“East of England Ambulance Service NHS Trust (EEAST) a”

The coroner’s concerns

East of England Ambulance Service NHS Trust (EEAST) a.        The time taken to identify the scenario as a rescue and to call Fire Service, particularly given the use of the phrases ‘fell down headfirst in the rocks at the seafront’ and ‘caught head down in the rock’ within the first 60 seconds of the call. There was a further failure to promptly call the fire service when reaching an ‘accessible entrapment’ solution following the entrapment script. b.        Lack of understanding of other emergency services capabilities e.g. Fire and Rescue Service, HMCG. c.        Poor situational awareness by the Call Handling Team which then informed how the response by the emergency services was managed. Had Suffolk Fire and Rescue Service (SFRS) been called when Police were, Saffron would have been extricated when there was a possibility of successful resuscitation. d.        Passage of information to Fire Control Room was inadequate and confusing. The tone and language of the call used by the EEAST caller alerting the Fire Control Room suggested at best confusion and at worst an inadequate appreciation of the situation, including the requirement for the situation to be treated as a rescue and the need for timely action. Information passed during the call was inaccurate and did not reflect the information held by EEAST at the time of the call. Had this information been passed the Fire Service would have responded without the need for further clarification with HMCG as to the requirement for Fire Service involvement. e.        Inaccurate and poor recording of information on the CAD notes by the EEAST Call Handler and others involved in the management of the response, which resulted in partial and inaccurate information being communicated both internally within EEAST and to other emergency services. This included: 1.  No ETHANE message recorded in the CAD to transfer information e.g. the failure to promptly identify Saffron’s location and communicate this to other emergency services; 2.  No time of submersion expected to be recorded in the CAD for drownings, particularly from the caller in order to inform decision making around when to cease resuscitation attempts. I recognise that this is not a script question, but when a caller provides this information anyway, it is valuable clinical information for those making resuscitation decisions; 3.  No entry in the CAD to remind responders of the JRCALC timings; 4.  Incomplete/unintelligible CAD notes entries (e.g. 20.00.38 hours “the water is now”). f.         There was a failure to apply the JRCALC guidelines on submerged persons through: 1.  Failure to record the time Saffron was seen to be submerged so as to create an accurate start point to focus resuscitation efforts; 2.  Having failed to do this, the JRCALC guidelines were not applied in that the submersion start point was not set at the time the first responder attended the scene to focus rescue efforts; 3.  The assessment that the rescue had changed to a recovery operation without the examination of the patient (other than viewing from a distance) and within 30 minutes from the time of the call (as the earliest start point) was a failure to consider JRCALC timescales and a failure to apply JRCALC guidelines; 4.  The effect of these failures was to create the impression for each emergency response unit subsequently attending after the EEAST RRV that the activity was not a rescue but a recovery when the guidelines clearly stated otherwise. g.        The failure to apply JESIP principles either in the management of the call by EEAST call handling staff or at the scene of the incident, examples of which are: 1.  Inadequate communication from EEAST to other emergency services (EEAST, SFRS & HMCG). This created a confused picture of what was happening at the scene and created an impression of inertia by emergency services prior to the Fire Service arrival; 2.  Inadequate effort to share situational awareness and enable a jointly managed response to the incident. NHS England a.        Noting the concerns articulated above, consideration of how JESIP working and JRCALC considerations can be incorporated within call handler scripts used by NHS Ambulance Services, whether this be NHS Pathways or MPDS. JESIP Interoperability Board a.        Evidence of interoperability working in relation to the use of ETHANE message format and the application of JESIP for single casualty incidents involving a multi agency response, indicated that insufficient or no consideration (with the exception of the Fire Service) was given to apply JESIP in such circumstances. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to:  Chief Constable Suffolk Constabulary  Chief Officer Suffolk Fire and Rescue Service  Chief Executive HM Coastguard I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12 SIGNATURE Darren STEWART OBE HM Area Coroner for Suffolk Saffron Cole-Nottage – Prevention of future deaths report – 2026-0345_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0345

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0