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The Manchester Arena Inquiry has now concluded. The closure notice from the Inquiry Chairman is available here.

Volume 2 is divided into two sub-volumes: Volume 2-I and Volume 2-II. Volume 2-I is 695 pages long. Volume 2-I begins with a Preface and then continues with Parts 9 to 16. Volume 2-II is 189 pages long. It contains Parts 17 to 21 and the Appendices. A list of the names of the twenty-two who died is at page vii of Volume 2-I and at page iii of Volume 2-II.
A large format version combining Volume 2-I (ia, ib and ic) and Volume 2-II is also available.
Volume 2-I (standard format)
Volume 2-II (standard format)
Volume 2 (large format)

Narrowing the gap


If the Care Gap is to be made as short as possible, ambulances and specialist ambulance resources need to reach the scene of a mass casualty incident without delay. Ambulance personnel need to work collaboratively with their colleagues from the other emergency services. Specialist resources will be required and many witnesses advocated a consultant‑led response.6

Where the incident is terrorist in nature and of a type such that Operation Plato has been declared, the affected area needs to be zoned accurately and the hot and warm zones need to be shrunk as quickly as possible. All casualties, whatever zone they are in, must be triaged and treated promptly and evacuated to hospital as speedily as possible. That includes the triage, treatment and evacuation of those in the hot zone.

Ambulance service resources generally

Getting ambulance personnel to casualties quickly in the event of a mass casualty incident is an obvious way of shortening the Care Gap. For that to happen, ambulances need to be available to deploy immediately and in sufficient numbers. Currently, that does not normally happen. That is because, around the UK, ambulance services are always “playing catch-up”: at any moment each ambulance in the country will be dealing with an incident, with other emergencies building up behind that incident in order of priority.7

Ambulance services generally do not have any spare capacity within their frontline resources. As the Ambulance Service Experts noted: “They are normally stacking emergencies with multiple emergencies waiting to be assigned to a particular ambulance.8 This means that, in the event of a mass casualty incident, it is likely that the number of ambulances necessary for the care and treatment of the casualties will not be available to attend immediately or anything like immediately.

The night of the Attack on 22nd May 2017 is an example of that. Of the 319 North West Ambulance Service (NWAS) vehicles available that night, only seven were able to deploy straightaway,9 far fewer than was needed. The Ambulance Service Experts considered that, with the existing resources available to ambulance services and current levels of demand, such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country. I was informed that, over the course of the last ten years, the demand on ambulance services has doubled, with the trend of increasing demand continuing.10 So, this problem is only going to get worse if left unchecked. That is a very concerning state of affairs.

Ensuring that ambulances reach the scene of any mass casualty incident swiftly is a critically important part of making the Care Gap as short as possible. Not only do ambulances contain the personnel and equipment able to provide many life‑saving interventions, but they are also the vehicles by which casualties are best transported to hospital. If ambulances do not attend the scene quickly and in sufficient numbers, lives will be lost.

It is not for me to dictate to central government or to the NHS how finite resources should be spent. However, I consider that all ambulance service trusts should review their capacity to respond to a mass casualty incident. Having done so, they should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the numbers required.11 The Department of Health and Social Care (DHSC) should give urgent consideration to any recommendations made by the trusts and the NHS commissioners.

Ambulance service specialist resources

Connected with this review is the issue of specialist ambulance service resources.

Where the mass casualty incident is the result of a terrorist attack, there may be sound reasons why only those with specialist skills and equipment should be deployed forward, at least initially. Ambulance services introduced Hazardous Area Response Team (HART) operatives to address this issue.12 As I explained in Part 14 in Volume 2‑I, a HART crew comprises specially recruited personnel who are trained and equipped to provide the ambulance response to high‑risk and complex emergency situations.

They are able to work in dangerous areas during or after a terrorist attack. They are therefore vital to making the Care Gap as short as possible in such a situation. There may be respects in which the training of HART operatives could be improved. Furthermore, strong voices have advocated the view that the clinical response to a terrorist attack should be consultant‑led. I will address those issues below. None undermines the importance of HART in narrowing the gap.

Given the importance of HART in any response to a terrorist attack, it was concerning to hear evidence that this specialist resource is not always available to respond as swiftly as expected. Keith Prior is the Assistant Chief Ambulance Officer in the West Midlands. He is also a Director of NARU, which works nationally on behalf of each ambulance service trust in England to provide a co‑ordinated approach to emergency preparedness, resilience and response.13 He gave evidence that ambulance services around the country are “struggling” to maintain the minimum levels of HART staff.14 He said that, of all the ambulance service trusts, only one is able to achieve that minimum level routinely.15

Keith Prior’s view was that there are not sufficient numbers of HART personnel.16 He explained that NARU’s view is that there needs to be an increase in the membership of HART if a proper response to an incident such as the Attack is to be achieved.17 Also, he considered that there is currently a lack of understanding on the part of ambulance commanders about what HART can provide in the response to a terrorist attack.18 NARU has been taking steps to address this lack of understanding, but Keith Prior explained that more remains to be done.19 I accept the evidence of Keith Prior that these are real issues that need to be addressed.

The Ambulance Service Experts identified an increasing tendency in recent years for HART resources to be deployed for less serious calls. They describe this as a problem20 and observe that the deployment of HART to a Major Incident should be mandatory.21 I agree that, in the event of any Major Incident, it is highly undesirable that HART should be delayed in attendance by being engaged in another incident that does not require specialist resources.

I recognise that steps are being taken to increase certain other specialist resources of the ambulance service. However, HART operatives have particular skills and capabilities that would be invaluable in the event of a terrorist attack.

The review of resources I identified at paragraphs 20.11 to 20.15 should encompass an assessment of whether each ambulance service trust has an adequate number of trained specialist personnel to respond effectively to a mass casualty incident.22 On the evidence I heard, the numbers are currently not sufficient.

DHSC and NARU should also develop procedures to ensure that, so far as possible, each ambulance service trust is able to deploy or call upon HART resources immediately in the event of a Major Incident.

As part of that, DHSC and NARU should develop procedures to ensure that, so far as possible, each ambulance service trust can call upon cross‑border support in respect of HART resources immediately in the event of a Major Incident.

NARU has developed new national standards and training courses for ambulance commanders.23 Their purpose is to improve standards and standardise command competence. I welcome that.

I recommend that DHSC and NARU ensure that all ambulance commanders receive regular Major Incident training. The training should include training on HART capabilities, on all the command roles and where they will be located, on how to gain situational awareness through the deployment of sector commanders and other roles, and on the importance of getting ambulance personnel to casualties without delay.

Joint Operating Principles

At the time of the Attack, the third edition of the Responding to a Marauding Terrorist Firearms Attack and Terrorist Siege: Joint Operating Principles for the Emergency Services (JOPs 3) was in force.24 In Parts 11 and 12 in Volume 2‑I, I addressed the detail of that edition of JOPs and its position in a hierarchy that involves the Joint Doctrine: The Interoperability Framework (the Joint Doctrine)25 above it, and, below it, at a national level, the Counter Terrorism Policing Headquarters (CTPHQ) Operation Plato guidance,26 and, at the local level, Greater Manchester Police’s (GMP’s) Operation Plato plans.27 JOPs 3 dealt with the response to a Marauding Terrorist Firearms Attack. This addressed zoning and the fact that, as of 2017, specialist resources such as HART were able to enter the Operation Plato warm zone, but not the Operation Plato hot zone.28 For that reason, zoning is of importance to the Care Gap. Casualties will almost inevitably be present in the Operation Plato hot zone. The quicker this zone is shrunk and then reclassified to warm or cold, the quicker the casualties within it will be treated. Similar and connected considerations apply to the Operation Plato warm zone. Casualties are also likely to be in that location. Shrinking and then reducing the warm zone to cold will enable a broader range of emergency responders to enter and therefore speed up the treatment of casualties there as well.

Since the Attack, changes have been made to JOPs. The fourth edition was issued in November 2017. Then, in 2019, there was a shift away from the concept of a Marauding Terrorist Firearms Attack to the broader concept of a Marauding Terrorist Attack. That led the edition numbering to restart. In March 2019, the first edition of the Marauding Terrorist Attack Joint Operating Principles was issued. In December 2020, a second edition was issued.29 That is the edition currently in force (the current JOPs).

Chief Inspector (CI) Richard Thomas was the Head of Specialist and Counter Terrorism Armed Policing Capabilities at CTPHQ in 2017. He remained in that post as a civilian when he gave evidence in January 2022.30 His evidence gave rise to issues of operational sensitivity so it was necessary for some of it to be heard in a restricted session. However, CI Thomas confirmed in open evidence that the current JOPs and the current CTPHQ Operation Plato guidance simplify the description of each zone. They provide greater clarity in relation to the deployment of both non‑specialist and specialist resources into zones.31 The evidence overall indicates that the current JOPs provides not just greater clarity but also greater flexibility to commanders in relation to the forward deployment of both non‑specialist and specialist resources.32

This greater clarity and flexibility is desirable. However, the evidence revealed that some senior emergency service commanders continue to lack confidence that the approach contained in the current edition of JOPs will necessarily work to produce a better outcome. Mark Hardingham is Chair of the National Fire Chiefs Council, which provides advice to government about matters that have a bearing on fire and rescue services and which seeks to provide the professional voice for those services.33 He explained that the National Fire Chiefs Council considers that JOPs ought to include specific reference to the Care Gap and the steps commanders need to take to minimise the gap.34

NARU also considers that JOPs would benefit from improvement.35 The substantive changes NARU considers should be made are as follows.36

First, greater emphasis should be placed in JOPs on the rapid deployment forward of all emergency services to save lives. Rather than waiting for the ideal conditions to deploy forward, the presumption should be to deploy forward. In particular, the need to deploy specialist paramedics and doctors into hazardous areas, where that is necessary to assist casualties, must be prioritised.

Second, the emergency services need to work together to align their perception and understanding of risk. Overall, there needs to be a greater tolerance of risk across the emergency services.

Third, in the aftermath of a terrorist attack, the possibility of a secondary device will often, if not always, exist. The presumption should be on deployment unless there is a proper basis for believing that a real risk of a secondary device exists. JOPs should make clear that this is the position. A hypothetical chance should never prevent deployment.

NARU’s points, all of which have force, highlight an issue that featured throughout the emergency response evidence. That issue is: how is a situation in which commanders from different emergency services assess risk differently to be addressed? The Joint Doctrine and the current JOPs assume that commanders will agree both the risk and the forward deployments that are appropriate based on that risk. The evidence I heard reveals that this assumption may not be correct. The different emergency services may have different appetites for risk, and certainly individual commanders may do. The emergency response to the Attack demonstrates how this is capable of creating a problem and a delay in deploying responders forward.

To give just one example, shortly before 01:00 on 23rd May 2017, a Joint Emergency Services Interoperability Principles (JESIP) huddle took place between CI Mark Dexter, the GMP Ground Assigned Tactical Firearms Commander; Stephen Hynes, the NWAS Operational Commander; and Station Manager Andrew Berry, the Greater Manchester Fire and Rescue Service (GMFRS) National Interagency Liaison Officer. The GMFRS Chief Fire Officer, Peter O’Reilly, participated by telephone. The issue of zoning was the focus of the discussion. It is impossible to listen to the recording of that discussion without concluding that, even at that late stage, nearly two and a half hours post‑detonation, there was no joint understanding of risk across the three emergency services.37

In the course of the evidence, the question of whether this situation should be resolved by JOPs giving one of the commanders a trump card or casting vote was examined.38 I am satisfied that there would be significant problems in doing so in a formal sense. However, I am also satisfied that there should be a working assumption that in certain situations particular commanders should take the lead and that their views should prevail, unless there is a compelling reason not to follow them.

For example, in an Operation Plato situation, the views of the police commander about which resources can and cannot be deployed into particular areas should be followed, unless there is a compelling reason not to do so. The current JOPs has sought to achieve greater clarity in relation to this situation. However, the evidence I heard indicates that if clarity has been achieved in the document itself, that clarity has not been communicated adequately to those who will actually have to respond to events such as the Attack.

Decisions about zoning and the forward deployment of specialist and non‑specialist resources will be critical to the treatment of casualties in an Operation Plato situation. They will be capable of dictating whether lives are or are not saved. In the circumstances, the Home Office, His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), the College of Policing, the Fire Service College, NARU and JESIP should review and, as necessary, update the Joint Doctrine and JOPs. The following matters should be considered in that review.

First, achieving a situation in which commanders understand that the critical decisions of the commander most directly concerned in the issue under consideration are followed, unless there is a good reason for not doing so.

Second, achieving a situation in which risk appetite, by which I mean the understanding, acceptance and management of risk, is common across the three emergency services.

Third, achieving a situation in which deployment forward of specialist resources is the presumption, to be displaced only in the presence of a properly evidenced basis for not deploying resources forward.

Fourth, achieving a situation in which the possibility of a secondary device does not delay forward deployment of resources unless there is a proper basis for believing that such a device exists.

Fifth, achieving a situation in which the three emergency services all use the same terminology to describe the Operation Plato hot, warm and cold zones and all have a common understanding of those terms. That need also arises in Major Incident situations in which Operation Plato is not declared. In the same way, a situation must be achieved in which the three emergency services work jointly, using common terminology and sharing an understanding of those terms.

I recommend that the Home Office, HMICFRS, the College of Policing, the Fire Service College, NARU, individual police services and JESIP review what changes need to be made to the CTPHQ Operation Plato guidance and Major Incident Plans in order to achieve those aims. This calls for an urgent response.

High-fidelity training

The observations I have just made relate to the extent to which JESIP can help to reduce the Care Gap. In Part 21, I will make some further and more general recommendations in relation to JESIP, the Joint Doctrine and JOPs. However, changing policy and guidance is not, of itself, enough. The changes need to become embedded in those who may actually be called upon to respond in the event of an Operation Plato situation. That requires training and multi‑agency exercising.

In her evidence, Lieutenant Colonel Dr Claire Park, a consultant in pre‑hospital care and critical care and anaesthesia who has worked closely with the firearms teams of the Metropolitan Police Service,39 described her involvement in the design and delivery of Major Incident training. She explained that this involves the use of simulated casualties, designed to test whether those with particular injury patterns get the required treatment when they need it. It explores whether deaths could have been prevented.40 It also helps to prepare those who will be required to respond to a mass casualty incident for the significant assault on their senses that the incident will involve.41

Lieutenant Colonel Park described this as “high-fidelity” training.42 I consider such training to be vital. The Home Office, CTPHQ and the College of Policing should consider introducing the use of regular high‑fidelity training to give emergency responders better experience of the stress, pressure and pace of a no‑notice attack.

Training is not enough. Areas for improvement need to be identified and change implemented. The local resilience forums have an important role to play in this, as do each of the individual emergency services and the control rooms. Training is not an end in itself. One of the important purposes of training is to drive change, and that needs to be understood across the emergency services.

Embedding medics with police firearms officers

I heard evidence about the approach taken by nine other countries to the Care Gap. Each of those countries faces a substantial terrorist threat. I am grateful for the level of co‑operation I received. It was necessary for me to hear most of this evidence in a restricted session because to have heard it in an open session may have assisted terrorists to mount further or more deadly attacks in the countries concerned. I have taken that evidence into account in the conclusions I have reached. I set that evidence out in my Report to the extent that it is responsible to do so.

On the face of it, an effective way of narrowing the Care Gap would be to embed doctors with the police firearms officers who can enter an Operation Plato hot zone. That would involve the doctors deploying into an area where the most seriously injured casualties were likely to be. This would get around all of the delays and difficulties created by the designation of zones. Such doctors would need to be highly skilled and trained so as to enable them to carry out triage, emergency treatment and evacuation in circumstances of extreme danger and stress.

This is what happens in France, where doctors are embedded with police firearms teams with the job of entering the highest‑risk areas, akin to our Operation Plato hot zones. I am able to say this without breaching operational sensitivity because the work of the counter‑terrorism unit of the French National Police is public knowledge. That team is known as RAID. This stands for Recherche, Assistance, Intervention, Dissuasion, which translates into English as Search, Assistance, Intervention, Deterrence.43

France has experienced much violent Islamist extremist terrorism. In the course of the evidence relating to security for the Arena, I heard about the events of the night of 13th November 2015, when ten ISIS terrorists launched co‑ordinated attacks in Paris. Three men went to the Stade de France, where France and Germany were playing football. Each man was wearing an explosive device.

Each of the attackers detonated their device and died. A passer‑by was killed and others injured. Within minutes, further terrorists armed with automatic weapons launched an attack at sites in the city centre, murdering nearly 40 people. Shortly afterwards, a further group of terrorists arrived at the Bataclan theatre, armed with military‑grade firearms and wearing explosives vests. They shot dead three people outside and then entered the theatre, opening fire on the crowd.

It was during this phase of the Paris attacks that RAID was engaged. Members of the RAID team entered the Bataclan along with commandos of a second police team, the Brigade de Recherche et d’Intervention. This translates into English as the Brigade for Research and Intervention. They did so in order to neutralise the threat, just as police firearms officers would do in a comparable situation in the UK. The difference in France is that embedded within each RAID team is a highly trained physician.

In 2015, Dr Matthieu Langlois was the Chief Physician of RAID. On 13th November, he formed part of the RAID team that entered the Bataclan. He entered the theatre along with his RAID colleagues and a fellow medic from the Brigade de Recherche et d’Intervention, Dr Denis Safran. As other members of the teams sought out and engaged the terrorists, the two doctors performed triage in the combat zone.44

They carried out what is described in an article in the journal Critical Care as “salvage therapies”.45 Tourniquets were applied to 15 patients and a further 15 underwent wound compression with haemostatic dressings; two patients received subcutaneous morphine and two received tranexamic acid (TXA); two thoracic exsufflations were performed. All this occurred in the combat zone.46

Having completed the salvage therapies, the doctors set about managing the evacuation of the injured to hospital, stopping in an area in the entrance to the theatre where additional treatments could be undertaken if absolutely necessary to prevent death before arrival at hospital. All of the casualties were evacuated even before the threat had been neutralised.47 What was achieved was remarkable.

I heard evidence from Dr Langlois. I am grateful to him for being prepared to assist me. He qualified as an intensive care anaesthetist in 2000 and thereafter worked in the accident and emergency department of a major hospital in Paris. In 2008, he joined RAID, initially alongside his existing responsibilities as a hospital consultant. In 2012, he became the Chief Physician of RAID. In that post, he was responsible for the selection and training of RAID’s members and for its operational management. He developed the tactical response plan of RAID and led the tactical emergency care during all counter‑terrorism interventions in France between 2012 and 2021, of which, sadly, there were many.48 He was able to speak from a position of considerable authority.

Dr Langlois explained that RAID doctors are carefully selected to ensure that they have the physical and psychological qualities necessary to enable them to act effectively in situations of extreme stress.49 Following selection, the doctors are highly trained and thereafter undergo regular further training and take part in exercising.50

In the event of a terrorist attack such as that which occurred at the Bataclan, the RAID doctors deploy into the area that broadly equates with an Operation Plato hot zone, along with and at the same time as those whose role it is to neutralise the threat. The doctor will triage the casualties and carry out any life‑saving interventions that are needed. The casualties will then be extracted to a ‘forward casualty nest’ at the edge of the hot zone, where the risk is acceptable and the casualties can be reassessed. Further treatment can be provided here if necessary to save life before the casualty is extracted to the ‘casualty collection point’ in the green, safe zone and then on to hospital.51 The casualty will stop at these points prior to hospital only if absolutely necessary to ensure that they are able to survive the extraction.52

The French describe this as the casualty flow. It is designed to get the casualty from the hot zone to treatment at hospital as quickly as possible.53 I will consider at paragraphs 20.88 to 20.96 what lessons can be learned from the approach in France, which is not unique, to the issue of evacuation to hospital.

At an early stage, it seemed to me that an obvious way of narrowing the Care Gap was for the UK to adopt a RAID‑style model. However, the evidence has persuaded me that the situation is by no means as straightforward as I had thought and hoped. There are a number of cogent reasons why such a model may not transfer across to the UK. It is not possible for me to explain all of those reasons in an open report, but I can say the following.

In the UK, Armed Response Vehicles provide the primary response to no‑notice incidents such as a terrorist attack. Firearms officers have neutralised the threat during most recent terrorist attacks in the UK. There has been substantial investment in the development of a significant Armed Response Vehicle network. It is not practicable to embed a doctor within each Armed Response Vehicle team. That is a summary of evidence given by CI Thomas in a restricted evidence session on 17th January 2022.54 There was widespread agreement with his view from other witnesses. Lieutenant Colonel Park has, as I have explained, substantial experience working with the Metropolitan Police Service firearms teams. John Lawrie is a research analyst with expertise in counter‑terrorism; he conducted the analysis into the approach taken by different countries to the Care Gap. Both agreed with CI Thomas.55

Counter Terrorist Specialist Firearms Officers (CTSFOs) provide a specialist firearms capability in counter‑terrorism and organised crime operations. They will deploy in support of Armed Response Vehicles at incidents if the initial Tactical Firearms Commander decides that their specialist skills and/or equipment would be of value. Because Armed Response Vehicle officers provide the primary response to no‑notice incidents, including Marauding Terrorist Attacks, it is unlikely that a CTSFO team with an embedded clinician would form part of the initial response during the critical stages of the golden hour, the first hour of the emergency response.56 Indeed, it is almost inevitable that the CTSFO teams would arrive after HART operatives. Although on the night of 22nd May 2017, the CTSFOs did in fact arrive at the Arena before HART, Lieutenant Colonel Park agreed that this is contrary to what could reasonably be expected to occur in general. Normally, they would arrive later.57

CTPHQ maintained that embedding doctors with CTSFOs would therefore bring no material benefit to the response to a terrorist attack and that clinical care is best provided under the control of the NHS and ambulance services.58 CTSFOs, CTPHQ asserted, would be of no assistance in the early stages of an incident because they would be unlikely to be there. By the time a CTSFO doctor arrived, work should already be under way by HART operatives.

CTPHQ’s position was that if a greater level of skill and training is required of HART, that is a matter for DHSC, the NHS and ambulance services. The level of HART skill highlights an important issue, to which I will turn in paragraphs 20.86 and 20.87.

A number of further practical issues with embedding doctors within police firearms teams were expressed by other witnesses. Philip Cowburn of NARU, for example, explained that he does not consider there to be, currently, a sufficient number of doctors with expert skills in pre‑hospital emergency medicine within the UK to provide a cadre of embedded doctors. He points out that pre‑hospital emergency medicine is a relatively new sub‑speciality in the UK, compared with France.59 It is his view that it is vital to find a way of getting experts in pre‑hospital emergency medicine forward quickly, but he considers that a RAID‑style model is not the way of achieving this.60

The best place for someone with severe injuries to be treated is in hospital. The quicker they get there, the better. Sometimes, it will be necessary for that person to receive treatment at the scene to enable them to survive to hospital. First responder interventions, namely haemorrhage control and airway opening,61 may suffice and most people can be trained to do those.62 I will turn to that issue in further detail at paragraphs 20.149 to 20.159. However, more sophisticated treatments may be required, such as bridging interventions like chest decompressions or gaining intravenous access to provide analgesia, and these must be done by a healthcare professional.63

Sometimes, the patient will not survive to hospital unless given enhanced care interventions at the scene.64 Such interventions typically involve addressing internal bleeding. They include the use of advanced techniques such as chest decompressions and thoracotomy. These can be carried out only by those with a high level of skill and training, normally consultants in pre‑hospital emergency medicine.65

Accordingly, it is clear that, if all of those capable of surviving a mass casualty incident are to be given the greatest chance of doing so, clinicians able to provide all three levels of intervention must reach them urgently. On the evidence I heard, the adoption of a RAID‑style model is not necessarily the solution. However, I am not satisfied that we have reached the stage in the UK at which such an approach should be discounted altogether.

Lieutenant Colonel Park considered that a RAID‑style model was worthy of further examination66 and John Lawrie agreed.67 It was clear to me that CI Thomas was dubious but accepted that further consideration might be of value.68

Given the very considerable benefits that RAID brought to the response to the Bataclan attack and to other terrorist attacks in France, I consider that this model, or parts of it, should not be rejected until more work has been done. For example, while I accept that it will not be feasible to embed doctors in all Armed Response Vehicle teams, and while it is unlikely to be appropriate to embed doctors in all CTSFO teams, there may be value in doctors being embedded in one or the other type of team in some locations or on some occasions. As is perfectly obvious, some locations and/or occasions may represent more attractive targets for terrorists.

I recommend that CTPHQ review the evidence heard during the Inquiry, including that heard in restricted sessions, to consider the advantages and disadvantages of embedding doctors with some police firearms teams, and if so, how that could be achieved. CTPHQ should also review the experience of other jurisdictions that embed medics with police firearms officers, such as RAID in France, to understand how their systems operate and whether they ought to be replicated in the UK or some further learning taken from them.

Alternatives to embedding doctors with police firearms officers

I recognise that the result of that further consideration may be that a decision is made that doctors should not be embedded with police firearms teams. It is therefore necessary to consider other ways in which a consultant‑led response to a terrorist attack can be achieved. Two proposals were explored in the evidence, which merit consideration.

First, around the country, a number of air ambulance organisations operate. Most within England are charities and the extent to which they have links to the NHS varies between the organisations. In Wales and Scotland, air ambulance services are entirely state‑funded.69 The air ambulance organisations form part of the UK’s frontline emergency response service, providing life‑saving treatment to those in urgent need of pre‑hospital emergency medicine.

I understand that most of these organisations provide a consultant‑led pre‑hospital emergency medicine response rapidly, either by helicopter or, where more appropriate, by rapid‑response car.70 Most are therefore able to provide the three levels of intervention to which I have referred, namely first responder interventions, bridging interventions and enhanced care interventions. These interventions are the ones that will save the greatest number of lives in a mass casualty situation.

Many witnesses considered that air ambulance organisations have a role to play in narrowing the Care Gap in a mass casualty situation resulting from a terrorist attack. Those witnesses included Dr Andrew Curran, Medical Director of the North West Air Ambulance Charity,71 Dr Thomas Hurst, Medical Director of London’s Air Ambulance Charity,72 Dr Gareth Davies, who has been responsible for the medical governance of a number of air ambulance organisations, including London’s Air Ambulance Charity,73 and Lieutenant Colonel Park, who has considerable experience of a number of air ambulance operations.74 They represented a body of opinion with considerable experience and authority on the point.

Dr Hurst was unequivocal: air ambulance organisations have a valuable role to play in a situation such as that which occurred on 22nd May 2017. That role includes, he considers, both providing life‑saving interventions to casualties and providing leadership and advice to the ambulance personnel present at the scene.75 Lieutenant Colonel Park further explained the value of air ambulances and those who staff them. She described how they “add a very significant decision-making capability on scene, are less likely to be overwhelmed by the critically injured patient, and are used to dealing with multiple seriously injured patients simultaneously and making rapid decisions during evolving events”.76

I accept this evidence. I also accept that, for air ambulance operations to make the contribution that they plainly are capable of making in the aftermath of a terrorist attack, and, indeed, to any mass casualty incident, some things need to change.

Dr Curran explained that air ambulance provision is not available 24 hours each day in every part of the UK.77 He considers that this is inequitable and that there should be 24‑hour pre‑hospital emergency medicine provision in all parts of the country.78 Dr Hurst agreed.79

Witnesses generally made clear that air ambulance personnel, with some exceptions, are not usually trained in entering or equipped to enter the zones of greatest danger in the event of an Operation Plato incident.80 If they are to perform this role, they will require training and equipment. They would have to be trained with the other emergency services that will deploy in response to a terrorist incident.

I was impressed by the dedication and resourcefulness of those who staff the air ambulances in this country. Most in England are charitable organisations, but they all have a potentially important role to play in the response to a terrorist attack. They are capable of providing the kind of rapid consultant‑led response that will be needed. Lieutenant Colonel Park explained that London’s Air Ambulance had deployed in the emergency response to the terrorist attack at Fishmongers’ Hall on 29th November 2019 and had been able to make a significant contribution.81 That evidence supported me in my view about the potential value of this resource.

I recommend that DHSC, NHS, NARU, ambulance service trusts, Air Ambulances UK, CTPHQ and JESIP consider how air ambulance organisations might be integrated into the emergency response to a terrorist attack. I further recommend that those organisations consider what training and resources would be required to integrate air ambulance organisations into the emergency response to a terrorist attack. I regard these as potentially important improvements in the emergency response to a terrorist attack and work needs to be done to achieve them urgently.

Second, it was explained to me that it is possible to train some HART operatives up to the level of providing bridging interventions.82 However, it is unlikely that they could be trained to provide complex interventions such as the use of a thoracotomy.83 Such training would not provide a complete solution to the problem. Despite that fact, this is an issue worth considering.

DHSC and NARU should consider further training of HART personnel so that at least one member on every HART deployment has the ability to deliver most enhanced care interventions.

Evacuation to hospital

In dealing with the approach of RAID in France, I explained that the focus is on the quickest evacuation from the scene to hospital at the expense of treatment, unless that treatment is necessary to enable the casualty to reach hospital alive.

The current system within the UK ambulance services is based heavily on the idea that triage will take place a number of times and in different places. At its most basic, our current model involves primary triage. This is also known as ‘triage sieve’. Primary triage will take place where the casualty is located or at the Casualty Collection Point. It will be followed by secondary triage, or ‘triage sort’, at some safer location, usually the Casualty Clearing Station.84

Primary triage involves the casualty being given a designation from P1, the most seriously injured, to P3, walking wounded. Treatment should be given only if vital to save life: for example, the application of a tourniquet to stem catastrophic bleeding or the opening of an airway.85 Those who have died should also be identified during this process.86 Secondary triage involves the reassessment of the casualty using a more sophisticated method of observation and the application of a wider range of treatments.87 All of this occurs before the casualty is even in an ambulance. The events of the Attack demonstrate that this process may cause significant delays in casualties arriving at hospital.

Some countries take a different approach and have a much stronger emphasis on the rapid evacuation of casualties to hospital. France falls into that category.88 At least one other country has an even stronger focus on evacuation: prioritising the extraction of casualties without delay and with no deference to zoning.89

This is a complicated issue. The evidence I heard does not provide a complete answer. The emphasis in the UK is on ensuring that there are no hold‑ups when a casualty arrives at hospital. There was a detailed system in Manchester to ensure that casualties arrived at the most suitable hospital for their treatment and that the hospitals had time to prepare for their arrival. In almost every case, this system as designed worked well on the night of the Attack.

Arrival at the most suitable hospital is, however, different from arriving at that hospital at an appropriate time. On 22nd May 2017, there were lengthy delays in some casualties arriving at hospital. It may be that other countries deal with the evacuation of casualties to hospital more effectively than the UK does, with their emphasis being on getting casualties to hospital, using whatever vehicles are available, as soon as possible rather than waiting until hospitals are ready.

One practice that I was told about concerned me. It was explained to me that more ambulances than there were casualties requiring transportation to hospital were needed at a scene before transportation could take place. This is because when the first ambulances arrive at the scene of a Major Incident, all of the paramedics are required to leave their ambulances and go to assist with treating casualties in the Casualty Clearing Station. That leaves no one to drive or look after patients on the journey to hospital: the ambulances remain empty and parked. It is necessary to wait for further ambulances containing paramedics who are not required to assist in the Casualty Clearing Station to arrive before any patient can be moved to hospital. If none of the ambulances is double‑ crewed, it will take more ambulances to arrive before transportation begins.

This does not seem to me to be a satisfactory system, as it builds in additional delay. This delay is made even more severe when ambulance services around the country are already running at, or beyond, their full capacity and it may take a very long time for sufficient additional ambulances to arrive. In evidence I explored whether it were possible for other people, such as police officers, to drive ambulances to reduce the number of paramedics required. I was told that this was not possible, but it seems to me that there must be a workable solution to this problem.

In the circumstances, I recommend that DHSC, the Faculty of Pre‑Hospital Care, the College of Paramedics and NARU review the current model operated in the UK by reference to the different approaches around the world in order to see whether triage at different times and in different places remains best practice, or whether there should be a greater emphasis on rapid evacuation to hospital.

Early scene triage tool

Philip Cowburn has expertise and experience in a number of areas of relevance to the Care Gap. He is a long‑serving consultant in emergency medicine at a busy inner‑city emergency department and trauma Team Leader at a major regional trauma centre. He was involved in setting up and developing the Great Western Air Ambulance Charity and has been Acute Care Medical Director of a regional ambulance service for over ten years. He was actively involved in the development, education and governance of HART and now oversees the medical component of those teams from a national perspective. He has worked as medical adviser and clinical governance lead to specialist police teams within the South West for 15 years. He has been Medical Advisor to NARU since 2021.90

At paragraph 20.90, I explained the existing approach to triage. Philip Cowburn told me in evidence that many clinicians in his area of practice had developed a concern that these existing triage tools were “slow and cumbersome”.91 What was required, they considered, particularly in a mass casualty situation, was something that was very rapidly deployable.92

NHS England oversees the budgeting, planning, delivery and day‑to‑day operation of the commissioning side of the NHS in England. Part of NHS England’s role involves ensuring that the NHS is properly prepared for dealing with an emergency. NHS England developed the Emergency Preparedness, Resilience and Response Framework to provide a structure within which all NHS‑funded organisations could meet the requirements of the Civil Contingencies Act 2004, among other requirements.93

As part of that work, NHS England established a group to consider whether a fresh approach to triage was needed. That was a sensible step. Philip Cowburn was appointed to lead this group. Lieutenant Colonel Park is a member of the group and also gave evidence to me about its work.94 The group has benefited from contributions from experienced military and civilian clinicians in pre‑hospital and Major Incident management and from academic experts in the field.95

When Philip Cowburn gave evidence to the Inquiry, he explained that an early scene triage tool had emerged from the work of his group. This was described by him as a simple concept, designed to enable the identification, at speed and by people under stress, of those casualties whose lives are truly at risk. Its purpose is to improve upon and replace primary triage.96

Lieutenant Colonel Park explained in evidence that this tool is based on six main principles: it is simple to use; it prioritises the use of first responder interventions, namely haemorrhage control and airway opening; it removes the requirement to take physiological measurements; it prioritises those with penetrating torso trauma for early evacuation; it does not allow any person other than a healthcare professional to label a casualty as dead; and it involves a straightforward system for the tagging of casualties involving the use of coloured cards to provide visible identification of the priority of patients.97

The evidence I heard about what happened in the City Room left me in no doubt that effective triage is vital in a mass casualty situation. It will narrow the Care Gap. That is for the obvious reason that in such circumstances there will be patients who will die unless treated promptly, and others, although in need of treatment, whose survival is not at immediate risk. The early identification of the time‑critical casualties will enable effective prioritisation. It will make sure that those who need treatment urgently receive it.

On hearing the evidence, I regarded the development of the early scene triage tool as significant. That was particularly so because it was explained to me that the intention is that this tool be used by all first responders, not just paramedics.98

At the time when he gave evidence, Philip Cowburn’s expectation was that major progress would be made in relation to the development of this tool during 2022. In fact, progress was expected both in relation to the early scene triage tool and in relation to the issue of triage more generally.99

As a result, in July 2022, I sought an update from Philip Cowburn.

Philip Cowburn provided me with a comprehensive report in writing on 3rd August 2022. This sets out a proposal for major change in the approach to triage at the scene of a Major Incident.100

A concept called the Major Incident Triage Tool has been devised. This tool, which will be known as MITT, was field‑tested in August 2021. The testing used both quantitative gauges and qualitative gauges. The former involved identifying how long triage had taken. The latter involved asking what those who had used the new tool in the field test thought of it. MITT proved to be superior to the existing system for triage on both gauges. It is proposed that MITT entirely replace the existing approach of primary and secondary triage. That proposal has the support of NHS England.101

While Philip Cowburn’s group regarded MITT as a significant improvement on the existing procedures, the group identified an additional need. In the event of a mass casualty situation, there was a risk of responders being overwhelmed by the sheer number of casualties that they needed to triage. What was needed, the group concluded, was an additional tool that was capable of being applied rapidly and by a broader range of responders in a mass casualty situation.102 This is the early scene triage tool that Philip Cowburn explained was under development at the time when he gave evidence.

Work has progressed since then. What the group has now devised is both quick and easy to use. It is designed to provide an element of control and structure to the inevitable confusion that will ensue in the early stages of a Major Incident. Importantly, it can be used by any responder with the ability to provide first responder interventions, not just the staff of an ambulance service.103

Based on the material currently available, it appears to me that Philip Cowburn’s group has identified a triage tool that allows the rapid assessment of multiple casualties, while prioritising life‑saving interventions. Those interventions are ones that must be delivered quickly to maximise the survival of critically injured patients. The working title of this new tool is ‘Ten Second Triage’. If that name endures, it will be known as TST.104

If all first responders present in the City Room on the night of the Attack had been trained in TST, it would have made a difference. Triage would have been much more efficient.

The early indications are that TST has the support of the representative bodies of the ambulance service, police, fire and rescue service, and military. By the time Volume 2 of my Report is published, a field test based around a terrorist attack will have been undertaken in relation to TST. As part of that field test, the relationship between MITT and TST will be assessed. I cannot prejudge the outcome of that field test, but it is important that, once the field test has concluded, NARU and the representative bodies of the other emergency services should analyse what has been learned as quickly as possible and implement change swiftly.105

The work of Philip Cowburn’s group has been guided by experts in the field. It has been undertaken to a standard of excellence. Philip Cowburn’s report to me indicates that the emergency services have expressed a commitment to implementing MITT and TST.

I recommend that the representative bodies of the emergency services review the proposals of Philip Cowburn’s group urgently and, in the event that they agree that they represent an improvement on the existing approach to triage, implement them as soon as possible. The bodies to whom I direct this recommendation are: the College of Policing, the College of Paramedics, the Fire Service College, the National Police Chiefs’ Council, the National Ambulance Resilience Unit and the National Fire Chiefs Council and also, given its oversight role, the Home Office.