1. Surge Capacity - the Experience in London on 7 th July 2005 Dr Penny Bevan Dr Penny Bevan Head of Emergency Preparedness Department of Health, UK

2. Context London Population 7.2 million Approx 2-3 million commuters per day Majority of people travel by public transport London underground system over 100yrs old in places 08.30 -> 09.00 hrs peak of the morning rush hour School term time

3. Emergency planning in London 30 yr history of Irish Republican Terrorism Fire, Police & Ambulance coterminous LESLEP Guidance London Resilience Team in place 2 yrs before any other resilience team Exercise, exercise, exercise [Atlantic Blue, Top Off 3, Triple Play ]

4. Health Services in London Currently 5 Strategic Health Authorities 31 Primary Care Trusts One ambulance service 33 hospitals with Emergency rooms 16,500 hospital beds [this includes mental health, care of the elderly and long stay]

5. Health Services in London By the end of 2006 One Strategic Health Authority 31 Primary Care trusts One Ambulance service 33 hospitals with Emergency Rooms

6. Health Emergency Planning in London All health organisations have emergency plans 5 SHA areas have all planned and exercised in their patch and cross London London participated in Triple Play Health sits on the London Resilience Forum Health involved in all multi-agency planning and exercises

7. 7 th July 2006 Shortly before 09.00 hrs on 7 th July an incident at Aldgate Underground Station Initially thought to be a Power surge

8. London Underground System

9. Incidents on 7 th July Shortly after 09.00 hrs three incidents reported on the “tube” these were rapidly confirmed as IEDs 9.50 hrs bomb on bus in Tavistock Square

10. Initial assessment At one hour –??8 bombs –??1000 casualties By one and a half hours clearer idea on number of incidents and number of dead and casualties

11. IEDS on Underground

12. Initial Health Response London Ambulance Service control alerted when first incident reported Ambulances deployed to all scenes [>4] Helicopter Emergency Medical Service Audit Day meant all staff at Centre – rapidly deployed to the scenes Bus in Tavistock Square immediately outside the British Medical Association 7 Hospitals “on take” Further hospitals “on stand-by”

13. Difficulties with Underground sites PowerLightingHeatDust Restricted access to patients Crime scene (deceased are evidence) Secondary devices ?CBRN Distance from surface Communications Other stationary trains on the system

14. Casualties 52 plus 4 deaths 700 “casualties” 350 transported to hospital by ambulance 103 patients admitted to hospital for at least one night No inpatients aged over 60 yrs No inpatients were children 12 with lower limb amputations

15. Blast injuries many self evacuated and later realised they were deaf management of blast lung was not really an issue “tattooing” of victims with body parts and blood concerns re HIV and Hepatitis B & C what was released from the tunnels by the blast?

16. Mutual Aid Initial uncertainty about numbers Ambulance service requested mutual aid from outside London – Co-ordinated by ASA Offers of beds/ITU/Burns beds received by DH from all around the country Ambulance support from voluntary aid societies (Red Cross / St John’s Ambulance)

17. Hospital Response Seriously injured casualties were distributed around the nearest hospitals All were teaching hospitals A significant number needed immediate lifesaving support/surgery Staff were called in or told to wait until next shift Additional supplies requested from NHS Logistics [5hr delivery time when traffic not gridlocked]

18. e.g. 3 patients transported to one hospital All had lower limb amputations These 3 patients used 87 units of O neg blood before bleeding was controlled All survived without ARDS/DIC or renal failure Only three patients died after reaching hospital

19. Effect on hospitals Routine work suspended Long stays in ITU for some patients Claims of significant effect on some hospital year end financial position.

20. Communication and Media Massive, almost immediate, international media coverage No scenes to film at resulted in enormous pressure on hospital switchboards Interviews are important both leaders and front line staff Joint Agency Working critical

21. What worked well with the Media Crisis training and planning put into practice Effective joint agency communication Ability to influence normal emergency demand “crisis” was played down

22. Lessons learnt from the media Access to timely and accurate information More focussed coordination of VIP visits Visual record of emergency response Being prepared for long-term press investigations Real difficulty with media trying to get into hospitals

23. Things that went well HEMS Clinical Governance Day –18 pre-hospital doctors available –Provided good medical support on each site LAS Senior Managers Conference –100 managers in one place Bus explosion outside the BMA –experienced doctors on site Health Gold at LAS HQ for meeting Two neighbouring Directors of Ops attended HQ

24. Lessons Learned Communications – mobile and fixed line telephony failed All minor injuries taken to one hospital [due to above] Minor injuries went to hospital with large number of major casualties [due to above] Transport for staff to get to and from work Identify research issues

25. Lessons Learned Blood – the needs were great and there were some difficulties communicating with the blood banks – have a dedicated line Skin – plan to use banked skin appropriately or identify additional sources Surge in switchboard capacity When telephony failed most staff had stopped carrying their pagers

26. Staff Staff are people as well as professionals HCWs were killed and bereaved Manage staff so all do not come in a first response – you need staff for further shifts Transport and access Support for those distressed by the events particularly those affected and staff at scene.

27. Aftermath 21 st July – 4 failed bombs –BMA Memorial Service Heightened awareness and alerting meant many false alarm calls Ambulance in support of Police response to these calls Mental Health consequences Research - contaminants and blast injuries Sharing the lessons learned

28. 21 st July 2006

29. any questions? Department of Health Emergency Preparedness Division