Report of the 7 July Review Committee:Conclusion

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11.1 This report provides an analysis of some of the lessons to be learnt from the response to the 7 July attacks on London. Many of these lessons will be applicable to any major incident in any large city. 11.2 Throughout the review, we have taken the perspective of an informed layperson, and considered the issues from the point of view of the people involved in the response and those caught up in the attacks. This perspective has revealed some key lessons for the future. Overall, London’s emergency plans must be recast to take account of the needs of the individuals involved, rather than focusing solely on impersonal ‘incidents’. In particular, there is an urgent need to put in place plans to support those who are bereaved, and those who survive, both in the immediate aftermath and in the weeks and months that follow. 11.3 The plans, systems and processes that are intended to provide a framework for the response to major incidents in London must be revised and improved. Communications within and between the emergency services did not stand up on 7 July. As a result, individual emergency service personnel at the affected Tube stations and at Tavistock Square could not communicate effectively, in some cases with each other, and in other cases with their control rooms. 11.4 It is essential that London’s emergency services are equipped with digital radio equipment so that they no longer have to rely on mobile telephones to communicate between the scenes of major incidents and the control rooms. 11.5 It is unacceptable that the emergency services, with the exception of the British Transport Police, are still not able to communicate by radio when they are underground, 18 years after the official inquiry into the King’s Cross fire recommended action to address this problem. The Committee has been told that this problem will be resolved by the end of 2007. We will be asking for regular progress reports, in public, and if there are any delays we will be asking why. 11.6 The most striking failing in the response to the 7 July attacks was the lack of planning to care for people who survived and were traumatised by the attacks. Hundreds of people were left to wander off from the scenes. An estimated 1,000 adults and 2,000 of their children are likely to have suffered from post-traumatic stress as a result of their experiences on 7 July. 3,000 others are estimated to have been directly affected by the explosions. The majority of them are still not known to the authorities, are not part of any support network of survivors, and have been left to fend for themselves. Those who are known to the authorities in some cases received excellent care and support following 7 July. Others registered their details but received no follow-up contact, and no advice or information about the support that was available. 11.7 We met survivors from each of the four explosions, and were struck by their fortitude and their desire to improve the response to major incidents in the future. The insights they were able to offer have informed every aspect of our report. Their views and the information they provided were invaluable to us in building up a picture of what 120 of 151 happened on 7 July. We are pleased to see that the Government is now finally talking to survivors, albeit belatedly and behind closed doors. Survivors and bereaved people between them possess a vast wealth of experience and knowledge, and we can learn an enormous amount from them. 1.8 The Committee would like to record its thanks to those who took the time and effort to contribute to our review. We hope that as a result of those contributions, this report and the recommendations we make will improve the effectiveness of the response to any future major incident in London, or indeed any other city. We received a huge amount of information and a wide range of views from organisations and individuals affected by the 7 July attacks. We would direct you to the transcripts of our meetings and private interviews, and to the written submissions we received, all of which are published in volumes 2 and 3 of this report. 1.9 This report is not the end of our examination of these issues. We invite those who read it to respond in writing to us at 7july@london.gov.uk 1 1 by 30 September 2006. We will consider all the responses we receive when we conduct our follow-up review in November 2006, when we will be asking the authorities for progress reports on the implementation of our recommendations. 11.10 We would conclude by paying tribute to those who los survived the attacks, and the hundreds of individuals who on 7 July showed s tremendous bravery, initiative and compassion as they worked to rescue the injured, protect the public, and ensure a speedy return to order in our city. t their lives on 7 July, those who uch 121 of 151 122 of 151 Findings and Recommendations 123 of 151 Findings and recommendations There is an overarching, fundamental lesson to be learnt from the response to the 7 July attacks, which underpins most of our findings and recommendations. The response on 7 July demonstrated that there is a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individuals, and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved. We argue in this report that London’s emergency plans should be re-cast from the point of view of people involved in a major or catastrophic incident, rather than focusing primarily on the point of view of each emergency service. A change of mindset is needed to bring about the necessary shift in focus, from incidents to individuals, and from processes to people. The First Hour – establishing what happened A range of circumstances could create the urgent need for passengers to communicate with the train driver and vice versa. A large proportion of Tube trains do not currently have a facility for passengers and train drivers to communicate with each other in an emergency. This represents a significant weakness in the safety of the Tube for passengers, and limits the ability of the emergency services to respond rapidly and effectively to any incident that might take place. These facilities must therefore be put in place as quickly as possible, in the interests of the safety of passengers in the normal course of events, and in particular in the event of a major emergency. 1. We recommend that London Underground, Tubelines and Metronet, as part of the review of the Public Private Partnership to be completed in 2010, negotiate a more rapid rollout of facilities for passengers and train drivers to be able to communicate in the event of an emergency. We would draw the attention of the Public Private Partnership Arbiter to this recommendation and others relating to the review of the Public Private Partnership. Communications from the trains to the London Underground Network Control Centre and the emergency services were inadequate or non-existent on 7 July. As a result, transport and emergency service workers had to run from the trains to the platforms and back again to communicate with their colleagues and supervisors. Given the importance of communications in the minutes following any sort of emergency on a Tube train, we consider that the timeframe for the rollout of the new radio system must be significantly reduced from the current projection of twenty years. In the meantime, an interim 124 of 151 solution must be identified to provide a robust and resilient form of communication between drivers and their line controllers. 2. We recommend that, as part of the review of the PPP to be concluded in 2010, London Underground, Metronet and Tubelines seek to speed up the rollout of the new radio system to enable train drivers to communicate with their line controllers. . In the meantime, we recommend that Transport for London conduct a study of possible interim solutions to increase the reliability and resilience of radio communications between train drivers and line controllers. We request that Transport for London provide us with an update on progress in time for our November 2006 follow-up review. etropolitan Police Commissioner Sir Ian Blair told us that he regards the inability of the mergency services to communicate underground as ‘a significant problem for London’.117 We gree with his assessment. The inability of the emergency services to communicate nderground is not a new or novel problem. It has been recognised as a major weakness for the st 18 years, ever since the official inquiry into the King’s Cross Fire in 1988. Since then, there s been a failure by successive governments to take the necessary action to install underground communications for the re can be no excuse for failing now to deliver facilities to enable underground radio munications by the end of 2007, which was the target date given to us by the emergency transport services in November 2005. We intend to monitor progress towards this deadline in November 2006, May 2007 and November 2007, and will be publicly asking the emergency and transport services to provide us with update reports setting out the progress that has been made and explaining any delays. 4. We recommend that Transport for London provide an update on progress in rolling out the CONNECT project in November 2006, May 2007 and November 2007, so that we can monitor the delivery of the contract. The timely completion of this project is essential to enable all London’s emergency services to communicate underground. 5. We recommend that the Metropolitan Police Service, London Fire Brigade and London Ambulance Service provide us with an update on the rollout of digital radio systems within their services in November 2006, May 2007 and November 2007, so that we can monitor progress towards full implementation of TETRAbased radio communications across London’s emergency services. 3 Mea u pa ha transport and emergency services. The com and 117 Transcript of Committee meeting, 1 March 2006, page 17 125 of 151 It is going to take at least another 18 months to implement digital radio communications nderground. In the meantime, an emergency system of underground communications needs to be available, which is capable of being put in place much more quickly than a leaky feeder cable. So far as we can gather, no serious c chnologies as an interim measure pending the s rapid, nd it was quickly established that there had been an explosion on the train. All the emergency rvices were aware of the explosion at Aldgate East by 9.14 am. A major incident had been declared separately by the by 9.15 am, 25 minutes af e trol Centre called the emergency services to the scene at 8.59 am, but the first Fire ngine did not arrive until 9.18 am, 19 minutes later, and the Metropolitan Police did not inciden We can the scene and control ntres, was less effective at Edgware Road than it was at Aldgate. This could be a result of the emerge minutes ite by site: King’s Cross/Russell Square not am. u onsideration has been given to alternative te rollout of CONNECT and Airwave, or as a backup measure in the longer term. 6. We recommend that Transport for London conduct a feasibility study to asses the costs and effectiveness of Personal Role Radios and other available technologies to enable communications for emergency and transport services in underground stations and tunnels. We request that Transport for London provide an update on work in this area by the time of our follow-up review in November 2006. Site by site: Aldgate It is clear that the initial deployment of the emergency services to Aldgate station was a se London Fire Brigade, the London Ambulance Service and the police, ter the explosion. Site by site: Edgware Road It took longer at Edgware Road than at Aldgate for the emergency services to establish and communicate to each other that there had been an explosion. It is not clear to us why this should be the case, given that the train stopped only 50 yards into the tunnel, and London Underground workers alerted their Network Control Centre to the incident within minutes. Th Network Con E declare a major incident until 9.32 am, followed two minutes later by a declaration of a major t by the London Fire Brigade. only conclude that communications at the scene, and between ce ncy services focusing on the incident at Aldgate, which was reported just a couple of before the incident at Edgware Road. S Communications problems made it difficult for the emergency and transport services to establish what had happened to the passengers emerging from the tunnel at King’s Cross station. The initial deployment of ambulances and fire engines to Russell Square was much slower than at the other sites, and it took longer to establish what had happened. The first 999 call was received until 25 minutes after the explosion, and a major incident was not declared until 9.38 126 of 151 7. We recommend that emergency plans be amended so that, when an incident takes place in an Underground tunnel, the emergency services are deployed to The Lon response on the Tube. It is regularly required urgently to attend life-threatening incidents. mergency Response Unit vehicles should be automatically exempt from the congestion charge, would h The Em oncern tion underground. n e e an automatic exemption from the Congestion Charge. d once the CONNECT project is completed. y of There is London he London Fire Brigade’s debriefing report identifies communications between the emergency that mo and ove and nat co-ordi ncy Services Procedure Manual sets out in broad terms how the emergency services will respond to major and catastrophic incidents. It clearly states that a major incident can be declared by any of the emergency services, the implication being that this will be done on behalf of all the services. On 7 July, each of the emergency services arriving at the scenes of the explosions separately declared major incidents within their own service. It is not clear to us why each of the emergency services found it necessary separately to declare major incidents. the stations closest to the train in either direction. don Underground Emergency Response Unit is a crucial element of any emergency E and should be allowed to drive in bus lanes. They should also have blue lights. These measures elp the unit to get to the scenes of emergencies on the Tube much more rapidly. ergency Response Unit works mostly on the Tube network. It is therefore a cause for c that they do not have radios that func 8. We recommend that Transport for London lobby the Government to obtai blue light status for Emergency Response Unit vehicles. This would, amongst other things, exempt Emergency Response Unit vehicles from bus lan restrictions and the Congestion Charge. 9. We recommend that, in the meantime, Transport for London grant th Emergency Response Unit automatic access to bus lanes and 10. We recommend that the Emergency Response Unit obtain Airwave radios to be able to communicate undergroun 11. We recommend that the Emergency Response Unit consider the feasibilit obtaining an interim/back-up solution to enable its staff to communicate underground, such as Personal Role Radios. Establishing what happened - findings room for improvement in communications between the emergency services and the Underground Network Control Centre. T services as a point for further consideration. From the information we have seen, we believe re effective communications between the emergency services in relation to each scene, rall, could have reduced the duration of the period of uncertainty about the location ure of the incidents and enabled the emergency services more rapidly to put in place a nated emergency response. The London Emerge 127 of 151 It is common sense that one declaration of a major incident, by whichever service is first at scene, ought to automatically mobilise units from ‘all three’ services - police, fire and ambulance – and activate major incident procedures within all the services. It is difficult to envisage a major incident, especially on the Tube, which would not necessitate the atte of the fire, ambulance and police services, at least in the first instance until the situation has been assessed and the emergen the ndance cy response fully mobilised. cy cy response. 12. We recommend that the London Resilience Forum review the protocols for declaring a major incident to ensure that, as soon as one of the emergen services declares a major incident, the others also put major incident procedures in place. This could increase the speed with which the emergency services establish what has happened and begin to enact a co-ordinated and effective emergen The First Hour – rescue and treatment and it would become difficult to make or receive lephone calls. It happens every year on New Year’s Eve. It happened on a larger scale after rk. London’s emergency services nevertheless relied to internally among their senior officers. This d for a wholesale review of how senior officers within he decision to switch off mobile telephone networks to the public, enabling a small number of lephones, is based on an assessment of e balance between the extent to which the public interest will be best served by providing a se to lised area. We are not in a position to second-guess whether it was the right thing to Reliance on mobile phones It ought to have been predictable that in the event of a major incident in London, mobile telephone networks would become congested te the 11 September attacks in New Yo varying extents on mobile phones to communicate led to some major communications problems on 7 July. The rollout of new Airwave digital radio communications across the emergency services will alleviate this problem up to a point. We will be closely monitoring progress in meeting the target of the end of 2007 for the rollout of Airwave, as we consider it to be an essential element of effective communications within and between the emergency services above and below ground. In the meantime, there is an urgent nee the emergency services communicate with each other in the event of a major incident. At the moment, each of the services is reviewing its own communications, internally. There would be some benefit in the services cooperating to identify possible solutions, rather than each of them independently reinventing the wheel. T key people to communicate using specially-enabled te th continuing public telephone network or closing it down to facilitate an emergency respon an incident. The tension on 7 July was between the belief that this is a strategic decision, because it is broadly in the public interest, or an operational decision, given that it applies only to a loca do from an operational point of view to invoke ACCOLC on the O2 network around Aldgate on 7 July. We were not party to discussions at the Gold Coordinating Group where the decision was made that ACCOLC should not be invoked. However, there are important lessons to be learnt from the experience. 128 of 151 􀁸􀀃 If ACCOLC is to be maintained as a system, it is essential that the relevant authorities t to use it. position to assess the potential impact of ACCOLC on other services involved in the 􀁸􀀃 ver 13. We recommend that the London Resilience Forum, as a matter of priority, coordinate a review across London’s em cations b rol ro R s of this review in November 2006. Me phones. We request that the emergency and transport services provide us with d h ed if n 5. The protocols which require mobile telephone operating companies to verify e amended, so that any instructions are verified with the Gold Co-ordinating Group rather than the authority issuing e leared’ within three hours, during which time almost 200 vehicles and 400 staff and managers ensure that at any given moment the right personnel are in possession of ACCOLCenabled telephones. There is no point in a technical facility if the relevant authorities do not make sure that the right people have the equipmen 􀁸􀀃 The current command and control structure provides that only the Gold Coordinating Group can decide to turn off the mobile phone networks to the public. The City of London Police acted outside this framework. This should not be allowed to happen again; the command and control structures that are put in place in the event of a major incident exist for good reasons, not least because the individual services are not in a emergency response. To be effective, these structures must be observed by all concerned. Protocols for operating companies to verify requests should be consistent with whate decision-making framework is in place. ergency services of communi etween managers at the scenes of major incidents, their respective cont oms and the Strategic Co-ordination Centre. We request that the London esilience Team provide us with the result 14. embers of the London Resilience Forum should put in place regular checks to nsure that key senior officers are equipped with ACCOLC-enabled mobile etails of their plans to conduct such reviews, showing what will be done, and ow frequently, to ensure that the technology can actually be effectively us ecessary. 1 instructions to activate ACCOLC should b the instructions. We recommend that the London Resilience Team review thes protocols and report back to us by November 2006. 16. All the authorities involved in the response to a major or catastrophic incident must operate within the established command and control structure. This is essential for the effective strategic management of the response. The City of London Police must provide the Committee with assurances that, in future, it will operate within the agreed command and control structures in the event of a major or catastrophic incident in future. Communications within the London Ambulance Service We are in no doubt whatsoever that individual members of the London Ambulance Service, along with the other transport and emergency services, worked extremely hard, under exceptionally difficult circumstances, on 7 July. Their many individual acts of courage, skill and initiative led to the saving of many lives that may otherwise have been lost. All four sites were ‘c 129 of 151 were deployed, and 404 patients were transported to hospital. The fact that there were four separate incidents across London, and that three of them were in tunnels underground the emergency response very complex and difficult to manage systematically and effectively Even allowing for the difficult circumstances that prevailed on 7 July, those on the front line were let down to varying degrees by a significant breakdown , made . of communications within the ndon Ambulance Service. London Ambulance service personnel at the Tube stations and at her ambula happen pitals were st right nu s at the scenes; delays in getting some of the injured to hospital; and a failure to manage trategically the despatch of ambulances from the scenes to hospitals around the city. We welcome the steps the London A systems o London Ambulance Service’s lack of capacity to deliver quipment and supplies to the scenes of major incidents at multiple sites. As a result of this, ntial onse of the emergency services on 7 uly. It is understandable that emergency services personnel will be inclined to attend to the ept tion among some survivors that emergency services personnel were prevented om entering the tunnels to rescue the injured. We have not been able to establish the extent roving its communications systems in time for our follow-up review in November 2006. Lo Tavistock Square were unable to communicate with the control room. Their requests for furt nces, supplies and equipment did not get through. They did not know what was ing at the other incidents. They could not receive instructions as to which hos ill receiving patients. This breakdown in communications led to a failure to deploy the mbers of ambulances to the right locations; a lack of necessary equipment and supplie s mbulance Service is taking to address the problems it experienced with its radio n 7 July. The experience of 7 July showed the e there was a lack of basic equipment, such as stretchers and triage cards, and a lack of esse supplies, such as fluids, at the affected Tube stations and at Tavistock Square. We welcome the London Ambulance Service’s acknowledgement of this problem, and its statement of intent to address it. There was a general failure to maintain records of the resp J urgent and immediate priorities of rescuing the injured, but it is important that records are k so that lessons can be learnt from the response. It may also be important from the point of view of any investigation or inquiry following a major incident. There is a percep fr to which this happened, or why it may have happened, because of the lack of records of the response. 17. We request that the London Ambulance Service provide us with an update on progress in reviewing and imp 18. We request that the London Ambulance Service provide us with details of its plans to increase its capacity to deliver supplies and equipment to the sites of major incidents in time for our follow-up review in November 2006. 19. We recommend that the London Ambulance Service and London Underground review the potential for storing rescue and medical equipment at stations. We request that they report back to us by November 2006 telling us what progress has been made in conducting this review, and what options are under consideration. 130 of 151 20. W e a s out this task. No i Staff fr the inju staff fro July, Gr ly found o esson to e learn s that hospitals in the vicinity of a major incident need to know about it as on s possible, and would benefit from guidance as to how to respond. 21. s be amended to provide for the notification of all hospitals in the vicinity of a major incident, even if they are e recommend that the London Emergency Services Liaison Panel review its mergency plans with a view to identifying a lead agency for maintaining ccurate records of the response to major incidents. At each scene, there hould be a nominated individual who is responsible for carrying tif cation of hospitals in the vicinity of the incidents om Great Ormond Street Hospital played a crucial role in the rescue and treatment of red at Russell Square, even setting up a field hospital. It is reasonable to anticipate that m hospitals close to a major incident will be likely to volunteer their assistance. On 7 eat Ormond Street Hospital was not notified of the incident at Russell Square, and on ut about it when paramedics arrived asking for equipment and assistance. The l b t from this i so a We recommend that emergency plan not designated hospitals with major accident and emergency departments. The First Hour – the uninjured and walking wounded minutes following the explosions on the Tube, passengers outside the affected carriages t know what had happened, whether they were in danger, or what they should do. Thos hought about evacuating the train via the doors did not know whether or not the current ill turned on. In the did no e who t was st Passengers were afraid that the smoke would be followed by fire. They did ot know whether anyone knew they were there or if help was on its way. Communication from on instru 22. fected by a major incident as soon as possible after the arrival of emergency or transport service 23. s e us with a report on how it plans to take forward this work, in time for our follow-up review in November 2006. n an official source is essential under these circumstances, to provide reassurance and evacuati ctions, and to protect the safety of the passengers trapped underground. We recommend that London’s emergency plans be revised to include an explicit provision for communication with people af personnel at the scene. We recommend that Transport for London review the communications system that are in place to enable station staff and/or the emergency services to communicate with passengers on trains that are trapped in tunnels. We request that Transport for London provid 24. We recommend that Transport for London conduct a feasibility study on alternative forms of emergency lighting for new/refurbished rolling stock, and report back to us by May 2007. 131 of 151 We recommend that Transport for London review the potential for providing torches in drivers’ cabs for use in the event of loss of lighting and failure of emergency lights. 25. Transport for London/London Underground should produce a plan for provision of basic first aid kits on trains and at stations, in time for the 2007/08 budget-setting process. 26. Transport for London should also consider whether it would be practicab carry basic first aid kits on buses, and Network Rail operators should produc plans for provision of first-aid kits for public use (and for use by qualified first-aiders) at mainline railway stations and on trains. We recommend that Transport for London and Network Rail report back to us on this issue by November 2006. le to e eed ally be carried out through the end of the train ther than carriage doors. This was not clear to passengers trapped in the bombed by November 2006, showing the timescale for the installation of safety notices in all carriages on Tube trains. Passengers need to know what to do in the event of an emergency on a Tube train. They n to know, for example, that evacuations will norm ra Underground trains on 7 July. 27. We recommend that Transport for London install clearly visible safety notices inside the carriages on all Tube trains, instructing passengers what to do in case of emergency. We request that Transport for London provide us with a plan, The First Hour – reception of the uninjured and walking wounded Metropolitan Police Service, which is 29. put in f We have found that there was no systematic establishment of survivor reception areas on 7 July. As a result, many survivors simply left the scenes of the explosions, without having given their personal details to anyone or received any advice or support. 28. We recommend that the London Resilience Forum identify a lead agency for the establishment of survivor reception centres at the sites of major incidents in the initial stages before handover to local authorities. We believe this task would most appropriately fall to the already responsible for the collection of personal details of survivors. We invite the London Resilience Forum to report back to us in November 2006 to tell us which agency will take the lead, and what plans have been place to ensure that survivor reception centres are set up close to the scene o any major incident in future. 132 of 151 We recommend that London Underground Limited, train operating compa and Transport for London identify, in consultation with local authorities the emergency services, at least two potential survivor reception centres close 30. nies and to Tube stations, overground rail stations and major bus stations in central s of those sites and involve them in emergency planning processes and exercises. working collate plica oubt have hampered the efforts of those at the Casualty Bureau to establish who was involved the incidents. It may also have had implications for the police investigation that followed 7 uly. The London A jured patients on 7 July. This problem causes unnecessary distress to the injured and their s for cident. on Ambulance Service come forward with possible solutions in time for our follow-up review in November 2006. 33. ss London. They should then liaise with the owners/occupier A total of 946 injured people have given statements to the police - less than a quarter of the number of people who are estimated to have been directly caught up in the attacks. In the absence of an individual charged with the responsibility of collecting details of survivors at the scenes, it seems that the collection of contact details of survivors of the 7 July attacks was carried out in an unco-ordinated, piecemeal fashion, where it was carried out at all. It is understandable that the immediate priority for the emergency services personnel at the scene is to tend to the most seriously injured. Nevertheless, the failure to collect and the details of those who walked away from the trains and bus had significant tions im for the care of survivors in the weeks and months that followed 7 July. It will no d in J mbulance Service has itself acknowledged that there was inadequate tracking of in loved ones, and can result delays of several hours, and in some cases days, before families are notified of the whereabouts of their missing relative or loved one. 31. We recommend that the Metropolitan Police Service establish protocols for ensuring that personal details are collected from survivors at the scene of a major incident. We request that the Metropolitan Police Service report back to us on what action it has taken by November 2006. 32. We recommend that the London Ambulance Service review its mechanism finding out and recording the identity of seriously injured patients who are able to give their names and any other details at the scene of a major in We request that the Lond We recommend that the London Resilience Forum coordinate a review acro the emergency services of protocols for identifying survivors of major incidents and ensuring that their names, once taken, are passed on to the Casualty Bureau and receiving hospitals. 133 of 151 The First Hour – communication with the wider public t to clarify t terest o be se possible in emergency planning processes and xercises. 34. A senio ing accurate, timely advice and information to the public throughout the day. lts in a loss emergency services, who begin to be seen as unnecessarily cretive. On 7 July, in the first two hours following the explosions on the Tube, there was a publicly 35. its plans to provide basic advice, as opposed to detailed information, for the public within an hour of a major incident if at all possible. 6. We recommend that in the event of major incident in London, the skills, to act as the police spokesperson throughout the day. That person’s ia, Clearly, there is a balance to be struck when engaging with the media, and it is importan he basis for any engagement in emergency planning. But there is a clear public in t rved by involving the media as fully as e We recommend that future resilience exercises include senior representatives from the media as participants rather than simply as observers. r Metropolitan Police Service officer should take the primary responsibility of provid In a major emergency, a tension inevitably arises between the desire of the media to obtain information as quickly as possible and the need for the emergency services to establish all the facts before making public announcements. When this balance does not work it resu of credibility on the part of the se clear gap between what was known by the media and what the Police were prepared to confirm . We recommend that the Metropolitan Police Service, in consultation with the London Media Emergency Forum, revise 3 Metropolitan Police Service should appoint a senior officer, with appropriate primary responsibility would be to communicate with the public, via the med to pass on accurate and timely advice and information. The rest of the day – searching for friends and family The Casualty Bureau was set up too slowly because of an avoidable error. This caused distress many people who were trying to track down their loved ones and unable to get through on happen The volume of calls received by the Casualty Bureau could never be handled within the Metropolitan Police Service. New technology is being put in place that will enable calls to be redirected to Casualty Bureaux outside London, and we understand that the Metropolitan Police is working with the Home Office to identify other ways to manage the initial large volumes of calls to a Casualty Bureau. to the published telephone number. We trust that the lessons have been learnt and this will not again. 134 of 151 The Casualty Bureau should not have been a profit-making venture for any telephone company. ‘0870’ 37. n high volume of calls to a Casualty Bureau, in time for our follow-up review in November 2006. a. review the technical protocols for establishing a Casualty Bureau to ensure that may be set up. d . 2006. at are set up in the immediate aftermath of an incident, so that callers can be transferred on to an However, we recognise that this lesson has already been learnt, and the profits made from the (national rate) telephone number donated to charity. We request that the Metropolitan Police Service provide us with an update o the implementation of the new ‘Casweb’ Casualty Bureau technology, and any other measures that might be identified to manage the initial 38. We recommend that the Metropolitan Police Service: that errors and technical problems do not delay the establishment of a Casualty Bureau in the future. b. ensure the use of a free-phone number for any future Casualty Bureau c. prepare standard public information about a Casualty Bureau, to include instructions as to its purpose and information about sources of advice an information for people who do not need to report missing persons 39. We request that the Metropolitan Police Service report back to us on progress against these recommendations, in time for our follow-up review in November 40. We recommend that the London Resilience Forum develop plans to establish a public information line as well as a Casualty Bureau in the event of a major incident. The plans should provide for the information line to be integrated with the Casualty Bureau and any support services th information or support service having called the Casualty Bureau. The rest of the day – communication with the wider public ssage to ‘go in, stay in, tune in’ was replayed on the broadcast media for some time should have been withdrawn. This led to unnecessary confusion. We recommend that the MPS establish a process whereby advi The me after it sory messages 42. cating publicly the timelimited nature of news statements during the response to a major incident. The decision to withdraw and subsequently reinstate the bus service in central London was difficult and based on potentially competing priorities. The decision must be taken at an operational, rather than political, level, on the basis of reaching a decision that will best serve the safety of people in London. We are satisfied that the right decisions were taken on 7 July. The withdrawal and reinstatement of the bus service in London was an enormously complicated 41. are explicitly time-limited, and updated on an hourly basis, even if there is no change in the basic advice. We recommend that the Metropolitan Police Service liaise with the Media Emergency Forum to establish a protocol for communi 135 of 151 and challenging undertaking. That the network was back in operation by 5 pm is a remarkable chievement, and one for which Transport for London staff deserve congratulations. he Metropolitan Poli assive e f ngestion. We recommend that the k done by the ia E the valu learnt. 4. tion with the London Media Emergency Forum, produce a guidance document on the establishment and running of an effective media centre that meets the needs of the media, building on the lessons to be learnt from their experience on 7 July. here is a risk that, unless a standard package is developed soon, local authorities will continue m to take the lead in developing a standard communications package for use by cal authorities, including the internet, pager alerting systems, ‘buddying’ schemes and ndon a T ce Service is the lead agency for communicating with the media. As a result, its messages tend to focus on police-related issues. Given their lead role in communicating with the media and the public, and the prominence which tends to be given to their messages, the police are well placed to communicate authoritative messages to the public about non-policing issues, such as advice on the use of mobile telephones and advice about schools. It is inevitable that, in the event of a major incident in London, the use of mobile phones will m ly increase, as people try to track down their friends and family. This surge can b managed to some extent by the telephone operating companies using technical fixes, as was done on 7 July. Demand could also be managed by asking the public to restrict their use of mobile telephones. This was not effectively done on 7 July – telephone operating companies attempted to get their message across via the media, but their voices were lost in the mass o communications that were taking place on the day. Important messages to the public such as this might be more effectively passed on via established authoritative spokespeople such as the Metropolitan Police. 43. We recommend MPS news statements include key pieces of advice and information relating to broader issues, including advice on the use of mobile phones in the event of network co Metropolitan Police Service, in consultation with resilience partners, develop a standard list of issues to be covered in early news conferences in the event of a major incident. We request that the Metropolitan Police Service report bac to us in November 2006 to tell us what action has been taken towards this end. The fact that plans were in place to establish a media centre was the result of work Med mergency Forum following 11 September 2001. The success of the QEII centre shows e of involving the media in emergency planning. However, there are lessons to be 4 We recommend that the Metropolitan Police Service, in consulta T to develop their own individual systems for communicating with local businesses. This will result in inconsistency across London, and an inability for the systems to be used in a coordinated way in the event of a major incident. There is an opportunity for the London Resilience Foru lo possibly conference call facilities, such as are in place in the City of London and some Lo boroughs. 136 of 151 45. We recommend that the London Resilience Forum work with local authorities and business organisations to produce a standard communications package to facilitate effective communications between local authorities and businesses. We wou etropolitan Police Service in maintaining their systems despite the peaks in the numbers of We request that the London Resilience Forum provide us with an update on progress by November 2006. ld like to record the remarkable achievement by both Transport for London and the M visitors to their websites. The following weeks – the bereaved and friends and family of survivors 46. We to e on centre for people looking for missing loved ones following a major incident. accommodation if necessary. We believe that this function could be fulfilled by the Family Assistance Centre – its role should be expanded and recommend that the London Resilience Forum review its emergency plans nsure that they include provision for the establishment of a recepti This should provide for their basic needs, including up-to-date information on progress in locating missing people, and practical assistance, such as help in finding developed to include explicitly these roles as well as its police evidencegathering role. The following weeks – support for survivors he collection those who wer st several times, and they had therefore not been kept informed about available support, 7. We recommend that the London Resilience Forum identify one lead agency the Assistance Centre would be the most appropriate body to collate and manage this information. In particular, plans he feedback we received about the Police Family Liaison system was overwhelmingly positive. T and management of contact details of survivors has been haphazard. Some of e not seriously injured on 7 July, in particular, told us how their details had been lo guidance and information. 4 responsible for collating details of survivors and maintaining a definitive list. This lead agency should then act as the main channel of communication with survivors. We consider that must be put in place to address any data protection issues that are likely to arise in relation to the sharing of details among relevant authorities. T We heard accounts from severely injured survivors who were helped immeasurably by Family Liaison Officers in a variety of ways. We would like to record our congratulations to the Metropolitan Police Service Family Liaison Officers. 137 of 151 The success of King’s Cross United is partly due to its independence, and the fact that it is run by survivors for survivors. The gap in provision of support services was that there was no adily available advice on how to go about setting up a support group, and there was no hemselves future, any Assistance Centre that is set up following a major incident should have explicitly within its remit the provision of tools and guidance for port on health risks to be aware of, including post-traumatic stress disorder and any other conditions likely to be experienced by survivors of 49. up survivor groups in the future. We request that this guidance be published sychological Support The nam Centre heard a urvivors living outside London told us that they felt particularly isolated and excluded from the atic stress disorder, and what support will be provided to them and by whom. Plans for humanitarian assistance centres should include clear plans for marketing and advertising any services that are set up, bearing in mind the location and nature of the incident re official body that actively put survivors in touch with one another if they wished to be in contact. The survivors we have spoken to tended to want informal contact, led by t but effectively supported by people with experience of running survivor groups, and with expertise to provide appropriate support and guidance. 48. In setting up survivor groups, and where requested should act in a supporting / facilitating role. In particular, it would be useful to provide advice and sup in the following areas: a. How to establish and run a secure internet site; b. How to ensure that survivor groups are not infiltrated by journalists, conspiracy theorists, or voyeurs; c. Practical advice on sources of information and support available to survivors; d. Guidance the incident in question; e. Support in the form of counselling and advice for people who emerge as leaders of the group. We recommend that the Department for Culture, Media and Sport conduct a review of the lessons to be learnt from King’s Cross United, by talking to those involved, with a view to developing guidance for people who may want to set by November 2006 so that we can consider it as part of our follow-up review. P e ‘Family Assistance Centre’ was a misnomer, and it led survivors to believe that the existed only to provide support for bereaved families. This prevented survivors who bout the centre from making use of the services it provided. S psychological and other support services that were available. The failure to plan for the care of hundreds of people who are likely to have suffered psychological trauma having survived the 7 July explosions is completely unacceptable. Plans for responding to major incidents should include plans that extend into the months following an incident, setting out how survivors will be informed of any health risks, including post-traum 138 of 151 and the people likely to have been involved. Clearly, NHS trauma services should be involved in 50. survivors in the immediate aftermath and the onths following any future major incident. These should include plans for tside the city (this element of the plans should be drawn up in consultation with the Association of Chief Police Officers and other relevant partners). We request that the London Resilience Forum report back to us on progress that has been made in this regard by November 2006. 51. future should simply be named ‘[date or location of incident] Assistance 52. g s been taken. Medical follow up Survivors we spoke to had outstan smoke they inhaled in the tunnels. They had not yet heard from any official body about the mmunication with survivors. It should provide regular updates, including information and advice about any ongoing monitoring of Legal Survivo le it had b the emergency planning process on an ongoing basis. The London Resilience Forum should invite NHS trauma services to join its meetings. Having done that, the London Resilience Forum should develop detailed plans for the care of m making survivors aware of the support services that are available through a variety of channels. They should also include explicit plans for caring for those who live ou Any assistance centre that is set up in response to a major incident in the Centre’. The name ‘Family Assistance Centre’ was misleading and resulted in survivors not coming forward for assistance. We recommend that the London Resilience Forum urgently find a way to resolve the problems that have prevented the NHS trauma service from havin access to details of survivors, so that those who are known to the police or other authorities can be contacted by the NHS trauma service. We request that the London Resilience Forum report back to us in July 2006 to tell u what action has ding concerns about the possible health implications of the possible risks and any arrangements for ongoing monitoring of their health. 53. The Assistance Centre should take on the role from the outset of being the main channel of co health impacts of the incident. Advice rs who had benefited from pro bono legal advice reported to us how immensely valuab een. However, access to this advice seems to have been inconsistent. 139 of 151 Support for survivors - findings Overall, those who were severely injured on 7 July gave us positive feedback about the su that was made available to them through the Assistance Centre, the Police Family Liaison Service and other channels. But there seems to have been a complete absence of planning the large numbers of people who were not seriously phy pport for sically injured but were traumatised by eir experiences. The survivors who came to give their views and share their experiences with major in must b 54. London Resilience Team, in consultation with all the urvivors of 7 July, produce incident will be addressed both during, immediately after, and in the months th a pro t by November 2006. Follow-u This rep respond in don.gov.uk th the Committee were motivated by a desire to make things better for others caught up in a cident in the future. The lessons we have identified on the basis of their experiences e incorporated into future emergency plans. We recommend that the members of the London Resilience Forum and with s a guidance document setting out how the needs of survivors of a major that follow. We request that the London Resilience Team provide us wi gress repor p ort is not the end of our examination of these issues. We invite those who read it to writing to us at 7july@lon by 30 September 2006. We will consider all the responses we receive when we conduct our follow-up review in November 2006, when we recomm will be asking the authorities for progress reports on the implementation of our endations. 140 of 151