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 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 My response to your Matters of Concern is report: ‘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.’ 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
• 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 Chief Fire Officer

A30

& 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.

Dear Mrs Griffin 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.”

A25

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.”

A26

In April 2023, Chief Inspector (who manages the Force Incident 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 to 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. 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.

A27

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 intention of Chief Inspector , 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).” “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.

A28

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.

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.

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. Continued…/2 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

…/2 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 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.

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

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 A32 meetings to include police, fire and coastguard.
1. www.jesip.org.uk

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 A33

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 A34

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 A35 technical jargon and abbreviations.

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.

A23 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.

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. A2 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

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 A3 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.

Dear Ms Griffin,

A6

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.

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

) A14 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.

Dear Ms Griffin IVAN RUMENOV IGNATOV (DECEASED) Ambulance Chief Executives (AACE) dated 8th behalf of the AACE. Committee UK ambulance service clinical practice constituted to mandate or groups. together when an incident consideration is given to further rescue services to processes AACE work closely and regularly at a and rescue. We have representation you have raised. through research led by the Home Office. AACE are not responsible for the training Chairman: Managing Director:

Chairman:

Managing Director:

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 A19 questions please do not hesitate to get in touch.

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 tragic 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 fleet 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 fleet currently consists of the Shannon, Severn, Trent, Tamar and Mersey 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 the Coastguard of a certain level of capability and availability and/or training such that they form part ofthe 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 the Coastguard is the tasking authority and responsible for coordinating searches, the method of communication with the Lifeboat is via the Coastguard following IMSAR protocols as a maritime search and rescue capability. Having other multiple organisations able to communicate with the Lifeboat is not effective. 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 to 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 shared directly with emergency services partners which focusses on capabilities and limitations such as search equipment and communication capabilities. A16

10. The RNLI will also work with the Coastguard to participate in some partner awareness 'open day' events that showcase capabilities between emergency services/search and rescue partners. A17