Ivan Ignatov

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

1st August 2023 

BY EMAIL: 

Rachael Griffin 
Senior Coroner 
Coroner area of Dorset 

Dear Ms Griffin 

IVAN RUMENOV IGNATOV (DECEASED) 

I am writing in response to the preventing future deaths report we received at the Association of 
Ambulance Chief Executives (AACE) dated 8th 
behalf of the AACE.  

 June 2023, and I respond as our Managing Director on 

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh 
Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, 
co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the 
English ambulance services and the improvement of patient care. It is a company owned by NHS 
organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison 
Committee UK ambulance service clinical practice 
constituted to mandate or 
meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-
groups. 

guidelines (the “JRCALC guidelines”). AACE is not 
instruct ambulance services however it has national influence via the regular 

With regard to your matter of concern relating to ambulance services: 

There is a lack of knowledge and/or understanding amongst emergency services and search and rescue 
services, especially around terminology, process and communication for them to ensure they can work 
together when an incident 
consideration is given to further 
rescue services to 
processes 

are understood to avoid any doubt of what action is taken when an incident is ongoing. 

ensure communication can be facilitated without delay, and ensure terms and 

arises without confusion or misunderstanding arising.  I would request that 

 national and local training or guidance across emergency and search and 

AACE work closely and regularly at a 
national level with our partners in police, fire and rescue, and search 
and rescue. We have representation 
on the UK Search and Rescue (UKSAR) national groups hosted by 
HM Coastguard (HMC) on behalf of the Home Office. I am pleased to learn from colleagues at HMC, that 
details of your concerns will be discussed at the UKSAR Communications working group and the efficacy 
of interagency operational communication will be examined further with particular relevance to the points 
you have raised. 

In addition to the UKSAR forums, interagency liaison and training across the emergency services is 
continuous. Along with the other emergency services, the ambulance sector and the National Ambulance 
Resilience Unit (NARU) looks to embed the principles of the Joint Emergency Services Interoperability 
Programme (JESIP) doctrine throughout our operational services. An essential element of the JESIP 
programme is to optimise clear communication with interagency working and the Medical Advisor to NARU 
is aware of your concerns and is looking to ensure learning from this tragic incident takes place. We are 
also aware of ongoing work following the Manchester arena inquiry looking to improve interoperability 
through research led by the Home Office. 

AACE are not responsible for the training 
services at a regional level, training is often reviewed and updated and where possible joint training 

of ambulance staff, however we are aware that within ambulance 

Chairman: 

Managing Director: 

A18 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 exercises with partner emergency and search and rescue services takes place. We are very aware of the 
importance of working together to ensure incidents are managed well when multiple agencies are involved. 

On behalf of AACE, I would like to extend our sincere condolences to the family of Ivan Rumenov Ignatov. 

I hope this response has adequately addressed the concerns that you have raised. If you have any further 
questions please do not hesitate to get in touch. 

Yours sincerely 

Managing Director 

Chairman: 

Managing Director: 

A19

The checklist sets out the questions which custody officers must ask when assessing detainees.  Once 

this amendment has been made the College will write to forces informing them of the change. 

We are aware that many force’s custody systems are embedded within a wider records management 

systems and may take some time to update their systems. 

There is a substantial list of questions about issues that may indicate a higher risk of harm for detainees 

and the answers to these questions are recorded.  When answers to the existing questions suggest a 

risk of harm, custody officers should enquire further and take steps to ensure the safety of the 

detainee.  We are aware that this is a very common process with custody officers routinely assessing 

whether detainees should be subject to extra checking and arranging for this extra care. 

2. 

Insufficient national guidance to custody officers on how to assess risk ( low , med, high 

risk like policing grades missing persons). 

There is very limited evidence on the effectiveness of risk assessment tools.  These tools are designed 

to assist professional judgement. The College has produced risk assessment principles that give strong 

and consistent messages about assessing risk. The first of the ten principles makes clear that risk 

assessing is not a certain process and that assessors make decisions in situations of considerable 

uncertainty. Principle three makes clear that risk assessing is a matter of judgement and balance. 

Principle four states that harm can never be totally prevented. The ten risk principles, taken together, 

give comprehensive guidance on how to carry out risk assessment. 

The ‘high, medium, low’ grading system for missing persons is still based on officers using their 

professional judgement. It does not transfer well to the custody setting because the role of the custody 

officer and the function of detention is completely different to the roles and functions in relation to 

investigating a missing person.  We consider the current arrangements in which custody officers 

consider the nature of the risk of harm and how best to reduce or remove that risk to be effective (by, for 

example, increase visiting, removing ligature material from detainees, enlisting the support of an 

appropriate adult, calling in a medical practitioner). Creating categories of risk in a custody setting would 

not, in our view, assist in managing the nuances of risk that custody officers routinely manage.  We do 

however maintain an open-mind based on the evidence and work with partners. 

3.  Lack of guidance on releasing a person without an address. 

It is important to recognise that, if a custody officer concludes that the reasons for detention no longer 

exist, the law is clear that the detained person must be released, with or without bail, unless there are 

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 other powers to detain (S34 Police and Criminal Evidence Act 1984).  As set out below, in our 

experience, there would not have been sufficient grounds to detain Mr Ignatov for mental health 

assessment. This means that, regardless of his accommodation situation, he had to be released when 

the custody officer concluded that there were no grounds for continued detention. 

There is content in Detention and Custody APP on action to take if a person does not have an address 

when being released from custody.  It must be borne in mind that it is not unusual for detainees to be of 

no fixed address, and it is noted in the APP that detainees could be referred to social care, 

hostels/refuges etc. There are two issues to be considered. Firstly, is there a likelihood that the detainee 

may come to harm – the police can signpost detainees to support services but do not have powers to 

take further action unless their behaviour gives rise to concerns about a person’s mental health to the 

extent that they should be subject to a mental health assessment under mental health legislation.  For 

this to happen, there would need to be a belief that the person presented a risk of significant harm to 

themselves or others. Whilst there were some indicators of this in the case of Mr Ignatov, in our 

experience, the circumstances as described would not have met the threshold to justify detaining him for 

the purposes of mental health assessment. In such cases, options for the custody officers include 

signposting detainees to available support before release.  There are no additional powers to detain. 

The second issue relates to steps that may be taken if a person does not attend a police station or court 

to answer their bail. Detainees of no fixed address pose particular problems in this regard and custody 

officers, when releasing people without a fixed address, will have regard to any other arrangements that 

could be put in place to communicate with the released person, should that be necessary.  For example, 

there may be services regularly accessed by the person that could be used as an information conduit, or 

family/friends who may be willing and able to assist. 

The Detention and Custody APP contains a number of references to risk assessment prior to release. 

Reference is made to referral of detainees to social care, healthcare and charity support organisations. 

APP states that forces should also provide written material to help a detainee self-refer to agencies 

should they wish to at a later point. 

Thank you once again for raising these issues of concern, and we hope that the above assists in 

addressing your recommendations. 

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 Yours sincerely  

Chief Executive Officer 
College of Policing 

Chair 
National Police Chiefs’ Council (NPCC) 

A4

Mrs Rachael Griffin 
Senior Coroner for Dorset 
Dorset Coroner’s Court 
Town Hall 
Bournemouth 
BH1 6DY 

Dear Mrs Griffin 

Dorset Police 
Force Headquarters 
Winfrith 
Dorchester 
DORSET 
DT2 8DZ

 Date: 26th July 2023 

INQUEST INTO THE DEATH OF IVAN RUMENOV IGNATOV 

I am writing in relation to the above inquest and specifically the Regulation 28 Report, 
(to prevent future deaths), that you have directed to the Chief Constable following the 
conclusion of the inquest hearing. The Chief Constable has asked me to respond on 
her behalf, as I had oversight of the conduct of the inquest into Ivan’s death, at Chief 
Officer level, on behalf of Dorset Police. 

Firstly, I want to take this opportunity to both express my personal condolences, and 
condolences on behalf of Dorset Police, to Ivan’s friends and family for their loss. 

Secondly,  I  am  grateful  to  you  for  bringing  the  matters  of  concern,  raised  in  the 
Regulation 28 report, to my attention. I welcome the opportunity to reassure you that 
we have very seriously, and carefully, considered what we can learn from Ivan’s death 
with  a  view  to  improving  the  service  that  we  provide  to  the  public.  If  you  have  any 
further queries or concerns arising out of this response, I welcome the opportunity to 
discuss them with you. 

I will use the remainder of this correspondence to respond to each of your concerns, 
as set out in the fifth box of the Regulation 28 report, quoting your concerns ahead of 
response, for ease of reference. 

“There  is  not  sufficient  clarity  in  the  identifying,  collating  and  recording  of 
factors  which  may  increase  a  person’s  risk  on  the  Niche  system  that  Dorset 
Police,  and  other  forces  nationally,  use  and  as  a  result  information  could  be 
missed which is vital to a person’s risk assessment and their risk to themselves
or others.” 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                       
 
 
 We have updated the Niche system in a way that we believe addresses this concern. 
A dropdown menu is now included in the Custody Record for every detainee for the 
purposes of capturing such information. 

Additionally,  it  is  our  intention  to  remind  Custody  Staff  of  the  12  factors  indicating 
increased risk (as featured in the College of Policing Authorised Professional Practice 
- in relation to detention and custody risk assessment) by way of News Bulletin, and 
will  then  be  reviewing,  that  due  consideration  is  being  given  to  these  factors  by 
Custody  Staff,  by  way  of  dip  sampling,  as  a  part  of  our  culture  of  continuous 
improvement within the Dorset Police Custody hierarchy. 

We also note that the Regulation 28 report has been addressed to Niche directly, so 
it may be that they can provide you with further reassurance in this respect. 

“There is not sufficient guidance given to custody sergeants on a national basis 
of how to assess a person’s risk.” 

In preparing this response, we have been in contact with the College of Policing (who 
have also received the Regulation 28 report) and, on the basis that this is a National 
issue,  they  have  indicated  to  us  that  they  will  be  addressing  this  concern  with  you 
directly in their response to the Report. 

“There is no guidance, that I am aware of, which addresses what should be done 
by  police  forces,  and  particularly  custody  sergeants,  when  a  person  is  to  be 
released without an address to reside at and I would request consideration is 
given to such guidance being provided.” 

The College of Policing have again indicated that they will be addressing this concern 
with you directly in their response to the report, on the basis that this is also a National 
issue. 

“There  is  a  lack  of  knowledge  and/or  understanding  amongst  emergency 
services  and  search  and  rescue  services,  especially  around  terminology, 
process, and communication for them to be ensure they can work together when 
an  incident  arises  without  confusion  or  misunderstanding  arising.  I  would 
request  that  consideration  is  given  to  further  national  and  local  training  or 
guidance  across  emergency  and  search  and  rescue  services  to  ensure 
communication  can  be  facilitated  without  delay,  and  ensure  terms  and 
processes are understood to avoid any doubt of what action is being taken when 
an incident is ongoing.” 

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   (who  manages  the  Force  Incident 
In  April  2023,  Chief  Inspector 
Managers  as  the  Performance,  Standards  and  Partnership  lead  for  Contact 
Management)  met  with  Senior  Members  of  His  Majesty’s  Coastguard  to  deliver  a 
bespoke  Missing  Persons’  Package,  to  promote  conversations  and  understanding 
around  these  issues,  and  indeed  all  joint  Agency  incidents. It  is  Chief  Inspector 
  view  that  this  has  prompted  reflection,  from  all  present,  in  respect  of  joint 
working,  which  is  proving  to  be  an  incredibly  positive  move  forward,  in  terms  of 
providing a foundation for future working between Dorset Police and HMCG. 

A  Senior  Manager  from  HMCG  also  attended  the  Force  Incident  Manager  and 
Deployment Manager Continuing Professional Development days in July 2023. These 
Events  are  held  several  times  a  year  to  generate  discussions  about  policies, 
processes,  and  deployments.  These  particular  sessions  served 
improve 
understanding in terms of the respective obligations of Dorset Police and HMGC. This 
meeting was so positive and productive, that Dorset Police and HMCG have agreed 
to similar meetings every six months, for the specific purpose of reviewing our working 
practices and ensuring compliance. We also believe that these meetings will serve to 
improve the understanding of agency-specific terminology. 

to 

Where  HMCG  are  considering  a  tactical  option  in  relation  to  any  response,  a 
mandatory so-called Connect Call with the HMCG Duty Coastal Officer (equivalent to 
a  National  Inter-agency  Liaison  Officer)  will  take  place  with  the  HMCG  Regional 
Control Room, to provide a briefing to ensure shared situational awareness and that 
all relevant parties understand the overall tactical plan. All Duty Coastal Officers are 
now Police Search Adviser (“PoLSA”) trained, in the same way that Police equivalents 
are. It  is  also  our  understanding  that  Duty  Coastal  Officers  are  also  able  to  assist 
regarding any unclear terminology at the time of an incident of concern. 

The  Joint  Emergency  Services  Interoperability  Programme  (“JESIP”)  is  the  agreed 
national  approach  to  multi-agency  working  in  response  to  incidents,  regardless  of 
whether  they  are  low  level  or  major  incidents.  In  simple  terms,  it  represents  all 
Agencies,  ensuring  that  their  respective  Commanders  are  in  contact  at  the  earliest 
opportunity, and at the appropriate location, to share their awareness of the matter in 
question and to agree matters, such as which agency will take primacy, what actions 
are  required,  and  what  the  risks  are,  in  relation  to  the  incident  in  question.   It  also 
covers radio communications, safety matters, and the understanding of capabilities of 
each  agency.  Since  Ivan’s  tragic  death,  a  significant  amount  of  work  has  been 
undertaken within the scope of the JESIP in terms of joint working. Dorset Police is 
developing those relationships further with all, so-called, Blue Light Services. 

A26 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Finally, we understand that the number of Airwaves radios (used by the Police), that 
are held and used by HMCG, will continue to increase. All of these radios have access 
to a, so-called, Talkgroup to enable agencies to speak with each other when required. 
We also understand that the National Police Air Service now have access to all HMCG 
radio communications. 

“Leaflets given to detainees, when released from police custody, are not always
accessible  due  to  language  or  literacy  barriers  and  I  would  request  that 
consideration  is  given  nationally  by  NHS  England  and  all  Police  Forces  to 
ensure  that  any  documentation  detainees,  especially  any  providing  help  and 
assistance, is accessible to them.” 

The leaflets used by Dorset Police can now be printed in any language following a 
successful  trial  of  using  the  Google  Translate  translation  software.  It  is  also  the 
intention of Chief Inspector Neil Phillips, in his capacity as Custody Lead for Dorset 
Police,  to  share  this  development  with  the  National  Custody  Lead  (based  at  the 
National Police Chiefs’ Council). 

The leaflets used by Dorset Police can now be printed in any language following a 
successful  trial  of  using  the  Google  Translate  translation  software.  It  is  also  the 
,  in  his  capacity  as  custody  lead  for  Dorset 
intention  of  Chief  Inspector 
Police, to share this development with the national custody lead (based at the National 
Police Chiefs’ Council).” 

“In  the  Niche  occurrence  log  when  an  entry  is  placed  entitled  “Primary 
Investigation” where there are 15 different sections to be completed, number 2 
deals with the suspect. This does not however cover anything concerning the 
risk to the suspect themselves. There is nowhere other than on the custody risk 
assessment  where  officers  managing  the  case  can  record  the  risks  to  the 
suspect themselves, unless they record this as a free type entry on the custody 
record  or  the  Niche  occurrence  log.  Information  gathering  and  collating  can 
therefore  be  missed  and  key  information  around  a  suspect’s  risk  may  not  be 
highlighted  in  a  clear,  easily  accessible  location.  When  a  person  is  released 
from police custody, the investigating officer and the custody sergeant submit 
reports for the bail application to be considered by the duty Detective Inspector 
to approve.” 

Although  you  have  not  itemised  this  as  a  concern  at  Section  2  of  Box  5  of  the 
Regulation 28 Report, I also want to take the opportunity to offer, what I hope will be, 
reassurance to you in this respect. 

In short, we are in the process of implementing changes to Niche, locally, which will 
see  Section  2  of  Occurrence  Logs  on  Niche  amended,  to  prompt  the  Custody 
personnel to consider risk and vulnerability regarding the detainee in question. 

A27 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I  do  hope  that  this  reassures  you  that  Dorset  Police  have  reflected  on  the 
circumstances of Ivan’s death, and the inquest, and we have taken meaningful steps 
to avoid such an occurrence in the future. 

As  I  have  indicated  above,  I  would  welcome  contact  from  you  directly  if  you  would 
benefit from discussing the contents of this response. 

Yours sincerely 

T/Assistant Chief Constable 

A28

Dorset & Wiltshire Fire and Rescue Service 
Five Rivers Community Health & Wellbeing Centre, 
Hulse Road, Salisbury, Wiltshire SP1 3NR 

Date: 

22 August 2023 

Rachael C Griffin 
Senior Coroner 
His Majesty’s Coroner for the County of Dorset 

By email only. 

Dear Rachael, 

I am writing in response to Coroner’s Support 
the Coroner’s report written under 
and regulations 28 and 29 of the Coroners (I 
inquest into the death of Ivan Rumenov 

, letter of 8 June 2023 and 
paragraph 7, schedule 5, of the Coroners and Justice Act 2009 

Officer, 

nvestigations) Regulations 2013, concerning the 

Ignatov, who lost his life in July 2020. 

On behalf of Dorset & Wiltshire Fire 
express my sincere condolences to Ivan’s 
the inquest was conducted in such a way that 
to be rigorously examined, and subsequent 
appropriate actions implemented across a 

and Rescue Service I would like to take this opportunity to 

family.  I very much appreciate your efforts to ensure that 
allowed the circumstances surrounding this incident 

areas identified to ensure lessons are learnt and 

wide range of organisations. 

My response to your Matters of Concern is 
report: 

focussed on those raised in section 5, 2, iv, of your 

‘There is a lack of knowledge and/or 
rescue services, especially around 
[sic] they can work together when an incident 
I would request that consideration is given to 
emergency and search and rescue services 
delay, and ensure terms and processes 
taken when an incident is ongoing.’ 

understanding amongst emergency services and search and 
terminology, process and communication for them to be ensure 
arises without confusion or misunderstanding arising. 
further national and local training or guidance across 
to ensure communication can be facilitated without 
are understood to avoid any doubt of what action is being 

directly involved in the search and rescue operation on this occasion, 

Although the Service was not 
we work closely with our colleagues in the 
services, including police, ambulance, and His 
identify that we remain committed to the Joint 
(JESIP).  The JESIP joint doctrine 
train all our incident commanders and contains 

wider emergency services and search and rescue 

Majesty’s Coastguard.  It is for the reasons you 
Emergency Services Interoperability Principles 

interoperability framework forms the foundation on which we 
the five principles of joint working: 

•  Co-locate 
•  Communicate 
•  Co-ordinate 
•  Jointly understand risk 
•  Shared situational awareness 

These principles are applied at all levels of our 
(strategic).  Following the initial acquisition 

incident command from level 1 (initial) to level 4 
of skills, the command competence of individual Dorset 

Chief Fire Officer 

 QFSM FIFireE 

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 & Wiltshire Fire and Rescue Service incident commanders is continually assessed and recorded at 
specific frequencies.  This is achieved through both naturally occurring incident attendance and 
exercising, in line with National Operational Guidance. 

The Service is an active member of the Dorset Local Resilience Forum, who consider JESIP as a 
key area for continuous improvement.  Through this forum, the challenges of intra-operability with 
partners, who have different radio communications, is an area of focus for the Blue Light Group on 
18 September 2023.  Our Service will be appropriately represented at this meeting. 

I trust that my response addresses the issues that you have raised, that are directly relevant to 
Dorset & Wiltshire Fire and Rescue Service.  Please be assured of our commitment to continuous 
improvement. 

Yours sincerely, 

Chief Fire Officer 

Chief Fire Officer 

 QFSM FIFireE 

A30

Bay 3/13 
Spring Place 
105 Commercial Road 
Southampton 
SO15 1EG 

Senior Coroner Rachael Griffin 
The Coroner's Office for the County of Dorset 
Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

28 July 2023

Dear Senior Coroner Griffin, 

Inquest into the death of Ivan Ignatov – response to Regulation 28 Prevention of Future 
Deaths Report 

I  write  on  behalf  of  His  Majesty's  Coastguard  ("HM  Coastguard")  in  response  to  your 
Regulation 28 Report, dated 08 June 2023, issued following the inquest into the tragic death 
of Mr Ivan Ignatov. 

We  have  carefully  considered  the  learnings  arising  from  the  inquest  into  the  death  of  Ivan 
Ignatov, and the concerns set out in your Regulation 28 report. 

As an  organisation  dedicated to saving  lives, HM  Coastguard  welcomes any opportunity to 
reflect and learn. For HM Coastguard to undertake our role, we rely upon close collaboration 
and working arrangements with our emergency services and search and rescue partners. We 
are  grateful  for  your  report,  encouragement  for  improvements  in  multi-agency  operations, 
understanding and communications. 

I  hope  that  the  below  information  (attachment  1)  reassures  you  that  HM  Coastguard  are 
committed to addressing the concerns identified and have substantive plans in place to work 
with  our  partners  both  locally  and  nationally  to  improve  safety.  We  welcome  any  further 
recommendations and feedback from HM Senior Coroner. 

Yours sincerely, 

Chief Executive 

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 Attachment 1 

Ongoing Inter-Agency Liaison 
,  HM 
During  the  inquest,  we  provided  HM  Coroner  with  a  statement  from 
Coastguard's Lead for  Civil  Resilience. Tristam provided an  overview  of  the  joint exercising 
and  training  events  that  take  place  at  a  local  level,  via  the  Local  Resilience  Forum  (LRF), 
Dorset Local Search and Rescue Committee (LSARC) and the Dorset Blue Light Group. 

The Dorset LSARC is chaired by HM Coastguard and includes the wider search and rescue 
community and is not limited to category 1 responders. LSARC meetings typically include HM 
Coastguard  updates  for  search  and  rescue,  updates  from  each  organisation,  reviews  of 
significant  incidents (including lessons identified, joint operational learning,  informal mission 
reviews  and  operational  learning  reviews),  interoperability  and  exercise  and  training 
opportunities. The Dorset Blue Light Group is chaired by the Civil Contingencies Unit for Blue 
Light organisations and meets twice a year to discuss matters including 'hot topics', debriefs, 
urgent business and concurrent risks and joint organisational learning. 

The following inter-agency meetings have taken place since the conclusion of the inquest. 

•  05 June -HM Coastguard participated at a debrief with emergency services and local 

authority partners following the Bournemouth Pier Incident 

•  06 June – HM Coastguard participated at a Working Together workshop held on 

behalf of the High Sheriff of Dorset by the LRF (during which our Coastal Operations 
Area Commander gave an overview of HM Coastguard capabilities) 

•  07  June  –  HM  Coastguard  participated  at  the  Dorset  LRF  Capability  Risk  Review 

Meeting. 

•  15 June –  HM Coastguard participated at a further debrief with emergency services 

and local authority partners regarding the Bournemouth Pier Incident. 

•  05  July  –  HM  Coastguard  participated  in  a  Dorset  LRF,  Dorset  Prepared  Website 

consultation. 

•  12 July – HM Coastguard attended the Dorset Police Force Incident Commander CPD 
(Continual  Professional  Development)  event  during  which  our  Coastal  Operations 
Area Commander gave an overview and update on HM Coastguard capabilities. 
•  25 July – HM Coastguard participated at a further debrief with emergency services and 

local authority partners following Bournemouth Pier Incident. 

The following events or meetings are scheduled to take place in the coming months: 

•  02 August – HM Coastguard will attend the Dorset LRF BMG / Dorset LRF Capability 

Risk Review meeting. 

•  09  August  –  HM  Coastguard  are  a  Guest  speaker  at  the  Water  Save  Search  and 
Rescue  Workshop  which  will  be  attended  by  emergency  services  and  Search  and 
Rescue partners. We will provide an overview and update on Lost & Missing Persons 
Search with a water safety and rescue focus. 

•  23 August –  HM Coastguard will attend the  Dorset LRF executive which covers the 

highest risks for the area from the National Risk Register. 

•  31 August to 3 September HM Coastguard will work with emergency services and local 

authority partners at the Bournemouth Air Festival. 

•  18  September  –  HM  Coastguard  will  attend and participate at the Dorset  LRF Blue 

Light Group 

•  18 September – HM Coastguard will Chair the Dorset LSARC. (Details of content of 

meeting set out above) 

•  26  September  –  Our  Coastal  Operations  Area  Commander  attending  Dorset  LRF 

Strategic Coordinating Group training. 

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 •  26  September  –  HM  Coastguard  will  attend  the  Dorset  Police  Force  Incident 

Commander CPD event. 

A number of these meetings have provided an opportunity to directly address your concerns 
and improve understanding  between partner  organisations. For  example, Area  Commander 
 attended the Dorset Police Force Incident Commander CPD on 12 July to update 
the force on the capabilities of  HM  Coastguard and  its declared facilities,  the importance of 
calling  HM  Coastguard's  coordination  centre the  Joint Rescue  Coordination  Centre  (JRCC) 
early,  and  the  on-the-ground  roles  undertaken  by  full-time  coastal  staff  at  incidents.  This  is 
part  of  an  initiative  set  up  between  HM  Coastguard  and  Dorset  Police to  promote  effective 
working between the two agencies and will be the first of many CPD sessions HM Coastguard 
will  facilitate  with  the  Dorset  Force  Incident  Managers,  with  the  next  one  scheduled  for  26 
September 2023. 

Further stakeholder engagement 
Additionally,  from  September  2023,  the  JRCC  Manager  will  be  working  closely  with  HM 
Coastguard's Coastal Operations Area Commander to increase resources for and further build 
on  stakeholder  engagement.  They  cumulatively  have  in  excess  of  45  years'  experience 
working for HM Coastguard and working with other search and rescue organisations. 

Work  is  already  underway  to  strengthen  engagement  with  other  stakeholders  to  establish 
communication with equivalent level personnel from the following organisations: 

•  Hampshire Police 
•  South Central Ambulance Trust 
•  Dorset Police 
•  NPAS Bournemouth 
•  Dorset Fire 
•  Hampshire Fire 
•  South West Ambulance Trust 

Emergency Services Control Room Liaison 
Following the inquest, HM Coastguard are committed to fostering direct relationships between 
personnel  in  our  control  rooms  and  those  of  our  emergency  services  partners,  and  to 
developing shared understanding of each other's roles and capabilities. To achieve this,  we 
have put together a clear plan which is set down below. 

HM Coastguard External Visits 
In order to address the Senior Coroner's concerns around control room level communication 
and understanding,  all  staff  based  at  the Joint Rescue Coordination  Centre in Fareham  will 
partake in a series of Emergency Services Control Room visits (Police. Fire and Ambulance) 
commencing in September 2023. 

Visits will involve small groups (2-4 staff members at a time) and will require staff to spend the 
working day at another Emergency Service Control Room. A specific set of objectives will be 
provided  to  ensure  the  experience  provides  maximum  benefit  and  to  ensure  consistency 
across visits. Objectives will have a particular focus on developing an understanding of each 
emergency service including the following: 

•  Roles 
•  Resource availability, capabilities, and limitations 
•  Areas of responsibility 
•  Processes 
•  Terminology 
•  Means of communication 

A11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 On completion, HM Coastguard Team Leaders will ensure that objectives have been achieved 
and capture  any  additional  learning  with  a  view to imbed  within our  operation. To  date,  two 
visits have already taken place, with team members from the JRCC visiting Hampshire Police 
Control Room on 7 and 8 June and 26 and 27 June. 

Emergency Services and Search and Rescue Partner visits to the JRCC 
Additionally, other Emergency Services have been invited to visit the JRCC to enhance their 
understanding of HM Coastguard's operations. 

JRCC  staff  have  prepared  bespoke  presentations  for  each  emergency  service  in  order  to 
deliver specific and relevant information to visiting personnel in a consistent manner. 

HM  Coastguard Team  Leaders and staff  will  ensure that  the content  includes specific detail 
identified  from  incident  reviews,  experience,  and  operational  learning. As  with  the  external 
visits, there will be a particular focus on improving our partners' understanding of: 

•  The role(s) undertaken by HM Coastguard officers. 
•  Our resource availability, capabilities, and limitations 
•  Our areas of responsibility 
•  Our processes (including around the tasking of search and rescue assets) 
•  Our terminology 
•  Our means of communications 

Visitors  will  engage  with  staff  in  both  Maritime  and Aeronautical  teams  to  ensure  that  they 
receive a full appreciation of operational activity within the JRCC. 

One visit has already taken place with South West Ambulance staff attending on 5 July. The 
following two visits are also due to take place: 

•  11 Aug – visit from South West Ambulance (Tactical Officers) 
•  11 Sep - visit from South West Ambulance (Senior Staff) 

In order to be able to capture Control Room staff in different roles and working patterns, visits 
will be available during day shifts, but the JRCC also intend to hold a series of evening ‘open 
day’ events for all services. These will predominantly take place outside of HM Coastguard's 
peak season which occurs from July through to September. 

Feedback from partners on visits to the JRCC will be collated following each visit and following 
external visits via HM Coastguard Team Leaders. Content will then be reviewed by the JRCC 
Rescue Coordination Centre Manager through monthly meetings to ensure that objectives and 
presentation  content  is  reviewed  and  adjusted  accordingly.  Any  identified  learning  will  be 
communicated within the teams at the JRCC. 

UK Wide Engagement 
The geographical area routinely covered by the JRCC in Fareham stretches from Torbay in 
the South West to Hastings in the South East. Visits to Control Rooms covering Sussex will 
follow on in due course. 

Learning and best practice garnered from this inter-agency liaison will also be shared more 
widely across the entire HM Coastguard community to further develop the work already being 
undertaken by Coastal Area Commanders and RCCMs in different parts of the UK. 

HMCG Capability Document 
During  the  inquest,  we  provided  the  Senior  Coroner  with  a  Capability  Matrix,  which  was 
prepared in 2021 for the purpose of informing partner emergency services across the UK of 
HM Coastguard's capabilities. 

A12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 inquest,  this  was  updated  to  provide  further 

Following  the 
information  around  our 
communications  capabilities.  We  enclose  a  copy  of  the  updated  Capability  Matrix  with  this 
response. This has also been uploaded to the MCA's ResilienceDirect page, where it can be 
downloaded and viewed by our emergency services partners. ResilienceDirect is a web-based 
platform  used  by emergency services that allows for  real  time  information  sharing  between 
services. 

We understand the RNLI are also considering similar updates and information sharing via their 
ResilienceDirect page’. 

‘Connect’ call capabilities. 
During  the 
its 
communications  capabilities  both  in  terms  of  VHF  (the  primary  means  by  which  HM 
Coastguard communicates with search and rescue assets) and telephony. 

inquest,  evidence  was  provided  by  HM  Coastguard  in  respect  of 

HM Coastguard has the technical capability to put a maritime rescue asset (such as an RNLI 
lifeboat)  into  a  ‘connect  call’  with  shore-side  responders  (such  as  the  police)  using  mobile 
phones via its Maritime Rescue Coordination Centres ("MRCC"). This capability facilitates the 
connection of a mobile phone to a marine VHF radio, with the HM Coastguard control room 
able to participate in the call to ensure that information is shared accurately between partners 
and that appropriate actions are taken by the coordinating team within the MRCC. 

This capability features in the core training and assessments for staff in the MRCCs. This will 
also  now  feature  in  routine  exercising  with  other  stakeholders  and  during  the  Emergency 
Control Room visits. 

A13

Ms Rachael Griffin 
Coroner’s Office for the County of Dorset 
Town Hall 
Bournemouth 
BH2 6DY 

Dear Coroner, 

National Medical Director 
NHS England 
Wellington House 
133-155 Waterloo Road 
London 
SE1 8UG 

25 August 2023 

Re: Regulation 28 Report to Prevent Future Deaths – Ivan Rumenov Ignatov 
who died on 31 July 2020. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 June 
2023 concerning the death of Ivan Ignatov on 31 July 2020. In advance of responding 
to  the  specific  concerns  raised  in  your  Report,  I  would  like  to  express  my  deep 
condolences to Ivan’s family and loved ones. NHS England are keen to assure the 
family and the coroner that the concerns raised about Ivan’s care have been listened 
to and reflected upon. 

It should be noted that many of the concerns raised in your Report do not fall under 
NHS  England’s  remit  and  I  am  only  able  to  provide  comment  on  those  concerns 
relevant  to  NHS  England.  I  note  that  you  have  addressed  your  Report  to  several 
parties  involved  in  Ivan’s  case,  to  include  Dorset  Police,  who  are  better  placed  to 
respond to many of the concerns raised. 

In responding to your Report, I have consulted with colleagues from the South West 
region, the national Mental Health Team, and the Specialised Commissioning Health 
& Justice Team. 

Regarding  your  concern  over  accessibility  of  resources,  NHS  England  encourages 
local systems to consider how to best meet the needs of their population and address 
any  inequalities  in  access  and  support.  That  includes  providing  information  in 
languages  and  formats  to  meet  the  needs  of  the  population.  Any  translation  and 
interpreting  service  are  commissioned  at  a  local  level,  to  reflect  the  local  and 
population needs. 

You  also  raised  a  concern  over  custody  release  practices  and  guidance.  In  Ivan’s 
case, while the Police did identify the need for referral to a mental health practitioner, 
it  is  not  clear  from  your  Report  that  a  referral  was  made  to  the  relevant  Liaison  & 
Diversion (L&D) Team or to the Police and Crime Commissioner (PCC) commissioned 
Police  Custody  Healthcare  Services  (PCHS)  Team,  who  are  commissioned  by  the 
Police directly, and who will advise the police on ‘Fitness to Release’ decisions. The 
L&D Team are a vulnerability service, not a local mental health crisis service. They 
are  not  responsible  for  providing  any  physical  healthcare  within  a  police  custody 
setting  or  to  undertake  pre-release  assessments,  which  falls  under  the  remit  of  the 
PCHS. 

A22                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
  
 
 
 NHS  England  has  been  sighted  on  the  agreed  actions  between  Dorset  Healthcare 
Criminal  Justice  Liaison  and  Diversion  Team  (Dorset  CJLD)  and  Dorset  Police  to 
improve their working practices. There are a number of comprehensive actions being 
taken to include a new referral form and process between CJLD and the Police, joint 
training,  a  review  of  leaflets  used  to  ensure  that  they  are  appropriate  and  can  be 
understood by detainees, as well as a new memorandum of understanding between 
Dorset  Police  and  the  CJLD  setting  out  the  operational  policy  in  place  within  the 
custody setting. This memorandum will be shared with NHS England so that it can be 
incorporated into the regular contract monitoring process. I understand that you have 
been  informed  of  these  actions  separately  by  Dorset  Healthcare  University  NHS 
Foundation Trust. 

Search  and  rescue  services  such  as  Coastguard  and  Mountain  Rescue  are  tasked 
through the Police and do not fall under NHS remit. Any multi-agency working such as 
that  which  took  place  during  the  search  for  Ivan  should  be  governed  by  the  Joint 
Emergency Services Interoperability Principles: Home - JESIP Website. 

I would like to provide assurances on national NHS England work taking place around 
the  Reports  to  Prevent  Future  Deaths.  All  reports  received  are  discussed  by  the 
Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and  other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around preventable deaths are shared across the NHS at both a national 
and regional level and helps us pay close attention to any emerging trends that may 
require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director 

A23

Rachel Clare Griffin 
Senior Coroner for Area of Dorset 

Sent by email to: 

c/o 71-75 Shelton Street 
Covent Garden 
London 
WC2H 9JQ 

1 August 2023 

Dear Mrs Griffin 

Thank you for raising the concern in relation to the death of Ivan Rumenov Ignatov on 11 
August 2020.  It is with great sadness that I read about the circumstances of his death. 
The National Fire Chiefs Council (NFCC) is committed to a culture of learning and 
improvement and seeks to support fire and rescue services (FRSs) to embed a learning 
culture.  We actively track Prevention of Future Deaths Reports and share them with our 
members to ensure all opportunities to improve are taken. 

The NFCC supports the consistent and robust embedding of the Joint Emergency Services 
Interoperability Programme (JESIP) doctrine, which promotes effective interagency working 
through its principles of Co-Location, Communication, Co-ordination, Joint Understanding 
of Risk, and Shared Situational Awareness.  Following a series of high-profile incidents 
before 2020, all FRSs have reviewed their current policies and training in line with JESIP. 

One such incident was the attack at Manchester Arena and the subsequent 
recommendations of the Manchester Arena Inquiry.  The recommendations are now being 
overseen through a Ministerial board with national blue light services.  Part of the work 
linked to the Board, being led by NFCC and other blue light partners, is to establish a 
process of providing additional national assurance about the application of JESIP across 
blue light services, and this work will commence in autumn 2023. 

The NFCC produce and maintain a suite of National Operational Guidance, which is 
considered good practice.  All FRSs should adopt the NFCC National Operational 
Guidance for Incident Command.  This provides guidance and makes calls to action for 
FRSs to comply with, which instruct FRSs to test communication equipment to ensure it is 
compatible with other services and agencies, to train together, and to adopt agreed multi 
agency guidance.  It also calls upon incident commanders to communicate using agreed 
structured briefing and debriefing systems, use plain English, including avoiding acronyms, 
and to confirm that all parties understand the information passed to them. 

Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. 
Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 
1954 46 

Continued…/2 

A20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 …/2 

The NFCC also provides guidance for fire control rooms to recommend setting up and 
sharing information with our multiagency partners, using agreed terminology and briefing 
structures. 

The supporting framework of guidance provides the appropriate tools for all FRSs to 
embed effective multi agency communication at incidents and promotes the correct pre 
incident actions to ensure multi agency communication can be implemented easily when 
required. However, it is acknowledged that interoperability between agencies is both crucial 
to the successful outcome of an incident and difficult to achieve consistently. 

The NFCC have engaged with Dorset and Wiltshire FRS, the JESIP principles are well 
embedded within their service. They lead on multi agency training and working closely with 
the Local Resilience Forum to embed effective multiagency communication during the 
response phase. 

Evidence suggests that the issue identified primarily relates to interoperability with one 
agency. This had been identified prior to the release of the coroners recommendations and 
actions are underway to address this to improve inter agency working practices. 

In response to the recommendations made the NFCC believes that appropriate guidance is 
available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and 
operational guidance while continuing to develop existing guidance to make its application 
more effective. 

Yours sincerely 

Chair 
National Fire Chiefs Council 

Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. 
Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 
1954 46 

A21

National Police Air Service response to Regulation 28 – Ivan Rumenov Ignatov (

) 

NPAS had 2 actions, one was joint with other agencies, and one was purely for NPAS. 

The Senior Coroner requested a visit to NPAS Bournemouth to get a greater understanding of the 
work we do. This has been completed and there is an open invitation for any further visits that are 
required. 

The second actions related to Section 5 subsection 2 part vi of the report and concentrated on the 
communication between the relevant emergency services. In brief, the home force, NPAS and HMCG 
all have access to Airwave and an Emergency Service channel should have been opened by the 
Home Force. This would have allowed the 3 services to communicate easily and is covered by the 
JESIP principles for matters of this type. RNLI do not have Airwave but have access to VHF which the 
HMCG also have so they are able to communicate in this way. 

On liaising with HMCG the following actions have been agreed: 

•  A series of joint familiarisation briefings to be held between HMCG and NPAS - this 

will encompass all staff to ensure corporacy across both organisations and to reflect 
the fact that as a National Service, there may be occasions when landlocked bases do 
have to respond to incidents involving HMCG/ Water rescue.  It will also include the 
Comms departments of both agencies. 

•  This familiarisation briefing will be considered for roll-out to Comms element of 
Forces where water-based rescue is frequent i.e.; South Coast, North Yorkshire, 
Northumberland, Lancashire to ensure they have awareness of each agency and 
capabilities of each.  An approach for the same to be made to the RNLI. 
•  Work to be commenced to develop a joint "quick action card" which will be 

distributed to all Forces and which prioritises the need for the Host Force ( in this 
case Dorset Police) to set an Emergency Services channel on Airwave which would 
allow early communication.  We will be asking for Chief Coastguard and NPCC 
assistance to push this course of action. 

•  Monthly Comms meetings to be held between Head of Ops Centre/ Equivalent 
HMCG staff member to de-brief incidents of note and assess lessons learnt. 

•  Quarterly meetings between C/Insp Ops and Assistant Chief Coastguard to discuss 

any emerging themes, strategies and joint working opportunities. 

•  Reciprocal visits between the HMCG / NPAS Ops Centres - to be arranged. 

A14

July 2023 

Rachael C Griffin 
Senior Coroner 
The Coroner’s Office for the County of Dorset 
Civic Centre, Bourne Avenue 
Bournemouth BH2 6DY 
Dorset 

Re: Ivan Rumenov Ignatov 

Dear Ms Griffin, 

I write on behalf of Niche Technology in response to your Regulation 28 Report following the 
inquest into the death of the above named. Specifically, this response focusses on the 
following concern insofar as it relates to the NicheRMS365 application. 

i. 

There is not sufficient clarity in the identifying, collating and recording of factors which 
may increase a person's risk on the Niche system that Dorset Police, and other forces 
nationally, use and as a result information could be missed which is vital to a person's 
risk assessment and their risk to themselves or others. 

As you may be aware, NicheRMS365 is used by 27 police forces in England and Wales and over 
the  past  20  years,  working  closely  with  our  customer  forces,  we  have  striven  to  ensure 
compliance with all legislative and procedural guidance. It was, therefore, surprising to hear 
that some of the guidance issued by the College of Policing Authorized Professional Practice 
Guidance (APP) in relation to risk assessments appears to be missing. 

As a company, Niche Technology, can unilaterally make changes to the RMS, but we are not 
the  policing  experts  and  are  reliant  on  our  customers  to  advise  us  on  matters  such  as  risk 
assessment content. Nevertheless, we recognize the importance of the issues you raise in your 
report and, as described below, have already taken action on the matter.  

Developments in NicheRMS 
In  order  to  manage  changes  within  the  RMS  system  that  will  meet  the  needs  of  all  our  UK 
Forces  and  each  specific  area  of  policing,  the  UK  Niche  Forces  created  the  Minerva 
collaboration.  Amongst  other  tasks,  this  group  considers  compliance  with  APP  and  best 
practice, recommending and agreeing where change is required. 

With such a large community of users, it is more efficient to manage requests for change via 
the Minerva Management Board (MMB).  The Board is currently chaired by the Chief Constable 
of Avon & Somerset and on a day-to-day basis, is supported by a Programme Director who has 
oversight of all change requests. 

Canada and Australia:  Niche Technology Inc. | 629 McDermot Ave. | Winnipeg MB, R3A 1P6 | Canada 

USA: Niche Technology USA Limited | 2118 W. Chesterfield Blvd. Suite D100  | Springfield MO, 65807 | USA 

UK: Niche Technology UK Limited | Reg. office: Azets, Wynyard Park House, Wynyard Avenue, Wynyard, Stockton on Tees | UK TS22 5TB 

Reg. England and Wales, No. 5122974 | Australia ABN 84 735 920 227 

+1 204 786 2400 | www.NicheRMS com 

A5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 everal working groups, each with responsibility for a specific business area (for example, Public 
Protection or Criminal Justice, or Intelligence) receive and review requests for change from 
Niche customers relative to their business area. The requests are prioritized and passed up to 
the MMB, which agrees the overall order, priority, and delivery of the change requests with 
Niche Technology. 

Current action taken to respond to the Report following the Inquest into the death of Ivan 
Rumenov Ignatov 
As a matter of priority, the Minerva Programme Director will manage the issue raised in your 
report with the Minerva Criminal Justice working group. 

Action has already been taken which includes: 

1.  Circulating the facts of your report to Niche Technology customers; 
2.  Seeking views on the changes needed to reduce the chance of a similar occurrence; 
3.  Proposal of a temporary solution pending consultation with all Niche forces. 

Whilst we await the outcome of the consultation with forces, which I anticipate can 
be concluded within the next 4 weeks, the Programme Director is suggesting an 
interim solution that will involve staff making the appropriate detention log entry 
as occurs for other risk assessment questions. 

As you have identified in your report, the question of whether the detainee has 
been  arrested  before  is  not  specifically  asked.  However,  there  are  pertinent  risk 
assessment questions that officers and staff should be aware of and which can be 
utilized as an interim location for recording such information.  These are identified 
in the  screen shot below. 

Page 2 of 4 

A6

In the Dorset Coroner's Court 

BEFORE HM SENIOR CORONER MRS GRIFFIN 

IN THE INQUEST TOUCHING UPON THE DEATH OF 

IVAN  RUMENOV IGNATOV 

Response to Regulation 28 Report to Prevent Future Deaths on behalf of the Royal National 

Lifeboat Institution (RNLI) 

Background 

1.  The Senior Coroner has identified two concerns relevant to the RNLI which relate to the t ragic 

death of Mr lgnatov.  Those are; 

a.  Communication between all agencies; and 

b. 

lack of knowledge and/or understanding amongst emergency services and search and 

rescue services around process and terminology. 

2.  The  RNLI  is  a charity that provides,  amongst other things, a 24/7 search  and  rescue  lifeboat 

service  through  a  strategically  located  fl eet  of  over  400  lifeboats  located  at  238  lifeboat 

stations across the UK, Jersey, Guernsey and Isle of Man 

3.  The  RNLI  operates two main classes  of lifeboat - all-weather lifeboats and inshore lifeboats. 

Within  these  categories,  there  are  a  number of different vessels  and  specific  capabilities. 

Broadly speaking, all-weather lifeboats are capable of 25kts and are designed to operate In  all 

weather conditions,  day or night and  out to 100 nautical miles from  the coastline. They are 

inherently self-righting after a capsize and fitted with an  array of navigation, and search and 

rescue  equipment.  The  RNLI  all-weather  fl eet  currently  consists  of the Shannon,  Severn, 

Trent, Tamar and M ersey class lifeboats.  Inshore lifeboats are subject to weather limitations. 

However,  they have  their own advantages  in  that they  can  reach  people  in  circumstances 

where the all-weather lifeboats could not.  They usually operate closer to shore, in shallower 

water, near cliffs, and rocks.  They are designed to be quick and manoeuvrable, allowing RNLI 

crews to get as  close as  possible  to those  in need  of assistance.  The inshore lifeboat fleet 

consists of the Band D class lifeboats, as  well as the Eclass lifeboats on the River Thames.  In 

A15 

 addition,  the  RNLI  also  uses hovershore rescue  hovercraft for areas  that are  inaccessible  to 

conventional  RNLI  lifeboats such  as  mud flats  and  river estuaries.  Hovercraft  are  sited  at 

Hoylake, Hunstanton, Morecambe, and Southend lifeboat stations. 

4.  As the Senior Coroner is aware the RNLI works closely with, but is not part of, HM Coastguard 

(the "Coastguard").  The government has a statutory duty to provide search and rescue,  and 
this is provided through the Coastguard.  RNLl  lifeboats are a voluntarily "declared  asset" to 
the  Coastguard  and  will  respond to tasking  requests made by the  Coastguard.  A declared 
asset is a facility that has given a declaration to t he Coastgua rd of a certain level of capability 
and availability and/or training such that they form part of the Coastguard's incident response 

process. The Coastguard is responsible for coordinating rescues at sea  including determining 

the  deployment of appropriate  assets.  As  well  as  the  RN LI  lifeboats  this  may  also  include 

assets owned and operated by other organisations. 

Communications 

5.  As  t he  Coastguard  is  the  tasking  authority and  responsible  for coordinating  searches,  the 

method of communication w ith the Lifeboat is via t he Coastguard following IMSAR protocols 

as  a  maritime  search  and  rescue  capability.  Having  other  multiple  organisations  able  to 

communicate with the  Lifeboat is  not effect ive.  It can  lead  to  conflicting  information bei ng 

given and undermine effective tasking as well as creating a distraction for the crews receiving 

multiple messages.  This, in turn, could hamper the effectiveness of the lifesaving service and 
lives could be lost if the crew are distracted or given conflicting information. 

6.  For these  reasons it is not considered appropriate for the other agencies such as the police to 

have direct contact with the Lifeboats. 

Process and terminol(}gy 

7. 

It is clear from the inquest that more work needs to be undertaken so that other emergency 

services/search and rescue partners understand the RNLl's capabilities and how it  operates. 

8.  Further  it  is  also  clear  that  more  work  needs  to  be  undertaken  t o  ensure  emergency 

services/search and rescue partners understand the terminology that is used in relation to the 

RNLI  to avoid any confusion or misunderstanding with those emergency services/search and 

rescue partners.  By way of example around the difference between tasking and launching. 

9.  The  RNLI  is  therefore  in  the process  of updating a page on  the government website  called 

"ResilienceDirect" platform (resilience.gov.uk). 

It will give details about our capabilities and 

so  that this  information  can  be  readily  available to emergency  services/search  and  rescue 
partners.  We  also  pulling  together material  to  be shar ed  directly with emergency  services 

partners  which  focusses  on  capabilities  and  limitations  such  as  search  equipment  and 

communication capabilit ies. 

A16 

 10. The RNLI w ill also work with the Coastguard to participate in some partner awareness 'open 

day' events that showcase capabilities between emergency servi ces/search and rescue 

partners. 

A17

Ms Rachael Griffin 
HM Senior Coroner for the County of Dorset 
Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

Trust Headquarters 
Abbey Court 
Eagle Way 
Exeter 
Devon 
EX2 7HY 

10 August 2023 

Dear Ms Griffin 

Inquest touching the death of Ivan Rumenov Ignatov 
Response to Report to Prevent Future Deaths issued on 8 June 2023 

I write on behalf of South Western Ambulance Service NHS Foundation Trust (SWASFT) 
to respond to the Report to Prevent Future Deaths which you issued on 8 June 2023. 

SWASFT was not an Interested Person at the Inquest and therefore had no information 
about the concerns which HM Senior Coroner has raised in the Report prior to receiving it. 
SWASFT has been advised by HM Senior Coroner that, as it was not an Interested 
Person, a copy of the inquest bundle cannot provided. We are therefore able to respond to 
the issues set out in the Report only to the extent that the Report itself provides relevant 
information. 

With section 5 of the Report, paragraph 1(vi) states: 

A number of emergency services and search and rescue services were involved in the 
events on the 19th July after Ian had tried to take the motor vehicle. These were 
Dorset Police, National Police Air Service (NPAS) His Majesty’s Coastguard (HMCG) 
& the RNLI. The police radio was accessible by Dorset Police and NPAS as a channel 
of communication and HMCG and RNLI are able to communicate via VHF radio but 
there is no direct communication between all services, for example for NPAS and 
HMCG to directly communicate, they go via the police command centre. This can lead 
to a misunderstanding of what is going on, on the ground. In this case it was the belief 
of the NPAS Tactical Flight Operator (TFO), who was aware that there was a risk to 
Ivan's life from about 22.15 hours, and also the Force Incident Manager (FIM) in the 
police command centre, that a lifeboat had been launched, when in fact it had not. 
They therefore believed one was on route when it was not. If they had been aware that 
it was not on route this would have allowed for further communications or direct 

A31 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 requests to be made between agencies, and other actions being taken. I was told in 
the evidence that there is work ongoing around an emergency services channel for 
communications, but this would not include search and rescue agencies and I have 
been told this is taking a considerable period of time to develop. 

There appears to be from the evidence a lack of understanding between emergency 
services and search and rescue teams about the work each other undertakes, the 
language and terms they use, and the tasks they undertake. 

Paragraph 2(iv) states: 

There is a lack of knowledge and/or understanding amongst emergency services and 
search and rescue services, especially around terminology, process and 
communication for them to be ensure [sic] they can work together when an incident 
arises without confusion or misunderstanding arising. I would request that 
consideration is given to further national and local training or guidance across 
emergency and search and rescue services to ensure communication can be 
facilitated without delay, and ensure terms and processes are understood to avoid any 
doubt of what action is being taken when an incident is ongoing. 

We note that the remaining concerns within the Report do not appear to relate to 
ambulance services. We are also not aware of any specific concerns of HM Senior 
Coroner regarding communication issues between SWASFT and other agencies in relation 
to the incident involving Mr Ignatov. Therefore this response is limited to addressing the 
concern identified above at a general level. 

Joint Emergency Services Interoperability Principles (JESIP)1 

JESIP aims to improve the ways in which police, fire and ambulance services (as a 
minimum) work together at major and complex incidents. It is an ongoing arrangement but 
has been strengthened over the last couple of years. 

The JESIP Joint Doctrine (edition 3 published in October 2021) sets out principles for joint 
working between the different services, which SWASFT ensures are implemented through 
training and its own policies and standard operating procedures.  Those principles include 
communicating using language which is clear, and free from technical jargon and 
abbreviations. 

In respect of training, all SWASFT commanders must participate in a combined JESIP 
one-day facilitated course for commanders, control room managers and supervisors every 
three years. All commanders, and all front-line and control room staff, must participate in 
online training annually. This training supports multiagency working at the scene of an 
incident and within our control rooms. 

Work is also underway at present to set up Regional Head of Emergency Services 
meetings to include police, fire and coastguard. 

1. www.jesip.org.uk 

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 Joint working with HM Coastguard and the RNLI 

Invitations to attend JESIP courses are extended to colleagues from HM Coastguard. In 
addition, SWASFT is currently strengthening relationships by participating in a programme 
of visits by SWASFT and HM Coastguard commanders and other key role holders to other 
control rooms. This aims to further promoting shared understanding between SWASFT 
and HM Coastguard commanders of how each emergency service co-ordinates its 
response to incidents, and the terminology used by each service. During such a visit the 
visiting commander shadows the resident control commander, observing processes in 
operation and listening to communications with officers on-scene. 

We are also ensuring effective aide memoirs are in place for our dispatchers and 
commanders within our control room to support effective joint working with the HM 
Coastguard. This work has begun over the last few months and will be finalised during the 
forthcoming couple of months. The aim is to ensure that business-as-usual working 
between SWASFT and HM Coastguard is well embedded with key relationships formed, 
making sure that when the larger incidents happen we already have a strong working 
relationship. 

Notifications of incidents to other services 

A standard operating procedure is in place to guide the Emergency Medical Dispatchers in 
our Emergency Operations Centres (the EOCs – our control rooms in Bristol and Exeter) 
regarding receiving emergency calls from other emergency services, and when to notify 
the police, fire service, coastguard or utility providers of an incident to which an ambulance 
has been called. Outgoing calls to other services are made to dedicated blue light service 
lines into their control rooms in most cases. 

In 2019 multiagencies implemented a 3 way call process which can be instigated in the 
event of a Major Incident, to enable SWASFT and the police and fire services to directly 
communicate through control rooms. This process enables control rooms to effectively 
communicate on an open call (or via MSTEAMS in some areas) prior to the arrival of 
resources at the scene of an incident and facilitates effective command and control in the 
initial stages of an incident. The setting up of these calls are routinely exercised within the 
SWASFT EOCs. 

In the event of a Major or Significant Incident (Standby or Declared), each of SWASFT’s 
two EOCs can also notify, or be notified by, the police or fire services via an Inter Control 
Hailing Talkgroup. Following the initial notification, communications will be transferred to a 
specific multiagency talk group which will allow the three services to directly communicate 
regarding that incident through control rooms (while leaving the inter-control talkgroup free 
for any other notifications). This has been in place since late 2020. 

A major incident is any occurrence that presents serious threat to the health of the 
community or causes such numbers or types of casualties as to require special 
arrangements to be implemented. An incident such as that involving Mr Ignatov is unlikely 

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 to have met that threshold and therefore is unlikely to have resulted in the activation of the 
enhanced functionality described above. 

Memorandum of Understanding (MOU) with Devon and Cornwall Constabulary 

Although it relates to a different county within SWASFT’s area of operation, I would note 
that an MOU is in place2 between SWASFT and Devon and Cornwall Constabulary for a 
police officer or appropriate member of police staff, with access to police information and 
communications systems, to be present within SWASFT’s EOCs at times when it is 
considered that it would be beneficial due to anticipated demand levels. The police officer 
or staff member works alongside SWASFT Dispatchers, Dispatch Team Leaders and EOC 
Duty Officers to provide liaison relating to multiagency responses within Devon and 
Cornwall, and acts as a link between the police control room, operational police officers 
and the SWASFT EOC. 

Trust Incident Manager and Significant Incident 

Over the last 18 months we have instituted a Tactical Level Commander on duty within our 
control rooms and implemented a Significant Incident process to provide focus to complex 
incidents. In the event of a complex incident this should ensure adequate command 
arrangements are put into place. This role is also co-located with our special operations 
desk which dispatches our specialist responders (including Hazardous Area Response 
Teams - HART) and frequently communicates with multiagency partners. 

NILO - National Inter-agency Liaison Officers 

The Trust has a cohort of NILOs, who are trained to advise and support Incident 
Commanders, Police, Fire, military and other Government agencies on SWASFT’s 
operational capacity and capability to reduce risk and safely resolve incidents at which a 
SWASFT attendance may be required, including major incidents, complex or protracted 
multi-agency incidents. The Trust has two individuals on call 24/7 who can advise and 
deploy to support the response to incidents to ensure effective multiagency 
communication. 

Communications with aircraft / vessels 

The HEMS (Helicopter Emergency Medical Service) dispatchers located in the Trust’s 
EOCs can dispatch and communicate with any of the six air ambulances operating within 
the south west. Operational crew on the ground at the scene of an incident can also 
communicate with an air ambulance via an Airwave talkgroup. 

There are not direct communications links with helicopters operated by the National Police 
Air Service and accordingly communications are routed through the police control room 
who then contact us by telephone. 

2. The most recent version of the MOU, version 13, was signed in April 2023 

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 Similarly, communications with Search and Rescue (SAR) aircraft or vessels are usually 
via telephone calls between the Incident Support Desks within our EOCs and the Maritime 
and Coastguard Agency control room, who are in contact with their resources. It is 
potentially possible for the Trust’s EOCs to communicate directly with airborne SAR 
aircraft via the police sharers hailing radio talkgroup or one of the talkgroups used by the 
air ambulances, which are monitored by our ISD, however this is very rare as it requires 
the SAR aircraft to switch talkgroup. 

Conclusion 

In conclusion, in all communications with other organisations relating to ongoing incidents, 
staff in SWASFT’s EOCs and involved with incidents on the ground endeavour to adhere 
to the JESIP principle of communicating using language which is clear, and free from 
technical jargon and abbreviations. 

Yours sincerely 

Executive Director of Operations / 
Deputy Chief Executive 

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