The year of 2017 saw the most sustained period of terror activity in the UK since the Irish Republican Army bombing campaign of the 1970s which resulted in 36 deaths, over 600 casualties and a record number of terror-related arrests in the UK. Today, the UK terror threat remains severe suggesting a further terror attack is highly likely. The NHS must now be prepared to deal terror-related casualties in potentially large numbers. It is therefore vital that as healthcare providers, we must ensure that we are prepared for this threat at an individual level and organisational level. This will require collaboration with multiple organisations including the police, ambulance, fire, health service providers and local government. In turn they will construct detailed major incident plans and rehearse the response to such events, such as mass casualty triage and casualty dispersal. 

The necessity for this approach was exemplified by the response to the Manchester Arena bombing on 22 May 2017.1 Fortuitously 2 months prior the attack a major exercise was conducted in Manchester that focused on the dispersal of mass casualties and implementation of the lessons learnt from the Paris attacks of 2015, in preparation for such terrorist activity. This exercise undoubtedly facilitated the triage and distribution of casualties immediately following the Manchester blast ensuring hospitals were not overwhelmed and secondary transfers were appropriate. Furthermore, to facilitate collaboration, as individuals there is the need to understand the emergency service response to such an event, roles and responsibilities of other emergency personnel, and the unique characteristics of the injuries and injury patterns encountered. As individuals we must maintain our own skill set attending relevant specialty specific courses such as the Definitive Surgical Trauma Skills Course.

There remains a requirement to deliver a package of education and training to provide an open forum to learn from past experience and enhance collaborative working, and therefore enhance training and education so healthcare providers are prepared and ready to deal with the next domestic terror attack. To address this, in association with the Royal College of Surgeons of Edinburgh, the South Tees Hospitals NHS Foundation Trust convened the inaugural meeting: ‘The Domestic Terror Attack: Management of the Mass Casualty Trauma Scenario’. This day provided an opportunity for attendees from a diverse range of civilian and military backgrounds (medical, nursing, paramedic, police, fire, British Red Cross and local authority personnel) to share experience, knowledge and lessons learnt from past experience, particularly the Manchester Arena bombing. The study day was split into a morning session with a series of lectures and open discussion covering the police and prehospital response to a terror attack, lessons learnt from the Manchester bombing. It focused both on organisational and strategic challenges, as well as clinical considerations in the unique management of blast injury. In the afternoon, a number of workshops were conducted to refresh the surgical principles and techniques associated with damage control surgery and trauma resuscitation and provide an opportunity for open discussion with faculty and participants. The course was positively received by participants with a future event in collaboration with the college already planned.

Military medical personnel are well versed in dealing with injuries from gunshot wounds and explosive devices, as well as in managing multiple heavily injured casualties. All of these are potential scenarios in a future terrorist or terror-related event and these skills can be of use to clinicians with less experience. This is reflected in part of a revised role for the armed forces in providing Military Aid to the Civilian Authorities (MACA).2 MACA was first used following the Manchester bombings when a group of military clinicians with considerable battlefield experience from many conflict zones including Afghanistan was asked to provide support to the predominantly civilian clinicians in the Manchester hospitals.3 This issue collects lessons learnt from treating victims of the Manchester bombing as well as providing scenarios in which MACA can be deployed to maximal effect.