Introduction
It is inevitable that members of the public will be caught up in the aftermath of a terrorist attack. The government advice for those embroiled in such a situation is “Run, Hide, Tell”.140 Run: run to a place of safety. Hide: it is better to hide than confront. Tell: tell the police by calling 999.
Nothing I say in this Part of my Report is intended to undermine that advice. However, experience from the UK and around the world demonstrates that some members of the public choose not to run and hide, but instead to remain at the scene and help. Others will run towards danger to provide their assistance. These people are sometimes known as zero responders or immediate responders.141
The Attack showed that people other than members of the public, such as event medical staff or unarmed police officers, will also run to the scene of a terrorist attack and that police firearms officers are likely to attend quickly.
The evidence reveals that it is vital that all of those who choose to be present in the aftermath of a terrorist attack in any of these ways are able to provide what I have referred to already as first responder interventions.
Lieutenant Colonel Park explained the concept of first responder interventions and their significance.142 An obstructed airway or a catastrophic bleed may kill within minutes, long before professional clinical care is likely to arrive.143 These conditions may be capable of management by the application of simple techniques, which any member of the public can be taught. In my view, there needs to be widespread education about what those techniques are. That will save lives.
Educating the public
We need to ensure that as many members of the public as possible have the skills needed to provide first responder interventions so that if they wish to provide life‑saving assistance they can. I am satisfied that much work is already being done to achieve this, but more can and should be done.
The charitable sector has done extraordinary work to bring the need for better public education to the forefront. I heard from Brigadier Timothy Hodgetts.144 Since he gave evidence, Brigadier Hodgetts has been appointed as the Surgeon‑General of the UK Armed Forces, the most senior medical officer within the armed forces, and he now holds the rank of Major General. He is also Chair of Trustees of citizenAID, a position he has held since that charity’s inception.145
Brigadier Hodgetts explained that the aim of citizenAID is to provide the public with the knowledge to enable people both to keep safe in deliberate attack situations and to prioritise and treat the seriously injured. citizenAID is designed to empower the public to save lives in the critical minutes before the emergency services are able to attend: in other words, during the Care Gap.146Its work and that of other charities is invaluable. The website of citizenAID can be found at https://www.citizenaid.org/.
While I welcome the work of citizenAID and other charities in this regard, it is the state that has the primary responsibility for ensuring that members of the public have the knowledge necessary to save lives in a mass casualty incident.
I acknowledge that counter‑terrorism policing has introduced its own initiative. The National Counter Terrorism Security Office has commenced work to encourage employers to train their employees to understand the basics of first aid.147 That is to their credit, but much more needs to be done. I recommend the following.
First, the young must have the skills needed to provide life‑saving interventions in a mass casualty situation. As of September 2020, all primary and secondary school pupils were required to be taught health education, including first aid, as part of the National Curriculum. This involves children aged over 12 being taught CPR.148 I agree that this is necessary. The Department for Education should ensure that it continues.
I understand that children and young people are not currently taught to deal with catastrophic bleeds or airway impairment.149 I consider it vital that training in such matters is provided to young people. This training should be received before they leave secondary school; the earlier it can responsibly be provided, the better. The Department for Education should consider extending the National Curriculum requirement on first aid to incorporate this.
I recommend that the Department for Education give consideration to including training in all first responder interventions in the National Curriculum.
Second, until children and young people have all been educated in first responder interventions, there will be a gap. Those who have already left school may lack the necessary skills. That situation needs to be addressed. The public at large cannot be forced to undertake training in first aid interventions. However, something needs to be done to encourage greater awareness within the general population of what can be done to save lives in situations such as the Attack and indeed more generally.
I recommend that the Home Office consider a public education programme and the introduction of a requirement into law, perhaps through regulations issued under the Health and Safety at Work etc. Act 1974, that employers have a duty to train all employees, or certain categories of employees, in first responder interventions.
I emphasise that everything that can reasonably be done to educate the general population in first responder interventions should be done.
Control rooms
The operators within control rooms are able to provide guidance to members of the public who telephone seeking assistance. For example, North West Fire Control had guidance documents providing advice relating to certain risks.150 These documents enabled operators to provide assistance to callers confronted by building fires, incidents involving collapsed or collapsing structures, wildfires, flooding and acid attacks. Operators were encouraged to deploy this guidance by way of a series of prompts provided by their systems. That is all sensible.
As the circumstances of the Attack reveal, in the aftermath of a terrorist attack, the control rooms of all the emergency services will receive multiple calls. Control Room Operators may have a valuable contribution to make in providing guidance on first responder interventions. Such advice is capable of empowering those uninjured members of the public who choose to remain in the aftermath of a terrorist attack by providing them with the assistance they require in order to help the casualties.
I recognise that Control Room Operators working for the ambulance services already have skills and/or training in this regard, but I consider that there is value in those who work in the control rooms of all three emergency services having the ability to provide advice on basic trauma care. I recommend that the College of Policing, the Fire Service College and National Fire Chiefs Council consider devising training packages for operators within police and fire and rescue service control rooms that achieve this aim, and that DHSC and NARU take steps to ensure that the existing training for ambulance service operators is fit for this purpose.
Those who work in control rooms should not seek to subvert the government’s “Run, Hide, Tell” message, but experience shows that many members of the public will in fact choose to stay and help. Control Room Operators are well placed to provide them with guidance.
Training of unarmed police officers
I will next turn to the position of unarmed police officers. I will address the position of firearms officers at paragraphs 20.175 to 20.183.
Often, unarmed police officers will arrive at the scene of a terrorist attack before the professional clinical response. The response to the Attack is an example of that. Officers of British Transport Police (BTP) were within the Victoria Exchange Complex when the bomb was detonated.151 Within minutes of the explosion they had rushed to the City Room, entering within about two minutes.152 GMP officers arrived at the scene within a short time of their armed colleagues. By 22:48, GMP unarmed officers had entered the City Room.153
Police officers such as these should be able to provide first responder interventions, including applying a tourniquet and opening an airway. However, the evidence I heard reveals that the unarmed officers generally lacked the skills to deliver the help they desperately wanted to provide. The footage I watched from body‑worn video cameras of the unarmed officers and the evidence more generally demonstrates that the officers were frustrated by their inability to do more to help.
All unarmed police officers should be trained to provide first responder interventions. I heard evidence from a series of police officers of Chief Officer rank. In light of that evidence, I believe that there has now developed an understanding that this is so.
It is not necessary for me to rehearse all the evidence I heard on this issue. I will, however, refer to the evidence of Assistant Chief Constable Iain Raphael, the Director for Operational Standards in the College of Policing.154 The College of Policing is the body that sets the standards for policing and develops guidance and policy for policing. That involves the College setting standards for the training of police officers, including in first aid.155
ACC Raphael explained that the College of Policing was undertaking a review of its First Aid Learning Programme (FALP) and that there is an expectation that, from January 2023, the first aid training of all police officers will include training in first responder interventions. This will include the application of tourniquets and the opening of airways.156 Some police services, including GMP, have improved their training in this regard ahead of the conclusion of the review.
To assist the review and with a view to ensuring that expectation becomes reality, I recommend that the Home Office and the College of Policing ensure that all newly recruited and existing police officers and all frontline police staff, such as Police Community Support Officers (PCSOs), are trained in first responder interventions. That training should be provided urgently.
The evidence I heard left me unconvinced that the amount of time allocated to first aid training under the current system is sufficient to allow for proper instruction in these new skills. Each police service must ensure that adequate time is allocated to training in this crucial topic. The Home Office and the College of Policing should regularly assess and appraise the training on first responder interventions given by each police service to ensure that it is of an appropriate quality and that adequate time is allocated to it.
I have already referred to TST, the ‘Ten Second Triage’ tool. Philip Cowburn and Lieutenant Colonel Park consider that this tool should be capable of use by unarmed police officers and firearms officers.157 The aftermath of the Attack demonstrated that police officers would have benefited from training in the use of this tool. It would have enabled them to identify those in greatest need of help and to prioritise them for treatment or to direct paramedics to them, if paramedics had been there in sufficient numbers.
I recommend that the College of Policing ensure that it includes training in TST in its first aid training programme when, and if, it is adopted. This is even more important while paramedics and unarmed police officers have different views as to the degree of risk that it is acceptable to take.
I recommend that the College of Policing keep the national first aid training for all officers, including firearms officers, under continual review with a view to continuous improvement.
Firearms officers: Care Under Fire
In her evidence, Lieutenant Colonel Park explained the concept of Care Under Fire.158 Every soldier in the British Army is taught that, when a fellow soldier is shot on the battlefield, the uninjured soldiers should return fire in order to neutralise or manage the threat, but then as soon as possible provide first responder interventions for their injured colleague.159
While the concept is known as Care Under Fire, it obviously applies to other situations in which a soldier is dealing with a threat. For example, it follows from the evidence I heard that where a soldier has been injured by an Improvised Explosive Device (IED), their colleagues would be expected to provide them with life‑saving interventions alongside dealing with any secondary device.
I heard evidence that police firearms officers within the UK have been trained in first responder interventions.160 Members of Armed Response Vehicle teams will commonly respond at an early stage to a terrorist attack. On the night of the Attack, the first firearms officers had entered the Arena itself by 22:43, just over ten minutes after the explosion.161
The view of senior police officers is that such firearms officers should provide Care Under Fire, giving that term its broad meaning. Matthew Twist is Deputy Assistant Commissioner (DAC) within Specialist Operations, which is part of National Counter Terrorism Policing.162 He explained that he would expect Armed Response Vehicle officers, as they sought to neutralise a threat, to be considering whether they were able to start providing care to the injured.163 CI Thomas expressed similar views.164
I do not doubt that DAC Twist and CI Thomas, each of whom was experienced and expert, expressed their genuinely held views. However, on the evidence I heard, I do not believe that the firearms officers who formed Armed Response Vehicle teams on the night of the Attack had a sufficient understanding that part of their role was to provide Care Under Fire.
The firearms officers who initially attended the Arena provided no treatment to any casualty. Indeed, the only firearms officers who provided any treatment did not arrive at the scene until 23:09, 38 minutes after the explosion.165 They helped to treat a casualty on the raised walkway at 23:12 and a casualty in the City Room at 23:25.166 I do not criticise the firearms officers, who behaved bravely that night. Rather, I am identifying an apparent disconnect between the expectations of senior officers and the understanding on the ground.
Lieutenant Colonel Park, who is heavily involved in the training of the armed assets of the Metropolitan Police Service, confirmed that, although firearms officers are trained in basic life‑saving interventions, the need to provide those interventions in the response to a terrorist incident is not well enough understood by those officers.167 The events of the night of the Attack suggest that Lieutenant Colonel Park is right.
The capacity of firearms officers to provide first responder interventions will help to fill or shorten the Care Gap because they will generally be on the scene at a very early stage. It is important that they should understand that, having neutralised the threat or having established that there is no threat, they should where possible provide basic life‑saving interventions to casualties. I do not believe that this is currently adequately understood by the firearms officers on the ground. I recommend that the College of Policing and CTPHQ ensure that this important issue is urgently addressed in the training of all firearms officers.
Lieutenant Colonel Park raised the prospect that firearms officers might be deployed with analgesia.168 She pointed out that a number of police services had been trialling methoxyflurane, a non‑opioid painkiller used for the emergency relief of moderate to severe pain.169 She stated that consideration ought to be given to rolling this out nationally.170 Given the early stage at which firearms officers are likely to reach those most seriously injured in a terrorist incident, and given the likelihood that many they encounter will be in pain, this proposal has obvious value. The College of Policing and CTPHQ should review whether firearms officers should be deployed with and trained to use analgesia as part of providing Care Under Fire.
Training of firefighters
There was widespread agreement that firefighters have a vital role to play in the event of a terrorist attack. They have particular skills in the evacuation of casualties and those skills need to be maintained. They also have first aid skills. I consider that they should be trained to provide first responder interventions. This particularly applies to the specialist resources of the fire and rescue services who may be deployed forward in an Operation Plato situation. But, as with the police, this should also be the position with all firefighters. The National Fire Chiefs Council expressed the view that this was necessary.171 I agree.
I recommend that the National Fire Chiefs Council and the Fire Service College take steps to devise a training scheme that educates all firefighters in first responder interventions. The National Fire Chiefs Council and the Fire Service College should ensure that the training scheme is implemented first to specialist responders, then to all other firefighters. This should be applied nationally. Finally, the National Fire Chiefs Council and the Fire Service College may find it helpful to consult with the College of Policing when considering the scheme since it is apparent that the College of Policing has already undertaken a good deal of work in relation to this issue as part of its review.
Philip Cowburn and Lieutenant Colonel Park considered that TST should also be capable of being used by firefighters.172 There is no doubt that there will, in the future, be situations in which casualties would benefit from firefighters having the knowledge that this tool would give them. Accordingly, I recommend that the National Fire Chiefs Council and the Fire Service College consider including training in this tool in its first aid training programme.
Training of event staff licensed by the Security Industry Authority
Many events will require the presence of stewards and other security staff and some of those personnel will require a licence issued by the Security Industry Authority (SIA). That body is the subject of examination and recommendations in Parts 3 and 8, respectively, of Volume 1 of my Report.
Not every member of security personnel is required to be registered by the SIA, so no recommendation I make to the SIA can ensure that every such member of staff is trained in first responder interventions. However, every single additional person who has the necessary skills is capable of making a difference. I consider that all SIA staff should have those skills.
I recommend that the SIA take steps urgently to devise a training scheme in first responder interventions that educates all of those licensed with it, both existing licensees and applicants for a licence. The SIA may find it helpful to consult with the College of Policing in this, since it is apparent that the College has already undertaken a good deal of work in this regard. I also recommend that the SIA take steps to encourage the security industry generally to ensure that even those members of staff who do not require an SIA licence develop skills in basic trauma care.
The Home Office has a working group with the SIA.173 I recommend that the Home Office take the action available to it to ensure that all of those licensed or to be licensed by the SIA have appropriate first aid training as I have described it.
Event healthcare services
This section can be dealt with briefly because, although important, there was widespread agreement across all Core Participants about what was required.
In Part 16 in Volume 2‑I, I set out why the provision of event healthcare services at the Arena on 22nd May 2017 was inadequate. I have little doubt that such serious shortcomings occurred elsewhere at other venues. I fear that they continue to happen. At least in part, they were and are the result of inadequate regulation by the state. That needs to be remedied.
There should be regulation that addresses the following.
First, a standard should be set for the level of event healthcare services that are required for any particular event. The evidence does not enable me to state what that standard should be, but the standard will inevitably have regard to the size of the crowd likely to attend an event and the profile of the event.
I recommend that DHSC consider what that standard should be. I do not consider that it is a standard that should be contained only within guidance. Serious consideration should be given to putting it on a statutory footing. The consequences of failing to meet the standard could be fatal.
Second, the standard should be capable of enforcement by a regulator. The Care Quality Commission (CQC) is the principal regulator of the health and social care sector. Clear and compelling evidence was given by Dr Edward Baker, the Chief Inspector of Hospitals at the CQC.174 He stated that the CQC considers that it is the appropriate body to regulate this area of activity.175 The CQC has made this point to DHSC in plain terms, but there have been delays in implementing the necessary changes.176 In my view, these changes should happen urgently.
I recommend that DHSC give urgent consideration to making the necessary changes in the law so as to enable the CQC to carry out the work it wishes to undertake in this important area.
Third, regulation of this area should have teeth. Those who provide event healthcare services may be responsible for the lives of very many people. If they breach the standard of services that the state decides to impose, there is a strong argument that there should be both civil and criminal consequences.
I recommend that DHSC consider, together with the CQC, whether the consequence of breaching the standard of provision for event healthcare services should be penal, including the possible imposition of custodial sentences.
All of these matters should be considered as a matter of urgency.
I recognise that some time is going to pass before the change I recommend is implemented. In the meantime, the licensing regime has a role to play. I acknowledge that this is not a complete answer because not all venues will be subject to licensing requirements. Even where they are, changing existing licences is not straightforward.
I recommend that the Department for Levelling Up, Housing and Communities review the guidance given to all licensing authorities on the decisions they make in relation to venues that hold events, and on what level of event healthcare services may be required at the events likely to be held at those venues. The guidance should indicate appropriate licence conditions to be used. The licensing authorities should then impose conditions accordingly or make those standards a requirement to meet existing conditions.
Ambulance Liaison Officer
Jeremy Cowen is an Emergency Planning Officer with the Northern Ireland Ambulance Service. He has a special interest in event and venue safety, and experience and expertise in that area. He provided a witness statement to the Inquiry.177 It contains his informed views about how the Care Gap should be addressed. I am grateful to him for the valuable contribution he has made to the Inquiry’s work.
Among Jeremy Cowen’s suggestions was that, where a particular risk threshold for an event is reached, an Ambulance Liaison Officer should be physically present. That person will be a member of the ambulance service. In the event of a Major Incident, the Ambulance Liaison Officer should be able to gain good situational awareness quickly and therefore pass an early METHANE message. The Ambulance Liaison Officer will also be able to initiate the ambulance service’s Major Incident Plan.178
It seems to me that the Ambulance Liaison Officer may be able to perform the role of NWAS Operational Commander until someone dedicated to that role arrives. I have no doubt that, on the night of 22nd May 2017, an Ambulance Liaison Officer would have made a valuable contribution to the emergency response.
There was considerable support for the view of Jeremy Cowen. Keith Prior made clear that NARU agreed that Ambulance Liaison Officers are capable of providing real benefit.179 The Ambulance Service Experts agreed in principle that Ambulance Liaison Officers are a good idea.180 I also agree.
The Ambulance Service Experts explained that work remains to be done to make sure that Ambulance Liaison Officers work in practice. In my view, two broad issues need to be addressed. First, there needs to be a mechanism by which the threshold at which an Ambulance Liaison Officer must be present at an event is identified. The most important factor will be the number of attendees, but there are likely to be other factors of relevance such as audience profile. Second, there needs to be a mechanism by which a requirement to appoint an Ambulance Liaison Officer in appropriate circumstances can be imposed on venue operators.
I recommend the following. In the first instance, DHSC and NARU should consider the scope of the role of an Ambulance Liaison Officer and issue guidance to ambulance services. The Home Office and DHSC should consider how the threshold for a requirement that an Ambulance Liaison Officer be present is to be identified.
If this scheme is going to work, ambulance services will need to be prepared to make members of their staff available to fill the role of Ambulance Liaison Officer. The resources of ambulance services are already stretched. The Home Office, DHSC and NARU should consider how this situation is to be resolved. It is likely, it seems to me, that venue operators will need to fund the presence of an Ambulance Liaison Officer where one is required. The Home Office should also consider how the presence of an Ambulance Liaison Officer in appropriate circumstances can be made mandatory. It may be that this should form part of the Protect Duty, which I deal with extensively in Volume 1 of my Report, or part of the regulation of event healthcare services.
Equipment
Another aspect of ensuring preparedness in the event of a terrorist attack is making sure that those who will provide assistance have the equipment they need. That applies to zero responders, to paramedics including members of HART, to police officers whether armed or unarmed, to event medical service providers and to others who may fill the Care Gap. The evidence revealed that, at the moment, there is a risk that some or all of these groups may lack the equipment they require in the event that a mass casualty incident occurs.
Public Access Trauma kits
The concept of Public Access Trauma (PAcT) first aid kits was explained by DAC Twist in his evidence.181 The idea is that they are available in publicly accessible locations and contain the equipment that would be required to provide first responder interventions. The kits also provide basic instructions. They are designed for ready use, even by untrained members of the public.182 These are plainly an excellent idea.
CTPHQ has been working with others, including charities, to promote these kits. I commend both CTPHQ and the charities for that work, but so important is this equipment that more needs to be done.
I recommend that DHSC consider the equipment that ought to be included within a PAcT kit. It is not clear to me that the CTPHQ kit necessarily contains all the equipment that might be used by a zero responder to carry out first responder interventions. In particular, while it does contain tourniquets and instructions, it is not clear to me that it contains instructions and equipment to enable an airway to be opened.
Brigadier Hodgetts described a “grab bag” that citizenAID makes available.183 While he was envisaging something that might be used by the organiser of an event as opposed to a member of the public, he described things such as a stretcher that might usefully be included.184 The contents of PAcT kits need to be given further consideration.
I recommend that the Home Office and DHSC consider how a situation is to be achieved in which PAcT kits are available in all locations in which they are most likely to be needed. It may be that this is something that can be addressed as part of the Protect Duty, or alternatively as part of the work that I have recommended DHSC undertake to ensure that there is an appropriate standard imposed on those who provide event healthcare services.
Ultimately, how this is to be achieved is a matter for government. But it is clearly a matter of importance. I do recognise the difficulties in balancing the need for public accessibility against the risks of theft or vandalism which sadly exist. Such risks will need to be accommodated in the government’s plans, but my expectation is that such issues will have arisen in many other contexts, such as publicly available defibrillators and emergency throwlines, and solutions may be available.
Connected with PAcT kits, which allow equipment to be available permanently within publicly accessible locations, DAC Twist raised the concept of “drop bags”.185 These are, as I understood it, essentially the same as PAcT kits, but they are designed to be carried by members of Armed Response Vehicle teams and dropped as they enter the scene of a terrorist attack. The aim is that they will then be used by members of the public in the same way as PAcT kits. NARU supports their introduction186 and I agree that they are a good idea. DAC Twist explained that they are already in use in a number of police service areas, with full implementation expected by 1st October 2022.187 I hope very much that implementation by that date will be achieved.
Hazardous Area Response Team equipment
As I have explained, Lieutenant Colonel Park described treatments called “bridging interventions”.188 These are interventions that a member of the public would not be able to perform.189 They require specialist skills and equipment. They involve the splinting and carrying out of traction on broken limbs.190 This is an important procedure because it reduces the casualty’s pain, enabling them to be moved, and also because it reduces bleeding, which can cause death.191
Lieutenant Colonel Park explained that members of HART would not commonly take into hazardous areas equipment that enables them to carry out bridging interventions.192 It was her view that consideration should be given to the specialist resources of ambulance services carrying such equipment into those zones.193 I agree. I recommend that DHSC, the Faculty of Pre‑Hospital Care, the College of Paramedics and NARU consider issuing guidance on how to ensure that specialist paramedics take with them into a warm zone equipment that enables them to carry out bridging interventions.
Stretchers
Once triage and any treatment needed for immediate life‑saving purposes, such as the application of a tourniquet or airway release, has been undertaken, casualties need to be evacuated. The means by which this is done is relevant both to the speed at which it will occur and to the safety and comfort of the casualty. What happened on the night of the Attack was unacceptable, with casualties carried away from the City Room on unstable advertising hoardings. The Home Office, DHSC, the Department for Transport and the Department for Levelling Up, Housing and Communities should conduct a review to ensure that stretchers that are appropriate in design and adequate in number are always available for use by the emergency services and in appropriate locations in the event of a mass casualty incident.
In 2019, Dr Langlois and colleagues in France carried out an assessment of the types of stretcher that best enable rapid extraction of casualties in mass casualty incidents.194 The results of that analysis are informative. They are publicly available and should be read by all of those who may have responsibility for the response to any mass casualty incident, including a terrorist attack.
The technology may have moved on since the work of Dr Langlois and his colleagues, and, in any event, different types of stretcher may be appropriate to different kinds of environments. I consider that work ought to be undertaken in the UK in order to identify the type of stretcher that is of greatest utility in the event of a mass casualty incident. That work should be undertaken by DHSC, with input from other bodies as DHSC considers appropriate. The product of that research should be rolled out to all those with responsibility for the response to a mass casualty incident, including a terrorist attack, whether in the public or private sector.