This document provides information to paramedic students about responding to major incidents at West Midlands Ambulance Service (WMAS). It discusses the purpose of major incident training and examples of past incidents in the WMAS area. It outlines the roles and responsibilities of different emergency services at an incident. It also covers topics like triage, decontamination, civil disorder response, health and safety considerations for rail and helicopter incidents, and the specialized resources available to WMAS for mass casualty response. Confidential information is also discussed that should not be shared outside of those who need to know operationally.

1. NHS CONFIDENTIAL
Major Incident

2. NHS CONFIDENTIAL
Purpose
• To provide Paramedic student staff with knowledge, in respect of
Major Incident & CBRNe capabilities of WMAS and an
understanding of experiences and to learn about new initiatives
that the Trust has implemented to aid the response phase of an
incident in a safe and controlled environment.
• Note some elements of this induction session are of a confidential nature, this information is shared with
you to enhance your skill set whilst responding to an incident, but certain aspects of this information
discussed should not be shared outside those that need to operationally know.

3. NHS CONFIDENTIAL
Some incidents within the
WMAS area

4. NHS CONFIDENTIAL
Birmingham Pub Bombings
21 November 1974
21 killed and over 182 injured

5. NHS CONFIDENTIAL
Birmingham Tornado
28 July 2005
0 dead, 30 Injured and over 1,000 houses damaged

6. NHS CONFIDENTIAL
Summer Floods 2007
13 fatalities, 48,000 houses damaged,350,000
persons without water, 40,000 persons without
electricity. 60 billion cubic meters of water fell.

7. NHS CONFIDENTIAL
Snow Disruptions
February 2009
Major disruptions to the roads, schools, NHS &
the Ambulance Service in the West Midlands

8. NHS CONFIDENTIAL
Swine Flu
May – December 2009

9. NHS CONFIDENTIAL
Volcanic Ash Cloud
April 2010
Major disruptions to the NHS

10. NHS CONFIDENTIAL
Civil Unrest
8 - 14 August 2011
4 Dead, many injured, disruption to the
Emergency Services & millions of pounds of
property damage

11. NHS CONFIDENTIAL
May – July 2013
Mosque bomb attack incidents
in Birmingham and the Black Country

12. NHS CONFIDENTIAL
Incident Aerial Overview
RVP
CCS

13. NHS CONFIDENTIAL 13
Major Incident Declaration
A major incident may be declared by any one of the
emergency services.
What is a major incident to one of the emergency
services may not be so to another.

14. NHS CONFIDENTIAL
Major Incident - to be or not to be?
Two options for Major Incidents
•Standby
•Declared

15. NHS CONFIDENTIAL
Major Incident (Standby) - Deploy to scene the
nearest:
•Silver level manager
•Emergency preparedness Manager/NILO*
•20 Ambulances,
•10 RRVs
•10 officers
•HART
•Put a call out for Medics
*National Interagency Liaison Officer

16. NHS CONFIDENTIAL
Major Incident (Declared) - Deploy to scene the
nearest:
•Silver level manager
•Emergency preparedness Manager
•20 Ambulances,
•10 RRVs
•10 officers
•HART
•Put a call out for Medics
•Alert voluntary aid societies such as St John, Red Cross
SARS for availability of assistance.
•Contact PTS control and request immediate assistance
•Activate MI ISU E1 X 2 Incident Support Unit
•Activate NCMCEV x 1National Capabilities Mass Casualty Emergency Vehicle

17. NHS CONFIDENTIAL
Roles and Responsibilities

18. NHS CONFIDENTIAL 18
Ambulance: Role & Responsibilities
• To save life together with the other emergency services
• Assess the incident
• Co-ordinate the on-site operational NHS response
• Liaise with other emergency services on site
• Identify and activate the resources needed to respond
• Manage the NHS activity at the scene
• Co-ordinate the NHS communications at the scene
• Triage, treat casualties, assist extrication, decontaminate and transport
• Protect the health & safety of all personnel on site

19. NHS CONFIDENTIAL 19
Police: Role & Responsibilities
▪ the saving of life together with the other emergency services
▪ the co-ordination of the emergency services, local authorities and other
organisations
▪ to secure, protect and preserve the scene
▪ control sightseers and traffic through the use of cordons
▪ the investigation of the incident and obtaining and securing of evidence in
conjunction with other investigative bodies where applicable
▪ the collection and distribution of casualty information
▪ the identification of the dead on behalf of Her Majesty’s (HM) Coroner
▪ family liaison officer role
▪ the prevention of crime

20. NHS CONFIDENTIAL 20
Fire: Role & Responsibilities
▪ life-saving through search and rescue
▪ fire fighting and fire prevention
▪ rendering humanitarian services
▪ management of hazardous materials and protecting the environment
▪ provision of qualified scientific advice in relation to HAZMAT incidents via
their scientific advisors
▪ salvage and damage control
▪ hazard assessment and safety management within the inner cordon
▪ decontamination of contaminated persons who may have been exposed to
Chemical, Biological, Radiological or nuclear contaminates (CBRN) to
include Mass decontamination

21. NHS CONFIDENTIAL 21
CSCATTT
• CSCATTT is your guide to managing major incidents
• Following it will help organise the response
• C OMMAND & CONTROL
• S AFETY
• C OMMUNICATIONS
• A SSESSMENT
• T RIAGE
• T REATMENT
• T RANSPORT

22. NHS CONFIDENTIAL 22
CSCATTT
• COMMAND AND CONTROL
Gold
Bronze
Silver
Strategic
Tactical
Operational

23. 23
Dynamic Risk Assessment
What is it?
• On-site assessment by competent employees to ensure
that controls are adequate and/or to add additional
controls if required

24. 24
Cordons
Cordons control the movement of persons into and out of
the incident site and provide a safe environment in which to
work
Inner Cordon –
•Intended to limit access to essential personnel for safety & forensic reasons
•Enforced by police where no hazards present or by Fire Service when hazards exist
•Boundary normally marked with tape
Outer Cordon –
Controlled by police
Physical barrier (barrier, tape, vehicle)
Restrict access to public & media
Preserve access & egress for emergency services
Identification required for access

25. NHS CONFIDENTIAL 25
Communication
My call sign/Major Incident Declaration
Exact Location
Type of incident
Hazards at scene
Access & Egress
Number of casualties
Emergency services
Initial report should follow the METHANE format
Casualties
Hazards
Access and Egress
Location
Emergency Services
Type
Safety / PPE

26. NHS CONFIDENTIAL 26
Triage
Sieve
AV
CRT less than 2

27. NHS CONFIDENTIAL 27
Triage Sort

28. NHS CONFIDENTIAL 28
Triage – Casualty Clearing Station

29. NHS CONFIDENTIAL
Civil Disorder

30. NHS CONFIDENTIAL 30
A civil disorder can be defined as:-
• “Any situation in which the conduct of individuals will,
in the opinion of the police, require special
arrangements to deal with it and its consequences”

31. NHS CONFIDENTIAL 31
Key Roles & Responsibilities
• Provide neutral medical support to all injured parties.
• Identify and activate the resources needed to respond
• Co-ordinate and manage the on-site operational NHS
response
• Triage & Transport casualties to hospital
• Ensure the health, safety and protection of all
personnel and equipment on site

32. NHS CONFIDENTIAL 32
Action by Ambulance Personnel
• Approach the incident silently.
• Use only Blue lights
• Ensure PPE is worn at all times – incl. Hard Hat
• Follow Instructions from Ambulance Incident
Commander (AIC) / Police Incident Commander (PIC)
• Stand-by behind Police lines as identified by PIC
• Receive casualties from Police Medics
• Crews to remain in their vehicles
• When called to receive casualties - Reverse to the
incident with their rear doors open.
• Ensure personal safety at all times

33. NHS CONFIDENTIAL 33
Health and Safety - Railway
• Never enter Railway property unescorted unless it is absolutely
essential
• Wear high visibility clothing and hard hat at all times
• If access to the track area required (for casualty access of safety)
advise EOC they require “Power Off”
• Confirm with EOC that the power has been switched off by
Network Rail and check with if present a rail incident officer.
• Where possible wait for the arrival of the Rail Incident Officer
(RIO) before entering the track area and advise them of your
intentions
• Don’t get closer than 3 metres to overhead line equipment
• Avoid touching conductor rails - treat all rails as LIVE
• Its not just power off – its power off, think about diesel trains

34. NHS CONFIDENTIAL 34
Health and Safety - Railway
• Get help from Railway staff if possible
• Step over, not on rails, sleepers and cabling
• Avoid crossing the tracks near points.
• Don’t step within the moving blades of points.
• Ask Network Rail Control for any information regarding
hazardous construction materials
• Ask Network Rail Control for information regarding goods that
the trains may be carrying
• Move 30 metres from a detonator before a train passes.
• Don’t enter tunnels unless Network Rail confirms that trains have
stopped.
• Don’t forget to provide an all clear message to EOC

35. NHS CONFIDENTIAL
Helicopters

36. NHS CONFIDENTIAL
Operational air ambulances.
•RAF Cosford
•Strentham Services
•Tattenhill Airfield
•Coventry Airport
They carry a crew of three - Pilot, two Paramedics or
Flight Doctor and Paramedic.
In total have flown more than 30,000 missions

37. NHS CONFIDENTIAL 37
Helicopter Zones

38. NHS CONFIDENTIAL 38
Approaching or Leaving
ARP - TG 282

39. NHS CONFIDENTIAL
CBRN

40. NHS CONFIDENTIAL
HazMat vs. CBRN
HAZMAT
• Is an accidental release of a substance, agent or
material which results in illness or injury to the public
or the denial of an area or the interruption of the food
chain
CBRN
• Is a deliberate murderous and malicious act, the
intention of which is to kill, sicken or prevent society
from continuing with their normal daily business

41. NHS CONFIDENTIAL
The Model Response
• An aspirational model for all agency response to a
CBRN attack
• Agreed across government
• Based on defined numbers of casualties (fatal &
contaminated)
• Against a time line for the duration of the incident –
crisis to consequence

42. NHS CONFIDENTIAL
CBRN Incident
Identified
A & E Secured
Mass Decon
Starts
Rest Centres Open
EA Notified
PSU Arrives Documentation
Teams Dispatched
Casualty
Decon Starts
DSTL Advice
Available
DIM Operator
Arrives
0 min 15 30 45 60 75 90 105
GOVERNMT
POLICE
FIRE
HEALTH
LOCAL
AUTHORITY
ENVIRON
MILITARY
JointDynamicRisk
Assessment
PCT, A & E,
HPA Alerted
Possible
Emergency
Decon
LA Alerted Temp Mortuary
Plan Activated
Cordon
Established
Assessment of
Environmental Footprint
JRLO Notified TPU Alerted COBR Sits
Model Response – Methodology

43. NHS CONFIDENTIAL
The Ambulance Service Role
• Co-ordination of NHS resources at the scene
• Act as gatekeeper to wider NHS services
• Decontamination of casualties
• Treatment and care of casualties at scene
• Provision of appropriate means of transporting casualties
to treatment centres
• Provide NHS communications at the scene

44. NHS CONFIDENTIAL
Decontamination
• Remove from the source of contamination (HART/Fire
and Rescue)
• Remove all clothing, interim or emergency Decon’

45. NHS CONFIDENTIAL
Interim Options

46. NHS CONFIDENTIAL
Command & Control
The NHS Zones
• Hot Zone
– The area of gross contamination. The Fire Service and HART
operate in this area wearing BA with gas tight suits.
– Mandate from DH that Ambulance service will operate in hot
zone with suitable CPPE
• Warm Zone
– Contaminated by people evacuating the Hot Zone or by
weather conditions. Contamination levels will be greatly
reduced. Ambulance Decontamination Staff will operate in
CPPE within this area. In effect this is the Inner Cordon.
• Cold Zone
– No contamination present. Normal Major Incident procedures
apply.

47. NHS CONFIDENTIAL
Decon
Shower
Decon
Shower
I
n
n
e
r
C
o
r
d
o
nHOT
ZONE
WIND
CCP
Casualti
es Triage
Sieve &
Sort
A&E
Loading
Point
O
u
t
e
r
C
o
r
d
o
n
DECONTAMINATION & EVACUATION
WAR
M
ZONE
COLD
ZONE
Emergency Responders
not in PPE Do Not Cross
the Cordon into the
Warm Zone under any
circumstances
Casualty
Clearing
SELF PRESENTERS
Triage
by
Hart

48. NHS CONFIDENTIAL
Safety Triggers for Emergency Personnel
STEP 1: ONE Casualty:- Approach using normal procedures
STEP 2: TWO Casualties:- Approach with caution, consider all
options, report on arrival and update
control
STEP 3: THREE Casualties:- Do NOT approach the scene
Withdraw
Contain
Report
Isolate yourself
Send for specialist help
STEP - 123

49. NHS CONFIDENTIAL
The Plume
• Formation is complicated & dynamic
• Meteorological conditions & thermal currents are
main influence
• Light wind = Short, fat plume
• Strong wind = Long, thin plume
• Plumes in an urban area do not follow a straight
line.

50. NHS CONFIDENTIAL
Plume Safety
IF POSSIBLE:
• Withdraw
– Uphill
– Upwind
– Close Doors/Windows
– Air Con
• Contain
• If contaminated isolate yourself
• Send for specialist help
• METHANE assessment to be provided as soon as
possible

51. NHS CONFIDENTIAL
CBRN Defensive measures
• EPD – Electronic Personal Dosimeter
• EH20 – Escape Hood 20 (15 minutes protection)
• NAAK1 - Nerve Agent Antidote Kit 1
• PRPS – Positive Respirator pressure suit
• MDU - Mobile Decontamination Unit
• STEP123 approach

52. NHS CONFIDENTIAL

53. NHS CONFIDENTIAL
EH20 ESCAPE HOODS

54. NHS CONFIDENTIAL
Combopens (NAAK Mk1)
Syringes Numbered:
1 – Atropine
2 – Pralidoxime Chloride

55. NHS CONFIDENTIAL
PRPS

56. NHS CONFIDENTIAL
The Mobile Decontamination Unit
• Made by the NBC Group, it consists of two structures – TM18 and
TM36.
• Requires an area of 10m X 10m.
• Can decontaminate either: 2 lines of walking casualties,
• 2 lines of ambulant casualties or a mixture of both.
• After training the manufacturers state it should take
• 4 operators 10 minutes to erect.
• It is recommended a minimum of 6 persons erect the structure, bearing
in mind the TM36 tent canvas is a six person lift.
TM18 TM36

57. NHS CONFIDENTIAL
Road Haulage - Hazmat
• Tremcards (Transport Emergency Cards should be
carried on each vehicle transporting hazardous cargo
(but is it safe to approach?)
• UN number of a plate on the external of the vehicle
(the International System for Identifying Hazardous Substances)
• Orange hazard plate with relevant information to deal
with the cargo if compromised

58. NHS CONFIDENTIAL
Hazard Warning Panel

59. NHS CONFIDENTIAL
SPECIALIST RESOURCES

60. NHS CONFIDENTIAL
WMAS Major Incident Support Unit
Locations
In addition to the
Vehicles listed there are also
E2 vehicles in B’ham and a
D3 vehicles at the HART
base

61. NHS CONFIDENTIAL
Hart Specialist Vehicles
• Forward Command Vehicle
– Satellite Communications
– Wi-Fi Network
– VoIP Capability
– Operator Audio/Video
• Reconnaissance Vehicle
– Medical Equipment
– PPE
• Equipment Vehicle
– Bulk dressings
– Bulk O2
• Land Rover Discovery x 2
• Volvo Response vehicles x 2

62. NHS CONFIDENTIAL
WMAS Mass Casualty Response
• In addition to routine assets, specialised assets (HART and
Emergency Preparedness) include
• HART assets
• 10 x ISU Equipment (E) vehicles within the Region
• 2 x National Capability Mass Casualty Equipment Vehicles
(NCMCEV)
• Additional consumables: 2400 self help packs, 1,000 burns
packs, 500 Responder packs

63. NHS CONFIDENTIAL
Incident Support Unit - Equipment (E)
• Review of Trust assets in April 2009 – result was a
major investment required for mass casualty
capability - £1.7 million.
•Casualty Clearing Station (1 x SF54) plus generator,
lighting, heater
•10 stretchers with A-frames, 2 x P1 medic bags,
5 x P2 & P3 medic bags
•Consumables including 02 masks, body bags,
self help first aid kits, burns packs, stretcher heat
bags, pillows, space blankets, triage tags,

64. NHS CONFIDENTIAL
National Capability Mass Casualty
Emergency Vehicle (NCMCEV)
• Form part of National Capability distributed
across the UK
• Contain:
• Mass oxygen delivery system
• Adult Trauma packs x 80
• Paed Trauma packs x 20
• VR1 ventilators x 16
• Amputation packs x 10
• Emergency Dressings packs x 1
• 3 x 3 POD boxes of blast bandages,
dressings packs, eye speculums, triangular
bandages, burns dressings and steristrips

65. NHS CONFIDENTIAL
Additional resources
• Mass oxygen delivery system
• Self Help first aid packs
• Triage sieve bands
• Prometheus Mass Casualty Treatment pack x
1 (100 mixed priority casualties - Hart)
• Mass oxygen delivery system is also available to support an
incident on some D1 units

66. NHS CONFIDENTIAL
Logistical Support
• Based in Staffordshire for deployment any where
within Region ISU L1, ISU L2 & ISU L3
• These incident support units can supply an incident
with a solution for resupply and staff welfare, on full
deployment a field kitchen unit can de deployed and
established

67. NHS CONFIDENTIAL
Medical Emergency Response Incident
Teams – MERIT
• MERIT consists of a highly skilled Immediate Care doctor and a
MERIT Paramedic
• They will operate normally: 12 hours on the Air Ambulance from
Cosford (or if weather denies the helicopter deployment via a RRV)
and then 12 hours on an RRV of an evening from the Hart base
• Arrangements for the provision of additional advanced medical
care to the scene of incidents include a pool of BASICS doctors,
HEMS doctors and Care Team doctors who can be deployed to
the incident scene without drawing resources from receiving or
supporting hospitals.
• In addition each WMAS one call team has an appointed MIO
available

68. NHS CONFIDENTIAL
NACC
The NACC is a national initiative and is activated under the following conditions:
• An Ambulance Trust is experiencing pressure which is, will or might
jeopardise its ability to provide a safe service.
• There must be a Request from a Chief Executive (or Deputy) of an
Ambulance Trust
• The primary NACC is based in LAS, with a secondary within WMAS (MP)
should LAS not be in a position to provide.
Its functions are to:
• Collect data from all other Trusts on their internal pressures and to collate it
into a national overview.
• Decide on each Trust’s ability to support the national ambulance
infrastructure
• Coordinate the movement on resources nationally to support the challenged
Trust(s)

69. NHS CONFIDENTIAL
Mutual Aid
• An agreed process for all Ambulance Trusts to support each other
if faced with a situation of not being able to provide a safe service.
• All resources (incoming or outgoing) will have a designated
Convoy Assembly Point (motorway service station) and a
designated Convoy Assembly Point Manager
• Ambulances travel as cells (10 ambulances + 1 Officer, Band 7 or
above)
• Mutual Aid Support Vehicle (HART base, Oldbury) will meet with
convoy to supply (where necessary):
• Radios (Mutual Aid ARP)
• Patient Report Forms
• A-Z of West Midlands Region
Also carries Welfare and Hygiene bags in case of overnight stays.

70. NHS CONFIDENTIAL
Interoperability Airwave TG
• Use of Airwave Radios on a designated TG
• Requested by any of the blue light services
• Activated by the FDI at Force Control
• Allows scene Commanders to communicate without
being face to face

71. NHS CONFIDENTIAL
WMAS MI Plan
• Additional MI Action cards:
• Major Incident Plan V8
• Can be found in the Emergency Preparedness pages
of SharePoint (Trust Intranet site)

72. NHS CONFIDENTIAL
Any further enquires contact your local EPM
➢Adrian Crowe/Justin Burke Jones – Black Country & EOC
➢Keith Nevitt – Birmingham
➢Kevin Morrey – Hereford, Shropshire & Worcestershire
➢Richard Moore – Coventry & Warwickshire, Staffordshire