concluded that this may result in a delay in the dispatch of resources as it would be difficult
to ensure that the information was only requested for the very limited area of the Greenwich
stretch and might require callers to move some distance in order to locate the signage. It would
be easier for callers to identify landmarks, roads etc in the vicinity instead.

Where a caller is uncertain of the exact location, call handlers are required to probe the caller
to ask for help from people nearby or identify roads, landmarks etc. On this occasion the call
handler made several prompts fo assist the original caller to identify the location, but she was
very distressed. The call handler asked her if there was someone else who could assist and a
passing couple then took over the call. This couple provided the coastguard reference, which
was noted by the call handler on the CAD. The call handler attempted to locate the call more
precisely by asking for nearby road names and postcodes. The female passer-by, by
ascertaining that the original caller lived nearby, established the postcode and was able to
identify that the Riverside Campus for University of East London was on the opposite side of

the river. Having reflected on the point raised we are satisfied that we do not need to change
the advice given to call handlers in this regard.

| hope this reply is helpful in explaining the actions taken to address the matters of concern.

Yours sincerely

2 oa Garrett Emmerson

Chief Executive Officer

NFCC _
National Fire |
Chiefs Council The professional voice of the UK Fire & Rescue Service

Assistant Coroner Xavier Mooyaart
Southwark Coroner’s Court

I Tennis Street

Southwark

SEL 1YD

Hertfordshire Fire and Rescue
Service Headquarters

Old London Road

Hertford SG13 7LD

Telephone: 01992 507507
Fax: 01992 503048
Direct Line:

Contact:

My Ref: DK/999LC/PFDR
Your Ref: 02922-2018

6" August 2019

Dear Mr Mooyaart,
Prevent Future Deaths Report for Robert Cobbina, FP

I am Chief Fire Officer for Hertfordshire and write as Chair of the 999/112 Liaison Committee
(999LC)* regarding the above report sent to the Committee on 26" June 2019. Thank you for the
report and the opportunity to identify lessons from this tragic event.

Perhaps before I respond to the Coroner’s Concerns it would be helpful to provide some background
to the way in which 999 calls are handled in the UK.

When a member of the public dials 999 (or 112) in the UK. their telephone supplier will connect them
immediately to BT 999 call handlers. The BT call handler will ask “Emergency which service?” and
based upon the response received will connect the caller to the emergency service they ask for in the
area that the caller is calling from. In order to identify that service the operator needs a response from
the caller indicating which service they need and also the location of the caller. The former is obtained
from the caller, the only exception being where they cannot communicate and in that case the operator
will follow some specific actions known as ‘The Silent Solution’, however that is not relevant to this
case.

The latter, the location, is obtained by the BT system through its connections to a number of databases
which include, billing addresses for landlines and through location services available via the mobile
network providers. All of this happens within a matter of seconds as soon as the call is presented to

Departments, the commercial telephone providers, BT who provide 999 call connection services and the
Emergency Authorities (Police, Fire, Ambulance and Coastguard) throughout the UK. ij
? With many years of experience to draw upon it is the view of the 999LC and BT that asking BT operators to i
seek further information about call types in order to test whether the caller is asking for the correct service i
would simply introduce an unnecessary delay — the operator would also need considerable training to understand
the capabilities and roles of all of the emergency services — these transfers are currently achieved in a matter of
seconds.

I
' For clarity the 999LC is the UK Government’s body which oversees the relationship between Government
|

the BT operator such that by the time the operator has ascertained which service is required they are
also presented with location and can quickly connect the call to the relevant emergency service
control room.

Once the call is handed over to the emergency service control room the location information, via a
system called the Enhanced Information Service for Emergency Calls (EISEC), is also passed to the
service, In almost all cases this is now in a data format and is presented on to operators mapping
screens, and, with the recent addition in to many control rooms of the Advanced Mobile Location
(AML) system, this can be accurate to within a few metres,

Based upon this location information and the information that is then gleaned from the caller about
their emergency the control room operators will despatch, as appropriate, the necessary responders.
As this is happening control room operators or supervisors will consider whether other emergency
services may also be required. Should that be the case then they will contact the other emergency
services using priority methods which we all have for such purposes.

It is perhaps pertinent to this case to note that all of the above assumes that the member of the public
making the emergency call only makes one-call, to one emergency service. In the event that they
make further calls it will be likely that the information will already have been made available by the
initial service where it is obvious that other services are required; for example in the event of a road
traffic collision it is likely that a call to the Fire Service will result in Police and Ambulance being
notified by the fire control operator and vice versa.

Coroner’s Concerns (Point 1)

IfI may now turn to the specific concerns raised by the Coroner these appear to relate to two aspects;
prompting callers to alert multiple emergency services and the use of location information available to
the caller on scene.

With regards to the need to alert multiple services it is the view of the 999LC that this should not be
required of the caller; once a call is received by one of the emergency services then we believe that it
would be reasonable for the public to expect that the emergency services will work together to ensure
that the appropriate resources are identified to resolve the incident irrespective of where the first call
is received, Given the context of an emergency, where callers may well be traumatised, it would also
be inappropriate to rely on them to ensure that appropriate information is passed to every relevant

service.

For that reason all emergency service control rooms have a range of methods available to them to
share information with other services, which includes the capability to share information with services
across the UK and indeed, as occasionally happens, with services in other countries. Control room
operators also receive training to help them understand the capabilities of other services such that they
are able to identify which may need to be alerted for specific emergencies. In some cases this may
also be supported by system prompts presented to the operator based upon information that they input

or are presented with,

Coroner’s Concerns (Point 2)

With regards to the concern that the callers in this case were not prompted for additional location
information then, as noted above, the emergency services have access to the EISEC and AML systems
which can provide, especially in the case of AML for callers using most mobile phones, very accurate
location information without the need for callers to provide it. It is therefore often not necessary for
additional landmarks to be sought. Each emergency service does however have a variety of back up
capabilities to identify location where the primary means has not provided sufficient accuracy. This
ranges from simply asking the caller, through the use of landmarks such as described in the report,

identification of motorway marker posts, and even local colloquialisms. I do not have details of the
call handling for this specific incident, however it is entirely possible that the operator felt that they
had an accurate location of the caller. Clearly in this case though the location of the deceased was
substantially more difficult to ascertain and might, like many incidents we attend, have been moving
due to the flow of the river,

Future Developments

As I am sure you would expect the emergency services are keen to provide the most efficient and
effective service possible to the public and there are therefore a number of future developments which
will further improve that:

« Emergency services that do not currently have access to the latest location services are
expected to have plans in place to introduce these soon;
* The current system of incident transfer between emergency services is being developed to |
utilise data transmission via a protocol called Multi-Agency Incident Transfer (MAIT), this
allows emergency services to speed up transfer of incident details from one service to another.

I hope that this response provides you with the reassurance that you seek but should you require
further information please do not hesitate to contact me.

Yours sincerely,
Co

Chief Fire Officer, Hertfordshire Fire and Rescue Service
Chair of the 999 Liaison Cominittee

ary to the 999/112 Liaison Committee
London Ambulance Service NHS Trust

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