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Abstract
This is the third paper in a three-part series detailing the lessons identified during the National Health Service (NHS) England clinical debrief meetings which followed the response to the 2017 Manchester and London terrorist incidents. It covers the postincident and recovery phases including rehabilitation, bereavement support, psychological support, network and regional lessons, NHS communications and supply organisations. It also summarises the military application of these lessons and outlines the next steps for further development.
- major incidents
- terrorism
- eprr
- post-incident phase
- recovery phase
- military
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Key messages
This article summarises the 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
This paper is the third in a series detailing the lessons identified during the National Health Service (NHS) England clinical debrief meetings which followed the response to the 2017 Manchester and London terrorist incidents. The first two papers detailed the lessons identified and feedback from the prehospital and hospital phases of the response.1 2 The aim of this third paper is to cover the postincident and recovery phases including rehabilitation, bereavement support, psychological support, network and regional lessons, NHS communications and supply organisations. It also summarises the military application of these lessons and outlines recommendations for the next steps in development of post incident resources.
Rehabilitation
All agencies reported significant gaps in the national provision of rehabilitation services. Key issues raised included funding and continuity, requiring multidisciplinary teamwork and integration with outpatient services and out-of-area facilities. There is a perceived lack of provision of trauma rehabilitation at more ‘peripheral’ hospitals. Replication of a network model was suggested as one solution by replicating the organisation of services with a hub and spoke model linked to centralised trauma centres.
Suggested membership of the multiprofessional rehabilitation team for case conferencing included rehabilitation clinicians, occupational therapists and orthotics services, social and safeguarding representatives (local authority), play and school support (for children), family and relative support and psychologists.
Further observations from the rehabilitation team are listed in box 1.
Observations from rehabilitation teams
Two phases were suggested: (1) initial, acute in-hospital care and (2) longer term, usually outpatient follow-up, including orthotics and occupational therapy input.
A rehabilitation ‘response’ to the acute phase is limited by number of rehabilitation consultants requiring careful cross-cover arrangements and consideration of a wider scale or ‘distributed’ response, for example, at a national/supraregional level.
An acute trauma rehabilitation model with routine follow-up taking place at the 4–6 week stage with postinjury functional screening.
Key challenges include capacity and access to specialist care inpatient services such as spinal cord injury. Ongoing care needs are often at reach or repatriated.
Access to legal and financial support must also be considered.
Potential controversy regarding screening for post-traumatic stress disorder and ongoing cognitive dysfunction following non-severe trauma brain injury (or ‘postconcussional’).
Access to post-trauma psychological support.
A ‘distributed’ approach to rehabilitation services would also support the development of services by increasing the experience and training of clinicians and support personnel.
Bereavement support
During the NHS England debrief sessions, bereavement services which had supported relatives and loved ones following the Manchester incident provided feedback with some of the greatest impact of all the lessons identified. Clearly, a highly emotive subject, not least due to the young age of many of the victims, there was significant reflection regarding the provision of services to support care of the dead and their families. Lessons were noted for all instances of violent or sudden death and the need for a nationally approved and endorsed approach was raised.
For Manchester, a forensic mortuary was established at the predetermined location of The Royal Oldham Hospital. Preparation of the facility required movement of bodies and the delivery of a mobile CT scanner for postmortem assessment. In total, the team required to provide the service amounted to around 100 personnel including identification teams, administrative support, pathologists and associated staff.
A summary of key observations are listed in box 2.
Key observations of bereavement services
A single point of contact is required for effective communication with the bereavement team and mortuary services.
Accommodation and rest areas were initially inadequate and required significant extra resources to provide a satisfactory capability.
Bereavement nurses are required in major incident plans to support relatives and loved ones.
The ‘Swan’ model10 was highlighted as an example of best practice for bereavement resources and included the provision of rooms for families to stay on site, memory boxes, quiet spaces, spiritual care boxes and the opportunity to spend time with the deceased in compassionate surroundings.
Primary healthcare support to families was also provided through access with an on-call general practitioner.
Support nurses were allocated to families with 24/7 access on a shift rota for the first 48 hours.
It was essential to recognise the distinction between forensic and care service needs—Police Family Liaison Officers were supported in providing information and guidance to families.
Psychological support
Another key area of discussion was that of psychological support—not only for victims of the incident but also the responders and medical personnel involved, both prehospital and in receiving hospitals.
Key observations are shown in box 3.
Key observations from psychological support services
Psychological support must be integrated into major incident plans with accessible services provided to victims, relatives and staff from the reception phase onwards.
Support should also be provided to ‘phased’ staff members—such as those coming onto shift after the initial reception phase or providing contingency services.
Meeting the specific needs of all personnel by the provision of individual and team-level debrief, support and monitoring.
Challenge of continuity for onward care and out-of-area liaison.
Provide treatment and support to families together wherever possible.
Social media interaction guidelines—reducing the impact of messaging for vulnerable individuals or groups and deciding the most appropriate messaging system or approach such as information sheets, via community services or school or place of work.
Consistent psychological ‘first aid’ approach with self-care advice and internal organisational support.
Wider strategic issues of resourcing a response: the need for a significant number of psychology.
One of the main outputs from the clinical debrief process was a series of presentations on the principles of psychological support for sharing. These principles are summarised in box 4.
Principles of psychological support
STOP→ REFLECT→ LEARN→ IMPROVESTOP→ REFLECT→ LEARN→ IMPROVE
Establish the specific needs of individuals and groups; provide access to helplines and further advice.
Provide clear information about ‘making sense’ of the incident: cognitive processes to appreciate what has happened and relate this to personal response—both physical and psychological.
Provide structured postincident debrief support: initial ‘hot’ debrief, later ‘cold’.
Support reflexivity: normalisation (avoiding cognitive dissonance), decompression, particular coping strategies and the restoration of normal function—both the individual and the team.
Identify and monitor high risk groups: advocate early contact and accessibility.
Recognition of poor coping, abnormal function or reaction—in self or in others:
Unintentional re-experiencing.
Intrusivity of memories/experiences.
Over-negativity and isolation.
Impairment in performance or psychosocial functioning.
Delayed recovery>months.
Network and regional lessons
Several lessons were also identified from a strategic perspective and the role of the network and regional response framework was closely scrutinised, mostly in terms of coordination and collaboration. Networks may include trauma networks, critical care networks, specialist paediatric services and specialist burns services as well as ambulance and voluntary services and responders. Existing scalable response frameworks are really only designed for the first few hours of the incident. Following this, a dynamic ongoing response will be required to counter evolving risks and allocate resources effectively.
The main role of a network is in the strategic planning phase to organise and agree capacity creation and dispersal frameworks between institutions, develop internetwork liaison and a mutual appreciation of capability at a supraregional level. During a major incident, the network does not take the role of ‘Gold’ command. However, their active role may be in advising the optimisation of capacity and contingency arrangements, facilitate repatriations and support postincident or exercise learning and academic output.
A summary of observations are listed in box 5.
Network and regional observations
Experienced clinical representation is essential at a strategic level in order to facilitate coordination between institutions and between networks and regions.
Local knowledge regarding potential capacity, medical facility capabilities and geography is vital and supports effective translation and utilisation of situational awareness when considering courses of action—in keeping with the principles of the Joint Emergency Services Interoperability Programme.11
Key elements of an effective network or regional response include a patient distribution framework with predetermined capacity and capability arrangements, a regional hospital specialty matrix and a good working knowledge of neighbouring networks.
Maintain close working with co-development of plans and training between the network, local ambulance trusts, local emergency preparedness, resilience and response teams and the conduct of multiagency exercises.
For a large scale, wider area response, the responder agencies should move away from ‘traditional’ physiologically derived primary triage to a more injury intervention-based approach. The need to differentiate P1 from P2 within a dynamic triage process is also unnecessary.
During a network/regional response, it is important to carry out regular clinical teleconferences to inform the clinical strategy as the situation develops.
The role of Hospital Ambulance Liaison Officers requires formalising and embedding into response plans more firmly—they can act as vital single portals of contact and information sharing.
Training and practice standards must be set regionally for common language and shared understanding, locally relevant policy, protocols and standard operating procedures.
Neighbouring networks may be required to provide support following secondary events such as a coordinated attack on a medical facility or infrastructure denial.
HM Coroners should be engaged with early to understand the expectations from a forensic point of view.
Consider the development of a clinical and/or administrative ‘passport’ for personnel who may be required to provide mutual aid and be tasked to work in other networks or organisations.
Further areas for development at a regional level include the establishment of a resilient interface between hospitals and the scene and between hospitals and the strategic coordination group. Training for hospital command staff can be initiated by generic teaching such as the Hospital Major Incident Medical Management and Support course although will also require regular exercises to confirm and develop this further in the context of local resources and facilities.
Trauma units and other facilities will require training and support to enhance capability to meet the needs of the response. Similarly, secondary transfer capability must be developed to ensure appropriate personnel, resources and transportation vehicles can be deployed.
Special cases may include very large-scale events leading to multiagency saturation (uncompensated incidents), infrastructure damage (compound incidents) or where the type of incident leads to an overwhelming quantity of a specific injury pattern or patient group, such as severe burns or paediatric cases. Special, likely nationally derived, arrangements will be necessary to manage such circumstances.
One final point for regional, if not national, consideration is the development of community resilience with self-delivered first aid or bystander support while waiting for trained medical assistance. Several initiatives already exist, such as CitizenAID3 in the UK and the ‘STOP the Bleed’4 campaign in the USA. The National Police Chiefs’ Council (NPCC) has also produced guidance setting out the three key steps for keeping safe in the event of an incident involving a firearms or weapons attack: ‘Run, Hide and Tell’.5
NHS communications
Communications are often the main subject of postincident reports and reflection. Provision of reliable and resilient communications is essential to ensure effective coordination at every level. Public safety and reassurance is the main government priority. Police will normally be the lead agency for communications and informing public although in certain circumstances higher level approval for messages or coordination is needed in which case central government may take control via cabinet office briefing room.
The main roles of the NHS communications cell are to assist at local level and also provide central support at regional and national levels. The on-call service requires a minimum of four personnel to provide support to the strategic coordinating group, network liaison, media monitoring and a telecommunications capability. The ongoing training demand and external rota resilience remain a significant challenge to maintaining this function. A summary of further key NHS communications reflections are listed in box 6.
Key National Health Service communications reflections
Social and broadcast media will be live and intrusive. Be aware that journalists may cross ethical/moral boundaries to pursue the story. Confidentiality is the key issue.
Healthcare responders are likely to be questioned for information and challenge is managing media interaction—clear trust policy and media support are vital.
There is a need for clear boundaries for production company or other media teams filming or recording audio on site during an incident. Policy must address appropriate security and privacy issues.
Social media creates an immediacy of information and multiple perspectives which can raise the potential for error and misinformation. It is important to have a single point of contact or information hub for public messaging. Hospital coordination teams should also establish a communications team early in the response.
Families were potentially able to confirm deaths of loved ones through interaction with social media. Early intervention must therefore be taken to inform and support families and avoid conflict with formal forensic activity and the subsequent investigation process.
NHS supply
Resilient equipment and consumables supply and logistics will be a vital component of a larger scale incident involving a regional or supraregional response. However, even a localised response may require the supply of extra resource and single-line items, such as external fixators. The NHS supply organisation fed back key learning points from the incidents in 2017, as summarised in box 7, and also outlined the centralised process for accessing products, as shown in figure 1.
National Health Service (NHS) supply process for accessing products.
Main National Health Service supply organisational feedback points
The majority of regularly used consumables are held in sufficient quantities to enable an effective resupply in the event of a major incident requiring a regional/supraregional response.
During the response the aim will be to deliver emergency stocks within 5 hours.
Key challenges remain items produced by smaller scale developers or overseas product lines—ongoing work to identify alternative options or internal production capability.
Two main products: external fixators and specialised burns dressings are centrally stockpiled for distribution in the event of a large-scale incident.
Where potential gaps in supply have been identified there is an ongoing project to match clinical need to resourcing and provide increased ‘buffer’ stocks.
Military context
In terms of Defence Medical Service and wider military context, the lessons identified are likely to have many parallels with the challenges faced in providing medical care on exercise, on operations and in the warfighting role. The Operational Patient Care Pathway, by encompassing the full scope of medical care provision to the population at risk from point of injury to definitive care and rehabilitation, can be translated into an extended and prolonged major incident scenario. Challenges that draw comparisons include the security threat and ongoing engagement with ‘enemy’ forces such as a Marauding Terrorism Firearms Attack and the capability to maintain situational awareness representing the Intelligence, Surveillance, Target Acquisition and Reconnaissance function. The lessons identified may therefore be appreciated and considered by Defence, especially relevant to operating at reach with minimal logistic support and with extended lines of communication. Highlighting key lessons may also help to promote innovation in order to provide solutions to challenges, particularly in the relation to the resupply of consumables and adaptable medical technologies. Redistributed manufacturing options may also exist to support medical capability at far reach and this is an ongoing area of exploration.6
The next steps
The national clinical debrief process represented a unique opportunity to capture and collate learning points from each of the three UK terrorist-related incidents in 2017. The first two articles in this series7 8 have already detailed the lessons identified and feedback from the prehospital and hospital phases of the response. The most recent developments in terms of policy and doctrine since the debrief process include updated guidance on blood-borne virus risk management,9 the National Incident Response Plan1 and the Concept of Operations for Managing Mass Casualties.2
Ten key lessons can be identified for wider dissemination to guide further development of local or regional response frameworks, policy and doctrine and interoperable planning at all levels. These are summarised in box 8. However, the main reflection common to all three incidents was that the trauma systems and networks, receiving hospitals and responder agencies involved were not tested to fully capacity or capability. The unanswered question therefore remains to ascertain what would be the result had capacity and capability been completely overwhelmed?
Ten key lessons for dissemination and further development
Response plans must include integrated arrangements for psychological support, rehabilitation, bereavement care and support, media management and social and community assistance guided by centralised or established best practice
Lockdown and security measures must be defined and appropriate guidance provided for a dynamic, dispersed approach with regular exercising and rehearsal, including evacuation procedures.
Multiprofessional training should be developed from an individual to multiagency level according to local needs and based on generic templates with tabletop and practical exercises conducted from departmental up to organisational levels and in accordance with Joint Emergency Services Interoperability Programme principles.
‘Standby’ and ‘Declared’ nomenclature requires clarification and ensuring consistency between different organisations.
Development of appropriately governed, secure and reliable communication portals for information sharing—similar to social media platform systems such as WhatsApp or Wickr.
Development of enhanced triage and support to medical teams in forward areas with effective casualty distribution. A similar approach in hospital reception phase to facilitate prioritisation of cases and allocation of resources.
Recognise the impact on victims, relatives and responding personnel for short-term and long-term psychological issues and their subsequent support needs.
Development of standardised approaches for patient identification and registration, documentation and post-incident debrief and feedback to identify future training needs or resource gaps.
‘Whole-system’ business continuity measures in the context of a mass casualty or very large scale (uncompensated and/or compound) major incident incorporating rapid escalation and stepwise de-escalation approaches to the ‘new normal’ and routine activity.
Review of the ‘P4’ or ‘expectant’ category and clarify definitions of futility versus resource exhaustion.
Footnotes
Contributors PH attended the NHS England clinical debrief sessions, collected all data and is the sole author of the manuscript.
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.