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Abstract
This is the first article in a three-part series detailing the lessons identified during the NHS England clinical debrief meetings which followed the response to the 2017 Manchester and London terrorist incidents. It covers the prehospital phase including the overall key learning points, timeline information, scene challenges, resource utilisation, triage, distribution and helicopter emergency medical service feedback.
- major incidents
- terrorism
- EPRR
- prehospital phase
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Key messages
This article summarises key lessons from the national multidisciplinary debrief process which followed the three UK terrorist incidents in 2017.
The lessons identified cover all phases of the medical response and outline the main challenges, and examples of good practice, applicable to future incidents.
The military context and potential applications of this knowledge are also summarised.
Introduction
On 22 March 2017, a 52-year-old Khalid Masood drove a car along the pavement of Westminster Bridge injuring more than 50 people and killing five. After crashing into a perimeter fence near the Houses of Parliament he abandoned the vehicle and ran into New Palace Yard, attacking an unarmed police officer and fatally stabbing him. Two months later, on the evening of 22 May, a 22-year-old Salman Abedi detonated an improvised explosive device in the foyer area of the Manchester Arena as it filled with waiting parents and exiting attendees following the Ariana Grande concert. This attack injured over 500 people and led to the death of 23, including the attacker. Less than 2 weeks later, on the night of 3 June, a van mounted the pavement on London Bridge striking several pedestrians before crashing near Borough Market. The occupants, three men in their 20s–30s, Khuram Butt, Rachid Redouane and Youssef Zaghba, then exited the van and began to attack people with knives in the area around the market before later being shot dead by armed police responders. Overall, eight people were killed and 48 injured in this incident. All three incidents were believed to be the result of, or inspired by, radical Islamist terrorism.
The clinical debrief meetings that followed the responses to these terrorist incidents have identified many valuable lessons. The resilience and dedication of every emergency responder within each of the systems involved is testament to the planning and training that has followed previous incidents and shown the tangible value of organisational learning. The capabilities that have been developed and exercised subsequently can be replicated in any healthcare system and successfully demonstrate the importance of effective multidisciplinary coordination and collaboration. This paper is the first of a series of three which introduces and describes the context of the clinical debrief process, detailing the prehospital phase. The second article focuses on the hospital response and delivery of initial reception and definitive care phases1 while the third focuses on the immediate postincident and recovery phase.2 The aim of this paper is to provide the reader with a summary of the key lessons identified from these incidents throughout the detailed debrief and feedback sessions undertaken by NHS England.
Military aid to civilian authorities
Although the Civil Contingencies Act 20043 places no statutory responsibility on the MOD to plan and prepare for civil crises, government departments or civil authorities may request military assistance. This is officially termed Military Aid to the Civil Authorities (MACA). The MOD’s role is concentrated on providing niche capabilities, such as Explosive Ordnance Disposal, and standing support when civil capacity is overwhelmed. However, forces are not generated and maintained specifically for these tasks. The two key documents regarding MOD’s role are the NHS England MACA guidance4 and Joint Doctrine Publication 02.5 In the event of a widespread incident involving multiagency partners, requests for military aid will normally be coordinated through the appropriate Strategic Coordinating Group. However, if an exceptional emergency situation develops and an urgent response from military units is needed to save life, local commanders are authorised under standing arrangements to deploy without seeking approval from a higher authority.
From a Defence Medical Services (DMS) perspective, the debrief and feedback process, which followed the incidents in Manchester and London, included the sharing of corporate knowledge, especially regarding the management of blast injuries, as a constructive process of mentoring and assurance. Within the first few days following the incident in Manchester, a multidisciplinary military team of anaesthetic, surgical and theatre staff from Birmingham was invited to attend. The visit was characterised as an opportunity for external assurance and peer support to share learning as well as offer subject matter expertise regarding blast and ballistic injury management. This enabled NHS services to build expertise and confidence when dealing with less familiar mechanisms of injury and represented an excellent example of Defence Healthcare Engagement for which the DMS can have an enduring role. Further planned developments include a Major Incident Surgical Trauma course and related pocket guide or handbook.
Key learning points
A number of key learning points were common to all three incidents. These are summarised in box 1.
Collective learning points.
It is essential to have an effective Command and Control (C2) hierarchy with a structure that is collapsible or expandable to the needs of the incident. The key element was having senior clinical decision-makers working in teams at every level and during every phase from prehospital to rehabilitation.
Good communication and situational awareness are reliant on effective and resilient information sharing utilising single points of contact or portals with interagency liaison officers. A secure, end-to-end encrypted messaging service or media platform (such as WhatsApp or Wickr) was recommended as an ideal information system for all responders and specialist/hospital services.
Coordination and collaboration should be planned and practised at intra/inter-regional, multiagency and multiprofessional levels.
Further clarity and commonalty was recommended regarding ‘Stand-by’ and ‘Declared’ incident alert with inconsistency noted between some command levels and receiving hospitals.
Each region or network should develop an agreed casualty disposition framework together with an effective enhanced triage process: The ‘Pathfinder’ concept of Right patient, Right place and Right time.
From a practical perspective, the triage distinction between ‘P1’ and ‘P2’ is much less important than simply separating the walking from non-walking casualties—the need to move on from purely physiologically derived categorisation.
Patient identification is a significant risk and can be challenging, especially with younger casualties, and there is a need for standardised identification and documentation systems to facilitate continuity and effective clinical governance.
The consideration of effective forensic management and maintaining the chain of evidence.
Loggists are considered essential for all significant operational and strategic roles.
The psychological needs of emergency responders and hospital staff must be recognised as well as the patients and their relatives, and embedding these services at every level early on in the response.
Situational reports/multidisciplinary meetings should take place regularly (at least twice daily) throughout the hospital response phase.
The importance of a robust and well-informed media policy— information for staff and how to avoid potential pitfalls of high profile media intrusiveness, ongoing media demands and risk of unethical journalistic practices.
An ethos of mutual support was considered essential at every level: from an individual surgeon basis, within or between teams and intra/interorganisational.
It is not all about the trauma: medical teams are a key component of receiving hospital responses for facilitating the creation of bed capacity creation and ensuring safe transfer and handover of existing inpatients.
Maintaining access to other emergency or urgent care services such as for stroke and acute myocardial infarction (MI).
The challenge of being in the ‘hot’ zone as a receiving hospital: lockdown, staff and patient access, security and, if close to the incident, the potential role as a reception/rest area to general public.
A gradual, stepwise de-escalation will usually be required as hospitals return to the ‘new normal’ and this should be built into business continuity plans.
When step-down occurs, the hierarchal C2 structure should remain in place although may ‘scale-down’ depending on the ongoing situation.
A nationally agreed, standardised approach for debriefing and lessons identified should be developed for shared organisational learning and disseminating best practice.
Repatriations between regions/networks are a challenge in terms of capacity management, clinical responsibility, communication and ensuring continuity—such as rehabilitation and family support.
The challenges and opportunities of VIP and similar visits.
The challenge and controversy of the ‘P4’ or ‘Expectant’ category—does this need a better definition. Does the question refer to the concept of futility versus that of resource exhaustion or capacity saturation?
Inclusion of blood-borne virus (BBV) risk management, audiometry, psychological and bereavement services response in hospital plans.
Reflection following the Manchester incident suggested that the region had been well prepared in advance with a good shared understanding of the response framework. The benefit of recently held multiagency exercises following organisational learning from the Paris terrorist attack in November 2015 was recognised to be a significant factor as were the resources available on the night which had allowed a network response. The involvement of a large number of children and relatives as casualties represented a challenge for paediatric or adult-only trauma centres to keep families together as much as possible.
For both the Westminster Bridge and London Bridge incidents it was felt that the capabilities of the first responders and receiving hospitals had been able to meet the needs of both the scale and complexity of the case load. Casualties were appropriately distributed although clearly logistical and security issues had led to unavoidable challenges which were overcome as best as possible. Despite this, and the reflection that ‘saturation’ of the trauma system had not been reached, there were still a considerable number of important lessons that could be identified.
The prehospital phase
Timeline information
During the NHS England debrief sessions it was possible to collate most of the relevant information to enable an appreciation of the likely timeline for incidents of this type. The data are summarised in Table 1.
Timeline information for all three incidents
Key points to note are that the average time between that of the incident and the first casualty arriving at hospital and stand-down was around 33 min and 6 hours 20 min, respectively. Major incident declaration was made on average 15 min after the incident occurred which left less than 20 min for hospitals to prepare to receive the first casualty.
Scene challenges
The main challenge for all three incidents was the early recognition of both the situational aspects and the severity and complexity of the pattern of injuries. More than 50 emergency (999) calls were made related to the Westminster Bridge and differentiating this from another ‘conventional’ road traffic incidents proved difficult initially. Early on, situational awareness was limited and reliant on multiple conflicting perspectives and represented a rapidly evolving and mobile risk. As a result, the autodispatch system was switched off for the safety of responding personnel to avoid inadvertent deployment into a dangerous location.
In Manchester, the high ballistic load and formation of the improvised explosive device resulted in multiple severe soft tissue injuries from fragmentation along with penetrating injuries including to the brain and spine. During the Westminster Bridge incident the primary injury mechanism was blunt as would be expected from a motor vehicle strike, resulting in multiple soft tissue and bony injuries. During the London Bridge incident this was combined a case load of penetrating trauma from stabbing weapons—mostly to junctional areas of the upper torso and neck. As a multimodal, distributed and cascading incident this presented a very real challenge for casualty identification and timely extrication. Although actual attack phase of the incident was of very short duration (minutes) the subsequent management lasted several hours.
As well as the impact of witnessing the severe injuries and deaths including children, a significant disruptive factor at the scene in Manchester was noted to be the noise of alarms and sirens along with frequent radio communication interruptions. Hence, one of the main recommendations has been to consider appropriate radio control measures, that is, critical messaging versus background ‘chatter’. Repeated requests for precise categorisation and the triage status of casualties were also noted to be a distraction to responders with little practical benefit.
Clearing the scene with a full search or sweep for casualties is essential during a Marauding Terrorist Firearms Attack-type scenario where both uninjured and injured survivors may be in hiding. For example, the London Bridge incident called for a wide area of coverage for responders and movement of casualties into the ‘cold’ (permissive) zone around a large perimeter. Despite this, the ‘hot’ phase was over very quickly and already by the time a clear command and control structure was in place. This reinforces the importance of maintaining the Joint Emergency Services Interoperability Programme6 principles of continuously reassessing and modifying the response strategy.
Resource utilisation and equipment considerations
Initial resource utilisation in Manchester involved 60 ambulances, 8 rapid response vehicles with 300 personnel altogether including 3 Hazardous Area Response Teams (HART) and 5 prehospital care doctors. The London Bridge incident involved 29 ambulances, 14 solo responders and 2 HART with casualties. Both the London Bridge and Westminster Bridge incidents involved five hospitals in the response.
During the Manchester incident response, the first ambulances were required to unload equipment for use at the scene, thereby stripping them of the necessary resources to be used further. It was felt that the ideal alternative would be to use deployment of response vehicles with resilience stocks or demountable ‘pods’. If required, initially responding vehicles could drop off equipment and return for restocking.
An ongoing challenge remained how to maintain ‘core’ activity during the response to a serious incident, such as urgent stroke care and transport to primary coronary intervention services for myocardial infarction.
Casualty triage
In general, and for all three incidents, triage categorisation was noted to fluctuate with a casualty’s status often changing (improving or deteriorating) by the time they arrived at hospital. For example, during the London Bridge incident, 48 casualties were transported to hospital and eight died at scene. Of those transported, a 25% fall in the number categorised as P1, a 50% fall for P2’s and a three times increase in P3’s were noted between scene and arriving at hospital. The P1 case-mix consisted of around one-third blunt polytrauma and two-thirds penetrating trauma. Triage based on simple differentiation of ‘walking’ versus ‘not walking’ and with reference to injury pattern or potential specialist service need, for example, ‘limb amputation’ or ‘suspected spinal injury’, was generally agreed to be more effective for prioritisation and receiving hospital selection.
Table 2 shows the percentage triage for each category against relevant incident and mechanism.
Percentage triage categorisation for transported patients
Casualty distribution and transportation
During the Manchester incident, utilisation of the established distribution matrix resulted in the effective transport of casualties from scene. Almost all of the casualties were directed to the correct hospital first time with only two urgent secondary transfers being required subsequently. Significant value was placed on the role of senior personnel, including clinicians, to enhance the triage process and decision-making regarding casualty movement from the incident scene. Communication from scene to receiving hospitals was often noted to be difficult due to limited switchboard capacity and the need for a more direct or single point of contact was raised. Overall, 55% of casualties were transported to major trauma centres (MTC) and 45% to trauma units. Each hospital received at least 10 patients per receiving hospital. Most P1’s went to MTCs with 30% of these requiring critical care admission subsequently. Of note, the first casualty to arrive at hospital was transported by police, rather than the ambulance service.
For all incidents, receiving hospitals described a variation in messaging from the prehospital setting. Overall, most sites agreed that individual prealerts were not required and potentially caused confusion. Instead, information such as ‘five more casualties coming’ or ‘no further casualties due’ was considered appropriate.
Helicopter emergency medical service
During the response to the Westminster Bridge incident, the London helicopter emergency medical service (HEMS) team doctor was able to fulfil a number of roles: providing direct clinical care; in support of, or as part of, a Medical Emergency Response Incident Team; and as a scene medical advisor. The latter role facilitated the creation of an effective Command and Control infrastructure and communicating situational reports to control. The doctor subsequently handed over to the ambulance service commander. The HEMS doctor was also able to assist in providing enhanced triage for casualty assessment and distribution.
A further advantage of a HEMS response is the gaining of a ‘cockpit’ view which provides unique aerial overview of the scene—providing situational awareness and essential appreciation of the geography and scene layout.
Conclusions
The structured clinical debrief process which followed the incidents in Manchester and London in 2017 provided the opportunity to share and disseminate the lessons identified in a multidisciplinary and multiprofessional forum. Many of the key lessons were common to all three incidents although specific challenges were noted where circumstances differed and there was variation in mechanism of injury. Good communication and situational awareness had a vital role to play in the prehospital phase to ensure an effective and timely medical response. Like the Paris attacks in November 2015 and in Barcelona in August 2017, the process of casualty triage and transport has been reviewed and developed to ensure effective distribution with enhanced forward decision-making. These lessons can also be applied in the military context of providing a medical matrix for the response to a dynamic and often dispersed casualty incident where resources are limited and must be carefully directed.
Footnotes
Contributors PH is the sole author of this article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.