2 Dec 2016 Joshua Harry Smith · Prevention of Future Deaths report North Northumberland
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Concerns raised 7 Searches being stood down without confirming reported safety information View source Delay in deploying the Hazardous Area Response Team to a hazardous-area incident View source Failure to recognise location information from 999 calls View source Unclear multi-agency command control and co-ordination View source Failure to identify location from mobile 999 calls View source Failure to immediately alert police and other emergency services from 999 call information View source Failure to provide police control with essential incident information View source See 4 more concerns
Responses linked to these concerns
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AI-generated summary
Joshua Harry Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Searches being stood down without confirming reported safety information
Wider context from the report “The search for Joshua was briefly stood down after a North East Ambulance call to Joshua’s father indicated that Joshua was at home in his bedroom, without waiting for ████████ to check and confirm whether Joshua was in fact in his bedroom.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Delay in deploying the Hazardous Area Response Team to a hazardous-area incident
Wider context from the report “Joshua had explained in his 999 call that he was below cliffs having fallen, was injured and that an ambulance would not be able to reach him. The Hazardous Area Response Team of North East Ambulance was not deployed to the incident until approximately 3 a.m. arriving at the scene under an hour later and were 1.5 miles away from the incident at the time Joshua was swept out to sea by action of the waves.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise location information from 999 calls
Wider context from the report “The search for Joshua continued at Berwick Holiday Park (on the north side of the River Tweed and the town of Berwick-upon-Tweed) as a result of his location at Spittal Beach not being recognised from his 999 call .
After Joshua’s phone call was ‘listened back’ it was observed that he had described his location as Spittal, at the bottom of a cliff, near Spittal beach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Unclear multi-agency command control and co-ordination
Wider context from the report “The circumstances of the death showed that although there were examples of good co-operation and effort among the emergency services, overall command, control and co-ordination were unclear and JESIP was not followed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify location from mobile 999 calls
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately alert police and other emergency services from 999 call information
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumberland Fire and Rescue Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police control with essential incident information
Wider context from the report “Two Police Officers on Berwick Town Centre duties (which is north of the River Tweed) were asked in the street by paramedics for assistance in locating Joshua, and while paramedics went to look for Joshua on the north side of Berwick near the Holiday Park and cliffs, the police officers travelled to Spittal looking for Joshua although they had no name or further details at that time . A brief search of Spittal beach near to the cliffs by Police Officers was unsuccessful, before they returned to Town Centre duties. A report to Police Control was not made at that time.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review JESIP arrangements, assess their effectiveness, and engage blue-light partners to identify revisions and enhancements.
Verbatim wording from the response “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 a clear commitment that it will be more focused at operational firefighter and initial supervisory manager level. NFRS have released a range of learning and development materials across the service to support personnel already trained and have imbedded maintenance programmes established via the competence framework.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with Northumbria Police and NEAS to align frontline JESIP training content and delivery.
Verbatim wording from the response “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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and confirm missing-person and search-coordination arrangements through the developing Local Resilience Forum arrangements.
Verbatim wording from the response “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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing and embedding JESIP training focused on operational firefighters and initial supervisory managers.
Verbatim wording from the response “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 a clear commitment that it will be more focused at operational firefighter and initial supervisory manager level. NFRS have released a range of learning and development materials across the service to support personnel already trained and have imbedded maintenance programmes established via the competence framework.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dual-monitor emergency calls and immediately review confirmed or suspected missing-person calls independently of the call handler.
Verbatim wording from the response “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 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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-emphasise relevant operational protocols and enact operational-debrief recommendations across the service and operational personnel.
Verbatim wording from the response “Since the events of 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 enacted across the service and all operational personnel. NFRS missing persons protocols and procedures stipulate that under normal circumstances Police colleagues hold primary responsibility for the co-ordination and management of a missing persons search with fire and ambulance services assuming the primary role dependent upon whether there was a subsequent requirement for a rescues / recovery or medical treatment.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed JESIP principles across incident-command courses and maintenance programmes.
Verbatim wording from the response “JESIP principles are imbedded across all NFRS incident command courses and incident command maintenance programmes.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and embed JESIP joint-working principles with North East blue-light partners.
Verbatim wording from the response “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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Confirm Fire Control procedures for mobilising to EISEC locations that include sea or water areas.
Verbatim wording from the response “NFRS have 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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver JESIP training to frontline operational personnel from February 2017.
Verbatim wording from the response “Front line operational personnel are scheduled to be trained from February 2017. Personnel already trained to the JESIP principles include:” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint task-and-finish working group with partners by 1 April 2017 to develop an inter-service action plan.
Verbatim wording from the response “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.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police hold primary responsibility for coordinating and managing missing-person searches; fire and ambulance services lead only when rescue, recovery or medical treatment is required.
Verbatim wording from the response “Since the events of 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 enacted across the service and all operational personnel. NFRS missing persons protocols and procedures stipulate that under normal circumstances Police colleagues hold primary responsibility for the co-ordination and management of a missing persons search with fire and ambulance services assuming the primary role dependent upon whether there was a subsequent requirement for a rescues / recovery or medical treatment.” Source location 2016-0599-Response-by-Northumberland-Fire-and-Rescue-Service
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations