Monday, 9 May 2011

The 7/7 Inquest - Recommendations to the London Ambulance Service

Tonight the Patients Forum for the London Ambulance Service, of which I am chair, holds its monthly public meeting in the LAS HQ on Waterloo Road from 5.30pm. One of the main topics on the agenda will be the coroner's report issued last Friday concerning the 7/7 bombings and the role of the London Ambulance Service in those events. The LAS is not yet in a position to mount a full reply to the inquest findings but they are sending spokespersons along to give a preliminary response.

All of the emergency services in London were found wanting on that day and the LAS was among them. The LAS says that since that time it has put in place several major changes. The statement of the LAS re the inquest findings is as follows:

Communications Department
220 Waterloo Road
Tel: 020 7783 2286
Fax: 020 7783 2120

News Statement

6 May 2011
Response to Coroner’s inquests verdicts into the London Bombings of 7 July 2005

Chief Executive Peter Bradley said:
“Our thoughts today are with the families of those who were killed and the people who were injured on 7 July 2005.
“We appreciate that this has been a very difficult inquest for everyone involved, but we hope that it has helped to answer some of the questions that people have had about what happened to their loved ones.
“We are pleased that the actions and bravery of our staff have been recognised by the Coroner. They did everything they could, and through the care and treatment they provided were able to help save the lives of very seriously injured patients.
“We accept, though, that some aspects of our response on the day could have been better; communications issues affected the speed at which we were able to send crews to some of the scenes. For this reason, we are genuinely sorry if any families or survivors feel unhappy about our response.
“The Coroner has recognised that we have made a number of key changes over the last five years. These include improving systems in our control room where we manage 999 calls, introducing much more effective radio communications, and putting a system in place to send a set number of vehicles and managers when a major incident is declared. We are confident that, as a result, we are in a much better position to respond to any similar incidents in the future
“We will now carefully consider the Coroner’s recommendations, and will work with all other agencies to make changes that will further improve our response to major incidents.”

Notes to editors:

Improvements to our major incident planning since July 2005

The London Ambulance Service has made a number of significant developments and improvements since the bombings. These include:

• introducing the Airwave digital radio system, which includes coverage underground and the ability to send update messages to staff’s radio handsets when they are away from their vehicle.

• sending a pre-determined response to a major incident, including 20 ambulances, 10 officers and all available emergency support vehicles carrying extra equipment.

• creating two hazardous area response teams, which have their own large equipment vehicles carrying equipment that is capable of delivering help to large numbers of patients simultaneously – for example, mass oxygen systems that can be used to treat 48 patients at the same time, and medical supplies to manage the care of up to 80 adults and 20 children with serious injuries, as well as up to 300 walking injured patients.

• replacing our previous incident control room with a new purpose-built incident control room able to help manage multiple simultaneous major incidents.

• improving major incident training. Rosters have been developed for frontline staff to enable them to attend a series of dedicated training days, with one of these set aside for a session to update and refresh them on major incident procedures, followed by a tabletop exercise looking at major incident management. Additionally, training for operational officers has been enhanced and builds on training received on other courses.

• improving the way we carry out triage during a major incident to ensure that at least two people will now carry out the initial assessments of the patients involved, rather than one. One member of staff will keep a tally of the number of patients who have been triaged and some basic patient details, while the other carries out the assessments. These initial assessments are rapid because the aim is to get an overall picture of the extent of patients’ injuries, but the presence of a second member of staff means some initial treatment can take place, for example, opening up a patient’s airway, possibly putting in an airway adjunct (a device to keep a patient’s airway clear), and in some circumstances applying dressings. Ambulance staff who follow behind the triage team will start to provide more treatment, for example, the provision of drugs and pain relief.

• introducing new medical equipment. Our staff can now use tourniquets to stop the flow of blood from catastrophic bleeding from limbs; and they now have use of a drill type device to gain access to a patient’s bone marrow (intraosseous access) to administer fluids and provide drugs for pain relief. This is more effective for treating patients when they are in shock as it may be difficult to locate any veins.

For more information or to arrange an interview, please call the Communications Department on 020 7783 2286.

The edited version of the coroner's main findings are below and especially where they refer to the LAS. It is important that we the Patients Forum and users of the ambulance service in London really ensure that these changes have been implemented. As one of the relatives said at the inquest, the findings of the Kings Cross Fire Inquiry, several years before, were never implemented. It would be good if members of the public come along to the Forum meeting tonight and also to the subsequent meeting of the Forum where a detailed response to all of this will be given by the LAS.

State for the Home Department

Director General of Security Service

London Resilience Team Transport for London

London Ambulance Service

Secretary of State for Health

Barts & London NHS Trust

6 May 2011

Dear [Secretary of State] etc

Report under Rule 43 of The Coroner’s Rules 1984



Fifty two members of the public were killed as a result of four bombs being detonated on London’s transport system on 7th July 2005 (“7/7”). The names of the deceased are set out at Annex A to this report. I heard the evidence in these inquests in the capacity of Assistant Deputy Coroner for Inner West London, from 11th October 2010 to 3rd March 2011. I sat without a jury and have given verdicts of unlawful killing, with the medical cause of deaths recorded as “injuries caused by an explosion”, in respect of each of the deceased.


Where a Coroner is satisfied that the evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist in the future, and is of the opinion that action should be taken to prevent the occurrence or continuation of such circumstances, she may report the circumstances to a person whom she believes has power to take action. announced in court on 11th March 2011 that I was proposing to make such a report under Rule 43 of the Coroners Rules 1984 (“the Rules”).


I am satisfied that the criteria in Rule 43 (1) are met as far as some but not all of the recommendations put before me for consideration by the Interested Persons in these proceedings. This is my report.


It falls into two sections. For ease of reference, I shall continue to call them “Preventability” and “Emergency response”, which were the headings under which I examined the issues. Not all of this report will be directly relevant to you, but I wished to make one report that would read as a consistent whole and reflected the wide ambit of my conduct of these inquests. I attach, therefore at Annex B, a schedule of the recommendations contained in this report together with a note of to whom they are addressed, in the hope that this will assist you in responding to the issues I address specifically to you.


Given the public interest in these Inquests, it is appropriate that I provide an overview of the facts and circumstances relating both to what was and was not known about the bombers prior to 7/7, and the emergency response to the bombings. This is essential properly to set the context for the recommendations that I make. In doing so, I can also explain in outline those improvements which have already been made since 7/7 and therefore do not require further intervention.


However, given the parameters of Rule 43, it is not appropriate to comment upon all the inquiries I have pursued concerning the bombings. Therefore I have not set out in detail all of the evidence which I have heard or the narrative which it establishes and informs. That evidence is now, in any event, a matter of public record contained on the Inquests’ website which will be transferred to and maintained by The National Archives.


R1. I recommend that consideration be given to whether the procedures can be improved to ensure that “human sources” who are asked to view photographs are shown copies of the photographs of the best possible quality, consistent with operational sensitivities.

R2. I recommend that procedures be examined by the Security Service to establish if there is room for further improvement in the recording of decisions relating to the assessment of targets

R3. I recommend that the London Resilience Team reviews the provision of inter-agency major incident training for frontline staff, particularly with reference to the London Underground system.

R4. I recommend that TfL and the London Resilience Team review the protocols by which TfL (i) is alerted to major incidents declared by the emergency services that affect the underground network, and (ii) informs the emergency services of an emergency on its own network (including the issuing of a ‘Code Amber’ or a ‘Code Red’, or the ordering of an evacuation).

R5. I recommend that TfL and the London Resilience Team review the procedures by which (i) a common initial rendezvous point is established, and its location communicated to all the arriving emergency services (ii) the initial rendezvous point is permanently manned by an appropriate member of London Underground.

R6. I recommend that TfL and the London Resilience Team review the procedures by which confirmation is sought on behalf of any or all of the emergency services that the traction current is off, and by which that confirmation is disseminated.

R7. I recommend that TfL (i) reconsider whether it is practicable to provide first aid equipment on underground trains, either in the driver’s cab or at some other suitable location, and (ii) carry out a further review of station stretchers to confirm whether they are suitable for use on both stations and trains

R8. I recommend that the LAS, together with the Barts and London NHS Trust (on behalf of the LAA) review existing training in relation to multi casualty triage (ie the process of triage sieve) in particular with respect to the role of basic medical intervention.

R9. I recommend that the Department of Health, the Mayor of London, the London Resilience Team and any other relevant bodies review the emergency medical care of the type provided by LAA and MERIT and, in particular (i) its capability and (ii) its funding.

By virtue of Rule 43A(1), as a recipient of this report you must provide me with a written response to it, containing details of any action that has been taken or which you propose to take in response to those parts of this report that are addressed to you (as set out in Annex B), or an explanation as to why no such action is proposed. This has to be provided to me within 56 days beginning with the day on which this report is sent. If you wish to request longer than this period to respond, you should write to me requesting an extension of time and giving reasons, as soon as possible.

Yours sincerely

The Rt. Hon Lady Justice Hallett DBE

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