Major Incidents with Mass Casualties
NATIONAL PLAN FOR NHS BOARDS AND HEALTH AND SOCIAL CARE PARTNERSHIPS, 2019 OFFICIAL
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Document Title Major Incidents with Mass Casualties – READER INFORMATION National Plan for NHS Boards and Health and Social Care Partnerships, 2019. Target Audience • NHS Board Chief Executives Owner & Contact Details • Chief Officers, Health and Social Care Health Resilience Unit, Scottish Government Partnerships Health and Social Care Directorates, • NHS Resilience Leads St Andrew’s House, • Scottish Government Directorates 1 Regent Road, Edinburgh EH1 3DG Document Purpose 0131 244 2429 To set out how statutory health and social [email protected] care services will respond in the event of a single or multi-site major incident with Scottish Government Sponsor Department mass casualties. The Directorate For Health Performance and Description Delivery, Health and Social Care Directorates Sets out strategic and operational Publication Date arrangements – a so-called Concept of May 2019 Operations – for NHS Boards and the Health and Social Care Partnerships to Review Date respond effectively to a major incident September 2019 and six-monthly thereafter. with mass casualties in Scotland. Outlines a range of approaches to be implemented to meet the needs of adults and children in these challenging circumstances.
Superseded Documents Mass Casualties Incident Plan For NHS Scotland, 2015
Action Required NHS Board Chief Executives and Chief Officers of Health and Social Care Partnerships should consider the contents of this document, assess their capabilities and prepare to meet the requirements as set out in this plan in the event of a major incident with mass casualties being declared.
Scottish Government Reference A24114250 OFFICIAL
Contents
Executive Summary iv Glossary v 1 4 Introduction 1 National Response and 9 Purpose 1 Coordination Arrangements Scope 1 Central Government Emergency 9 Definitions 2 Response Arrangements Major incidents with mass casualties 2 Local and Regional Response 10 Patient triage categories 2 Arrangements Reporting 10 Situation Reports 10 2 Casualty reporting 10 Planning Context 5 General 5 Planning assumptions and principles 5 5 NHS Coordination: Strategic 11 Health Group 3 Role and remit of the SHG 11 SHG membership 12 Legislation and Statutory 7 Activating the SHG 12 Obligations De-Activating / ‘standing down’ the SHG 13 Equality and Diversity 7 Key considerations 13 Human Rights 7 The SHG and Scottish Government 13 Safeguarding 7 Establishing a Health Information Cell 13 Inequalities 7
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6 8 Roles, Responsibilities And 15 Response by Services Following 23 Accountabilities a MI-MC Declaration Government Level: Scottish Government 15 Scottish Ambulance Service 23 Health and Social Care Directorates Casualty Clearing Station and 23 Military Assistance To Civil Authorities 15 Casualty Distribution (MACA) Patient Transport Services 24 Military Support for Blast and High 15 Private and Voluntary Ambulance 24 Velocity Injuries Services Mutual Aid From NHS England 16 Public Transportation 24 International Support 16 Patient Transfer Vehicles 24 Care Inspectorate and Healthcare 16 Responding Territorial NHS Boards – 24 Improvement Scotland Acute Services NHS Boards – Category 1 and 2 16 Treatment Centre(s) For P3 Casualties 25 Responders Acute Services – Children 25 Scottish Ambulance Service 16 Acute Services – Burns Care 26 Territorial NHS Boards 17 Casualty Dispersal Plan— 27 Other NHS Boards 18 Patients in Trauma Centres NHS 24 18 Mobile Burn Teams 27 NHS National Services Scotland – 18 Acute Services – Supporting Hospitals 27 National Procurement Rehabilitation 27 NHS National Services Scotland – 18 NHS National Services Scotland – 28 Scottish National Blood Transfusion National Procurement Service NHS National Services Scotland – 28 Health and Social Care Partnerships 18 Scottish National Blood Transfusion (HSCP) Service NHS 24 29 Special Helpline Capability 29 7 GP Out of Hours (OOH) Coordination 30 and the 111 Service Activating and Standing Down 21 Health and Social Care Partnerships 30 the National MI-MC Plan HSCP – Community Mental Health 31 Declaration and activation 21 Services Stand down 21 Primary Care 32
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9 A Other Services 33 Annexes 45 Third Sector Agencies 33 Annex 1 47 Mass Fatalities and Mortuary Services 33 Situation Report Proforma Annex 2 50 Strategic Health Group: Activation Flowchart 10 Annex 3 51 Communications 35 Strategic Health Group: Sample Agenda Roles and responsibilities 35 Template Casualty information 35 Annex 4 52 Role of the Responding TB 35 Strategic Health Group: Recovery Cell Role of all other Territorial NHS Boards 36 Annex 5 53 Role of the national NHS Boards 36 NHS 24 - Special Helpline Information Role of Scottish Government 36 Request Key stages and messages 36 Annex 6 54 Special Helpline Action Cards: Single Ministerial Briefing 37 Point of Contact and NHS 24 Role Casualty figures disclaimer/explainer 37 Annex 7 55 Messages for Key Stakeholders 37 Coping With Stress after a Major Incident Annex 8 59 Mass Fatalities 11 Annex 9 60 Recovery 39 Communications: Checklist Actions Debriefing 39 Annex 10 61 Communications: Incident Alert Psychosocial Support 39 Statement Template Annex 10a 62 Communications: NHS Board Message 12 Template Annex 11 63 Finance 41 NHS Boards: Communications During a Major Incident with Mass Casualties Annex 12 65 Shared Situational Awareness - 13 METHANE Background Information 43 Annex 13 66 Major Trauma Centres 43 Psychosocial Support for Staff after a Reception Arrangements for Ministry of 43 Major Incident Defence Patients (RAMP) Other potential impacts for non-health 43 sectors to be considered VIP Visits 44
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Executive Summary
Major Incidents with Mass Casualties: National Plan For NHS Boards and Health and Social Care Partnerships 2019 has been produced jointly by Scottish Government Health and Social Care Directorates (SG HSCD) and the Scottish Trauma Network with the support of a national multidisciplinary group. It describes how SG HSCD, NHS Boards and Health and Social Care Partnerships (HSCP) will work together at strategic and operational levels to deliver an effective response to major incidents which result in a large number of adult and/or child casualties.
Replacing the 2015 plan which focussed on the NHS, this new national plan takes account of the needs of children, reflects the current health and social care services landscape and recent developments. More importantly, it reflects lessons and best practice identified following various major incidents resulting in multiple casualties that have occurred overseas and in the UK over the last 6 years.
The 13 sections of the plan focus on different aspects of the multiagency response to such incidents:
• Sections 1 to 3 explain the context within which the plan is set;
• Sections 4 and 5 set out the national coordination arrangements for such incidents;
• Sections 6 to 8 highlight the roles and responsibilities of the various health and social care services and how they will work together at different stages of the response to the incident; and
• Sections 9 to 13 focus on specific issues, such as mass fatalities, communications and other challenges that the responding agencies will have to take account of and be prepared to address simultaneously.
The various sections are supported by Annexes that provide further information to assist those responsible for implementing this plan.
In summary, this document sets out the approaches and actions that NHS Boards and HSCPs will implement in exceptional, challenging circumstances to make effective use of available resources and deliver the best possible outcomes for people who are injured, their families, relatives and carers.
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Glossary
Term or Acronym Meaning or Definition
Business Continuity Strategic and tactical capability of an organisation to continue delivery of services at acceptable pre-defined levels following disruptive incidents.
Business Continuity An holistic management process that identifies potential threats Management to an organisation, and the impacts to business operations those threats, if realised, might cause, and which provides a framework for building organisational resilience, with the capability of an effective response that safeguards the interests of stakeholders, reputation, and value-creating activities.
Business Continuity Plan Documented procedures that guide the organisation to respond, recover, resume and restore to a pre-defined level of operation following disruption.
C3 Command, control and coordination: C3 is a structured approach to incident management under pressure.
Capability A demonstrable ability to respond to and recover from a particular threat or hazard.
Casualty Bureau Initial point of contact and information, maintained by the police, for all data relating to casualties, fatalities and people thought to be in the vicinity of the incident who have not been accounted for.
Casualty Clearing Station Entity set up at the scene of an emergency by the ambulance service in liaison with the Medical Incident Officer to assess, triage and treat casualties and direct their evacuation.
Category 1 responder A person or body listed in Part 2 of Schedule 1 to the Civil Contingencies Act 2004. They are subject to the full range of civil protection duties in the Act.
Category 2 responder A person or body listed in Part 3 of Schedule 1 to the Civil Contingencies Act 2004. These are co-operating responders who are less likely to be involved in the heart of multi-agency planning work, but will be heavily involved in preparing for incidents affecting their sectors. The Act requires them to co-operate and share information with other Category 1 and 2 responders.
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Term or Acronym Meaning or Definition
CCA Civil Contingencies Act (2004) and the Civil Contingencies Act 2004 (Contingency Planning)(Scotland) Regulations 2005: Establish a single framework for Civil Protection in the UK. Part 1 of the Act establishes roles and responsibilities for Local (Category 1 and 2) Responders; Part 2 establishes emergency powers.
COBIS Care of Burns in Scotland: COBIS is a managed clinical network within NHS Scotland whose purpose is to enhance the delivery of care to patients who have suffered a severe burn injury.
COBR Cabinet Office Briefing Rooms: UK Government’s dedicated crisis management facilities, which are activated in the event of an emergency requiring support and coordination at the national strategic level.
CONOP Concept of Operations: A statement of arrangements for responding to a major incident or emergency. A description of how a defined system will operate to achieve defined strategic objectives. CONOP establish the higher-level framework within which more specific, operational-level plans, protocols and procedures will be developed and implemented.
DVI Disaster Victim Identification: is the internationally recognised term to describe the processes and procedures for recovering and identifying deceased people and human remains in multiple fatality incidents. The DVI process may commence on casualties who are alive and unconscious and or whose identities are unknown which could crucially benefit their treatment.
Emergency Preparedness The extent to which emergency planning enables the effective and efficient prevention, reduction, control and mitigation of, and response to emergencies.
Exercise The process to train for, assess, practice and improve performance in an organisation.
IEM Integrated Emergency Management: Multi-agency approach to emergency management entailing six key activities - Anticipation, Assessment, Prevention, Preparation, Response and Recovery – highlighted in the CCA.
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Term or Acronym Meaning or Definition
Lockdown The process of controlling the movement and access – both entry and exit – of people (NHS staff, patients and visitors) around a site or building/area in response to an identified risk, threat or hazard that might impact upon the security of patients, staff and assets or, indeed, the capacity of that facility to continue to operate. A lockdown is achieved through a combination of physical security measures and the deployment of security personnel.
MACA Military Aid to Civil Authorities: The collective term used by the Ministry of Defence for the operational deployment of Armed Forces personnel in support of the civilian authorities, other Government Departments or the community as a whole. Any deployment requires the approval of Ministers.
Major Incident scenarios Cloud on the horizon: Where an incident in one place may impact on others afterwards. Preparatory action is needed in response to an evolving threat elsewhere, even perhaps overseas, such as a major chemical or nuclear release, a dangerous epidemic or an armed conflict.
Slow burner: Where a problem creeps up gradually, such as occurs in a developing infectious disease epidemic. There is no clear starting point for the major incident and the point at which an outbreak becomes ‘major’ may only be clear in retrospect, e.g. Pandemic Flu. Long term resilience or business continuity of NHS Services is a key issue.
Headline news: Where a wave of public or media alarm ensues over a health issue, such as a reaction to a perceived threat. This may create a major incident for health services even if the fears prove unfounded. The issues may be minor in terms of actual risk to the population. It is the urgent need to manage information that creates the major incident.
Big Bang: A health service major incident is typically triggered by a sudden major transport or industrial accident. What may not be so obvious at first, however, are the wider implications. A major incident may build slowly from a series of smaller incidents such as traffic/ transport accidents or explosions.
Mass Casualty Incident A disastrous single or simultaneous event(s) or other circumstances where the normal major incident response of several NHS organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response.
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Term or Acronym Meaning or Definition
Mass Fatality Incident A major incident whose scale and nature is such that the fatalities arising as a consequence of it cannot, or should not, be dealt with by normal arrangements, and it is proportionate and necessary to invoke the DVI process.
Pre-Hospital Medical Care Clinical lifesaving interventions delivered by emergency medical practitioners and paramedics at the incident scene to stabilise casualties.
Recovery The process of rebuilding, restoring and rehabilitating the community following an emergency.
SGoRR Scottish Government Resilience Room: A coordination facility of the Scottish Government that is activated in cases of national emergency or crisis or during events abroad with major implications for the UK.
Regional Resilience RRPs and LRPs are the principal arenas for multi-agency cooperation Partnerships (RRP) in civil protection at local level in Scotland. They have a key role and Local Resilience in risk assessment, preparation and response. There are 3 RRPs in Partnerships (LRP) Scotland – North, East and West.
SitRep Situation Report: Recurring report produced by an officer or body, outlining the current state and potential development of an incident and the organisations’ or bodies’ response to it.
V/VIP Very Important Person: Persons who are conferred ‘special’ due to their status e.g. Ministers of State. Very Very Important Person is accorded to a VIP e.g. Royal Family, Dignitaries / Heads of State/PM. They are accorded special protection arrangements. NHS Boards are required to have and maintain plans (approved by Police Scotland) for ensuring the privacy and security of V/VIPs should they need to be admitted to hospital.
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1 INTRODUCTION Introduction
1.1 An effective response to a major incident with mass casualties (MI-MC) will require an integrated, collaborative approach by one or more NHS Board(s) and Health and Social Care Partnerships (HSCP) 1 as their delivery partners, working together with other Category 1 and 2 responders. In planning their response to challenges that these types of incident present, health and social care services will also need to ensure business continuity and the on-going provision of services for people who may require urgent medical attention not associated with the major incident(s). 1.2 This document sets out how Scottish Government Health and Social Care Directorates, NHS Boards and HSCPs will respond to the exceptional circumstances and challenges presented by a MI-MC in Scotland at a strategic and operational level, a Concept of Operations (see Glossary – CONOP). It has been developed by a national multi-disciplinary group under the auspices of the Scottish Trauma Network. 1.3 This national plan draws on lessons learned and best practice identified following reviews of mass casualty incidents in the UK and abroad over the last six years. Acknowledging the particular, unusual challenges and pressures that a MI-MC would present for NHS Boards and HSCP’s in Scotland, the plan describes the different approaches that will be implemented to make the best use of available resources in order to deliver the best possible outcome for casualties and their families.
Purpose 1.4 To provide a national strategic and operational framework – a CONOP – for statutory health and social care services to respond to a MI-MC in Scotland.
Scope 1.5 This national plan describes how NHS Boards that are designated Category 1 and Category 2 responders under the Civil Contingencies Act 20042 will collaborate with national NHS Boards, HSCPs and partner agencies to manage and support adult and child casualties, or provide specialist resources that may be needed in a MI-MC situation. It highlights the arrangements that will be implemented in Scotland at national (Scottish / UK Governments), regional/ territorial (NHS Board) and local (HSCP) levels. A separate document, titled Accompanying Information, will be issued to Chief Executives and Chief Officers. It contains specific, sensitive information on service capacity and other key resource information and should be used in conjunction with this plan.
1 A Health and Social Care Partnership (HSCP) exists within each Integration Authority. HSCPs are responsible for successfully integrating health and social care staff and services from the Council and NHS Board into a single, coherent delivery entity. 2 Civil Contingencies Act (CCA) 2004 and the CCA 2004 (Contingency Planning) (Scotland) Regulations 2005
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1.6 The focus of this national plan is on responding to the consequences of no-notice, sudden onset or ‘big-bang’ incidents3, the impact of which exceeds the capacity of a single territorial NHS Board and the local HSCP(s). While elements can be applied to any major disruption this national plan does not cover ‘slow burner’ incidents such as pandemic influenza.
Definitions 1.7 A Mass Casualty Incident (MCI) for the NHS is defined as an incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services’ ability to manage. 1.8 A MCI may involve hundreds or thousands of casualties with a range of injuries, the response to which will be beyond the capacity of normal major incident procedures to cope with and require further measures to appropriately deal with the casualty numbers4.
Major incidents with mass casualties 1.9 Several smaller scale major incidents may combine, occur in quick succession to become larger, or be geographically diverse, but require a mass casualty incident response to be triggered due to the large volume of simultaneous casualties and the potential impact on one or more territorial NHS Boards. For these reasons the term Major Incidents with Mass Casualties is used in this document, and for ease, abbreviated MI-MC. 1.10 For specialist services, such as Burns, the trigger threshold for activation of MI-MC arrangements will be lower due to the limited availability of resources for incident response.
Patient triage categories 1.11 During a MI-MC, casualties will be triaged into three categories: • People who are seriously injured as a direct result of the incident, who require immediate treatment and need to be admitted to an acute hospital – they are Priority 1 (P1) and Priority 2 (P2) casualties. • People with less serious injuries, who while needing assessment and treatment, may not need to be admitted to hospital. They may be attended to at the scene, in Emergency Departments or in a Priority 3 (P3) setting5. They may be supported by NHS 24 and followed up in the community; • People affected by the incident who may not be physically injured but require information, advice and reassurance. This group includes those who have been psychologically affected by an incident6. These categories are further explained in the table in paragraph 1.12.
3 See Glossary for explanation of other types of major incidents. 4 In this document the word ‘casualty’ refers to patients who are alive; it does not include fatalities. 5 See Preparing For Emergencies (2013) section 7.63. Information on the P3 facilities are contained in the Accompanying Information Pack. 6 See Preparing Scotland, Planning for the Psychosocial and Mental Health Needs of People Affected by Emergencies, 2013.
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1.12 The triage categories in the table below will be applied at the scene of the incident by
paramedics and clinicians. INTRODUCTION
Triage Categories
Priority Order of Description of casualties needs Group Treatment
IMMEDIATE P1 1 Life-saving procedures required
URGENT P2 2 Intervention required within 4-6 hours
DELAYED P3 3 Less serious cases who do not require treatment within the times given above
EXPECTANT Casualties whose injuries are so severe that they either cannot survive or would require so much input from the limited resources available that their treatment would seriously compromise the treatment of large numbers of less seriously ill casualties.
DEAD DEAD DEAD No medical attention required
Source: MIMMS: Hodgetts, Mackay-Jones.
1.13 As all Territorial NHS Boards7 (TB) may be called on to respond to a MI-MC situation, they should ultimately plan for and be prepared to receive and meet the needs of casualties in all three triage priority groups well beyond the end of the immediate response to the incident(s).
7 Responding Territorial NHS Board refers to the Board in whose area the incident(s) first occurred.
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4 Major Incidents with Mass Casualties – National Plan OFFICIAL 2 Planning Context PLANNING CONTEXT
General 2.1 This national plan is predicated on NHS Boards, especially the Category 1 and 2 responders, having in place: • Major Incident Plans that are scalable and tested through periodic exercising; • Surge/Escalation/Capacity-creation plans; • An up-to-date record and understanding of their organisation’s capabilities, and the resources that can be called on from local multiagency partners directly or via the local Resilience Partnership(s); • Effective and appropriately resourced Command, Control and Coordination (C3) arrangements at Board-level and a Control and Coordination facility within major acute (receiving) hospitals; • An agreement8 with their local HSCP(s) as to how they will work together, including clarity of each other’s roles and remits and mutual expectations, during a major incident / MI-MC; • Up-to-date business continuity plans and contingency arrangements for critical services.
Planning assumptions and principles 2.2 This national plan is based on the following assumptions: • MI-MC’s are likely to produce a mixture of casualty triage categories in the following proportions: 25% P1, 25% P2 and 50% P3. • The cause of the incident is likely to dictate the type of injuries from a MI-MC, with the most likely being: ––Severe Blunt Force or Ballistic Trauma (especially in firearms and bomb related incidents) across specialties. ––Burns ––Acoustic Injuries (where blasts have occurred) • NHS Scotland potentially has the capacity to respond simultaneously to up to 175 Priority 1 and Priority 2 (i.e. seriously injured) casualties9, acknowledging that this will require exceptional actions to be taken at national and local levels; • The focus will be on the initial 21 days post MI-MC incident, acknowledging that the consequences will impact on the health and social care services well beyond this period.
8 Stipulated within the NHSS Standards For Organisational Resilience, 2018, Standard 9 9 Derived from national exercise Border Reiver 2017 and subsequent Casualty Capacity and Distribution planning exercise carried out in November 2018.
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2.3 The principles underpinning this plan are as follows: • NHS Scotland will respond to a MI-MC as a single, unified and integrated entity, in conjunction with Health and Social Care Partnerships; • There will be a consistent and standardised approach to MI-MC’s across statutory health and social care services in Scotland; • There will be a ‘whole-system’ response to the treatment and care needs of patients following a MI-MC to secure the best possible outcomes for them: pre-hospital (at the scene of the incident), on admission to hospital (unscheduled care and acute services), and in the community (primary care, community and social care); • The needs of children and adults are equally and appropriately addressed; • There will be an holistic approach that addresses patient’s physical and psychosocial care needs; • There will be partnership working with other responders, statutory and third sector services, in accordance with Integrated Emergency Management (see Glossary); • Scottish Government and the Responding Territorial Boards and HSCPs will work together to support a return to business as usual as soon as possible.
6 Major Incidents with Mass Casualties – National Plan OFFICIAL 3 Legislation and Statutory Obligations
Equality and Diversity 3.1 In developing major incident / mass casualty plans, NHS Boards and HSCPs must be mindful of their duties under the Equality Act 2010. The Equality Duty requires public bodies to consider the needs of all individuals when developing policy, delivering services and in relation
to employees. It encourages public bodies to understand how different people will be affected OBLIGATIONS AND STATUTORY LEGISLATION by their activities so that services are appropriate and accessible to all, meet different people’s needs and treats everyone fairly.
Human Rights 3.2 NHS Boards and HSCPs must uphold the UK Human Rights Act (1998) in delivering services; this requires that account is taken of a range of factors including the dignity of individuals receiving treatment; end of life considerations; prioritisation of treatments and transparency in relation to decision-making as well as an individual’s preferences10.
Safeguarding 3.3 All services are expected to ensure that they maintain appropriate safeguarding measures at all times for casualties, especially when incidents involve children or people who are vulnerable, or if they become ‘persons of interest’, for example to the media, due to their connection with the incident. The same level of protection should be afforded these individuals and their families as that allocated to VIPs.
Inequalities 3.4 Services should, as part of their normal arrangements for reducing inequalities, have in place protocols for communicating effectively with people with learning disabilities / special needs and accessing interpretation facilities11 for those whose first language is not English. Checks should be made to ensure that the arrangements can be implemented quickly, especially out-of-hours, so that any potential barriers to accessing treatment and care in the immediate response and longer term are removed.
10 See Preparing For Emergencies Guidance, 2013, Sections 3.5 to 3.8 11 Territorial NHS Boards should consider developing protocols for prioritisation with Interpretation Services in MI-MC situations.
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8 Major Incidents with Mass Casualties – National Plan OFFICIAL 4 National Response and Coordination Arrangements
4.1 In the event of a MI-MC, the following response and coordination arrangements are likely to be activated at various tiers, each with potentially differing information reporting requirements from organisations. The response structure and the various groups it encompasses, and their relationship to each other, is depicted in the diagram below.
Scottish Government Scotland UK Government Response Office Response SGoR COBR GoR(O
S ) ARRANGEMENTS RESPONSE AND COORDINATION NATIONAL
Scottish UK Government Government Departments Directorates SGoR(M) NSC & Agencies & Agencies
Resilience Partnership(s) Response Strategic Tactical Gold Silver
Operational Bronze
Central Government Emergency Response Arrangements 4.2 The Scottish Government Resilience Room (SGoRR) and/or the Cabinet Office Briefing Rooms (COBR) are likely to be activated to establish cross-government coordination and ensure the multiagency response is appropriately managed at a strategic (national) level.
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Local and Regional Response Arrangements 4.3 Local and/or Regional Resilience Partnerships (L/RRP) may be convened to coordinate the efforts of multiagency partners. A Strategic Coordinating Group12 (SCG) may also be established during a large-scale or wide-area mass casualties incident to coordinate the actions of multiple L/RRPs. 4.4 These coordinating groups may have competing priorities and potentially request information in varying detail or formats from NHS Boards C3 Groups within relatively short timescales. Therefore, local C3 Groups should be appropriately resourced to gather and submit information timeously.
Reporting 4.5 NHS Boards will be required to report to Scottish Government (SG) on a variety of issues and impacts on health and social care services so that the response can be appropriately supported at national level and information communicated to ministers and/or the public. While efforts will be made by SG to streamline requests for information and reduce the burden on responding organisations, incidents of this nature place heavy, unavoidable information demands on organisations which they should be prepared for. 4.6 The primary reporting line for NHS Boards (including information from HSCPs) will be to the Scottish Government Health Resilience Unit (SGHRU). However the same (point-in-time) information should be simultaneously reported to the local Resilience Partnership(s) for the purposes of accuracy and consistency. 4.7 Scottish Government Health and Social Care Directorates (SG HSCD) and SGHRU are responsible for reporting on all aspects of the health service response to SGoRR. The Chief Executive of NHSScotland / Director General of SG HSCD is the designated Official for reporting to COBR on health and social care issues and/or participating in COBR meetings if necessary.
Situation Reports 4.8 All NHS Boards and HSCPs will be prepared to submit Situation Reports (SitRep) when asked to do so by SGHRU and / or the Strategic Health Group (see Section 5), using the national Situation Reporting pro-forma (Annex 1) to ensure shared situational awareness and common understanding of the impact and consequences of the MI-MC.
Casualty reporting 4.9 Every territorial NHS Board will have arrangements in place to timeously report casualty numbers they are treating to SGHRU and the Strategic Health Group when the latter is convened. 4.10 Scottish Ambulance Service will provide reports from the incident scene(s) and will be the single point of truth for such information. SAS will also be responsible for releasing casualty information to the Police and will consult SGHRU and the Strategic Health Group (when it is convened) before releasing any information to the media in the immediate aftermath of the incident. 4.11 Police Scotland is solely responsible for reporting and releasing information on fatalities resulting from the incident.
12 SCGs are not part of the formal Scottish Response structure, thus not reflected in the chart. They are tactical level groups that may be convened by Police Scotland, usually to deal with the consequences of terrorist incidents.
10 Major Incidents with Mass Casualties – National Plan OFFICIAL 5 NHS Coordination: Strategic Health Group
5.1 Following a MI-MC declaration, a Strategic Health Group (SHG) will be established by the Chief Executive of the territorial NHS Board in whose area the MI-MC incident first takes place or where the greatest impacts occur, if it is a multi-site incident. However, it will be open to this Chief Executive to formally pass on the role of SHG Chair to another Chief Executive at the outset, according to their judgement in the circumstances of an actual incident. Their decision for doing so must be recorded at the first meeting of the SHG.
Role and remit of the SHG 5.2 The SHG will provide strategic command for and coordination of NHS Scotland’s and the Health and Social Care Partnership's (HSCP) response for the duration of the incident in Scotland. A process flowchart for setting up an SHG is set out in Annex 2. 5.3 The SHG will: • Provide leadership and set the strategic objectives for health and social care services in Scotland i.e. NHS Boards and HSCPs; • Provide strategic command and coordination for an integrated health and social care GROUP HEALTH STRATEGIC NHS COORDINATION: services response to the incident, including decision making for NHS Scotland in collaboration with Scottish Government Health and Social Care Directorates (SG HSCD); • Assess the requirements for incident management and the implications for services when determining strategy and priorities; • Engage and work effectively with other statutory strategic partners; • Activate and maintain oversight of: ––Mutual aid and resource-sharing between NHS Boards13, coordinate NHS assets and monitor implementation / progress. (SAS will advise the SHG of Mutual Aid arrangements or Memorandum of Understanding that have been invoked with other UK NHS Ambulance Services and voluntary providers); ––Arrangements to effectively track patient transfers between healthcare facilities; ––A Health Information Cell (see paragraph 5.19); ––A Logistics and Resources Group to ensure effective management of key supplies including blood products and surgical equipment. • Develop / implement a communications strategy in conjunction with other Category 1 responders and SG to address both internal and external communications issues, appointing a suitably-trained spokesperson; • Maintain effective communications with SG HSCD and submit a SitRep to SGHRU at agreed intervals;
13 UK Ambulance Service mutual aid will be invoked through existing arrangements and will not be referred to the SHG for decision.
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• Undertake long-range planning, including a focus on the recovery phase. ––At the first sitting of the SHG, a senior Director should be tasked to develop arrangements (a ‘recovery cell’) focussed on returning the NHS and HSCPs to business as usual, and recovery. An outline of the key tasks for the recovery cell are contained in Annex 4. 5.4 The SHG will make decisions based on the agreed strategic objectives to be decided at its first meeting, such as, • To save lives and restore health • Safeguard staff, patients and members of the public • Minimise impacts on normal services and coordinate the return to business as usual as soon as possible. It will maintain a focus on strategic issues. An Agenda template for SHG meetings is set out in Annex 3. 5.5 Although implementing an agreed joint strategy, all NHS Boards will be in overall control of their resources /assets at all times during the response.
SHG membership 5.6 Membership will comprise: • The Chief Executives of all NHS Boards (or their Executive-level deputies). It is acknowledged that in some instances this may not be an Executive-level Director14; • A Chief Officer (or Head of Service) from the HSCP within the host/responding Territorial NHS Board area; • The SG HSCD Director of Performance and Delivery or Duty Director (nominally the SG HSCD ‘Incident Director’) who will act as the conduit to the NHS Scotland Chief Executive; • A Senior Communications Manager from the Territorial NHS Board (TB) that is chairing the SHG; • A representative (Executive-level / Service Director) from the host/responding TB to participate in and bridge with the multi-agency Strategic Coordinating Group (see paragraph 4.3). 5.7 A SG Health Resilience Unit (HRU) representative will attend SHG meetings in the role of SG HSCD Liaison Officer.
Activating the SHG 5.8 Following declaration of a Major Incident with Mass Casualties (MI-MC) by Scottish Ambulance Service, the Chief Executive or nominated deputy of the Responding TB will inform the SG HSCD Director of Performance and Delivery (via the customary SGHRU Duty Officer arrangement) of their intention to convene a SHG, and set one up within 2 hours of the declaration. 5.9 In the event of a multiple-site incident, the first affected Responding TB will be expected to convene and appoint a chair and deputy chair of the SHG. 5.10 The Chair and Deputy Chair should remain in those roles for a 72-hour period (substituting for each other for breaks) during the incident and while the SHG is operational, for continuity purposes.
14 It is vital that there is an effective handover process within Boards, especially during a prolonged incident.
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De-Activating / ‘standing down’ the SHG 5.11 Once it has been decided by the Chair (in consultation with the SG HSCD Incident Director) that a national response structure, i.e. the SHG, is no longer required, a stand-down process will be initiated. 5.12 The stand-down process will involve retaining a smaller SHG, comprising the key Responding Boards (see paragraph 7.4) and the SG HSCD Incident Director / SG HRU, meeting on a reduced frequency. During this phase, its key role will be to provide oversight of the recovery work being led by the senior Director tasked with focussing on returning organisations to business as usual, and recovery, when the SHG was initially activated / convened.
Key considerations 5.13 Meetings of the SHG will normally be by teleconference. The Chair’s Board will also provide: • The secretariat and ensure appropriate and effective recording / record keeping of all meetings organised under its auspices. All records must be stored safely and retained for any potential subsequent debriefs /inquiries; • ICT / telecommunications facilities and personnel; and • A senior Communications Manager (preferably the Board’s Director of Communications) to liaise with equivalents in other TBs and SG Health Communications, and to engage with the media. This individual will set up a (virtual) Health Communications Cell to keep all other responding Boards informed and to ensure consistency of public messaging. 5.14 Scottish Ambulance Service (Chief Executive or Gold Commander) will be the ‘single point of truth’ within the NHS for information on casualties / casualty numbers and their distribution GROUP HEALTH STRATEGIC NHS COORDINATION: to hospitals. NHS Boards should only release casualty information via and with the approval of the SHG. This process will be reviewed after 12 hours or when SAS has confirmed that the incident scene has been cleared of all casualties. 5.15 SHG Meetings may be subject to significant time pressure. Those taking part should make every effort to keep communications concise and focused, using a ‘3 minute briefing’ technique.
The SHG and Scottish Government 5.16 The SG HSCD Director of Performance and Delivery (or the Duty Director substituting for them) on the SHG and the SG HRU Liaison Officer will act as the bridge of communication to SG. They will provide regular updates on behalf of NHS Scotland to Scottish Government Resilience Room (SGoRR) and Ministers. 5.17 The SHG chair will liaise and work collaboratively with these Officials and the SG HSCD Director-General / Chief Executive of NHS Scotland while the SHG is in situ. 5.18 At the initial stages of the incident, Scottish Ambulance Service, in line with standard practice, will collate and submit aggregated casualty information from the scene of the incident simultaneously to SG HRU and the SHG, using agreed SitRep formats.
Establishing a Health Information Cell 5.19 The SHG will establish a Health Information Cell (HIC) within 3 hours of its first meeting. Led by a Director appointed by the SHG Chair (they will be a member of the SHG), the HIC will: • Perform an information-coordination function on behalf of the SHG;
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• Coordinate information in relation to patients and patient transfers between healthcare facilities, and other key information; • Be the focal point for conveying information on a patient’s whereabouts to the Casualty Bureau, and act as the point of contact for Casualty Bureau in relation to patients in the care of NHS Scotland. 5.20 The SHG chair will: • Make available IT / telecommunications equipment to the HIC; • Designate an appropriate15 NHS Board Director (who will also be a member of the SHG) to coordinate the HIC and to receive, process, coordinate and share patient transfer information with designated staff or single points of contact in other TBs only; • Request, if necessary, subsidiary resources (IT staff) from NHS National Services Scotland and other NHS Boards. 5.21 The HIC Lead will ensure that the contact details for the Cell are circulated without delay to all Territorial Boards, SAS, NHS 24 and the Casualty Bureau. (A provisional reporting pro-forma for use in such instances is under consideration). 5.22 All TBs will be required to: • Collate information on all (P1, P2 and P3) casualties received from the scene (including those transported by ambulance or self-presenting) and subsequent/secondary patient transfers to their healthcare facilities and submit it to the Health Information Cell (HIC); • Identify an appropriate individual to gather and submit patient information from the Board to the HIC via the contact details it provides, and to act as the single point of contact for the latter. 5.23 A Police Scotland Casualty Bureau (CB) will be established and will also gather / hold information on casualties. The SHG HIC will share appropriate information with the CB, in line with agreed protocols and guidance (see Accompanying Information Pack – Casualty Bureau). 5.24 When a decision has been made to ‘stand down’ the SHG, the Chair will request the HIC to undertake a final check to ensure that appropriate information regarding patients whereabouts has been communicated to the patients local TB16. It will then be the responsibility of the local TB to ensure that next of kin / relatives of the patient are kept informed of any subsequent transfers in relation to that patient, and the arrangements for following up the patient if necessary.
15 It is recognised that an NHS Board contribution will be proportionate to its capabilities. 16 This applies to patients domiciled in the UK. Information regarding non-UK domiciled patients will be communicated via the relevant authorities and in line with existing procedures to their country of residence with the assistance of the Foreign and Commonwealth Office.
14 Major Incidents with Mass Casualties – National Plan OFFICIAL 6 Roles, Responsibilities And Accountabilities
This section provides an overview of the roles, responsibilities, accountabilities and functions of key organisations that will be involved in delivering a health and social care response as part of this national MI-MC plan.
Government Level: Scottish Government Health and Social Care Directorates 6.1 The Cabinet Secretary for Health and Sport will be ultimately accountable for the response by the NHS and HSCPs, supported by the Chief Executive of NHS Scotland / Director General HSCD and the Chief Medical Officer. 6.2 The HSCD will support NHS Boards and HSCPs to deliver a ‘whole system’, accountable response by: • Coordinating the whole system response to high-end risks impacting on public health, the NHS and the wider health and social care system; • Ensuring an effective response to casualties and their families; • Supporting the wider SG response to MI-MC’s including ministerial support and briefing, and liaise with the UK Government officials as necessary; • Acting as a data and information conduit between NHS Boards /HSCPs and other parts of the SG with a remit for emergency preparedness and response; • Taking other action as required on behalf of the Cabinet Secretary / DG HSCD to ensure a ROLES, RESPONSIBILITIES AND ACCOUNTABILITIES national MI-MC is effectively managed; • Liaising with other SG Directorates on behalf of the NHS / HSCPs. • Appointing an HSCD Incident Director and ensuring they are fully briefed to participate in the SHG and be the conduit between the SHG and HSCD, and SGoRR.
Military Assistance To Civil Authorities17 (MACA) 6.3 Scottish Government Ministers are solely responsible for authorising and making a request to the Ministry of Defence (MOD) for military assistance under the MACA18 agreement. It is expected that the need for such assistance will have been fully discussed at the SHG and taken forward by the SG HSCD Incident Director. No direct request or approach should be made by NHS Boards to local Reservist Divisions. SG Health Resilience Unit will lead and coordinate the arrangements with MOD on behalf the SG HSCD.
Military Support for Blast and High Velocity Injuries 6.4 In the event of a MI-MC resulting in blast and high velocity injuries, SG HSCD, can if necessary, via the UK Government, request the MOD to make available suitably experienced personnel from within the Defence Medical Service (DMS) to provide expert advice and guidance on treatment of these types of injuries. However there are a number of clinicians working in the
17 See Glossary 18 Refer to NHS Scotland Guidance on Military Aid To Civil Authorities, SGHRU, 2018
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NHS in Scotland who as active military reservists, have the relevant operational experience and may be able to act as a source of advice and guidance to colleagues within the Responding Territorial Boards19. 6.5 A request by SG for assistance from the MODsʼ DMS will be aimed at enhancing local capability (i.e. supporting the local in-hospital response/local clinicians) to deal with these types of injuries, rather than increasing NHS Scotland’s capacity. Before making such a request to the MOD, SG (HSCD) will take advice from the SHG and COBIS20.
Mutual Aid From NHS England 6.6 SG’s Director-General of the HSCD is responsible for authorising all requests for support or mutual aid from NHS England via the Department of Health and Social Care. Such requests should be ratified by the SHG and submitted to SG HRU, who will take the appropriate action. 6.7 Arrangements for cross border working not covered under mutual aid arrangements for NHS Ambulance Services should also be requested in this way. It is acknowledged that cross border working occurs under routine business and this will continue as normal during a MI-MC incident.
International Support 6.8 In the extreme circumstances of capacity within the NHS in Scotland and the other three UK nations being exceeded, SG ministers may request international support via the UK Government. Consideration will be given to which countries are best placed to seek support from and offer appropriate standards of care including infection prevention control. Reciprocal arrangements are in place for the receipt of patients from overseas in these circumstances.
Care Inspectorate and Healthcare Improvement Scotland 6.9 On the advice of the SHG, SG HSCD may request that the Care Inspectorate and Healthcare Improvement Scotland suspend their inspection regime in organisations responding to a MI- MC incident, and will request that they take this into account when inspecting organisations which have recently responded.
NHS BOARDS – CATEGORY 1 AND 2 RESPONDERS
Scottish Ambulance Service 6.10 The Scottish Ambulance Service (SAS) is responsible for: • Declaring a ‘major incident with mass casualties’ following an ‘at scene’ assessment; • Notifying all receiving hospitals in the surrounding region of the MI-MC incident (using the METHANE21 format) to ‘stand-by’ to receive the agreed number of casualties in line with the national Casualty Distribution Plan, and advising other Territorial Health Boards (TB) to be similarly prepared. This will be done in accordance with the agreed Communication Protocol22;
19 NHS Boards maintain a secure and confidential list of these clinically experienced individuals and this information may be requested with the approval of the Strategic Health Group. 20 Care of Burns in Scotland – See Glossary. 21 METHANE is the recognised model for passing incident information between services and their control rooms. See Annex 12 22 Communication Between Scottish Health Boards During Major Incidents and Major Incidents With Mass Casualties. Draft Version 1.6, 20 December 2018. Contained in the Additional Information Pack.
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• Mobilising and tasking all medical assets required at the scene of the incident including the Pre-Hospital Medical Care Teams (see Glossary); • Requesting and coordinating additional support assets, such as those from HM Coastguard, if necessary; • Command and Control of all NHS assets and responders at the scene through the Ambulance Incident Commander; • Controlling all non-NHS medical assets and responders at the scene through the Ambulance Incident Commander. • Operations at the scene including the triage, treatment and transportation of casualties to the most appropriate receiving care setting; • Distributing casualties to receiving hospitals in the first 2 hours according to the national Casualty Distribution Plan; • Engaging with TBs to agree capacity and the casualty distribution plan beyond the initial 2-hour period taking into account the Major Trauma Triage Tool (see Accompanying Information Pack). This will be directed by the SAS Tactical Medical Advisor; • Invoking mutual aid from English Ambulance Service Trusts, if required; • Informing the SHG and SG HRU on the incident, including casualty numbers and type; • Providing continuing care for “business as usual” in conjunction with TBs; • Liaising with multi-agency partners as necessary including Police Scotland, Scottish Fire and Rescue Service and Resilience Partnerships as applicable.
Territorial NHS Boards 6.11 Territorial NHS Boards (TB) are responsible for: • Ensuring that effective 24/7 arrangements are in place within Emergency Departments (ED) / Trauma Units to receive Notification of an ‘MI-MC declaration’ from SAS in line with ROLES, RESPONSIBILITIES AND ACCOUNTABILITIES the agreed Communication Protocol (see Footnote 22); this should include a dedicated telephone line for SAS to call initially, internal dissemination procedures, and a single point of contact (staff) for SAS to contact subsequently; • Activating / being ready to activate their Major Incident Plans timeously. These plans should reflect capability to respond to the needs of children (see paragraph 8.12); • Implementing C3 arrangements at hospital and Board levels to (a) manage / oversee their response (b) assess/advise on business continuity challenges and (c) to focus on recovery later in the process; • Setting up the SHG (see paragraph 5.8); • Providing timely Sit/Reps / Briefing to the SG HRU to support SG coordination arrangements, as required; • Appointing a Director-level single point of contact and informing SG HRU of their contact details; • Implementing arrangements to create capacity within the ED to receive the pre-determined number of casualties (as per national Casualty Distribution Plan), and assess capacity thereafter; • Ensuring clinical services are ready to implement the necessary protocols and procedures (e.g. Surgeon Commander, signage, vests/tabards etc.) for a MI-MC; • Establishing their response priorities and the capabilities required to deliver them, and communicating them throughout the organisation and to the SHG when it is set up;
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• Linking / liaising with Resilience Partnerships and local interagency public communications; • Monitoring capability and identifying any additional assistance required; • Monitoring medical supplies, equipment and consumables23 and identifying any early- assessed additional requirements, and notifying the SHG and National Procurement (see paragraph 6.12); • Liaising with the Casualty Bureau and identifying set-aside areas for in-situ CB officers/ Documentation Teams within receiving hospitals, and ensuring that all frontline clinical staff are aware of protocols in relation to retention of evidence.
OTHER NHS BOARDS
NHS National Services Scotland – National Procurement 6.12 National Procurement (NP) is responsible for: • The National Distribution Centre (NDC) which provides delivery services and inventory information to NHS Boards. It normally operates between 22.00 on Sunday through to 06.00 on Saturday. Outside of these hours and in the event of the need to support a MI-MC, they should be contacted via the NSS out-of-hours Duty Officer (details in NHS Scotland Resilience: Directory of Key Contacts). NSS will then consider what support can be provided before the resumption of normal business services.
NHS National Services Scotland – Scottish National Blood Transfusion Service 6.13 The large acute hospitals hold sufficient blood component stock to cope with the initial numbers of casualties in an MI-MC situation. Scottish National Blood Transfusion Service (SNBTS) will: • Monitor stock and manage supplies of blood components and products and tissue components to the Responding TBsʼ hospitals during an incident, ensuring that adequate supplies remain available and making substitutions, if necessary, to maintain supplies.
NHS 24 6.14 NHS 24 will play a central role during a MI-MC incident providing quality assured tele-health and care information for the public at various stages during the response. When a MI-MC is declared by SAS, NHS 24 will be notified at the same time as TB’s and will: • Be ready to support the responding TB’s and partner agencies by preparing to activate relevant web pages with pre-agreed content onto their website; • Fulfil a public messaging function in support of TB’s to keep patients informed of which service to access if they have been injured in the incident, need medical attention for other reasons, or attending for routine appointments.
Health and Social Care Partnerships (HSCP) 6.15 As delivery partners to Territorial NHS Boards and Local Authorities, and with responsibility for local primary care, community, social work/social care and rehabilitation services, HSCPs have an important role to play in supporting the response to a MI-MC at various levels by:
23 A Consolidated Equipment and Consumables list outlining the potential requirements for a MI-MC has been developed and will be included in the Accompanying Information Pack (OFFICIAL SENSITIVE marking) and will be circulated electronically to Medical Directors and Executive Resilience Leads.
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• Chief Officer assuming membership of the Territorial NHS Boards’ C3 group and the SHG when it is convened, and establishing a tactical-level group to mobilise and coordinate the primary and community resources under their control; • Identifying, supporting and protecting vulnerable adults and children; the latter will be achieved by working with the local authority’s Chief Social Work Officer / Head of Children’s Services; • Working in partnership with Acute Sector sites to create capacity by supporting rapid discharges from hospital and commissioning additional social care support if necessary; • Engaging and steering resource from multi-disciplinary partners involved in the HSCP, especially Primary Care Services – GPs, Nursing, Pharmacy and Allied Health Practitioners, and other rehabilitation services; • Using their knowledge of the local services / area to signpost people to local services or to NHS 24/ NHS Inform and/or assisting those who are displaced to access medication or other everyday items; • Commissioning services from the third sector and independent sector and/or supervising volunteers at Rest Centres/ Family and Survivor Centres. ROLES, RESPONSIBILITIES AND ACCOUNTABILITIES
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20 Major Incidents with Mass Casualties – National Plan OFFICIAL 7 Activating and Standing Down the National MI-MC Plan
Declaration and activation 7.1 SAS will declare a ‘Major incident with Mass Casualties24’ following an ‘at scene’ assessment and notify all Territorial NHS Boards (TB), and NHS 24 in accordance with the agreed Communication Protocol; SG HRU Duty Officer will be informed simultaneously. SAS and the TB (Chief Executive/Duty Director) in whose area the MI-MC has (initially) occurred will decide to activate this national MI-MC plan. 7.2 The TB Chief Executive will take action to establish the Strategic Health Group as outlined in Section 5.
Stand down 7.3 The decision to stand down the NHS and HSCP national response (as outlined in this national MI-MC Plan) will be made by the Strategic Health Group in consultation with SG HSCD Incident Director who will take advice from SGoRR. 7.4 Although the national NHS/HSCP response may be ‘stood down’ and the full SHG deactivated, the SHG Recovery Cell will continue to meet to monitor progress toward a return to business as usual (see Annex 4), under the auspices of its Chair and a smaller cohort of members (essentially comprising the key responding TB, SAS, NHS 24) and SG HRU – see paragraph 5.12. ACTIVATING AND STANDING DOWN THE NATIONALMI-MC PLAN THE NATIONALMI-MC DOWN AND STANDING ACTIVATING
24 A MI-MC may be declared before the exact numbers of casualties or their type are known.
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8 Response by Services Following a MI-MC Declaration
This section sets out the actions that will be taken by the various organisations covered by this national plan, either singularly or in support of each other, to meet the exceptional demands and pressures that will be placed on the network of health and social care organisations and other partners following declaration of a MI-MC. The prevailing circumstances will call for services / organisations to enhance care provision or expand their functions beyond normal service provision to deal with the increased number of casualties.
Scottish Ambulance Service 8.1 Having declared a MI-MC, SAS will generate the capacity within the Ambulance Control Centre (ACC) to deal with the incident and activate their National Command, Control and Coordination Centre (NCCC), which is their strategic oversight facility. In parallel, SAS will notify SG HRU of the type/status of MI declaration in accordance with normal practice. 8.2 ACC will25: 1. Deploy a second wave of response to the incident scene based on the Ambulance Incident Commanders’ (AIC) requirements26; 2. Mobilise wider SAS on-call management structure, including Strategic Commanders and Advisors and the Tactical Medical Advisor (TMA); 3. Inform the closest designated receiving hospitals in the region of the incident and of casualty numbers and type, according to the information available; 4. Inform all other receiving hospitals in neighbouring regions to ‘stand-by’; 5. Through the TMA agree with the Responding TB and other TBs the plan for P3 patients, and business as usual, and submit this information to NHS 24 for them to upload onto their website.
Casualty Clearing Station and Casualty Distribution 8.3 Initial P1 and P2 casualties will be transported from the incident scene to the nearest designated major acute receiving hospitals as soon as transporting resources allow and in line with the national Casualty Distribution Plan (contained in Accompanying Information Pack) held by SAS Trauma Desk. P3 casualties will be directed to a holding point for later transport. RESPONSE BY SERVICES FOLLOWING A MI-MC DECLARATION FOLLOWING SERVICES RESPONSE BY Other P1 and P2 casualties will be treated in the Casualty Clearing Station (CCS) prior to the transfer of a patient to a receiving hospital capable of fully dealing with their injuries. This is to ensure the patient goes to the right place at the right time, first time to avoid secondary transfers. This decision will be made taking into account the Casualty Distribution Plan and in conjunction with AIC, Medical Incident Officer (MIO) and TMA.
25 Many of these tasks will happen concurrently. 26 This response may include additional managers to provide an incident command structure, Specialist Operations Response Teams (SORT), Pre-Hospital Medical Care Teams, specialist medical support to operate Casualty Collection Points and Casualty Clearing Station (CCS), air support, Patient Transportation and other emergency services.
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Patient Transport Services 8.4 SAS will consider how to make the best use of patient transport services to support the response, as appropriate, including drawing on an available pool of qualified ‘blue-light’ drivers such as those within the Scottish National Blood Transfusion Service if necessary.
Private and Voluntary Ambulance Services 8.5 SAS will engage relevant ambulance and fleet providers as and when necessary, according to assessed requirements and subject to the providers being able to meet the relevant service quality standards and safety requirements.
Public Transportation 8.6 Requests for support from public transport providers will be a ‘last resort’ option, directed through the local Resilience Partnership. The preferred option will be to call upon the Local Authority for such assistance and such requests will be made with the assistance of the local HSCP Chief Officer. Public transport will be used with caution to transport lower priority patients with an appropriate medical or appropriately trained escort.
Patient Transfer Vehicles 8.7 SAS will undertake secondary patient transfers that may be unavoidable during a MI-MC response. However, to alleviate the burden on them, TB’s should have pre-arranged (‘last- resort’ patient/care) transport arrangements in place to support accelerated discharges from hospital, to be activated in the event that they are in a Responding TB position. Only vehicles that meet care transport requirements should be used for this purpose. Some transfers may need to be multimodal in order to make best use of available capacity, especially if international transfer is required. Retrieval transfer teams will most likely be needed to support the latter.
Responding Territorial NHS Boards – Acute Services 8.8 Depending on the type, scale and impact of the incident, the Responding Territorial NHS Board(s) Acute Service will: • Continuously assess the impact of the MI-MC demands on services, and put in place escalation plans, accelerated discharge plans and business continuity/contingency plans as appropriate; • Submit the relevant Q&A pro-forma along with details of a Single Point of Contact to NHS 24 (see Annex 5 and Annex 6) within 2 hours of the MI-MC notification to enable them to prepare call handlers in advance of setting up a Special Helpline. NHS 24 will activate the Helpline within 2 hours of receiving the request and completed pro-forma from the TB (see 8.34); • Consider the redirection of business as usual emergency and GP urgent referrals to hospitals not participating in the MI response; • Implement plans to free up 10% of their total bed base (see paragraph 8.21) or as much as possible to allow patients from the incident scene to be rapidly placed and ensure patient flow: ––5% should be in the first six hours, and ––A further 5% within 12 hours of the incident’s declaration. • Prepare to surge their normal level 3 ventilated bed capacity in hospitals with level 3 Intensive Care capability, and maintain this for a minimum period of 48-72 hours;
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• Ensure that Trauma Units are prepared to manage patients who they would usually treat and transfer, for extended periods, along with preparing to receive additional repatriations from Trauma Centres; • Implement their (MI-MC) Rehabilitation plan; • Be prepared to submit information on bed/theatre capacity status (such as critical care units, Burns Units) to the SHG and SAS Trauma Desk soon after a MI-MC has been declared; • Be prepared to implement measures in the event of the national security threat level being increased27; • Ensure staff advise everyone who visits the care settings (ED or P3 facility) on where and how to access psychosocial support if necessary, and know how to make referrals to mental health services for people who require immediate assessment and treatment; • Be prepared to implement full or partial lock down of the receiving hospital for safety and security of staff and patients28 and to protect access to health care facilities to those in need of treatment. 8.9 Receiving hospitals should be prepared to: • Expand their emergency capacity into space not usually occupied by the emergency pathway. This will require the activation of business continuity plans; and • Consider the possibility of being required to act as a temporary rest or reception centre (for staff and patients visitors) especially if the hospital is in a scene cordon area.
Treatment Centre(s) For P3 Casualties 8.10 In order to alleviate pressure on acute receiving hospitals, and Emergency Departments in particular, when a MI-MC has been declared, the Responding TB(s) and those in the surrounding areas will: • Establish one or more Treatment Centres29 or appropriate facilities for the treatment and management of P3 casualties away from the scene of the incident, preferably within the grounds of an acute receiving hospital because of the possibility of patients moving through the triage categories and deteriorating; • Inform SAS, NHS 24 and the Police Casualty Bureau of the location of the P3 facility, as well as its capability and staffing (including the single point of contact) of these units, and upload details of the facility and how to access it onto their public-facing website. 8.11 When considering options for additional staffing for the P3 facilities, it is important that General Practitioners and secondary care clinicians are deployed to perform what they are used to, upscaling if necessary, but not branching out into new / unfamiliar territory. In these circumstances GP resources should be focussed on reducing non-MI-MC patient flow into the
hospital where it is possible and safe to do so. A MI-MC DECLARATION FOLLOWING SERVICES RESPONSE BY
Acute Services – Children 8.12 In MI-MC incidents that result in predominantly or a large number of child casualties, the response to P1 and P2 casualties will be as outlined below, in the context of assessed national capacity and capability. SAS and the at scene triage teams will: • Prioritise all P1 and P2 children who appear to be under the age of 12 to be sent to the three Children’s Hospitals – Hospital For Sick Children Edinburgh, Royal Hospital For Children in
27 NHSS Preparedness For an Increase in the UK Threat Level, Scottish Government NHS Scotland 2017 28 Lock Down Guidance – currently being revised by NHS National Services Scotland Health Facilities 29 A list of NHS Boards P3 Centres is included in the information pack accompanying this plan.
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Glasgow, and the Royal Aberdeen Children’s Hospital; • Send children estimated to be over the age of 12 by the at scene triage teams preferentially to adult Emergency Departments/Trauma Units. 8.13 Depending on the scale of the incident, some children triaged as P3 casualties may be initially triaged and sent to adult Trauma Units which have in-patient paediatric services30 as capacity dictates. In these circumstances, Paediatric specialists from the Children’s Hospitals will provide support and consultation remotely to clinical colleagues if necessary. 8.14 To enable the paediatric hospitals to maintain business as usual as far as possible to patients not involved in the MI-MC, in the immediate aftermath of the incident (4 hours post incident) normal paediatric referral and admission processes, for example for medical pathologies of mild to moderate severity, may be provisionally diverted from Children’s Hospitals to local units with in-house paediatric services to maintain tertiary capacity for the MI-MC response. 8.15 In instances where the parents/carers and their children have been injured and require in- patient care and treatment, every effort will be made to treat the adult and child in the same healthcare facility, so they are not separated in a crisis situation. In these circumstances, the triage destination will be decided by SAS at scene taking into account injuries to both parent and child, scale of the incident and proximity of receiving hospitals. In the event of a parent and child being treated in the same ward, clinical teams from adult acute care services will provide treatment for the adult or vice-versa if the child is to be treated in an adult facility. 8.16 This approach to parents/carers and children will only be considered where the adult casualty is conscious and their identity and relationship to the child has been verified.
Acute Services – Burns Care 8.17 In the event of a MI-MC resulting a significant number of burn-injured casualties, the approach to the dispersal and care of patients will be as follows taking into account the percentages of Total Body Surface Area Burn (TBSA):
Patient type Injuries Plan – Immediate Plan - Later [A] Potential TBSA Attend nearest After day 1: Establish system of Outpatient Burns Adults <10% Emergency care and follow up in local hospital Children< 5% Departments (ED); ED and Plastics dressing clinic of nearest Plastics Unit. [B] Treatable Large TBSA Take to nearest After Day 1: Disperse to the four Burns not requiring Adults 10-50%; Burns/Plastic Scottish Plastics Surgery Units on immediate ventilation Children 5-20% Surgery Unit or days 1 to 4 after injury. Children’s Hospital; [C] Treatable Very TBSA Take to National Treat in National Hub. If capacity Severe Burns Adults >50%; Burn Hub (Glasgow) exceeded, transfer to England Children >20% using National Burns Bed Bureau [D] Injured Patients + Multiple Injuries Treat at Local Continue care at TC using Mobile where Cutaneous + Inhalation Injuries Trauma Centre (TC)/ Burn Team. Burn is lesser priority ICU; [E] Untreatable Extreme / Comfort care in local District General Hospital theatre Burns Untreatable recovery, High Dependency Unit, or in extremis, at the scene.
30 Inverness, Ninewells, Kirkcaldy, Borders, Forth Valley Royal Hospital, Wishaw, Crosshouse, Dumfries.
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Casualty Dispersal Plan—Patients in Trauma Centres 8.18 In a terrorist related MI-MC incident, a significant number of casualties may be in group d“ ” above i.e. patients where the burn is part of a group of multiple injuries, and the burn is of lesser immediate priority. These casualties will be best treated initially in their nearest Trauma Unit (usually in ICU) to optimise survival with a contingency plan being made for them. This is consistent with the approach adopted by Burn Surgery Units in Scotland (especially in the West of Scotland) whereby burn patients are often treated in ICU’s out with the Burns Units, including carrying out major burn surgery.
Mobile Burn Teams 8.19 Mobile Burn Teams (MBT) will be organised from the National Hub Unit (under development by the Care of Burns in Scotland network) and other Burns Units to treat burn patients in the Major Trauma Centre (MTC) at the Queen Elizabeth University Hospital, and the MTC at Royal Infirmary Edinburgh. The MBT will also assist Plastics teams in treating burns in the Dundee TU and Aberdeen TU if required. 8.20 In order to mobilise MBT in exceptional circumstances, the Strategic Health Group in consultation with SG HSCD (Incident Director and Chief Medical Officer) will decide on the cessation or reduction of elective plastics work for a period of days or weeks post incident so that an adequate number of clinical and nursing staff can become available to treat burn injuries.
Acute Services – Supporting Hospitals 8.21 Acute hospital services outside the area of the Responding TB / receiving hospital i.e. those not directly receiving patients from scene will be considered as ‘supporting hospitals’ for the incident. They will be expected to: • Maximise available total bed capacity by up to at least 10% (see paragraph 8.8), especially level 3 intensive care beds, within 12 hours of the incident declaration for general use and to support the decant of patients from other receiving units, and using the Bed Capacity and Capability tool to notify the Trauma Desk; • Support patient transfers by providing suitably skilled transfer teams for each patient needing to be moved. 8.22 All hospitals with critical care capacity should have in place plans to support the retrieval or transfer of patients. All available retrieval teams will be called upon to support transfers of critical care patients, but only if this will not reduce the at scene response or Responding TB / receiving hospital’s capability. 8.23 Consideration will be given to utilising capacity (Level 3 critical care and surgical) and RESPONSE BY SERVICES FOLLOWING A MI-MC DECLARATION FOLLOWING SERVICES RESPONSE BY capability at the Golden Jubilee National Hospital, for example for a second wave of secondary transfers from Major Trauma Centres, or stable patients awaiting surgery.
Rehabilitation 8.24 Rehabilitation services may come under extreme pressure following an MI-MC. The well- established multi-disciplinary rehabilitation services within the acute hospital and community sectors may need to work differently for a period post incident, and with a different rehabilitation pathway. 8.25 The availability of rehabilitation related supplies/equipment (e.g. wheelchairs and other aids) may also come under severe pressure. TB Acute Services should:
Response by Services Following a MI-MC Declaration 27 OFFICIAL
• Implement a pre-determined multi-disciplinary operational rehabilitation plan for such circumstances which set out when and how rehabilitation specialists will be involved in assessment and treatment of P1 and P2 casualties with severe and complex trauma. The operational plan should identify local rehabilitation services and their (normal/current) capacity and options for flexing this to accommodate the additional demand; and • Develop follow-up arrangements for patients who do not need inpatient rehabilitation. 8.26 To reduce pressure on, and avoid patients being moved to Rehabilitation Units after an MI- MC, rehabilitation specialists within Scotland will, on an ‘exceptional circumstances’ basis, implement an outreach multidisciplinary team model, working across TB boundaries to support patients in acute units. 8.27 The military have extensive rehabilitation experience which may be of use to the NHS in an MI-MC situation to improve patient outcomes. Utilisation of these services would be via a MACA request (see Glossary) being made via the Scottish Government. Such requests could be for: • Access to Military Rehabilitation Subject Matter Experts for advice and assistance on individual cases, especially for trauma and ballistic-related rehabilitation; • Mobilisation of Military Rehabilitation Teams within the NHS; • Use of the Defence Medical Rehabilitation Centre to support patients where the NHS cannot offer appropriate rehabilitation.
NHS National Services Scotland – National Procurement 8.28 Responding to a MI-MC will be resource intensive and may require some clinical and non- clinical products to be managed centrally to ensure continued supply. Receiving hospitals may make simultaneous requests for urgent re-supply and this will need to be managed to ensure all of them can continue to effectively support patients. Specialist equipment will also be needed at the scene to allow for treatment outside of normal care settings where patients are held for transport. 8.29 Coordination by National Procurement (NP) and the National Distribution Centre (NDC) will be necessary (taking into account their hours of operation – see paragraph 6.12) to ensure adequate stock is available to support the initial response and the requirements of receiving hospitals. 8.30 During a response to a MI-MC, NP’s role will be to: • Assist Responding TBs with obtaining items on the Consolidated Equipment and Supplies list; • Delivering additional supplies that are held centrally to the relevant TB’s timeously to support operational need; • Provide product sourcing support and arranging accelerated product dispatch from suppliers for products that are exhausted or held in insufficient quantities to meet the exceptional demands created by the incident; • Implement a single point of contact/call handling service for enquiries from TBs on stock and deliveries. • Escalate any significant problems relating to stock availability, delivery access and timescales via NSS to the SHG and SG HRU / SG HSCD for assistance with resolution.
NHS National Services Scotland – Scottish National Blood Transfusion Service 8.31 Scottish National Blood Transfusion Service (SNBTS) will:
28 Major Incidents with Mass Casualties – National Plan OFFICIAL
• Manage blood products and tissue stocks based upon volume of usage during the response to the incident. This will be achieved by working closely with SAS and Responding TBs to monitor the situation, and being ready to move blood stock and tissues when necessary; • Maintain responsibility for donor management during the incident and any public calls for blood donations. There will be no call for donors to self-present to any of the blood collection centres, unless indicated by SNBTS; • Ensure the recovery of blood stocks following a return to business as usual. 8.32 Early in an incident it may be necessary for SNBTS to request a suspension of the normal blood stock management processes and ensure supplies are controlled. It may also be necessary for acute hospitals to restrict elective activity in order to preserve stocks. If these actions are necessary, SNBTS and TB Medical Directors will advise the Strategic Health Group who will discuss the matter with the SG HSCD.
NHS 24 8.33 On receiving notification of a MI-MC from SAS, and the Q&A information (see Annexes 5 and 6) from the Responding Territorial Board(s) (TB), NHS 24 will activate its Helpline capability to advise patients (i.e. casualties from the incident and others generally seeking healthcare) on access to in/out-of-hours healthcare services. A single point of contact31 (SPOC) from the TB(s) will be expected to update NHS 24 of any service changes and all further communications between the two organisations will be via the SPOC.
Special Helpline Capability 8.34 NHS 24 will: • Put a special free-to-call helpline number on standby and have non-clinical staff ready to support it. It will be activated on the instruction of the responding TB and / or the SHG within 4 hours, and promoted via the websites of all TBs, SAS and Police Scotland as a single point of contact for the public affected by the incident to access consistent information and potential appropriate sign-posting on to local services. All responding TBs and HSCPs will submit the completed Q&A pro-forma in Annex 5 (along with any press releases issued) to NHS 24 within 2 hours of the incident being declared so that call handlers can be briefed before the helpline is activated; • Liaise with the Police Casualty Bureau to support / reunite casualties in the aftermath of the incident, as far as possible; • Provide a dedicated NHS Inform web page for those involved in the MI-MC incident. It will promote basic health information, FAQ’s and signpost to services specific to the incident e.g. P3 Treatment facilities. The SHG Communications Cell will ensure that the NHS Inform page is populated with the appropriate, up-to-date information. A MI-MC DECLARATION FOLLOWING SERVICES RESPONSE BY www.nhsinform.scot/Alert 32 • Use its digital platforms to support the nationally agreed public communications plan and push out messages accordingly (see section 10.9 Communications). • Issue the ‘Coping with Stress After a Traumatic Incident’ (Annex 7) on NHS Inform and alert call handlers and clinical staff to the potential increase in this type of call and the appropriate action to take.
31 A designated individual who must be accessible for the duration of the incident, and their contact details. 32 The NHS Inform webpage will only be made active for the duration of the incident.
Response by Services Following a MI-MC Declaration 29 OFFICIAL
GP Out of hours (OOH) Coordination and the 111 Service 8.35 During an Out-of-Hours (OOH) period NHS 24 will: • Triage patients who require urgent medical attention and direct them to the most appropriate point of onward care within their area of residence. The TB SPOC will be required to notify NHS 24 of any changes to services; • Seek information on service capacity/demand, relocation of services and local mutual support arrangements with other TBs to get an overview of and coordinate services; • Create additional staffing capacity to meet potential additional demand on services. NHS 24 will endeavour to reduce pressure on responding services by reviewing the clinical appropriateness of each patient contacting the service, without compromising patient safety; • Deploy Advanced Nurse Practitioners; • Redirect the public to appropriate services resources as directed by the Responding TB. 8.36 TBs are expected to have a pre-arranged business continuity plan for re-directing patients 24 hours a day, and named leads (and deputies) for in and OOH Primary Care Services. This will also apply to patients who are not involved in the incident. 8.37 In the longer term and during the recovery phase, NHS 24 will provide mental health support via the following telehealth services: • Breathing Space for people over 16 years experiencing low mood, depression or anxiety. Staff will be ring-fenced to support the recovery phase of an MI-MC incident; • NHS Living Life which offers Cognitive Behavioural Therapy (CBT) and Guided Self-help using a CBT approach for those suffering low mood, mild to moderate depression and/or anxiety. This will compliment TB/HSCP recovery arrangements for those affected by major incidents.
Health and Social Care Partnerships 8.38 In the immediate aftermath of a MI-MC declaration, the HSCP Chief Officer(s) (or their nominated Lead Resilience Senior Manager) will assume membership of the local Territorial Boards’ (TB) C3 Group. In the event that the TB is responding to the incident, their immediate priority will be to assess the level of response required by the range of multi-disciplinary partners involved in the HSCP and take the necessary action to identify, support and protect vulnerable people in terms of both their physical and mental wellbeing. This will include: • Assisting with hospital flow and capacity creation within receiving hospitals to make beds available throughout the hospital, and within Emergency Departments; • Deploying Social Work, Allied Health Professionals, Advanced Nurse Practitioners and Rehabilitation Medicine Specialists to assess or facilitate discharge, to assist with safe decision making and flow from the acute sector and admission avoidance at the front door; • Liaising with Minor Injuries Clinics, Community / Cottage hospitals and rehabilitation services, where appropriate, to access capacity; • Identifying additional resources in the community such as Hospital at Home services, Nursing / Residential Care, Intermediate Care, Respite, Care at Home to support accelerated discharge assistance for patients; • Identify Primary Care (GP, Nursing, Pharmacy and Allied Health Practitioner) staff who may be able to provide support in a P3 Treatment Centre or Urgent Care for low priority casualties
30 Major Incidents with Mass Casualties – National Plan OFFICIAL
directed to these units; • Helping to divert referrals away from hospital / Emergency Departments by liaising with and supporting NHS 24, the Out of Hours Service, SAS, Links Workers, the primary, community, social care teams and where appropriate the third and independent sector; • Provide multidisciplinary support, as required, for the Survivor and Family Reception Centres; these Centres may be augmented by the Third Sector via arrangements put in place by the local authority.
8.39 Following the immediate response, in the medium term (i.e. day 1 onwards), HSCPs will: • Invoke business continuity plans to enable primary care, community and social care services to support the ongoing treatment, care and support of patients in the community or in an alternative care setting; • Where primary and community care is appropriate, ensure access to appropriate assessment, treatment/ rehabilitation and/or care for those affected by the incident; • Continue to support the creation of capacity and flow through the acute hospital(s); • Ensure appropriate onward referral to specialist services. Particular attention should be given to the identification, assessment, care and treatment of any mental health needs, and enabling appropriate patients to access specialist rehabilitation services; • Ensure carers and families of individuals affected by events related to the incident have appropriate access to information, advice, advocacy, and welfare benefits; • Ensure any children of individuals affected by the incident are, as appropriate, assessed in terms of care, support, risk and protection. Consider kinship care arrangements as appropriate and where possible; • Assist with the repatriation of casualties where possible; • As required, liaise with local authority education and housing departments; • Explore further community capacity requirements through partnership working with Third / voluntary sector networks.
HSCP – Community Mental Health Services 8.40 As part of the immediate response to the MI-MC, the HSCP will mobilise Community Mental Health Teams (CMHT) to: • Arrange for the provision of information, advice and support for distressed individuals at the acute receiving hospital; • Ensure adequate mental health assessment, care and support is offered with attention being given to follow up arrangements; RESPONSE BY SERVICES FOLLOWING A MI-MC DECLARATION FOLLOWING SERVICES RESPONSE BY • Work collaboratively with ED staff to ensure professional advice on where to seek treatment and support and the issuing of the post incident leaflet (Coping With Stress After a Major Incident (see Annex 7)); • Ensure that arrangements for psychosocial care and mental health support are in place, coordinated and signposting to other agencies, such as NHS 24. Also ensure adequate mental health liaison resources are made available to those care providers which have responded to the incident. 8.41 In the medium term, CMHT’s should: • Work with the two psychological Trauma Units33 and local agencies to design and deliver
33 The Rivers Centre (NHS Lothian) and Anchor (NHS Greater Glasgow and Clyde)
Response by Services Following a MI-MC Declaration 31 OFFICIAL
an appropriate mechanism that is able to identify people who continue to need support and welfare arrangements beyond those that their families / informal social networks can provide. It should signpost them to agencies and facilities that are able to offer the enhanced psychosocial support they require; • Monitor the need for specialist mental health services from specific organisations for the projected numbers of persons who are likely to need specialist assessment and treatment and report this to their HSCP and NHS Board. 8.42 In the longer term, as some people involved in the incident may develop new episodes of psychiatric disorders or exacerbations of previous disorders may require specialist care in the medium and long-term, mental health services should: • Develop referral, assessment and treatment processes for people who need further or extended care; • Identify methods to continue to deliver assessment and treatment for patients in the long- term before these facilities are absorbed into their ordinary business; • Work across sectors of care to identify patients who require monitoring or may present later in need of specialist care; • Develop likely triggers for patients who might need intervention during similar or subsequent events or at specific times of the year, and options for responding to their needs.
Primary Care 8.43 As outlined in section 8.38, as part of the immediate response GPs, Advanced Practitioners and Community Pharmacy services may be asked to: • Support the treatment of lower priority patients (P3) and assist in managing patients triaged away from Emergency Departments; • Support NHS 24 to provide virtual web based consultations and the supply of medication to the scene or to P3 Treatment centres; • Support messages being issued to the public to give reassurance following the incident. GP Out of Hours providers and other similar resources can support a response. Available nursing care / medical care capacity may be utilised to augment other services where patient presentation is greatest. 8.44 In the medium and long term, Primary Care services will be an important part of the mechanisms to ensure those involved in the incident receive appropriate mental health support and are able to triage those who are emotionally traumatised. Primary Care services and Community Mental Health Teams should work together and with the specialist psychological Trauma Units in Edinburgh and Glasgow to develop appropriate pathways for these services.
32 Major Incidents with Mass Casualties – National Plan OFFICIAL 9 Other Services
Third Sector Agencies 9.1 Third sector agencies may be requested to support the response to a MI-MC by any of the health and social care organisations covered by this plan. Requests may either be made directly to local agencies or via the Resilience Partnership if appropriate. It may become necessary to coordinate the response requests through central arrangements to get the best use of these resources and ensure deployment is effective. 9.2 It is important to ensure that all agencies commissioned to support the health and social care response in a variety of settings comply with the requisite standards and operate within clearly identified parameters, as they will be providing a service to potentially vulnerable adults and children.
Mass Fatalities and Mortuary Services 9.3 In the event of mass fatalities, national arrangements for the identification of victims, known as Disaster Victim Identification (see Glossary) procedures34, are likely to be invoked. This involves the deceased being taken to a mortuary in line with the policy agreed between the Procurator Fiscal (PF) and the Police DVI Lead. 9.4 The PF will decide which mortuary the deceased should be taken to. Any decision about the mortuary arrangements to adopt in a mass fatality incident will usually be made after the PF has consulted with the Gold Commander, Police and relevant Territorial NHS Boards and local authorities. The requirements for mortuary arrangements will depend upon the number of deceased, their condition and the level of post-mortem investigation required by the PF and the Police DVI Lead. Their decision will be based on the various factors set out in Annex 8. 9.5 Police Scotland DVI has conducted suitability assessments of the main mortuaries in Scotland and has, with the agreement of the PF, identified the following as ‘designated mortuaries’ suitable to be used in a mass fatalities incident (certain limitations apply): • Aberdeen City Mortuary
• Dundee City Mortuary SERVICES OTHER • Edinburgh Royal Infirmary Mortuary • Queen Elizabeth University Hospital, Glasgow • Raigmore Hospital Mortuary, Inverness. 9.6 Territorial NHS Boards responsible for the abovementioned mortuaries should ensure that effective business continuity plans are in place for the facilities and can be activated without delay in the event that they are commissioned by the PF. 9.7 Resilience Partnerships also have multi agency Mass Fatalities Plans which include the activation of Emergency Mortuary Arrangements if necessary.
34 DVI Teams may commence the DVI process on casualties who are alive but unconscious or their identities unknown to assist with their identification, which could be of critical benefit for their treatment.
Other Services 33 OFFICIAL
34 Major Incidents with Mass Casualties – National Plan OFFICIAL
10 Communications
10.1 A MI-MC presents unique communications challenges in terms of keeping patients informed of the impact of the incident on services, keeping staff informed of the situation and engaged, sharing information with partners, and generally managing a burden of expectation. 10.2 During a MI-MC, Scottish Government (SG) will manage communications at national level, and the Resilience Partnership (RP) will coordinate the local multiagency response. The Strategic Health Group’s Communication Cell will directly manage NHS communications and contribute to the SG and RP responses. 10.3 Territorial Boards (TB) should be aware that a MI-MC is likely to: • Be treated as a potential criminal situation, may be subject to inquiry or investigation and be treated as a security threat. As a result, sharing of information is likely to be strictly controlled; • Require sustained input over a number of weeks; therefore sufficient staff resources should be made available to manage the communications support. The Checklist on Communications Actions for NHS Boards in Annex 9 highlights the key actions that should be implemented.
Roles and responsibilities
Casualty information 10.4 Police Scotland or another national agency will normally lead on public communications regarding the incident itself. However, Scottish Ambulance Service (SAS) will be the ‘single point of truth’ within the NHS, reporting on and issuing all information to the media on the number and management of casualties. SAS will: • Keep the SHG informed of the number and type of casualties; • Participate in the SHG Communication Cell to keep Boards up-to-date and ensure that there is consistency of information; and • Liaise with the other emergency (blue-light) services. At the initial stages of the incident TB’s will only issue communications regarding impact on their local healthcare services; they should be cleared with the SHG Communications Cell. 10.5 Police Scotland’s Casualty Bureau will be the point of contact for the public trying to locate family and friends. COMMUNICATIONS
Role of the Responding TB 10.6 The SHG Communications Cell (CC) Lead (who ideally should be the Director/Head of Communications of the Responding TB) will: • Brief/advise the SHG, SG, and the RP of the NHS’s communications plan; • Provide the ‘message‘ / ‘lines’ to be issued by all NHS Boards regarding the incident, for consistency;
Communications 35 OFFICIAL
• Provide details of the single point of contact (SPOC) for other Boards to submit information to, and coordinate that information; • Be able to access resource and support from other NHS Communications Teams, including out-of-hours, for the Responding TB.
Role of all other Territorial NHS Boards 10.7 All other NHS Boards will: • Identify a SPOC to liaise with and/or be part of the SHG CC; • Be prepared to provide support to the Responding TB / the SHG CC. This could include: ––Gathering information from other Boards ––Social media monitoring ––Responding to elected members’ enquiries ––Managing media presence at healthcare sites ––Video/recording 10.8 All Boards will manage the messaging regarding impact on their local services, and internal communications for staff. However the messages should be shared with the Responding TB via the SHG CC before being issued.
Role of the national NHS Boards 10.9 NHS 24 will: • Upload a dedicated Incident Alert page onto NHS Inform which will only go live on approval of the SHG / the SHG CC (see paragraph 8.34). This page will: ––Not be visible at other times. Sample of the content of this page is attached at Annex 10. ––Contain commonly recognised information about the incident and signpost the public to places where they can obtain further information (such as the relevant police website, or Casualty Bureau website); and ––Inform the public where and how to access alternative healthcare services. The information content of the page will be the same as or consistent with the information on the Casualty Bureau’s website and will include hyperlinks to the site. • Also set up a specialist helpline. 10.10 NHS NSS SNBTS will: • Issue any public messages regarding the public donation of blood. All NHS Boards, SAS, NHS 24 and SG will reflect this messaging in communications with the public.
Role of Scottish Government 10.11 Scottish Government will: • Ensure that any national messaging is shared with the SHG CC and the Responding TB prior to release; • Be appraised of the impact of the incident on the NHS by the SHG / the SHG CC.
Key stages and messages 10.12 It is important that TB’s put out consistent / non-conflicting information. Annex 11 highlights the key internal and external messages that should be issued by TB’s at various time periods during a MI-MC.
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Ministerial Briefing 10.13 The production of ministerial briefings is the responsibility of SG HSCD. Briefs will be prepared by SG HRU and submitted to the Cabinet Secretary for Health and Sport by the Director of Performance and Delivery (the Incident Director). They will provide the Cabinet Secretary and other Ministers with up to date information on the NHS and HSCP response and the impact on services.
Casualty figures disclaimer/explainer 10.14 During the early stages of an incident, it is often not possible to provide accurate casualty figures. However, where indications of numbers involved are available, these should be shared but heavily caveated as a best guesstimate based on the circumstances emergency services are responding to at that time.
Messages for Key Stakeholders 10.15 The SHG (Communications Cell) will consider using key stakeholders such as Royal Colleges to share information with members, depending on the nature of the incident and the audience reach required. COMMUNICATIONS
Communications 37 OFFICIAL
38 Major Incidents with Mass Casualties – National Plan OFFICIAL 11 Recovery
Debriefing
11.1 NHS Boards and HSCPs involved in the national response will be expected to undertake an internal debrief (a clinical debrief and an organisational response debrief) of the incident: • A ‘hot’ debrief within two weeks of the stand-down decision; and • A structured debrief within one month. The reports of these debriefs should be submitted to the NHS Board for consideration and to SG HRU; the latter will organise a national debrief involving all the responding Boards and HSCPs within eight weeks of the stand-down decision.
Psychosocial Support 11.2 ‘Psychosocial’ refers to the emotional, cognitive, social and physical experiences of people in the context of particular social and physical environments. Everyone involved in such an incident is likely to benefit from psychosocial support after a MI-MC and most people are likely to receive it from their families and a range of agencies. However all Territorial NHS Boards should be prepared to address psychosocial issues with patients / service users who have been involved in the incident (staff may need to be trained in Psychological First Aid) and to signpost them to appropriate services. 11.3 After a major incident, staff who attended to support as first responders and those who worked to provide subsequent care in hospital or community settings, are at risk of developing mental health disorders. Territorial NHS Boards (TB), SAS and HSCPs should be prepared to offer psychosocial support to staff as needed following the MI-MC (see Annex 13), and should consider proactively raising staff awareness of the symptoms that are normal during the initial period following a traumatic incident. The leaflet ‘Coping with Stress After a Major Incident’ (Annex 7) should be accessible via NHS Boards’ websites and NHS Inform. 11.4 Some relatives may need bereavement support following the incident. There are a number of staff within TB’s who are trained to provide this level of support – see Accompanying Information Pack. In the event of a relatively high demand for short-term bereavement support, a neighbouring TB may be able to provide staff to meet this need on a short term basis. Such resources are also available from voluntary organisations and staff should be made aware of how to signpost to them. RECOVERY
Recovery 39 OFFICIAL
40 Major Incidents with Mass Casualties – National Plan OFFICIAL 12 Finance
12.1 During and following a MI-MC costs associated with responding to the incident(s) will need to be identified, monitored and documented, so that discussions may subsequently take place between relevant parties in relation to recovery of monies. 12.2 All responding organisations should ensure they have arrangements in place to enable them to track expenditure and subsequently account for the costs related to the incident response. FINANCE
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13 Background Information
Major Trauma Centres 13.1 There are 4 Major Trauma Centres in Scotland, each working with the Scottish Ambulance Service and local hospitals as part of a Major Trauma Network to deliver high quality, specialised, integrated, multi-specialty care to severely injured people on a 24/7 basis. There are 4 regional Major Trauma Networks in Scotland: North, West, East and South East. A map highlighting the hospitals within the regional networks is contained in the Information Pack accompanying this plan.
Reception Arrangements for Ministry of Defence Patients (RAMP) 13.2 Reception Arrangements for Ministry of Defence (MOD) Patients (RAMP) are agreed between the MOD, Department For Health and Social Care and the NHS in the 4 UK nations. They refer to the movement, secondary healthcare and welfare of MOD patients35 who have been aero- medically evacuated from overseas locations to the UK (normally to the Queen Elizabeth Hospital, Birmingham, but other Hospitals may be used in exceptional circumstances). 13.3 Under normal circumstances the MOD patient transportation, admission, transfer and clinical management will be managed according to arrangements made between the MOD Royal Centre for Defence Medicine and NHS providers, primarily in the Birmingham area. 13.4 In the case of a major incident involving numbers and/or types of MOD casualties that cannot be managed by normal resources within NHS England, the NHS England National Duty Officer will contact SG HRU Duty Officer to instigate arrangements under the RAMP framework. 13.5 Tracking and support of MOD patients will remain the responsibility of the MOD.
Other potential impacts for non-health sectors to be considered 13.6 A MI-MC could have an impact on any non-healthcare services. TBs should consider and have plans in place to address the impact of these during a MI-MC activation:
Transport Infrastructure Extreme disruption to transport services can be expected in the local area, especially if the transport infrastructure or transportation hubs have been the target of a terrorist incident. Security Services may also advise the temporary shut-down of transport / transport hubs to prevent suspects escaping or further potential attacks from being staged. This should be considered in local plans / planning a response.
Power and Gas Supplies There may be temporary loss of power and gas supplies to an area where an incident has occurred depending on the cause of the incident. Additional loading in any location where temporary clinics are established should also be considered to prevent overload of health care
35 MOD patients may include military personnel, dependents of military personnel, Government personnel posted overseas and other entitled persons.
Background Information 43 BACKGROUND INFORMATION BACKGROUND OFFICIAL
facility power supplies.
Telecommunications There may be considerable disruption to telecommunications including mobile phones and land lines in the local area following the incident. In addition to this, there will be high demand for these services following an incident with large numbers of people using telecommunication channels. This may be accompanied by disruption to the infrastructure supporting telecommunications networks. NHS Boards should ensure their C3 arrangements take this into account and put in place contingencies.
Environmental Local conditions can impact on accessibility to healthcare facilities and the ease with which responders can reach casualties who require urgent care. Weather conditions can impact on the number of casualties in an incident and the type of treatment and staff required to respond. Extreme temperatures can increase the risk of shock and bring about exposure- related illness.
Water Supplies Water supplies could be the cause of a mass casualty incident or be impacted upon by an incident. NHS Boards should have business continuity utility plans to allow services to continue in the event of a disruption to or contamination of supplies. Arrangements should be in place to obtain advice from Health Protection Scotland and other specialist agencies during any incident of this nature. Lack of water supplies may require a change in the way patients are cared for and immediately affect treatment.
VIP Visits 13.7 It is likely during and/or following a MI-MC there will be significant interest from V/VIPs to visit hospitals and those affected. This may need to be coordinated by Scottish Government to ensure that appropriate arrangements are in place. Visits from VIPs can require extensive resourcing and organisations need to carefully consider these against the need to deliver ongoing patient care.
44 Major Incidents with Mass Casualties – National Plan OFFICIAL A Annexes
47 Annex 1: Situation Report Proforma
50 Annex 2: Strategic Health Group: Activation Flowchart
51 Annex 3: Strategic Health Group: Sample Agenda Template
52 Annex 4: Strategic Health Group: Recovery Cell
53 Annex 5: NHS 24 - Special Helpline Information Request
54 Annex 6: Special Helpline Action Cards: Single Point of Contact and NHS 24 Role
55 Annex 7: Coping With Stress after a Major Incident
59 Annex 8: Mass Fatalities
60 Annex 9: Communications: Checklist Actions
61 Annex 10: Communications: Incident Alert Statement Template
62 Annex 10a: Communications: NHS Board Message Template
63 Annex 11: Communications: Timescales
65 Annex 12: Shared Situational Awareness - M-E-T-H-A-N-E
66 Annex 13: Psychosocial Support for Staff after a Major Incident
Annexes 45 ANNEXES OFFICIAL
46 Major Incidents with Mass Casualties – National Plan OFFICIAL
ANNEX 1
OFFICIAL SENSITIVE WHEN COMPLETE
SCOTTISH GOVERNMENT HEALTH RESILIENCE UNIT SITUATION REPORT Notes All incidents that have occurred within, or impacted on the NHS Board must be reported to SGHRU in line with the Incident Reporting Levels set out in Annex B.
SGHRU Contact Numbers: • 0131 2442429 – Weekday working hours (08:30 to 17:00), and • 07623 909981 – Out of hours emergency pager (17:00 – 08:30 week days, at weekends and Public Holidays).
This pro forma and Annex A should be completed and submitted to SGHRU [email protected] no later than 2 or 3 hours following the occurrence of an incident – see Annex B ‘Incident Reporting Levels’ for further information.
NHS Board: Incident (Type): Date of Occurrence: Time (24 hr) Report No. Name of Reporter: Designation Email: Telephone: Work: Mobile:
SITUATION – OVERVIEW Describe concisely what has happened – (with details of immediate impacts on people, equipment and buildings- Annex)
BACKGROUND A concise overview of events leading to this incident; summarise the nature of the Board’s (strategic and operational) response to date; who is in the lead; other agency involvement currently.
ASSESSMENT Overview of your assessment of the incident and current situation; any direct/wider implications on emerging risks and/or uncertainties that could impact on recovery; highlight any resource or capability issues.
RECOMMENDATIONS Outline specific next steps, timeframes and by whom; summarise potential resource/capability needs, if any; highlight any need for external assistance required.
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Annexes 47 ANNEXES OFFICIAL
ANNEX 1
OFFICIAL SENSITIVE WHEN COMPLETE
SCOTTISH GOVERNMENT HEALTH RESILIENCE UNIT SITUATION REPORT ANNEX A
Effects on capacity and capability Casualty details – numbers & types of injuries. Fatalities, if any.
Receiving hospital(s) – ED department activity, effect on BAU, any other issues, evacuations & lockdowns
Public Health issues – on Primary/Secondary Care, risk to public, scale of exposure)
Staffing impacts
Facilities – alternative facilities, disruptions to specific locations , interruptions or restrictions to essential services + utilities supply, damage to buildings, alternative shelter
Infrastructure – IT and Data systems access and security, supply chain issues
Public Information – media arrangements, casualty bureau(x), public information points, transport disruptions
Environmental impact – flooding, land contamination, pollution, waste management etc
A21801918 August 2018
48 Major Incidents with Mass Casualties – National Plan OFFICIAL
ANNEX 1
or pager or pager
ANNEX B followed by
, followed by ,
hours) hours)
- - of of - -
Reporting action and notifying for timeframe SGHRU reporting required No to SGHRU SitRep Submit 3 hours. within Immediate by phone (if out 2 hours within SitRep Immediate by phone (if out 2 hours within SitRep
-
SHG
. an
l and national
Potentially
ordination established.
Response Can be managed by the BAU within Department/Hospital capabilities and BCP’s Hospital at up set / C3 team MI or Board Level. regionaPossible co - Requires Board C3 group to be set up. be establishedwould Regional and national co ordination in place.
is
SITUATION REPORT impact
-
Scotland IT outages. NHS Boards – Incident Reporting Levels
Board and service provisionBoard / SCOTTISH GOVERNMENT HEALTH RESILIENCE UNIT a larger part of the hospital; has led to to led has hospital; the of part larger a Larger business continuity issues such
on
n the whole
Business continuityBusiness issues
ontinuity issues such as pan -
Impact Low. localised. Moderate. as local IT outages, major infrastructure damage, , and other issues Collisions Traffic larger R oad impacting or likely to lead to suspension or delay to healthcare services; contained to one hospital site. Impact o performance, as well as neighbouring Boards. NHS Loss of critical services and functionality. functions interrupted /suspended. Normal exists. workaround No specific functionalityThe critical is mission to the business and the situation is considered an emergency. or part of affecting the whole weather Severe terrorist incidents,Scotland, any incidents/accidents business casualties, major cause mass which c
local
–
Scale Minor Medium Significant Major
2018
Level
1 2 3 4 A21801918 August
Annexes 49 ANNEXES OFFICIAL
ANNEX 2 Strategic Health Group Activation Flowchart
MIMC Declared
Responding TB sets up SHG within 2 hours and agrees Chairing
CE or deputy informs SGHSCD via pager
Secretariat ensure Records stored Secretariat and ICT effective record keeping for later debrief facilities arranged and safe storage systems
SHG members contacted by TC details and agenda Responding Board or substitute to all Boards
Meeting to be set up within 2 hours
Meeting Concise Next meeting SHG chair confirmed objectives updates details and rationale recorded agreed provided confirmed
Post Meeting
Comms cell set up with other Boards, led by SHG chair appoints HIC lead Senior Comms members on SHG and organises ICT facilities
Develop Comms strategy and link with HIC Lead establishes HIC within other consequence management 3 hours of SHG group / RP meetings
Reports back to SHG
50 Major Incidents with Mass Casualties – National Plan OFFICIAL
ANNEX 3 The Strategic Health Group: Sample Agenda Template
NHS SCOTLAND
Strategic Health Group Meeting on XX, at xx.xx hours Agenda
1. Welcome, members present & apologies • First meeting: introduction reminder of scope, agree strategic objectives 2. Urgent actions/decisions (only those needed immediately) 3. Situation & Response update • What has happened? (SAS) • Overview of casualty numbers/types (SAS & ‘home’ Board) • Casualty distribution update – capacity, effectiveness, balancing pressure (SAS) • Non NHS Impacts & Actions, significant concurrent issues (multi-agency link) • Safety & security issues • Other Actions from previous meetings 4. Strategic Priorities for NHS • Note Strategic Aims • Urgent & short term priorities • Medium & long term priorities 5. Actions required • Casualty management – current & future • Managing normal business • Mutual aid requirements – staff, physical resources • Joint working with other Cat 1 responders • Recovery plan • Communications Strategy • Any other actions 6. AOCB 7. Next meeting / Time
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ANNEX 4 The Strategic Health Group: Recovery Cell
Focus and Outline of Key Considerations The SHG Recovery Cell will be convened and led by a senior NHS Board Director, appointed by the SHG Chair.
The Cell will operate under the auspices of a (reduced) SHG and report to it.
Membership will comprise SG HSCD Resilience and Delivery Director or their nominee, SG HRU representative, nominated service Directors/ Heads of Service, Executive Directors For Resilience or Senior Resilience Leads from the key responding NHS Boards and HSCPs.
The focus will be on:
• maintaining an oversight of, monitoring and reporting on progress towards normal working / business as usual and recovery; • ensuring that mutual aid/resource-sharing principles are applied, and that there is effective use of resources; and • Facilitating repatriations.
Key considerations
• Intelligence / information gathering on impact and progress may be a complex process; • Return to business as usual may take considerably longer than normal; • Trauma cases may require multiple and prolonged returns to surgery and/or stays in critical care; • Specialist services may be needed (to be enhanced) to meet additional demand on a medium to long term basis; • Patients may need to be repatriated to homes / countries far away from the incident location and may require medium to long term care and rehabilitation within Scotland; • Discussions around the temporary reduction, alteration, suspension or cancellation of services by Boards/HSCPs supporting the incident that impact on performance and national standards; • Proactive capture of points to inform learning from response and facilitate recovery; • Financial implications.
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ANNEX 5
SPECIAL HELPLINE INFORMATION REQUEST: [email protected]
Please submit as much information as possible to NHS 24 on the template below. It will help to prepare Call Handlers working on the national incident public Helpline. Acknowledging that all information will not be available in the first hour of an incident, submissions should be version controlled so that Call Handlers impart up to date information.
Submit answers to questions 1-11 immediately to enable the line to be operational. As the impact on the Board/services becomes clearer, your NHS Board Single Point Of Contact should submit answers to Q 11-19. An update schedule will be agreed with the Board.
1 Please describe the disruption to services and identify location
2 How long has the incident being going on? (Date/time – hours/days/weeks)
3 What are the approximate numbers of casualties being dealt with at the site(s)?
4 Where are most of the casualties being treated?
5 Are there any public health consequences? e.g. smoke, contamination etc.
I was involved in the incident and I have a minor ailment, where should I go? (In-hours, out-of- 6 hours)
7 I need help but can’t get through to the ambulance service, what should I do?
8 Should I go to my local ED?
9 Which hospitals are affected?
10 I was caught up in the incident and left the scene. I now have pain, where should I go?
11 Is my family at risk if I’ve been in the vicinity of the incident?
INFORMATION REQUIRED WITHIN FIRST 8 HRS OF INCIDENT OCCURRING 12 My GP surgery won’t see me, what should I do?
13 Is there a website I can use for information?
14 My mental health is deteriorated due to the vast media coverage. What should I do?
15 Where can I donate blood? This information would be found at https://www.scotblood.co.uk/ 16 Concerns related to family and friends social care arrangements
17 Where can I find out if my family and friend were involved in the incident?
18 Will my hospital appointment be on tomorrow?
I’m due renal/cancer treatment, will it still be on and will the ambulance service still pick me up? 19 (Request information from SAS Strategic Operations Manager on x…….
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ANNEX 6
SPECIAL HELPLINE ACTION CARD BOARD SINGLE POINT OF CONTACT (SPOC)
1 Key contact details Request a special helpline by contacting either number below: Health Information Services Management: 0141 435 3889 (in hours) NHS 24 Team Leader: 0141 435 3889 (in hours) In exceptional circumstances, and only if the numbers above are unavailable please alert via 111 or email [email protected] Normal operating hours will be from 08.00 – 22.00, unless agreed otherwise.
2 Provide the appropriate information for the Q&A’s Pro-forma. 3 Provide a Single Point of Contact for the duration of the response that can answer any queries on Q&A’s. 4 NHS 24 will provide a 0800 number and staff the number appropriately within 4 hours. 5 Maintain a battle rhythm to update the Q&A information to ensure it is accurate and up to date as possible. 6 Call stats will be reported on a timely basis. They will be monitored to understand the uptake of the service and when to stand it down.
NHS 24 ROLE ACTION CARD
1 Notify 111 service delivery on-call of major incident with mass casualties. 2 Inform NHS 24 communications on-call to engage with host board communications cell. 3 Notify staff to support potential additional demand. 4 Initiate special helpline standby process. 5 Establish GP Out-of-hours hub as per internal contingency and escalation plan. 6 Initiate NHS Inform webpage and populate with appropriate information. 7 Signpost staff to mental health managing distress. 8 Support long term recovery arrangements through Breathing Space and Living Life.
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ANNEX 7
- accidents
with someone you
Be more careful around the home and drive more carefully are more common after a stressful event. Make time to go a place where you feel safe and calmly go over what happened in your mind. Don’t force yourself to do this. B ottle up your feelings. Talk about what happened trust. E xpect the memories to disappear straight away. Get embarrassed by your feelings and thoughts, or those of others. They are normal reactions to a stressful event. Avoid people you trust. • Don’t • • • •
eve ryone reacts djustment is a gradual Take time out to get sufficient sleep (your normal amount), exercise, rest ,relax, and eat regularly healthily. T alk to others about your experience and how you are feeling Keep your life as normal possible. Try to reduce outside demands on you and don’t take extra responsibilities for the time being. If you have been involved in a major incident, your experience is likely to be a very personal one. help to do can you What yourselforothers Remember, a process, and differently. Recognise it may take some time before you feel anything. At first may feel numb and the incident seem unreal. Over time, with support from family and friends, these feelings are likely to pass. In the meantime…. Do • • •
There is a
ncident I
February 2017 February
– ajor oping with 16793874 C Stress after a M if helpful leaflet this find may You or in involved been have you incident. traumatic a by affected you how on information provides It months and days the in feel may and understand helps and ahead, your of control more have experience. A for adults. intended It is children. with assist to leaflet separate
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ANNEX 7
for support or , if your Where Where to find more help Contact your GP GP surgery is closed and you feel y ou can’t wait until it re - opens , call NHS 24 free on 111 These websites also have more information on post traumatic reactions. www.rcpsych.ac.uk/healthadvice/problems disorders/posttraumaticstressdisorder.aspx www.nhsinform.scot/ptsd
Worry about your alcohol or drug use since the incident. Your performance at work since the incident. Someone close to you tells they are concerned about you. • • •
:
have
February 2017 February
– Wanting to talk about what happened and feel you don’t anyone to share your feelings with. Finding that you are easily startled and agitated. Vivid images of what you saw and have intense emotional reactions to them. Disturbed sleep, disturbing thoughts preventing you sleeping or dreams and nightmares. E xperience of overwhelming emotions that you feel unable to cope with or experience changes in mood for no obvious reason. Tiredness, loss of memory, palpitations (rapid heartbeat), dizziness, shaking, aching muscles, nausea and diarrhoea, poor concentratio n, breathing difficulties or a choking feeling in your throat and chest. Feeling emotionally numb. Relationships seem to be suffering since the incident. You might need help if you you if help need might You any experiencing been have ofthe following reactions for no is there and weeks several better getting them of sign 16793874 • A • • • • • • •
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ANNEX 7
e.g. activities
Being more jumpy and being on the lookout for danger Becoming more clingy with parents or carers Physical complaints such as stomach aches or headaches Temporarily losing abilities ( feeding and toileting) Problems at school Try to keep things as normal possible: keeping to your usual routine and doing normal as much you can, will help your child feel safer more quickly Be available to talk your child as and when they are ready. If it is difficult for you to do this, ask a trusted adult such as a family member or teacher to help Try to help yo ur child understand what has happened by giving a truthful explanation that is appropriate for their age. This may help reduce feelings of confusion, anger, sadness and fear. It can also help correct misunderstandings that might, for example, lead the ch ild to feel that they are to blame. They can also • • • • • How to Help Your Child: • • •
Nightmares Memories or pictures of the event unexpectedly popping into their mind Feeling as if it is actually happening again Playing or drawing about the event time and again Not wanting to think or talk about the event Avo iding anything that might remind them of the event Getting angry or upset more easily Not being able to concentrate Not being able to sleep I f a child has witnessed or experienced a traumatic event it is quite natural for them to be stressed. They may very upset and/or frightened. This should not usually last beyond four weeks. If symptoms of being very upset continue beyond four weeks, this may indicate Post Traumatic Stress Disorder (PTSD) and it is important to seek help for your child. These are typical reactions after a traumatic event: • • • • • • • • •
t with t with
ncident I June 2016
-
ajor Coping with Stress after a M assis to information Additional A14415397 children. children.
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ANNEX 7 – via
. There are some very
D escribe thinking that they are a bad person or talk about thoughts of deserving bad things to happen to them S how less trust in other people and be less able to experience a sense of safety E xperienc e overwhelming feelings in the form of shame, sadness and fear Avoid situations that they fear could increase their emotional response i . e might make them feel more frightened, threatened, ashamed or reminded of the event. • • • • What to do: If you have any concerns about your child, it is important to seek help your GP effective treatments including Cognitive Behavioural Therapy (CBT) for children and young people experiencing the effects of trauma . June 2016
-
help re - assure the child that although bad things can happen, they don’t need to be scared all the time In the event of a death, particularly a traumatic one, it can be difficult to accept the reality of w hat has happened. It is important to be patient, simple and honest in response to questions about a death. Some children, for example, will seem to accept a death but then repeatedly ask when that person is coming back. It important to be patient and clear when dealing with these questions, for example, it is better to say “John has died” than “John gone on a journey”. Children experiencing PTSD might show that they think differently either about themselves or other people. Blame themselves or show lowered self - esteem • What to look for: • Th ey might: • A14415397
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ANNEX 8 Mass Fatalities
Factors Determining The Identification Of An Appropriate Facility in Scotland The requirements for mortuary arrangements will depend upon the number of deceased, their condition and the level of post-mortem investigation required by the Procurator Fiscal (PF) and the Police DVI Senior Identification Manager (SIM).
In coming to a decision the PF and SIM will also take into account that the mortuary should:
• Have proportional and adequate facilities to provide for the receiving area, identification areas, equipment storage, family viewing area and all staff needs according to the scale of the incident; • Not be overwhelmed by potential numbers of deceased or length of the identification operation (that may extend from days to weeks, months or in some cases years after the incident); • Meet security requirements, in particular where there is a criminal investigation, terrorist/ suspected terrorist cause, CBRN consideration or where there is likely to be significant interest from the media; • Have adequate office space in or nearby for all mortuary administration and documentary processes (including DVI Teams and logistical infrastructure); • Have suitable communication provision e.g. telephone lines, internet/email access (preferably with access to Police systems) etc.; • Either be suitable for decontamination or be suitable to accommodate an alternative specialist decontamination facility (following a CBRN or HAZMAT incident); • Be capable of being commissioned, established and fully operational as soon as reasonably practicable after any incident and in any case within 24 hours (including availability of Pathologists, APT’s and logistical infrastructure); • Not conflict with the normal use of the premises and be suitable to return to a ‘business as usual’ setting, as soon as possible without consequences.
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ANNEX 9 Checklist of communications actions
Action required Completed (date & time) Responsible Officer Home board to identify liaison contact with other Boards Identify representative to liaise with home board Identify what, if any support is required or can be provided to other Boards who may be experiencing pressure Holding statement on social media and website Signposting to official information EXTERNAL Holding messages for switchboards signposting to Casualty Bureau Identify health spokesperson for any media/social media Issue advice on attending A&E Issue advice on impact on other services Holding statement on social media and website issued via internal channels Signposting to official information Contact switchboards to ensure appropriate messaging is available for members of the public Issue call for staff/volunteers (if INTERNAL required) Communicate impact on A&E to all staff Communicate impact on other services to all staff.
Incident Alert Templates An Alert Template has been developed (see Annex 10: Alert Templates) and will be populated based on the Methane report provided by SAS from the site; it will be agreed by the SG HSCD Incident Director and the Chair of the SHG when it is convened. It will be issued to all territorial Boards and NSS in the affected geographical area (i.e. the Region) when a MI-MC incident is declared. Distribution to the wider NHS will be agreed by the SG HSCD ID and SHG Chair, depending on relevance.
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ANNEX 10
COMMUNICATIONS: INCIDENT ALERT STATEMENT Templates messages for NHS 24 – NHS Inform
We are aware of an emerging incident in [insert geographical area].
NHS services are part of the emergency response to this incident, which is being led by Police Scotland. For further information, please visit [insert police web address /Twitter handle]
If you are concerned about a family member you believe may have been in the area and you are unable to make contact with them, please call contact the Police Casualty Bureau on xxxxx or visit [www.xxxxx] to register their details.
The NHS Boards and Health and Social Care Partnerships in the area are working hard to ensure that as few patients as possible are affected and that all casualties are being given the best possible care and support.
Please do not attend the Emergency Departments in [identify hospitals] unless you have to.
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ANNEX 10a
TEMPLATE NHS BOARD MESSAGE
Our hospitals are currently exceptionally busy. Please do not attend our Emergency Departments unless you have to.
To find out where you can access healthcare please visit our website [xxxx] or NHS Inform [xxxx]. We will provide updates as soon as we can on our social media channels and website.
Helping the NHS at this time You can help the NHS cope by choosing the right service for your needs, and attending Emergency Departments only if it is essential. If it is possible, you should try to avoid attending the Emergency Departments at [xxxx] hospitals at the present time, as demand for services is extremely high and this will impact on the amount of time you have to wait to be seen and treated if your problem is not immediately life threatening.
NHS Blood and Transplant We have sufficient blood stock at this current time, but if you wish to donate in the future please register at the SNBTS website [xxxx]
Other services Apart from your hospital, there’s a range of other primary care services that can offer help, such as your GP, pharmacist, dentist or optician. There are also specific services provided by midwives, health visitors and specialist nurses.
Planned treatment and outpatient appointments If you have a planned operation, procedure or outpatient appointment at a hospital affected by this incident, please visit the hospital website for further advice and information about routine services at this time. If you are still unsure what to do, contact the hospital direct. Patients already in hospital at this time will continue to receive normal care.
GPs Your GP practice will be open and working as normal but may be experiencing higher than usual demand for services. Please be patient when contacting them.
Emergency Departments If you need emergency treatment, Emergency Departments will be open to deal with serious and life- threatening conditions. As is always the case, only those adults and children with genuine emergency needs should go there. Emergencies include:
· major injuries, such as broken limbs or severe head injury · loss of consciousness · fits · severe chest pain · breathing difficulties · severe bleeding that can’t be stopped · severe allergic reactions · severe burns or scalds
Alternatives to ED If you become ill with a non-urgent condition and need advice, please visit NHS Inform for information [xxxx] or go to your local pharmacist. For more urgent conditions that you believe you can’t take care of yourself, you should contact your GP as usual, or call 111. For minor injuries or illness (cuts, sprains, rashes and so forth) you could visit a walk-in centre, minor injuries unit or urgent care centre if the problem can’t wait for a GP appointment. Bear in mind that these services may be busy because of the incident that has just occurred.
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ANNEX 11 NHS Boards: Communications During a Major Incident with Mass Casualties
Internal and external actions and timescales
INTERNAL MESSAGING
Timescale INTERNAL Communications messages Responsible Boards Day 1 Pre-agreed holding messages Responding TB Within 30 minutes of Incident – ‘do not attend hospital’. Further Responding TB being notified by SAS updates will be issued as soon as possible Day 1 Impact on services, we will update when All Boards Within 1 hour possible, advise on where to direct enquiries Management of staff who want to help All Boards Media/Social media guidance. All Boards Day 1 SHG will have been set up – led by chief exec Responding/other TBs Within 3 hours of the Responding Board; Communications Cell set up and led by Head/Director of Communications for the Responding TB. Instructions to staff/volunteers – where to Responding/other TBs attend/where help is needed Holding position on impact on services Responding/other TBs Day 1 Impact on services All Boards Within 6 hours Patient management All Boards Staff messaging All Boards Instructions to staff/volunteers – where to All Boards attend/where help is needed. Day 1 Patient management All Boards Within 24 hours Instructions to staff/volunteers – where to attend/where help is needed Day2 Thank you to staff – instructions for additional All Boards support Patient management All Boards Day 3+ Patient management All Boards Service impacts All Boards Instructions to staff/volunteers – where to All Boards attend/where help is needed Day 21+ Positive stories of staff efforts All Boards
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ANNEX 11 NHS Boards: Communications During a Major Incident with Mass Casualties
EXTERNAL MESSAGING
Timescale EXTERNAL Communications messages Responsible Boards Day 1 Pre-agreed holding messages Home Board
Within 30 minutes of Identify spokesperson(s) who will be Home Board being notified by SAS available for interview if required – medical director/CE Day 1 Details of incident, impact on services, All Boards signpost to Casualty Bureau and NHS Inform Within 1 hour NHS Inform incident pages established with NHS Inform key messages Details of when updates will be issued All Boards Day 1 State how often updates will be issued; record Responding/other TBs Within 3 hours specific messages Instructions to patients not involved in the Responding/other TBs incident in terms of accessing services Day 1 Updates on service impact All Boards Patient management All Boards Within 6 hours Day 1 Patient management All Boards Within 24 hours Impact on services All Boards Day2 Details on pressure within services – impact All Boards on outpatients/scheduled procedures Patient management All Boards Day 3+ Details on pressure within services – impact All Boards on outpatients/scheduled procedures Day 21+ Positive stories of staff efforts All Boards
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ANNEX 12 Shared Situational Awareness M-E-T-H-A-N-E METHANE is a tool which has also been introduced under the Joint Emergency Services Interoperability Principles programme. It is fundamental to the principle of Shared Situational Awareness and is the multi-agency incident reporting framework – see also Accompanying Information Pack.
METHANE provides a common structure for responders and their control rooms to share major incident information. The acronym stands for:
Has a major incident or standby been declared? M Major Incident (Yes/No? If no, then complete ETHANE message
What is the exact location or geographical location E Exact Location of the incident?
T Type of Incident What type of incident is it?
H Hazards What hazards or potential hazards can be identified?
A Access What are the best routes for access and egress?
How many casualties are there, and what condition N Number of Casualties are they in?
Which and how many, emergency responder assets/ E Emergency Services personnel are required or are already on-scene?
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ANNEX 13 Psychosocial support for staff after a major incident Most people involved in a major incident are likely to suffer short-term effects. In most cases, distress is transient and not associated with dysfunction or indicative of developing mental health disorders. Some people’s distress may last longer and be more incapacitating, for example where there are social factors maintaining their distress (e.g. separation from family, loss of home and possessions, social isolation).
A small proportion of people may require access to specialist mental healthcare. However, it is important to access the right help at the right time. Immediately following a traumatic event, personal, brief, single session interventions that focus on the particular event, should not be routine practice and do not need to be organised. Instead, follow Phase 1 advice on the next page.
Depending on the nature of events, around 70% or more of all people who are affected by major incidents are psychosocially resilient, despite their distress. Distress reduces in severity if they receive support they perceive as adequate and intervening early can reduce the risks of people developing disorders later.
The majority of staff who respond to major incidents cope well and recover if social support is available from relatives, friends and colleagues. Employers should support staff by ensuring that they are well briefed, well led and offered effective social and peer support. Recent research shows that events encountered in emergency departments affect the psychosocial wellbeing of staff, and the cumulative effects may be negative and long-lasting.
The phased strategy36 on the next page is advised to support all those involved in a major incident, to prevent mental disorders and to identify those who may need specialist mental health services.
36 Extract from NHS England’s Clinical Guidelines For Major incidents and Mass Casualty Events (2018). See Accompanying Information Pack for the MI-MC national plan.
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ANNEX 13 Psychosocial support timeline
PHASE 1: INITIAL SUPPORT Launched in reaction to the event • Psychological First Aid (PFA) and peer support • Includes the employer’s leadership response to a major incident by communicating key messages of acknowledgement, self-care and support services, internal and external to the organisation • Access to advice and support as necessary through existing universal services (community, primary care/GP and specialist services) • Intervene using low level interventions such as peer support leaving biomedical mental healthcare for people who need it.
IMMEDIATE - WEEK 1 IMMEDIATE Advice available from: Coping with Stress Following a Major Incident (NHS Leaflet available from NHS Board websites)
PHASE 2 : GETTING ADVICE Weeks two to four • Psychosocial support • Aim to manage distress, but an emphasis on maintaining social connectedness and people receiving social support • Involves listening, advice and support WEEK 2 – 4 • With their consent, some staff may be referred to a programme that offers monitoring over a longer period of time and access to screening. Advice available from: NHS Inform (signpost to an appropriate service)
PHASE 3: ADDITIONAL SUPPORT/GETTING HELP From two weeks onwards: • Continuing psychosocial support • Monitoring staff at risk via occupational health. • This may include referring people to: ––Primary care ––Specially created services to identify people who may need continuing support beyond four weeks
WEEK 2 ONWARDS ––A service for more intensive psychosocial care. Advice available from: Primary Care/own GP, for referral to specialist service such as The Rivers Centre (Edinburgh) or The Anchor (Glasgow)
PHASE 3: SPECIALIST SUPPORT/GETTING MORE HELP When symptoms are still present between four and twelve weeks after an event People with a history of the following may be at higher risk of developing a mental disorder than the general population: • Staff injured in the event or during the response • Exposure to high-severity of trauma • Close proximity to event • Dissociative response during the event • Significant (pre- or post-event) personal trauma, including developmental trauma and previous history of a mental disorder WEEK 4 – 12 • Personal or significant family psychiatric history • Perceived absence of social support network • Substance misuse • Traumatic bereavement *If people are distressed or have symptoms of a mental disorder after 4 weeks and any of these risk factors are present, an early referral to a specialist mental health service may be advised.
Annexes 67 ANNEXES Produced by Daysix for the Scottish Government and the Scottish Trauma Network