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Coroner of Inquests calls for review after ESJCR operator gave wrong instructions

Call handler 'started to panic' after being unable to find correct code on computer system

The Coroner of Inquests is calling for a review into training and policies at the Emergency Services Joint Control Room following a death by suicide.

Christopher Arrowsmith made two recommendations to the Department of Home Affairs following the inquest into the death of Ramsey man Philip Carl Massam, who died in February 2021.

When one of Mr Massam's colleagues called 999 to report the incident, the ESJCR operator failed to give appropriate guidance, with the inquest hearing that she 'started to panic' when she couldn't find the correct code in the control room's computer system.

The court was told the computer would have given different instructions to the operator had she been able to find the correct code.

Evidence from the operator's co-workers revealed that complaints had been made about her lack of attention and competency, as well as her accessing Facebook while on duty, although her supervisor stated that he would have taken action had he had concerns.

Despite concerns over the instructions issued by the ESJCR, medical evidence submitted to the inquest suggests the delay in starting medical treatment is unlikely to have made a significant difference to the 33-year-old's chances of survival.

While recording a verdict of suicide, Mr Arrowsmith recommended the DHA consider an internal review of its policies and procedures for ESJCR operators on accessing non-work related websites whilst on duty.

Mr Arrowsmith has also called for the department to consider including specific training dealing with calls of this nature as part of its two-year recurrency process.

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