Ivan Ignatov

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

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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.

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.