Major incident response: how each tragedy informs future nursing care

With every mass-casualty event comes fresh clinical understanding and greater preparedness

With every mass-casualty event comes improved clinical understanding and greater preparedness

  • NHS England has produced fresh guidance on responding to major incidents 
  • Lessons learned from terrorism in the UK have improved health services' readiness for future attacks
  • Reflecting on clinical responses to mass-casualty events reveals how dynamic teams can be in developing practice

The scene of the London Bridge terror attack in 2017.
Picture: Getty Images

When a bullet is fired into a gelatine block, the gelatine behaves in a similar way to human muscle tissue. By using high-speed digital photography, the impact of the bullet can be tracked.


people killed by terrorists in the UK between 2000 and 2017

Source: Global Terrorism Database 

A bullet from an AK47 assault rifle, for example, flies straight but then becomes unstable. As a result, it creates a large cavity associated with tissue stretching and tearing before it exits a victim's body.

This ballistic detail comes not from a police or army manual but from NHS England’s Clinical Guidelines for Major Incidents and Mass Casualty Events, published late last year.

Ready to respond

The guidelines are evidence of the advances made in the preparedness of UK health services to respond effectively to large-scale, challenging clinical scenarios.

‘I was sent to the park in my apron, starched collar and frilly hat. We had no training. It was ridiculous’

Carole Olding, lead trauma nurse at a London major trauma centre; in 1982, a nurse at the scene of an IRA bomb

But some tough lessons have been learned along the way.

Carole Olding is lead nurse for trauma in the emergency department at King’s College Hospital, one of London’s major trauma centres. She trains nurses in the management of mass casualties and played a leading role in the hospital’s response to the Westminster and London Bridge terrorist attacks and the Grenfell Tower fire.

Staff from St Thomas' Hospital went to nearby Westminster Bridge when reports of the
March 2017 terrorist attack emerged. Picture: Getty Images

Robust processes, excellent communication and dedicated staff

Mick Dowling is head of nursing for critical care at King’s College Hospital. In his 20 years at King’s, what has he learned about effective nursing responses to major incidents?

Mick Dowling.

‘It’s all about experience and preparation. We have a well-organised, well-structured team who understand their roles and responsibilities.

‘The senior team is very strong but we also have a dedicated, excellent workforce who can deliver whatever is needed to ensure patients are cared for.

‘I’m also assured by our processes and that we have the right people doing the right jobs at the right time.

‘And all my matrons and staff know they will get the support, the equipment, the tools, and that they’ve got the training to do the job when we ask them to do it.

‘But the factor that stands out is communication – the number-one priority in any major incident.’


When a major incident is declared, ‘everything swings into action’, Ms Olding says. ‘There’s this cascade that goes on – calling the essential people, getting the essential things you need, the extra blood, the extra fluid.

‘It’s about having the right people with the right skills to be able to make the right decision. And that’s why we have a lot of training.’

Recent events show how far we’ve come

She contrasts this slick, practised operation with an incident from 1982 when the IRA left a bomb beneath a bandstand in Regent's Park in London, killing seven soldiers.

The 1982 bombing of the bandstand in Regent's Park killed six members of a military band 
on the day; a seventh would die later. Picture: PA

‘I worked at University College Hospital and was sent to the park in my uniform, with the apron, starched collar and frilly hat. There was me and a senior house officer. We had no training. It was ridiculous, like headless chickens running around.’ 

In Northern Ireland, however, enduring violence during the Troubles meant that nursing and medical teams were to become much better equipped to respond to, and learn from, terrorist attacks.

‘Staff could change rapidly from doing a routine appendicitis to major trauma. They would turn the theatre round in a click of the fingers’

Margaret Graham, nurse, Royal Victoria Hospital, Belfast during the Troubles

Margaret Graham.

Nurse Margaret Graham, now retired, trained at the Royal Victoria Hospital (RVH) in Belfast, and later helped collect narratives from nurses who had worked through the conflict, published in 2015 in Nurses’ Voices from the Northern Ireland Troubles.

Better contingency planning was one legacy of the conflict, she suggests. After a bomb in Belfast city centre injured dozens and caused five people to lose 11 limbs between them, ‘we sat down with everybody and redesigned what was called the disaster plan’, she says.

‘It was a step-by-step guide, so everybody knew their roles and the telephone lines weren’t getting clogged up. A process was put in place.’

‘Staff were honing their skills daily’

Techniques, treatments and knowledge advanced rapidly, especially in emergency and intensive care, neurosurgery, fractures and theatres, because staff were honing their skills daily.

The Royal Victoria Hospital in Belfast, during the Troubles. Picture: PA

Ms Graham adds: ‘Staff could change rapidly from doing a routine appendicitis to major trauma. They would turn the theatre round in a click of the fingers.’

Treating so many victims of the violence meant that the RVH refined all sorts of emerging treatments and clinical practices, says Horace Reid, who also nursed at the hospital during the Troubles.

‘Because of the pressure of numbers and the severity of the injuries, the RVH was forced to adopt techniques developed elsewhere and quickly become very practised in them.’

‘If you can’t handle it, you shouldn’t be in this job – that was the attitude’

Horace Reid, a nurse during the Troubles

He cites external fixators for fractures, treatment for blast lung, and titanium plates in neurosurgery as examples where medical teams and nurses learned fast.

‘If you’re having a disaster every ten days, you get pretty proficient,’ he adds.

Evolution of psychological support

But one area where little progress was made, and which distinguishes that era from this, is psychological support.


people injured in the 2017 London Bridge attack. Eight people died, as well as the three attackers

‘There was no formal debriefing, no psychological care for the patients and certainly none for the staff,’ says Mr Reid. ‘If you can’t handle it, you shouldn’t be in this job – that was the attitude.’

By contrast, following the 2017 Manchester Arena terrorist attack in which 23 people including the bomber were killed, patients, families and staff at the Royal Manchester Children’s Hospital were offered immediate support, says lead nurse for critical care Clare Ryan.

‘There’s a recognised emotional burden when caring for people in highly charged situations’

Clare Ryan, critical care lead nurse, Royal Manchester Children’s Hospital

Psychologists, psychiatrists and the child and adolescent mental health team were on hand to provide one-to-one and group sessions, and that support continues, she says.

The hospital’s emergency department treated 29 children and five adults after the attack, and two years on, the experience continues to resonate among staff.

‘We know that in the critical care community and in adult intensive care there’s a recognised emotional burden when caring for people in highly charged situations,’ Ms Ryan says.

Self-care in the aftermath

A self-help app, developed with expert input after the bombing, allows staff to monitor their own well-being and to seek help if unusual and persistent symptoms occur.

Gina Stevenson, matron in the hospital’s paediatric emergency department, describes her team’s response to the deadly attack as calm, ‘very coordinated, very organised’.

‘There had been a recent run-through of the major incident plan in the trust, and the plan was followed. We’d rehearsed for it and the plan worked.’

Adding to the knowledge bank

Today, successful management of mass casualty incidents is characterised by preparation and planning, and the chaotic response Ms Olding remembers in Regent’s Park is a reminder that much has been learned.

And the learning continues. The Manchester attack was unusual because of the high number of young victims. Ms Ryan says that presented particular challenges. ‘We did have a couple of issues regarding identification because children under 16 don’t generally carry identification.’

‘The most important thing I’ve learned is terrible things can happen, and you have to be brave enough to challenge things when they’re wrong, not be part of the problem’

Emma Kennedy, manager, Grenfell outreach team

Close liaison with the police and other services, detailed descriptions of victims’ clothing and asking parents about ‘unique identifiers’ enabled identification of patients.

And a reunification area with dedicated staff meant the paediatric emergency department was not overwhelmed by concerned relatives.

Unique issues of the Grenfell fire

All major incidents bring their own unique challenges. Emma Kennedy manages a nurse-led Grenfell outreach team for Central and North West London NHS Foundation Trust.


emergency service workers were recognised in 2018 new year's honours following the 2017 terror attacks in London and Manchester

The Grenfell Tower fire in June 2017 left 72 people dead and dozens injured. It also left a community grief-stricken, traumatised and angry.

‘The community was so angry with anything that represented authority,’ Ms Kennedy says. ‘We were a representation of the state as far as the community was concerned.

Members of Grenfell outreach team. The nature of the tragedy meant that the nursing
response included supporting the community in the aftermath. Picture: Barney Newman

‘From the outset, the narrative was “I can’t trust you”. Basically, there was a shift in power. We had to be true servants of the population we were serving.’

But from those difficult conversations came collective learning – about building sustainable, accessible support and truly user-led services, for example; and using the community as a resource to promote health in that community, a model the wider NHS could use to its advantage, Ms Kennedy suggests.

As well as team learning, involvement in major incidents brings personal reflection and insight. Ms Kennedy says: ‘The most important thing I’ve learned is that terrible things can happen, and you have to be brave enough to challenge things when they’re wrong and not be part of the problem because of your own fear of being wrong, your own safety system.’

Further information

NHS England clinical guidelines for major incidents and mass-casualty events



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