Dear Mr Mooyaart Regulation 28: Prevention of Future Deaths Report for Robert Cobbina Thank you for your Regulation 28 Report dated 25 June 2019. would like to take this opportunity at the outset of my letter to offer my condolences to Mr Robert Cobbina's family, Thank you for informing the London Ambulance Service NHS Trust (LAS) of the concerns you identified at the inquest into Mr Cobbina's death, which took place on 10 June 2019. We welcome the opportunity to investigate your concerns and learn this incident: If we had been given earlier notification of the inquest and participation in the proceedings it is possible that the LAS would addressed not only the concerns you have raised in this Regulation 28 Report but also questions from the family by way of documentation and live witnesses The matters of concern you raised at inquest is as follows: 1_ Neither the caller nor the passer-by who continued the call with the emergency control room were prompted to request the coastguard or other waterborne assistance despite making it clear that the emergency related to a person in the river, Whilst it is understood that each service can subsequently involve other services a8 required, the concern arises that there was a potentially significant delay in involving the appropriate assets which would have been avoided at the point of triage. The dispatch of resources in any category of call is detailed in Operational Policy- Emergency Operations Centre (EOC) Management of Complex Incidents Procedure (OP61) OP61 sets out the fact that The Maritime Coastguard Agency (MCA) is responsible fortthe coordination of incidents on the River Thames and the Royal National Lifeboat Institute (RNLI) undertakes the search and rescue of patients from have the

OP61 states: The MCA must be informed of all calls involving the Thames, their banks and piers where the rescue of persons or vessels are involved. The Metropolitan Police Service (MPS) and London Fire Brigade (LFB) also have dedicated resources working on the Thames and may be requested as appropriate, but this must not prevent the MCA from being informed as have primacy over the rescue of patients: On 2 November 2018 at 11.36am the LAS received a call from the patient's wife informing the call handler that she found her husband's clothes and shoes near the River Thames by bench: As soon as the call handler had sufficient information from the caller including a delayed confirmation of the location they made a note on the call log: At 11,57am the dispatcher sent a message to the MPS via the CAD Iink system informing them that both the MPS and coastguard were required_ The CAD link system is designed to provide messaging system between the LAS and MPS to request attendance and provide updates in a speedy manner_ The dispatcher failed to follow this policy as they did not inform the coastguard directly_ Upon review of this incident it has become apparent that the procedure within OP61 needs to be reviewed to eradicate any ambiguity and the individual dispatcher and all staff working within EOC will be reminded of the correct procedure for informing the MCA. Before receiving this Regulation 28 Report a meeting was already diarised between the LAS and MCA which took place on 17 July 2019 and it was agreed that the LAS would remind all staff of the current process for informing MCA within OP61 and to work closely to achieve a more streamlined collaborative working agreement
2. Neither the caller nor the passer-by were prompted to identify existing signage placed along the riverfront providing coastguard location reference to enable a swift and precise arrival on scene_ The use of the coastguard signage along the River Thames was discussed at the meeting on 17 July 2019 and it was confirmed by MCA that coastguard signage is only specific to the Greenwich stretch of the Thames path We have reflected upon whether we should make it mandatory for call handlers to request the coastguard signage from the caller: However; we have concluded that this may result in a delay in the dispatch of resources as it would be difficult to ensure that the information was only requested for the limited area of the Greenwich stretch and might require callers to move some distance in order to locate the signage. It would be easier for callers to identify landmarks, roads etc in the vicinity instead_ Where & caller is uncertain of the exact location, call handlers are required to probe the caller to ask for help from people nearby or identify roads, landmarks etc. On this occasion call handler made several prompts to assist the original caller to identify the location, but she was very distressed The call handler asked her if there was someone else who could assist and passing couple then took over the call: This couple provided the coastguard reference , which was noted by the call handler on the CAD. The call handler attempted to locate the call more precisely by asking for nearby road names and postcodes: The female passer-by, by ascertaining that the original caller lived nearby, established the postcode and was able to identify that the Riverside Campus for University of East London was on the opposite side of they very the

the river Having reflected on the point raised we are satisfied that we do not need to change the advice given to call handlers in this regard. hope this reply is helpful in explaining the actions taken to address the matters of concern; Yours sincerely ZAn Garrett Emmerson Chief Executive Officer

NFCC National Fire CFOA Chiefs Council The professional voice of the UK Fire & Rescue Service Assistant Coroncr Xavier Mooyaart Southwark Coroner'$ Court 1 Tennis Street Southwark SEI IYD Hertfordshire Fire and Rescue Service Headquarters Old London Road Hertford SG13 7LD Telephone: 01992 507507 Fax: 01992 503048 Direct Line: Contact: My Ref: DKI999LC/PFDR Your Ref: 02922-2018 6"h August 2019 Dear Mr Mooyaart, Prevent Future Deaths Report for Robert Cobbina, am Chief Fire Officer for Hertfordshire and write as Chair of the 999/112 Liaison Committee (999LC)1 regarding the above rcport sent to the Committee on 26"h June 2019. Thank you for the report and the opportunity to identify lessons from this tragic event, Perhaps before I respond to the Coroner'$ Concerns it would be helpful to provide some background to the way in which 999 calls are handled in the UK. When a member of public dials 999 (or 112) in the UK their telephone supplier will connect them immediately to BT 999 call handlers_ The BT call handler will ask "Emergency which and based upon the response received will connect the caller to the emergency service they ask for in the area that the caller is calling In order to identify that service the operator needs & response from the caller indicating which service they need and also the location of the caller: The former is obtained from the caller; the only exception where they cannot communicate and in that case the operator will follow some specific actions known as The Silent Solution' , however that is not relevant t0 this casc _ The latter; the location, is obtained by the BT system through its connections to a number of databases which include, billing addresses for landlines and through location services available via thc mobile network providers All of this happens within matter of seconds as soon as call is presented t0 For clarity the 999LC is the UK Governinent's body which oversees the relationship bctween Government Departments, the commercial telephone providers, BT who provide 999 call connection services and the Emergency Authorities (Police, Ambulance and Coastguard) throughout the UK With many years of experience to draw UpOn it is the view of the 999LC and BT that BT operators to seek further information about call types in order to test whether the caller is for the correct servicc would simply introduce an unnecessary delay the operator would also need considerable training t0 understand the capabilities and roles of all of thc emergency services these transfers are currently achieved in a matter of seconds_ the service?"2 fromn. being the Fire, asking asking

the BT operator such that by the time the operator has ascertained which service is required they are also presented with location and can quickly connect the call to the relevant emergency service control room Once the call is handed over to the emergency service control room the location information; Via a system called the Enhanced Information Service for Emergency Calls (EISEC), is also passed to the service, In almost all cases this is now in a data format and is presented on to operators mapping screens, and, with the recent addition in to many control rooms of thc Advanced Mobile Location (AML) system; this can be accurate t0 within & few metres Based upon this location information and the inforation that is then gleaned from the caller about their erergency the control room operators will despatch; as appropriate, the necessary responders As this is happening control room operators 01" supervisors will consider whether other emergency services may also be required. Should that be the case then they will contact the other emergency services using priority methods which we all have for such purposes_ It is perhaps pettinent to this case to note that all of the above assumes that the member of the ma the emergency call only makes one call, to one emergency service. In the event that make further calls it will be likely that the information will already have been made available by the initial service where it is obvious that other services are required; for example in the event of a road traffic collision it is likely that a call to the Fire Service Will result in Police and Ambulance notified by the fire control operator and vice versa Coroner' $ Concerns (Point 1) Iflmay nOw turn to the specific concerns raised by the Coroner these appear to relate to two aspects; prompting callers to alert multiple emergency services and the use of location information available to the caller 0n scene With regards to the need to alert multiple services it is the view of the 999LC that this should not be required of the caller; once call is received by one of the emergency services then we believe that it would be reasonable for the public to expect that the emergency services will work together to ensure that the appropriate resources are identified to resolve the incident irrespective of where the first call is received. Given the context of an emergency; where callers may well be traumatised; it would also be inappropriate to rely on them to ensure that appropriate information is passed to every relevant service_ For that reason all ernergency service control rooms have a range of methods available to them to share information with other services_ which includes the capability to share information with services across the UK and indeed, 4s occasionally happens, with services in other countries. Control room operators also receive training to help them understand the capabilities of other services such that are able to identify which may need to be alerted for specific emergencies. In some cases this may also be supported by system prompts presented to the operator based upon information that input or are presented with, Coroner'$ Concerns (Point 2) With regards to the concern that the callers in this case were not prompted for additional location information then; a8 noted above, the emergency services have access to the EISEC and AML systems which can provide, especially in the case of AML for callers using most mobile phones, very accurate location information without the need for callers to provide it It is therefore often not necessary for additional landmarks to be sought: Each emergency service does however have a variety of back up capabilities to identify location where the primary means has not provided sufficient accuracy. This ranges from simply asking the caller; through the use of landmarks such as described in the report, public king they being they they

identification of motorway marker posts, even local colloquialisms Ido not have details of the call handling for this specific incident; however it is entircly possible that the operator felt that had an accurate location of the caller: Clearly in this case though the location of the deceased was substantially more difficult to ascertain and might; like many incidents we attend_ have been moving due to thc flow of river , Future Developments As I am sure you would expect the emergency services are keen to provide the most efficient and effective service possible to thc and there are therefore & number of future developments which will further improve that: Emergency services that do not currently have access to the latest location services are expected t0 have plans in placc to introduce these soon; The current system of incident transfer between emcrgency services is developed to utilise data transmission via a protocol called Multi-Agency Incident Transfer (MAIT); this allows emergency services to speed up transfer of incident details from one service to another: hope that this response provides You with the rcassurance that you seek but should you require further information please do not hesitate to contact me.