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 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 Sunday 14t 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. included: 1 Education provided t0 the Emergency Medical Director community with regard to Police Calls and the correct inforation being taken 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 &s to whether 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 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 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) crewslcontrol are aware that road closures can be compromised and events stopped for emergency purposes . This is WYFRS defaultlstandard 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 1Ok 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: Www leeds.gov.uk switchboard 0113 222 4444 Hlghways Helpline 0113 222 4407 they yet (1)

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 t0 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 t0 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 t0 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 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 serviceslcouncil Safety Advisory Group on 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 14th May 2017 have been discussed at length at this group and reassurance has been sought from all parties that the learning from this event has 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: Ensure that emergency services procedures are clear and well communicated with all stakeholders_ Make sure that marshals are well briefed around emergency protocol 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 are appropriate, kept to a minimum and are as safe as possible: