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Investigation and inquest
On 7th April 2015 I commenced an investigation into the death of Joshua Harry Smith aged 16 years. The investigation concluded at the end of the Inquest on 4th November 2016 with the following narrative conclusion:-
On the 4th April 2015 Joshua Harry Smith aged 16 years attended a party at a friend’s house, Joshua drank some alcohol, but was not drunk. He seemed fine when Joshua’s father collected him; arriving home at 00.30 a.m. on the 5th April 2015. At 02.15 a.m., Joshua contacted ambulance control by 999 call asking for an ambulance. He was below the cliffs near the southernmost part of Spittal Beach, (Northumberland) having fallen. Joshua had intended to jump from the cliff, then changed his mind, slipped and fell down the cliff to the bottom. Earlier text and Facebook messages showed that Joshua was thinking of taking his own life. After a prolonged search Joshua was eventually found clinging to a rock in the water at the base of the cliff at 04.01 a.m. There had been significant delays because Joshua’s first call to ambulance control advising his location as ‘Spittal’ was not heard until it was later played back, and while ambulance, police, fire and other agencies tried to locate Joshua. There was no indication that JESIP principles (Joint Emergency Services Interoperability Program) were followed regarding briefings or co-ordination of resources, and the Berwick ambulance crew felt that there was no search co-ordinator or person taking overall control. Other agencies did not feedback what resources they had committed to the incident. When Joshua was eventually located at 04.01 a.m., he lost his grip while holding onto a rock, and he was taken away from the shore by movement of the waves. An RAF Sea King helicopter by that time arrived and Joshua was winched out of the sea unconscious, and conveyed to Wansbeck General Hospital. Sadly Joshua’s death was confirmed at 06.15 a.m. at Wansbeck General Hospital.
Circumstances of the death
As described in the above narrative.
Coroner’s concerns
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.
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.
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.
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.
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.
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.
Information checked against the published report and official responses