Dear Mr Brown Thank you for Regulation 28 report detailing the tragic circumstance in which Joshua Smith lost his life. We wish to convey our condolences once at this tragic loss of life. Regarding the matters of concern, Her Majesty's Coastguard (HMCG) has noted the North East Ambulance Communications system limitation surrounding the inability to 'play back' live 999 calls. We have also reviewed our own systems, and updated guidance has been issued and training packages modified. As to the issue of Joint Emergency Service Interoperability (JESIP), we can report significant progress has been achieved in the wake of this incident: All Coastguard tactical commanders attend JESIP courses, and strategic level commanders attend the Multi-Agency 'Gold' course, known as 'MAGIC' . Every Coastguard officer completes online training in JESIP as of their basic training: Since early 2016, the Maritime and Coastguard Agency (MCA), of which HMCG is part; assumed responsibility for the provision of all UK-based Search and Rescue (SAR) aviation. These airframes are all equipped with Airwave radios specifically to enhance interoperability with other services in all emergency response operations Also since early 2016, HMCG has established an additional 18 full-time senior officer roles throughout the UK's coastal regions to further enhance its capability and engagement within Local Resilience Fora and with emergency service partners We INVESTORS Silver IN PEOPLE Thc Qucen' Diamond HM Coastguard Jubikaw vol zo2ring your again part

also conduct exercises and joint planning with the latter to improve mutual familiarity and habits of cooperation_ Most recently, we took further positive step in securing an HMCG seat on the National Interoperability Board, as well as appointing full-time Head of Resilience within the Coastguard HQ structure_ hope that these developments in the MCA give you an assurance of our intent to learn from the tragic events of 2015 and improve our interoperability and routine liaison with other emergency service partners.

Dear Mr Brown Regulation 28 Report dated 2nd December 2016 Joshua Harry Smith Inquest Ath November 2016 As of the operational debrief of the tragic events of 4th April 2015, and as result of the HM Coroners investigation culminating in the inquest of Joshua Harry Smith on 4th November 2016, Northumberland Fire and Rescue Service (NFRS) would Iike to provide the following narrative in response to Section 7 of the Regulation 28: Report To Prevent Future Deaths dated 2nd December 2016. We would like to state at the outset that NFRS have been very supportive of the national development of the Joint Emergency Services Interoperability Programme (JESIP) which has produced much needed practical guidance to help improve multi-agency response The Joint Doctrine: Interoperability Framework sets out a standard approach to multi-agency working, along with training and awareness products for organisations to train their staff. Together with our North East blue light partners in Northumbria Police and North East Ambulance Service (NEAS) we have committed to implementing and embedding the joint working principles and models Icontinued. Love FIRE Where TOP NopihumeerlANo KILLS You EpIMB? 2015 reuct# DISABLe? Live Northumberland County Council Fire part ABOUz ( 8

Although the call handling and initial mobilising for the incident were not undertaken by NFRS Fire Control personnel, steps have been taken to confirm, and reaffirm , the procedures which would be applied within our Fire Control in the event of NFRS receiving a similar 999 call. Our policy is for any emergency call to be 'dual monitored' as it is being taken by a duty supervisory manager to reduce the risk of a mobilisation error, incorrect information being relayed to responding crews or an incorrect address being recorded. As an additional confidence and assurance measure , NFRS have adopted a policy of instigating an immediate review of the call by someone other than the call handler whenever a call has been placed by a confirmed or suspected, missing person NFRS also reviewed the control procedure when using Enhanced Information Service Emergency Calls (EISEC) which allows Fire Control to pinpoint mobile phone signals within a specific area. We have confirmed that Fire Control would follow normal procedure and mobilise to this area even if the target zone covered part of the sea or water area_ Since the events f 4th April, NFRS has instigated a full review of our water rescue standard operating procedure (SOP) to ensure that the content remains appropriate and relevant We have ensured that salient operational protocols applicable to the incident have also been re-emphasised and we have ensured that all recommendations emanating from the operational debrief have been actioned across the service and all operational personnel: NFRS missing persons protocols and procedures stipulate that under normal circumstances Police colleagues hold primacy for the co-ordination and management of missing persons search with fire and ambulance services assuming the primacy role dependent upon whether there was a subsequent requirement for rescues recovery or medical treatment: It may be of interest that these arrangements will be reviewed and confirmed due to the current development of the Local Resilience Forum (LRF) Missing Persons and Search Coordination of which NFRS, Northumbria Police and North East Ambulance Service (NEAS) are statutory partners. In order to provide assurance with regard to the issues you have identified within Section 5 'Coroner's Concerns of your report it is incumbent upon uS to review our existing JESIP arrangements, consider their current effectiveness and engage with our blue light partners to collaboratively identify revisions and enhancements that can be applied. NFRS is committed to continual improvement with regard to operational response and incident command and it is our intention to continue to develop and embed our JESIP training with clear commitment that it will be more focused at operational firefighter and initial supervisory manager level: NFRS have released range of learning and development materials across the service to support personnel already trained and have imbedded maintenance programmes established via the competence framework: Front line operational personnel are scheduled to be trained from February 2017 . Personnel already trained to the JESIP principles include: Civil Contingencies Team; AII NFRS flexi duty officers at middle and senior levels; AllI Fire Control staff; NFRS supervisory managers via Continuous Professional Development Days; JESIP principles are embedded across all NFRS incident command courses and incident command maintenance programmes. Icontinued. have

As part of our ongoing internal JESIP training we will liaise with Northumbria Police and NEAS colleagues to ensure they are clear about the content and context of the front line training we will deliver, and to ensure that it is consistent and complementary to the training being provided at the same operational levels within our emergency partner services_ Our intention is to agree with partners on the implementation of a joint task and finish working group to develop a joint inter-service action plan to address the concerns raised during your inquest It is our intention, in collaboration and discussion with our 'blue light' partners, to seek to establish this group by 1st April 2017 . To assist with the facilitation of the group NFRS would like to nominate Station Manager Station Manager has extensive experience delivering incident command at all levels during secondment to the Fire Service College. Station 'Managerl Jis also our JESIP single point of contact and has been integral in developing NFRS JESIP structures. In order to ensure that operational response and effectiveness to any future missing person incident is optimised, we would Iook to include colleagues from HM Coastguard and Northumberland search and rescue teams and in the confirmation of JESIP principles across agencies and the delivery and execution of local joint exercising and training: The inclusion of HM Coastguard as an attendee at the Northumbria Local Resilience Forum and Emergency Services Liaison sub-group should assist in the delivery of these proposals_ We would anticipate that some of the deliverable outcomes of that process will be; Confirmation of JESIP principles across all agencies Affirmation of the application of JESIP principles at Operational, Tactical and Strategic levels Confirmation of agency primacy in missing persons cases Development of a 'front-line' joint exercising plan to compliment joint exercising arrangements at tactical and strategic levels Reaffirm commitment to JESIP at regional forums such as Northumbria Local Resilience Forum (LRF) and Emergency Services Liaison Group (ESLG) Each service to review, and if necessary revise, their existing JESIP delivery plans: To provide the required assurance and confidence that NFRS and partners have taken the necessary steps to mitigate the potential risk of reoccurrence of the issues highlighted within your Regulation 28 report you may wish to be provided with a copy of any jointly produced action plan for your review. would be happy to facilitate this with the agreement of our partners in due course. Should you wish discuss the content of this letter to provide further detail and context; please do not hesitate to contact me at your convenience

Dear Mr Brown Inquest into_the death of_ Joshua Harry Smith (Deceased) Regulation 28 Report to Prevent Future Deaths We are writing further to your Regulation 28 Report for the Prevention of Future Deaths dated December 2016 and issued following the Inquest into the death of Joshua Smith, which was held between 31 October 2016 and 3 November 2016 at Berwick upon Tweed Coroner's Court; On 6 January 2017 a multi-agency meeting took place in order to discuss the concerns you identified, and also to conduct a formal debrief. At the request of the agencies, Northumberland National Park Mountain Rescue were also in attendance, which offered the added benefit of their specific knowledge in matters of Search and Rescue_ This is joint response, sent by North East Ambulance Service NHS Foundation Trust and Northumbria Police_ Thank you for granting the agencies an extended period of time to consider your report. We understand that Northumberland Fire and Rescue Service and HM Coastguard are providing separate responses We will address each point you have raised in your matters of concern below: Communication with the Caller As identified in your Report, Joshua mentioned his location in the initial phases of the call; but this was not heard by the Call Handler until later, when the call was replayed. number of questions asked by the Call Handler were of the "closed" type, which limited the opportunity for Joshua to be more specific about his location: The nature of the questions posed by the Call Handler may be explained by the fact the NHS Pathways telephone triage system in use by the North East Ambulance Service requires Call Handlers to ask closed questions in order to identify the nature of the medical complaint and provide the most accurate ambulance response. Failure to follow NHS Pathways may lead to increased clinical risk and, ultimately, potentially unsafe calls. Northumbria, Durham and Cleveland Police Call Handlers are trained to the THRIVE standard_ THRIVE (Threat; Harm, Risk, Investigation, Vulnerability, Engagement) is risk assessment tool which assists call handlers to assess the nature of the emergency response required. The tool enables operatives to decide whether it may be necessary for another agency to become involved. Police Call Handlers are also trained in the use of the National Decision Making Model (NDM) , which is a dynamic decision making tool. REGEIVED Tony FES Harry

Such training ensures that risk to callers; and the appropriate level of response, is at the forefront of a Call Handler s mind. Within the remit of the ambulance service, however; the main consideration is clinical aspect; as the principle reason for contacting an ambulance is a medical emergency, With above in mind, NEAS must ensure that Call Handlers remain within the NHS Pathways licence requirements and maintain focus on clinical complaint: However, in order to enhance the skill set of Call Handlers and provide them with the necessary tools allowing them to identify triggers that would alert them to the need for other emergency services, as a result of joint work with Police colleagues_ specific THRIVE training program for NEAS has been devised with commencement of delivery in March 2017 . This further training will ensure that there is, so far as possible, a consistency of response between Control Room staff across agencies. Furthermore, NEAS operational staff have received training in NDM and Joint Emergency Services Interoperability Programme (JESIP) principles in 2016/17 Essential Annual Training, which will be repeated for the 2017/18 period. Whilst the above training is being rolled out; in order to enhance the Trust to respond appropriately to incidents of a similar nature, suitably trained 'Dispatch Supervisor" rol,e has been introduced to take over from the Duty Manager and deal specifically with this type of emergency: Communication between Aqencies As we believe you are aware, NEAS now have Tactical Advisors. In addition to standardisation of Call Handler training therefore , the presence of the Tactical Advisor will ensure that (1) the appropriate tactical response is made (dispatch of HART team, for example, being a matter raised in your Report), and a decision regarding the appropriateness of this response is_made more quickly and (2) communication between agencies is improved . This point was discussed at length during the meeting and the consensus reached was that in incidents of this nature, early communication with HMCG would be a priority. This approach is also reflected in the updated "Control action following 999 calls to water incidents" procedure in use at NEAS_ The Group were also informed of further training that NEAS HART operatives are conducting around incidents in or near water: HM Coroner may be aware that inter-agency training already takes place. For example, North/South "Blue Light" Working Groups are already in existence and meet regularly In relation to JESIP training between police, ambulance and fire services currently takes place Our organisations remain supportive of the approaches of the Joint Doctrine; Interoperability Framework and continue to work and train with our other emergency service colleagues. During our debrief meeting the agencies present considered that it would also be appropriate for HM Coastguard to receive JESIP training and to attend emergency response exercises more frequently in general. This is particularly the case as JESIP does envisage the involvement of HM Coastguard where appropriate Further positive discussion revolved around the type and level of information required by HMCG to equip them with the necessary details to make, an informed decision relating to their level of involvement and provide the necessary specialised support. The consensus was that the priority should always be to instigate effective inter-agency communication and set up a command and control centre where all the information can be funnelled and shared in an efficient and proactive way: An important point that was highlighted was the need to ensure that safeguarding concerns are also taken into relevant consideration in similar incidents _ Furthermore , our organisations work under Joint Operating Procedure alongside Durham Constabulary and Cleveland Police_ The aim being to provide information to police officers, police staff and partners in respect of the medical care options that is available through NEAS and the NHS_ The procedure provides guidance to staff on what action to take in the event of clinical care not being available. The procedure also informs NEAS of the powers and responsibilities the police service has in response to incidents involving medical matters This joint procedure enables our staff to directly contact our respective control rooms to seek advice and assistance whilst relaying information directly from the scene_ the the the ability the very fully

Use of Technology Your report identifies the fact that Joshua's location could not be clearly identified using his mobile phone_ As you are awarethe topography of the area (on or near cliffs) made triangulation difficult: Northumberland National Park Mountain Rescue have advised other agencies of a further software tool available to them, SARLOCK, which enables a text message to be sent to a missing person's phone_ If the phone is smartphone, the missing person is then able to click on the message and, using the internet, the smartphone provides Mountain Rescue with its location. Although this system cannot be independently utilised by other agencies, Mountain Rescue teams are able to distribute a notification of the casualty's whereabouts to all partner agencies upon notification of an incident to them: Serious consideration is being given to the relevance of sourcing expert advice from Mountain Rescue and the considerable benefits that could derive from the utilisation of this software. Although it is not possible to say whether this would have helped in Joshuas case, the potential benefits are clear for all to see The multi-agency meeting also identified that whilst the new Coastguard helicopter has Airwave capability (the standard communication system utilised by land based agencies), HM Coastguard currently only have limited access to the Airwave system: HM Coastguard are currently giving consideration to improving their Airwave capability, in order to facilitate communication between agencies_ NEAS Procedures As previously mentioned, in addition to the actions referred to above; NEAS have also finalised their revised procedure in respect of responding to a 999 call to water based incident. This new procedure (attached) has been considered by other partner agencies and has been approved. The agencies sincerely hope that the update contained within this letter will reassure both yourself and Joshua's family that lessons have been learned from this incident; and that efforts will continue to be made to prevent such a tragic incident occurring again_