The Saunders report into the Manchester arena attack

Disaster gap

Throughout the report, Sir John discussed the ‘disaster gap’, the period of time between an incident or injury occurring and the provision of medical assistance.

This gap can be mitigated through the actions of the general public (often termed zero responders or immediate responders), and this was certainly the case in Manchester, with many members of the public providing first aid at once.

The next wave of care providers are event first aiders and other first-aid trained responders, such as police officers.

The provision of training and equipment to members of the public, our police colleagues and designated first aiders is a key link in the chain of survival for victims of trauma.

First aid

The first aid supplier at this event was discussed at some length, with a focus on the training, education and staffing levels of the first-aid provision.

There was an audience of 14 500 at the concert on the night of the attack, and the first-aid provision fell far short of that recommended in the Purple Guide for an event of this nature (Events Industry Forum, 2022). The version of the Purple Guide published in November 2015 was in force at the time of the incident and this makes clear recommendations for staffing a concert of this size (Table 1). The company was also criticised for not providing adequate major incident training for its staff, and the consequent inability to pass a METHANE report (Table 2) from the incident, an intervention that would have proved hugely valuable for responding agencies.

Ambulance response

The report highlights the low numbers of frontline ambulance crews and paramedics who were sent into the City Room (the inner cordon), the site of the most casualties. A number of ambulances were held at a rendezvous point distant from the incident for some time at the request of an ambulance officer not yet part of the major incident command structure at that time.

The activation of the nearest hazardous area response team (HART) was criticised as being delayed, taking seven minutes to be activated. The second HART response was also activated approximately 30 minutes too late.

When the HART did arrive on scene, they were not all deployed to the City Room. As a key role of HART is deployment into the inner cordon of major incidents, there may have been benefit in deploying more than two HART operatives into this area. HART are also able to provide additional stretchers, which would have been valuable at this incident.

The report also discussed the provision of further equipment into the inner cordon by HART at future events, and made recommendations to investigate whether HART should be bringing additional splinting (including traction) equipment into the inner cordon with them.

Operation Plato

Initial 999 calls provided insight as well as bringing confusion into the incident, with some callers mentioning gunshots and others explosions. The incident was declared Operation Plato (Table 3), in the belief that it was a marauding terrorist firearms incident, and this was judged as a sensible and appropriate response.

The declaration of Operation Plato was not, however, appropriately conveyed to other emergency services. In a tactical sense, the scene was cleared as being a permissive environment (a cold zone) by firearms police rapidly and effectively. The report highlighted a potential for confusion in terminology here, in that an Operation Plato hot zone is a non-permissive area, where ambulance crews should not be deployed. In contrast, a major incident hot zone (or inner cordon) is an area in which ambulance staff not trained to HART or special operations response team (SORT) standards may operate. The report further highlighted confusion around policy and guidance in relation to which ambulance staff could operate in an Operation Plato warm zone.

Extraction of patients

It took one hour and eight minutes to remove all surviving patients from the City Room. This timescale was criticised for being prolonged and the method of their removal as suboptimal.

Many patients were removed on makeshift stretchers by the police and members of the public rather than on available ambulance equipment. All but six casualties were evacuated from the City Room on improvised stretchers. Attending ambulances and HART resources both had additional stretchers which could have been deployed to the scene; a mass casualty equipment vehicle was neither requested nor deployed to the scene.

Once patients had reached the casualty clearing station (CCS), many of them experienced a significant delay in being transported to hospital. In total, the CCS treated 38 patients before their transport to hospital. While the device was detonated at 22:31, it was not until 02:50 that the last patient left the CCS.

Communication and joint working

The ambulance service was criticised in relation to lines of communication and a lack of adherence to the principle of joint working as set out in the Joint Emergency Services Interoperability Programme (JESIP) (2022) guidelines.

The report highlighted that emergency services were poor at communicating with each other at a strategic level, especially in the initial stages of declaration of a major incident.

No multi-agency radio talkgroup was arranged in the early stages of the incident, and this would likely have been hugely beneficial.

There was also a significant delay in the first METHANE (Table 2) report being communicated to any emergency service control room. There were also failings in relation to establishing a co-located, multi-agency forward command point for emergency services. It was highlighted that the lack of communication and shared risk assessment led to a delay in ambulance staff being deployed into the City Room.

Funding challenges

Continued, sustained funding cuts to the emergency services were highlighted in the report. Any criticism or failings discussed must therefore be viewed against this backdrop.

It is likely to be impossible to maintain both core services and regular training and education in relation to major incidents with such ongoing cuts to funding.

METHANE report

While focusing on areas for improvement, the report gives clear praise in many areas, including regarding the first METHANE report.

The advanced paramedic who was first on scene entered the City Room and, within a minute, had passed a METHANE report to ambulance control. This was the first METHANE report sent by anyone and was hugely beneficial to the emergency response by the ambulance service.

Ambulance control, however, failed to share this METHANE report with other agencies. Sir John was clear that the ambulance service was fortunate to have this advanced paramedic on duty on the night of the incident and that he played a central role in saving lives.

Triage

The report details the triage of casualties and the CCS that was established. It would have been beneficial for triage tags to have been available in the City Room from the early stages of the incident. The report recommends that services consider stocking such triage tags in standard ambulance response bags.

The current models and flowcharts for triage were reviewed in the report and evidence was heard that they could be cumbersome to use.

A new triage system involving the Major Incident Triage Tool (MITT) and Ten Second Triage (TST) has been developed since the Manchester bombing and is likely to become operational in spring 2023 (Vassallo et al, 2022).

Discussion and critique were also directed at the system of sieve-and-sort triage and the holding of patients in a CCS before transport.

The report directed there should be further investigation into facilitating the rapid transport of patients. It posed the question of whether responders other than paramedics could perhaps drive ambulances to facilitate this prompt conveyance.

Major incident training

The report highlighted the importance of regular and appropriate major incident training to develop muscle memory to undertake a skill, role or activity.

Sir John found that frontline ambulance crews were adequately trained to an appropriate standard at the time of the incident and that there was a well-run programme for multi-agency exercises in place in Manchester.

In a related area, he discussed the importance of role cards as a positive aide-memoire for those managing a major incident. It was highlighted that such cards must be immediately accessible to those who may require them, not available only as part of a later, specialised major incident response. The JESIP (2022) and National Ambulance Resilience Unit (NARU) (2022) guidelines were highlighted as best practice for managing a prehospital major incident, and these state that the use of role cards or action cards is a suitable way to ensure appropriate actions are taken at the scene of a major incident.

Such cards may also make sure that all command roles are allocated. In relation to the Manchester Arena incident for example, the roles of ambulance safety officer and equipment officer were overlooked.

Concurrent recording of events

The use of body-worn cameras and voice recorders by responders and commanders was praised, and the importance of these as sources of evidence was highlighted.

Sir John also noted that knowing one's conversations and actions were being recorded may lead to those being taken more deliberately and thoughtfully.

There was no evidence that the use of such devices would have an adverse effect on a clinician's performance.

Enhanced care in the firearms hot zone

Sir John discussed the provision of medical care in an Operational Plato hot zone, and the difficulty of emulating the French RAID model, where a physician is embedded within an armed response team in the UK setup (Park et al, 2020). The report noted that, by the time a doctor embedded in a counter terrorist firearms team had arrived, medical care would already be well under way by HART.

The report concluded that more work may need to be done to facilitate enhanced care provision within a hot zone, which may include using doctors who were currently involved in prehospital care, perhaps through work with air ambulance or other organisations.

There was also a direction to investigate further upskilling of HART clinicians to provide enhanced care interventions.

Provision of analgesia

Paucity of analgesia provision within the inner cordon was highlighted as a problem. Fentanyl lozenges (or lollipops) were posited as a solution. These have been used for over a decade by some volunteer prehospital responders in the UK (Ellerton et al, 2013) as well as in the British army and some air ambulance services (Aldington and Jagdish, 2014; Carenzo et al, 2022).

The report recommended that fentanyl lozenges or sufentanil sublingual tablets should be made available to HART and possibly other paramedics.

Blood products

The availability of prehospital blood products was also discussed. It was concluded that equipping frontline ambulance or even just HART vehicles with blood was undesirable and unachievable.

However, it was stressed that it would be desirable to have blood products available, probably through enhanced care physician-led resources. It was also suggested that freeze-dried plasma could be carried on all HART vehicles as well as by other enhanced care teams (Oakeshott et al, 2019).

Tranexamic acid

A clear recommendation was made that the administration of intramuscular tranexamic acid should be investigated as an intervention available to all frontline ambulance staff.

Recent research has shown that the efficacy and bioavailability of tranexamic acid administered intramuscularly is acceptable (Grassin-Delyle et al, 2021), and would allow much earlier administration, especially in mass casualty incidents.