Milton Keynes Clinical Commissioning Group Incident ... · recovering from significant/major...

NO PROTECTIVE MARKING - Available to MKCCG Staff, Partners in the Thames Valley LHRP and LRF, MK Resilience Group, Hertfordshire LHRP and General Public

Document Owner: Debra Mordecai Version: 0.2

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Milton Keynes Clinical Commissioning Group

Incident Response Plan (IRP)

The main body of this document has no protective marking. As such, it is available to staff of Milton Keynes Clinical Commissioning Group, partners in the Thames Valley LHRP and LRF, Hertfordshire LHRP, MK Resilience Group and the General Public. Some Appendices are OFFICIAL SENSITIVE and not available to the General Public. The Plan will be stored on the CCG M Drive within the Shared Business folder and made available on the Public facing website. Any Freedom of Information requests should be directed to the Director of Transformation & Delivery.



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Document Management

Title of document Milton Keynes Clinical Commissioning Group Incident Response Plan

Description

This plan outlines Milton Keynes Clinical Commissioning Group (MKCCG) arrangements to ensure an effect response to and recovery from significant/major incidents and periods of increased demand.

Target audience All MKCCG Staff

Author Daniel Hale

Approved by MKCCG Board

Date of approval 22nd July 2014

Version Number 0.2

Next review date Reviewed July 2015 Next review: July 2016

Related documents

Superseded documents

Draft

Availability

The main body of this document has no protective marking. As such, it is available to staff of Milton Keynes Clinical Commissioning Group, partners in the Thames Valley LHRP and LRF, Hertfordshire LHRP, MK Resilience Group and the General Public. Some Appendices are OFFICAL SENSITIVE and are not available to the General Public. The latest version is situated on the M Drive within the Shared Business Folder. A public version will be made available on the public facing website with Appendices marked OFFICIAL SENSITIVE removed.

Contact details

Name: Debra Mordecai

Address: Sherwood Place, Bletchley, MK3 6RT

Tel: 01908 278708

E-mail: [email protected]



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In the event of a ‘Significant Incident’, ‘Major Incident Standby’ or ‘Major Incident Declared’ notification you do not have time to read this

plan.

Go straight to the ACTION CARDs on PAGE 39-46 for your immediate actions

You should then use the following sections to assist you in your response:

MKCCG Roles and Responsibilities - Section 4.4 Page 22

Method - Section 5.0 Page 24 Other Agencies Roles & Responsibilities - Section 4.3 Page

15

On ‘Incident Stand Down’ you should refer to Section 6.0 Administration 5 for actions

to be taken following an incident.



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Version Control: Version Date Section (s) amended

and reason Amended

by Summary of key changes

V0.2 July 2014

Whole document + comms action card

D Mordecai ‘Draft’ removed & Comms Action Card updated



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Distribution List The latest version of this document is situated on the M Drive within the Shared Business Folder and available to all MKCCG Staff. A public version is available via the MKCCG web page. A copy of the latest version is held in all On-Call Director/Senior Manager On-Call Packs.



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PAGE LEFT INTENTIONALLY BLANK



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Table of Contents

1.0 Introduction ........................................................................................................... 10 1.1 Scope ................................................................................................................... 10 1.2 Aim ....................................................................................................................... 10 1.2 Objectives ............................................................................................................ 10

2.0 Policy Statement ................................................................................................... 10

3.0 Information............................................................................................................. 10 3.1 Definitions ............................................................................................................ 11

3.1.1 Emergency ................................................................................................. 11 3.1.2 Major Incident ............................................................................................. 11 3.1.3 Significant Incident ..................................................................................... 11

3.2 Types of Incident ................................................................................................. 11 3.3 Risk Profile ........................................................................................................... 12 3.4 Planning Assumptions ........................................................................................ 13 3.5 NHS England ........................................................................................................ 13

3.5.1 Thames Valley Area Team ......................................................................... 13 3.5.2 Hertfordshire and South Midlands Area Team ............................................ 13

4.0 Command and Control Structure ......................................................................... 14 4.1 Strategic, Tactical and Operational Management Structure ............................. 14

4.1.1 Strategic Management (Gold)..................................................................... 14 4.1.2 Tactical Management (Silver) ..................................................................... 14

4.2 Multi-Agency Incident Management ................................................................... 14 4.2.1 Strategic Coordinating Groups (SCG) ........................................................ 15 4.2.2 Tactical Coordinating Groups (TCG) .......................................................... 15 4.2.3 Scientific and Technical Advisory Cells (STACs) ........................................ 15 4.2.3 Emergency Coordination of Scientific Advice (ECOSA) .............................. 15

4.3 Integrated Emergency Management Roles and Responsibilities ..................... 15 4.3.1 Police Service ............................................................................................ 16 4.3.2 Fire and Rescue Service ............................................................................ 16 4.3.3 Ambulance Service .................................................................................... 17 4.3.4 Public Health England ................................................................................ 17 4.3.5 NHS England Area Team (Thames Valley / Hertfordshire and South

Midlands) ................................................................................................... 17 4.3.6 Clinical Commissioning Groups (Milton Keynes CCG) ............................... 18 4.3.7 Acute Hospital Trusts (Milton Keynes General Hospital) ............................ 19 4.3.8 Community Trusts (CNWL/Milton Keynes Community Health Services) ..... 19 4.3.9 Out of Hours Providers (Milton Keynes Urgent Care Service)..................... 19 4.3.10 NHS Blood and Transplant (NHSBT).......................................................... 20 4.3.11 Primary Care .............................................................................................. 20 4.3.12 Local Authorities (Milton Keynes Council) .................................................. 20 4.3.13 Director Public Health ................................................................................. 21 4.3.14 Government Bodies/Arrangements ............................................................ 21 4.3.15 LRF Members ............................................................................................ 21

4.4 MKCCG Roles and Responsibilities ................................................................... 22 4.4.1 Chief Officer ............................................................................................... 22 4.4.2 MKCCG On-Call Director/Senior Manager (Incident Director) .................... 22 4.4.3 Business Continuity and Resilience Manager ............................................. 23 4.4.4 Incident Loggist .......................................................................................... 23 4.4.5 Incident Communications Manager ............................................................ 23 4.4.6 Heads of Service/Department / Directors ................................................... 23 4.4.7 All Members of Staff ................................................................................... 24 4.4.8 Incident Management Team ....................................................................... 24



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5.0 Method ................................................................................................................... 24 5.1 Triggers, Alerts, Activation and Stand Down .................................................... 24

5.1.1 Triggers ...................................................................................................... 24 5.1.2 NHS England Incident Levels ..................................................................... 25 5.1.3 Alert Messages .......................................................................................... 25 5.1.4 Casualty Classification ............................................................................... 25 5.1.5 METHANE Reports .................................................................................... 26 5.1.6 Activation ................................................................................................... 26 5.1.7 Escalation and De-Escalation ..................................................................... 29 5.1.8 Stand Down ................................................................................................ 29

5.2 Risk Assessment, Information Gathering and Decision Making ...................... 29 5.2.1 Risk Assessment ........................................................................................ 29 5.2.2 Situation Reporting ..................................................................................... 30 5.2.3 Decision Making ......................................................................................... 30

5.3 Incident Coordination Centre (ICC) .................................................................... 31 5.4 Shift Arrangements and Handover ..................................................................... 31 5.5 Press, Media and Communications .................................................................... 32 5.6 Staff Welfare ........................................................................................................ 32

5.6.1 Staff Counselling and Support .................................................................... 32 5.6.2 Family Counselling and Support ................................................................. 32

5.7 Vulnerable People ............................................................................................... 32 5.8 Helplines .............................................................................................................. 33 5.9 Financial and Budget Arrangements ................................................................. 33 5.10 Legal Advice ........................................................................................................ 33 5.11 Mutual Aid ............................................................................................................ 33 5.12 Recovery .............................................................................................................. 33

5.12.1 Recovery Planning Assumptions ................................................................ 34

6.0 Administration ....................................................................................................... 34 6.1 Incident Documentation ...................................................................................... 34 6.2 Post Incident Debrief and Reporting .................................................................. 35

6.2.1 Hot Debrief ................................................................................................. 35 6.2.2 Post Incident Debrief .................................................................................. 35 6.2.3 Multi-Agency Debrief .................................................................................. 35 6.2.4 Post Incident Report ................................................................................... 35 6.2.5 Storage and Retention of Documentation ................................................... 36

7.0 Associated Documents ......................................................................................... 36

8.0 Glossary / Lexicon ............................................................................................... 377

Action Card - Incident Director “Initial Call / Stand-By” ................................................ 39

Action Card - Incident Director “Incident Declared” ..................................................... 40

Action Card - Incident Director “Incident Stand Down” ................................................ 41

Action Card - Loggist Aide Memoir ................................................................................ 42

Action Card - Incident Communications Manager ......................................................... 43

Action Card - Initial Risk Assessment ............................................................................ 44

Action Card - Incident Director Hand-Over ..................................................................... 46

NHS Situation Report (Sitrep) .......................................................................................... 47

NHS England Situation Report ......................................................................................... 49

Mass Casualty Incidents .................................................................................................. 51



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Mass Fatality Incidents ..................................................................................................... 54

Chemical, Biological, Radiological, Nuclear & Explosives Incidents .......................... 566



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1.0 Introduction This plan sets out Milton Keynes Clinical Commissioning Group (MKCCG) response to a significant/major incident impacting upon the health economy, and outlines the command and control arrangements for the management of the local NHS. The plan is primarily for MKCCG staff, who will support NHS England Thames Valley Area Team or Hertfordshire and South Midlands Area Team in coordinating the health response in meeting the CCGs statutory requirements as a Category 2 responder under the Civil Contingencies Act 2004 (CCA).

1.1 Scope This plan is covered by the Emergency Preparedness, Resilience and Response (EPRR) Scope and Policy, as such this plan outlines the EPRR arrangements delivered by NHS Milton Keynes Clinical Commissioning Group, Sherwood Place, 155 Sherwood Drive, Bletchley, MK3 6RT in responding to and recovering from significant/major incidents and periods of increased demand or surge/capacity pressure within, or impacting on the Milton Keynes health economy. 1.2 Aim The aim of this plan is to increase MKCCG’s resilience in responding to and recovering from significant/major incidents by ensuring those charged with managing such an incident know and understand their role, are competent to carry out the tasks assigned to them and have access to available resources and facilities. 1.2 Objectives

The objectives of this plan are to;

Define what a significant/major incident is, outlining the command, control and coordination arrangements required to manage the response to and recovery from incidents;

Provide a clear procedure for activating MKCCG’s arrangements;

Define roles and responsibilities for both MKCCG and partner agencies;

Provide the arrangements for communicating information to staff, patients and stakeholders, prior to, during and following an incident; and

Ensure suitable coordination of the local NHS to enable the continuation of healthcare services.

2.0 Policy Statement

This plan document is included within the MKCCG Equality and Inclusivity Statements as per the EPRR Emergency Preparedness, Resilience and Response Scope and Policy.

In carrying out its functions, NHS Milton Keynes CCG must have due regard to the Public Sector Equality Duty (PSED). This applies to all the activities for which NHS Milton Keynes CCG is responsible, including policy development, review and implementation.

3.0 Information

For the purpose of the MKCCG’s EPRR Scope and Policy, the following definitions have been aligned to those used by NHS England to mean;



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3.1 Definitions

3.1.1 Emergency The CCA defines an emergency as ‘an event or situation which threatens serious damage to;

Human welfare in a place in the UK

The environment of a place in the UK; and

War or terrorism which threatens serious damage to the security of the UK’ For the purpose of this definition, an event or situation threatens damage to human welfare only if it causes or may cause;

Loss of life;

Human illness or injury;

Homelessness;

Damage to property;

Disruption to the supply of money, food, water, energy or fuel;

Disruption of a system of communications;

Disruption of facilities for transport; or

Disruption of services relating to health.

3.1.2 Major Incident For the NHS the term Major Incident is more commonly used and is defined as ‘any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations’ Generally Major Incidents will affect a number of blue light services and NHS organisations.

3.1.3 Significant Incident The definition of a Significant Incident is “Any incident that requires an increased amount of resources without warranting the invoking of the Major Incident Plan in full.”

3.2 Types of Incident

Incidents can arise in a variety of ways and as such response arrangements must be suitably flexible to assess and respond appropriately. Incidents/events may be further classified to define their scale using the following terms; Term Definition / Example

Major The sort of incident that NHS organisations are well versed in dealing with, such as multi-vehicle motorway crashes and so on.

Mass Much larger scale events affecting potentially hundreds of people rather than tens of people such as a major terrorist incident.

Catastrophic Events of such magnitude that they severely disrupt health and social care and other functions within the UK.

National Events which affect the whole of the UK, affecting the ability to provide services or increasing demand for services such as a blood shortage, fuel strike, pandemic or multiple events that require the collective capacity of the NHS nationally.



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Incidents may occur through a variety of situations; Type Example

Big Bang A serious transport or industrial accident or series of smaller unforeseen incidents. E.g. a train crash or explosion at a gas storage depot.

Rising Tide A developing infectious disease epidemic, or capacity/staffing crisis or forecast severe weather. E.g. pandemic flu.

Cloud on the Horizon

A serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action e.g. Chernobyl or Fukushima.

Headline News Public or media alarm over a health issue/scare e.g. reaction to the MMR Vaccine.

Act of Terrorism The calculated use of violence or explosives against civilians or the government e.g. London Bombings.

Internal Incident Anything which affect’s a provider’s ability to deliver business as usual services such as a fire or flooding, breakdown of utilities, major equipment failure or hospital acquired infections.

CBRNe Incident The intentional release of Chemical, Biological, Radiological, Nuclear or Explosive material e.g. Ricin or Anthrax poisoning. A CBRN Incident could be real or hoax.

Hazmat Incident The unintentional release of a Chemical, Biological, Radiological or Nuclear material through an industrial accident.

Mass Casualties Any event that results in a large number of casualties, with 100’s of people injured.

Severe Weather Incidents

Any dangerous or extreme meteorological events e.g. severe flooding, heatwave or snow.

Pre-planned major events

Pre-planned events which require major planning such as demonstrations, sports fixtures, air shows, music concerts.

3.3 Risk Profile

Planning assumptions are based on worse case credible scenarios and are taken from the National and Local (Thames Valley Local Resilience Forum and Milton Keynes Resilience Group) Risk Registers. As such a summary of the top risks are;

Flooding;

Influenza-type disease (pandemic)

Storms and gales;

Widespread loss of telecommunications;

Constraint on the fuel supply; and

Loss of utilities. These risks are supported by a suite of local and area multi-agency plans/frameworks. The maintenance and testing of these plans is the responsibility of the plan ownders, and is overseen by the Thames Valley Local Resilience Forum Planning and Delivery Group, Risk Assessment & Capability Group and Training and Exercising Organisational Learning Group, all of which report to the Thames Valley Local Resilience Forum Executive Group. Health Outbreak Plans are overseen by the Milton Keynes Health Resilience Group and Hertfordshire and South Midlands Area Team. As such MKCCG expects that Providers of NHS funded services within Milton Keynes have suitable, sufficient and validated plans to respond to and recover from incidents resulting from the above risks. In undertaking planning providers of NHS funded services ensure they have engaged with multiagency partners, and specialist NHS networks, including but not limited to;

Clinical Networks e.g. Trauma, stroke, critical care and burns

Paediatrics



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The National Threat Level in relation to international terrorism and Northern Ireland related terrorism is constantly reviewed, updated and published by HM Government.

3.4 Planning Assumptions

Planning assumptions are based on worse case credible scenarios, as such the perceived impacts of an incident likely to be caused by, but not limited to the following:

Increased numbers of injured or critically ill people;

Increased infection of people (Infectious Disease Outbreak);

Excess numbers of deaths;

Contamination of patients, the deceased or the environment;

Loss (including temporary) of infrastructure such as road or rail networks;

Temporary & long term displacement of individuals and communities; and

Shortage of NHS resources.

3.5 NHS England

NHS England is the Category 1 responder under the CCA. Due to its geographical location, MKCCG reports to two NHS England Area Teams, each of which has its own responsibilities with regard to incident response, as outlined below. The response to incidents must be dynamic to enable the most suitable response; as such the most appropriate area team to lead the response will be determined at the time of declaration/activation. As a Category 2 Responder MKCCG will be expected to support the responding Area Team in its response through its own response arrangements.

3.5.1 Thames Valley Area Team NHS England Thames Valley Area Team will lead on the planning for and response to a major incident occurring within or impacting on the geographical Milton Keynes healthcare economy area, e.g. a Major Incident declared by the Ambulance Service in response to a train crash. MKCCG also falls within the remit of the Thames Valley Area Team for the purpose of;

Local Health Resilience Partnership and Local Resilience Fora; and

Assurance and compliance to the National Core Standards for EPRR. 3.5.2 Hertfordshire and South Midlands Area Team NHS England Hertfordshire and South Midlands will lead on the planning and response to ‘business as usual’ arrangements for the Milton Keynes healthcare economy including system escalation planning in response to increase in demand or surge/capacity pressure. e.g. an internal major incident declared at Milton Keynes Acute Hospital Trust due to power failure or an increase in demand leading to breach of 4 hour waiting times. Hertfordshire and South Midlands will lead the response to increase in demand/surge capacity requiring escalation. MKCCG also falls within the remit of Hertfordshire and South Midlands Area Team for the purpose of outbreak and infectious diseases.



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4.0 Command and Control Structure An essential element of Command and Control is a clear and unambiguous chain of command, from the top of the organisation to the lowest level, and across all responding agencies. Every individual and organisation involved in the response to an incident must know exactly where they fit into the structure, what their role and responsibilities are, and what duties are placed upon them, with individuals being accountable for decision making at their level. As such the NHS will operate under the NHS England Command, Control and Coordination Framework, which are compatible with those of partners, stakeholders and the wider resilience community.

4.1 Strategic, Tactical and Operational Management Structure The ‘Strategic’, ‘Tactical’ and ‘Operational’ are titles of tiers of management adopted across the NHS and Emergency Services and may also be known as ‘Gold’, ‘Silver’ and ‘Bronze’ as defined below;

4.1.1 Strategic Management (Gold) At the strategic level of an organisation, there must be an identified individual who is in overall executive command, often referred to as Gold. This person will accept personal responsibility for the Strategic Management of the incident (including for decisions taken at a strategic level) and represents the top level of Command and Control. Gold will normally be the On-Call Director or the Chief Executive. There must only be one Gold within each organisation at any time. Gold is responsible for setting the strategy for their own organisation for resolving the incident; determining the strategic intentions, communicating them to and approving the plans developed by Silver. Each NHS organisation will appoint a Gold Officer to run the internal organisational response to an incident. In addition to these locality arrangements ‘NHS Gold’ will be appointed from NHS England/Public Health England who has responsibility for the NHS response.

4.1.2 Tactical Management (Silver) At the tactical level, there must be an individual appointed to be Silver. This person will accept personal responsibility for the Tactical Management of the incident (including for decisions taken at a tactical level), and will normally be a senior manager. There will normally only be one Silver at any one time. Silver is responsible for delivery of the Gold strategy by developing the tactical response, determining operational priorities and allocating physical resources. Silver should remain tactical and must not become embroiled in operational matters.

4.1.3 Operational Management (Bronze) This is the operational level of Command and Control, with Silver responsible for appointing as many Bronze Officers as required to deliver the tactical plans. Bronze is responsible for carrying out specific operational tasks often at the scene of an incident or at a supporting location such as a hospital.

4.2 Multi-Agency Incident Management Certain incidents will require the wider multi-agency coordination of the incident, for example severe weather events. In these circumstances, it is common for multi-agency groups to be set up at Gold and Silver levels. Although unlikely there may be an expectation for MKCCG to support these groups, depending on the circumstances and nature of the incident.



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4.2.1 Strategic Coordinating Groups (SCG) At Gold level a Strategic Coordinating Group will be established, based on the geographical boundary of the local Police Force; and chaired by the Chief Constable or their nominated deputy. The SCG will comprise of Chief Officers and strategic players from the emergency services, other responders and organisations directly involved in the incident. As incidents can move very quickly, representatives are expected to bring executive decision making power to the group without having to refer back to another person in their organisation for authority to act or commit resources. This group will meet as often as required, to develop the strategy for dealing with the incident. If the incident were of sufficient severity it may be that the local Strategic Co-ordinating Centre be opened and facilities provided for representatives and their support teams to work. These are usually but not exclusively based at Police Headquarters.

The responding NHS England Area Team, alongside the Ambulance Service will represent the NHS at an SCG, as such there is no requirement for MKCCG to attend. 4.2.2 Tactical Coordinating Groups (TCG) Tactical Coordinating Groups will be held on a more ad-hoc basis, and will usually be at a local Police Station or other similar facility. They will usually be chaired by the Police Tactical Commander, and will comprise of Silvers from all agencies involved in the management at tactical level. The responding NHS England Area Team, alongside the Ambulance Service will represent the NHS at TCG; however MKCCG may be required to support this function. Should MKCCG be requested to attend a TCG this should be undertaken by a member of the Senior Management Team, with support from the Business Continuity and Resilience Manager.

4.2.3 Scientific and Technical Advisory Cells (STACs) During some types of emergency, the Strategic Co-ordinating Group may require expert scientific and technical advice on which to base decisions. In England, this is facilitated through the Scientific and Technical Advisory Cell, chaired by Public Health England. STAC will comprise a small group of experts working together within a Strategic Coordinating Centre, or virtually with experts working remotely.

At government level this advice will be provided by the Scientific Advisory Group for Emergencies (SAGE).

There is no requirement for MKCCG to participate within STAC or SAGE. 4.2.3 Emergency Coordination of Scientific Advice (ECOSA) Due to their nature STAC and SAGE can take time to establish. In the interim period of a CBRNe or terrorist incident specialist scientific and technical expertise can be provided by ECOSA, facilitated by the Atomic Weapons Establishment, Defence Scientific and Technology Laboratory and PHE. There is no requirement for MKCCG to participate within ECOSA.

4.3 Integrated Emergency Management Roles and Responsibilities The blue light emergency services will normally provide the initial response to a major incident, supported by local authorities, NHS, utility companies (gas, water and electricity), Environment Agency, Military, Met Office and voluntary agencies. As



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such responding agencies are required to have robust and tested major incident and business continuity plans in place. During an incident they will fulfil the following roles and responsibilities;

4.3.1 Police Service The Police Service (Thames Valley Police or Hertfordshire Police Service) has the authority to declare a Major Incident, (but are not able to ‘stand up’ health organisations, which is the responsibility of the Ambulance Service). During an incident the Police Service is responsible for coordinating the responding emergency services, ensuring the protection of evidence and premises.

Where the incident is believed to be criminal or an act of terrorism Police Officers will be deployed to the hospitals and located within Emergency Departments to oversee the collection of evidence and to interview witnesses.

It is the responsibility of the Police Service to:

Alert the other emergency services and local authorities;

Save lives by working alongside the other emergency services;

Coordinate the emergency services and other organisations during the response phase;

Secure, protect and preserve the scene;

Investigate the incident alongside other investigative organisations;

Collect evidence and statements from those involved in the incident;

Set up and maintain cordons; and

Collect and distribute casualty information, via the Casualty Bureau.

Casualty bureau is a national police managed resource which will collate the details of any person involved in large scale incidents, including those killed or believed missing. The bureau will collate all of the details relating to people believed to have been involved or missing from family members, relatives and friends contacting them, and is responsible for identifying the locations of patients and the deceased so they can inform the family or next of kin. As such the bureau will require information about patients being treated within Hospital Trust’s including any unidentified patients and the deceased and Police Hospital Documentation teams will be deployed for this purpose.

4.3.2 Fire and Rescue Service

The Fire and Rescue Service has the authority to declare a Major Incident (but are not able to ‘stand up’ health organisations, which is the responsibility of the Ambulance Service). During an incident the Fire and Rescue Service is responsible for tackling fires, search and rescue and for the health and safety of those personnel working within the inner cordon. The fire service is also able to undertake mass decontamination should it be required.

It is the responsibility of the Fire Service to:


Save lives by working alongside the other emergency services;

Tackle fires or chemicals which have been spilt and other dangerous situations;

Rescue trapped casualties in conjunction with Ambulance HART Teams;

Mass decontamination of uninjured contaminated individuals;

Manage the health and safety of personnel at the scene;

Gather information and carry out hazard assessments;

Assist the ambulance service to egress casualties; and



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Help the police service recover the deceased.

4.3.3 Ambulance Service Ambulance Trusts (South Central Ambulance Service and East Coast Ambulance Service) have the authority to declare a Major Incident and activate receiving hospital arrangements. During an incident the Ambulance Trust is responsible for conveying patients from the scene of the incident to primary care institutions or Acute Trusts for treatment or on-going care.

Where possible during a mass casualty incident an ambulance officer will be deployed to receiving hospitals and will be located within A&E.

During an incident requiring the closure of Accident and Emergency the Ambulance Service will be notified of the closure by the responding NHS England Area Team/MKCCG. The Ambulance Trust may be able to assist with patient transfer if required during an incident requiring the evacuation of patients.

It is the responsibility of the Ambulance Service to:


Save lives by working alongside other emergency services;

Coordinate the NHS response at the scene

Nominate and alert the appropriate receiving hospitals

Undertake search and rescue of casualties, alongside the fire and Rescue Service using Hazard Area Response Teams (HART)

Set up a casualty clearing station;

Establish effective triage and determine the priorities for evacuation of the injured to hospital following treatment and stabilisation;

Undertake decontamination of patients at the scene using HART before conveying patients to hospital; and

Maintain emergency and routine ambulance cover. 4.3.4 Public Health England Public Health England has the authority to declare a major incident for health. During an incident they are responsible for protecting public health, and managing NHS resources during a public health incident. It is the responsibility of Public Health England to:

Co-ordinate the NHS response to public health incidents at the appropriate level assessing the impact to NHS services;

Provide 24 hour emergency management;

Provide expert advice on communicable disease;

Provide expert advice on chemical, biological agents and radiation;

Chair STAC meetings;

Undertake longer term public surveillance; and

Assess the medium term impact on the community and the health priorities for the recovery phase.

4.3.5 NHS England Area Team (Thames Valley / Hertfordshire and South Midlands)

NHS England has the authority to declare a Major Incident for health. During an incident they are responsible for managing the NHS response, reporting to the Department of Health as necessary.



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It is the responsibility of NHS England to:

Lead on the NHS response to significant incidents, major incidents and emergencies; initiating incident coordination centres (if required);

Provide a focal point for NHS and partner organisations;

Provide leadership, coordination or advice as required;

Maintain direct contact with all responding NHS organisations, cascading information as necessary;

Request information from all NHS organisations in the form of Situation reports to inform strategic decision making and provide information to government ministers when required;

Remain informed of the current status of relevant NHS organisations;

Mobilise mutual aid;

Inform and maintain dialogue with neighbouring NHS England Area Teams when appropriate;

Inform or escalate relevant issues to the NHS England Regional Team;

Liaise with multi-agency partners;

Ensure health representation at the multi-agency Strategic Coordinating Group; provide a health media statement if required in liaison with the regional communications team;

Assess the effects of an incident on vulnerable care groups, such as children, dialysis patients, elderly, medically dependent, or physically or mentally disabled;

Oversee the mass distribution of countermeasures; for example, vaccinations and antibiotics;

Provide support, advice and leadership to the local community on health aspects of an incident, in conjunction with Public Health England;

Provide psychological and mental health support to staff, patients and relatives in conjunction with the appropriate provider;

Proactively communicate information to all healthcare staff and ensure relevant guidance and advice is available, including private facilities where appropriate;

Continue to provide core business services;

Work with the local authority and community to support the recovery phase;

Assess the medium term impact on the community and the health priorities for the recovery phase;

Prepare a post-incident report for consolidation in the NHS report to be forwarded to appropriate healthcare Boards, and other interested organisations; and

Liaise with other Clinical Commissioning Groups (CCG’s) as required to assist with the mobilisation of the NHS locally.

4.3.6 Clinical Commissioning Groups (Milton Keynes CCG) Clinical Commissioning Groups have a responsibility to support NHS England and Public Health England in responding to incidents, by managing the local NHS response.

It is the responsibility of Clinical Commissioning Groups to;

Co-ordinate the local NHS response, assessing the impact to NHS services;

Provide 24 hour emergency management;

Assist the acute trust to manage patient flow, including supporting accelerated discharge;

Support the coordination of community and mental health response;



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Coordinate community hospital bed capacity in liaison with local community providers, local acute hospitals and any available local bed management system

Assess the effects of an incident on vulnerable care groups, such as children, dialysis patients, elderly, medically dependant or physically/mentally disabled;

Support the mass distribution of countermeasures;

Assist in the provision of psychological and mental health support to staff, patients and relatives in conjunction with the appropriate provider;

Proactively communicating information to all healthcare staff and ensure relevant guidance and advice is available, including to private facilities where appropriate;

Ensuring the continued delivery of core business;

Working with the local authority to support the recovery phase; and

Assessing the medium term impact to NHS Services and the community determining health priorities for the recovery.

4.3.7 Acute Hospital Trusts (Milton Keynes General Hospital) Hospital Trusts are responsible for the treatment of major incident patients and the on-going care of patients already within their care.

It is the responsibility of Acute Hospital Trust’s to:

Provide treatment and care for the injured or ill;

Notify the CCG if stood up as “declared” or “standby” for a major incident by the ambulance service

Notify the Clinical Commissioning Group if self-declaring a significant incident;

Notify the Public Health England Centre when dealing with public health emergencies;

Work with the Clinical Commissioning Group to manage bed capacity, liaising with specialist networks as required;

Implement the decontamination of patients who have self-conveyed from scene;

Assist the police in the collection of evidence;

Manage tertiary referrals; and

Maintain emergency and routine service continuity as soon as possible, providing situation reports as required.

4.3.8 Community Trusts (CNWL/Milton Keynes Community Health Services) Community Trusts are responsible for supporting the treatment of patients outside of an acute hospital setting.

Support the NHS response through the provision of staff, equipment or services;

Provide treatment and care for patients;

Notify the Clinical Commissioning Group if self-declaring a significant incident;

Support the rapid discharge of patients deemed medically fit from the acute setting;

Support the distribution of mass countermeasures; and

Prevent the deterioration of patients cared for within the community setting to prevent acute admissions.

4.3.9 Out of Hours Providers (Milton Keynes Urgent Care Service) Out of Hours providers are responsible for the delivery of services to support the Primary Care response to a major incident.



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It is the responsibility of Out of Hours Providers to:


Help provide appropriate clinical settings for the treatment of people with minor injuries and conditions, such as reception centres, minor injury centres, and walk in centres;

Provide care and advice to evacuees, survivors and relatives, including replacement medication at survivor reception centres; and

Support the distribution of mass countermeasures.

4.3.10 NHS Blood and Transplant (NHSBT) NHS Blood and Transplant are a Specialist Health Authority responsible for the collection and supply of blood, blood related products and organ donation / transplantation. As such they will co-ordinate national stocks of blood and blood related products, in the event of increased demands. NHSBT are also responsible for the maintenance and delivery of the National Antidote Service (pods of antidote medication for nerve agent, cyanide, obidoxime, and botulinum) which are accessed via the ambulance service. It is the responsibility of NHSBT to:

Control, manage and deliver the national stock of blood, blood related products and organs;

Deliver National Antidote Service Pods; and

Manage the public response to providing blood donations following an incident.

4.3.11 Primary Care

Primary Care is commissioned by NHS England, and are responsible for supporting the delivery of NHS services.

It is the responsibility of Primary Care Providers to:


Help provide appropriate clinical settings for the treatment of people with minor injuries and conditions, such as reception centres, minor injury centres, and walk in centres;

Provide care and advice to evacuees, survivors and relatives, including replacement medication at survivor reception centres; and

Support the distribution of mass countermeasures.

4.3.12 Local Authorities The Local Authority is responsible for supporting the emergency services, setting up Rest and Evacuation Centres for people who may have been displaced or evacuated. They will generally lead the recovery phase, restoring normality and stability.

It is the responsibility of Local Authority to:

Support the emergency services;

Support and care for the community, ie rest centres;

Co-ordinate the non-emergency services response;

Identifying vulnerable individuals in the community who may require additional support or care;

Ensure the continuity of council services; and

Manage the recovery and return to normality phases.



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4.3.13 Director Public Health

Directors of Public Health (DsPH) are employed by Local Authorities to ensure the promotion and protection of public health. As such they have a responsibility to seek assurance that suitable and effective NHS and Public Health England Plans are in place. As employees of the Local Authority, DsPH may not command NHS resources. It is the responsibility of the Director of Public Health to:

Support Public Health England and NHS England in the distribution of communications and media messaging which promotes and protects public health; and

Support the NHS and Public Health England response through the delivery of knowledge pertaining to the local demographic.

4.3.14 Government Bodies/Arrangements A range of other Government bodies will have key roles to play, depending on the type of incident or emergency and may become the Government Lead Department;

Environment Agency has responsibilities to protect water, land and air and will be involved in incidents affecting the environment (flood or pollution incidents) to prevent or manage the effects of the incident, provide specialist advice and public information and investigate the cause of the incident.

Health and Safety Executive (HSE) has a responsibility to ensure health and safety regulations are upheld and will be involved in incidents to provide specialist advice and undertake investigations. HSE also have a regulatory role in sites such as nuclear installations, hospitals, schools and railway safety, and have specialist expertise in CBRNe and major hazard industrial sites;

Highways Agency in an incident affecting the road network in England;

Department for Energy and Climate Change in an incident affecting the supply or distribution of fuel.

Met Office will provide forecast information on severe weather events, and are a key agency with regard to the Heatwave and Winter Planning.

HM Coroner is responsible for the deceased, including establishing the

cause of death, and identifying individuals. The Coroner will be responsible for establishing temporary/emergency mortuary arrangements.

4.3.15 LRF Members In addition to the multi-agency roles and responsibilities a number of the Local Resilience Forum members have major incident roles to support the response to and recovery from an incident;

Utility Companies (Gas, Water & Electricity) are responsible for making

safe the supply of services to enable the response to take place (this may involve turning off supply) and repairing and restoring services. Utilities companies are responsible for warning and informing the public of how services will be affected, and may hold useful information regarding vulnerable persons which can be shared.



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Voluntary Agencies such as St John Ambulance and British Red Cross have

the ability to support ambulance services through the provision of front line ambulance resources and patient transport services. They may also be able to support through the provision of general first aid and support at Rest and Evacuation Centres. Services such as the Royal Volunteers Service may be able to support community responses.

Religious Groups can provide specialist advice to incident management teams regarding religious issues/needs, they may also be able to support both first responders and affected communities during and after the incident with religious and emotional support.

The Armed Forces through Military Aid to the Civil Authority (MACA) can help in an emergency if there is a danger to human life or if there is a breakdown in services vital to the welfare of the community. Only the Police or Milton Keynes Council can ask for assistance in line with MACA procedures. Should the NHS require assistance from the armed forces this will be requested through the responding NHS England Area Team. The SCG will command the local armed forces response; NHS Organisations should cooperate with and assist the armed forces as advised by the SCG.

4.4 MKCCG Roles and Responsibilities The following roles and responsibilities have been defined for the response and recovery to a significant/major incident. Wider general roles and responsibilities to EPRR are defined within the Emergency Preparedness, Resilience and Response Scope and Policy.

4.4.1 MKCCG Chief Officer

The Chief Officer has ultimate responsibility for the CCG. During a major incident they should remain appraised of the situation providing strategic advice and decisions to the On-Call Director/Senior Manager (Incident Director) as required. As such they are responsible for:

Ensuring the continuation of core services;

Managing the internal Business Continuity Response (in line with the Business Continuity Plan);

Providing strategic support and advice to the On-Call Director/Senior Manager (Incident Director);

Ensuring member GPs and the Board remain appraised as appropriate;

Representing the CCG as the media spokesperson as required;

Ensuring an accurate log of actions and decisions is kept contemporaneously, signed and passed to the Business Continuity and Resilience Manager for retention, following stand down; and

Participating within post incident debriefing to ensure improvements and best practice are identified.

4.4.2 MKCCG On-Call Director/Senior Manager (Incident Director) The On-Call Director/Senior Manager will assume the role of Incident director, with responsibility of providing the Strategic and Tactical management of the Incident. As such the Incident Director is responsible for:

Undertaking Incident Alerting/cascade;

Setting and managing the strategic and tactical aims for the CCG and local NHS response;



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Liaising with NHS England to ensure it remains appraised of the incident as required/necessary;

Liaise and communicate with other key agencies;

Ensuring resources are made available to support the response;

Agreeing the press and communications strategy in conjunction with the Incident Communications Manager and NHS England;

Financial management of the incident, agreeing all additional cost and expenditure;

Ensuring the intelligence/Situation Report requirements of NHS England are met as appropriate;

Ensuring an accurate log of actions and decisions is kept contemporaneously, signed and passed to the Business Continuity and Resilience Manager for retention, following stand down;

Standing down the Incident Response Phase;

Participating within post incident debriefing to ensure improvements and best practice are identified; and

Identifying medium to long term impacts to NHS services.

4.4.3 Business Continuity and Resilience Manager The Business Continuity and Resilience Manager is the professional lead for EPRR and will assume the role of strategic and tactical advisor;

Providing Strategic and Tactical advice and guidance to the Incident Director and Chief Officer;

Managing the Incident Coordination Centre as required; and

Ensuring incident debriefing is undertaken with Post Incident Reports highlighting areas for improvement produced within the required timeframes.

4.4.4 Incident Loggist The Incident Loggist is responsible for ensuring a contemporaneous log of the incident is maintained on behalf of the Incident Director, accompanying them to Incident Coordination Centres and meetings as required.

4.4.5 Incident Communications Manager

The Incident Communications Manager will be provided by Greater East Midlands Commissioning Support Unit (GEM CSU) on call manager. It is the responsibility of the Incident Communications Manager to lead on all media and communications with regard to the incident for the CCG including;

Engaging with other responding communication leads within Milton Keynes as per the Milton Keynes Multi-Agency Media Response Plan

Producing (in conjunction with the Incident Director and multi-agency comms leads) any press/media statements and managing all press and media enquiries, statements and interviews specific to the CCG;

Monitoring and actively responding to all press and media in relation to the incident;

Supporting the warning and informing of staff, partner agencies, provider trusts and the public;

Briefing the Incident Director and any representative of the CCG undertaking liaison with the media or press.

4.4.6 Heads of Service/Department / Directors All Heads of Service are responsible for;

Attending Incident Coordination Centres and/or Meetings as requested/required by the Incident Director; and



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Participating within post incident debriefing to ensure improvements and best practice are identified.

4.4.7 All Members of Staff

All members of staff may be requested to support the response to an incident by;

Attending Incident Coordination Centres and/or Meetings as requested /required by the Incident Director or Recovery Director to provide specialist knowledge or support; and

Participating with post incident debriefing to ensure improvements and best practice are identified.

4.4.8 Incident Management Team

The aim of the Incident Management Team is to assist the Incident Director in making decisions in response to the incident and will be formed by the Incident Director as necessary/required with attendance from Executive Directors, Heads of Service, CCG Staff and External Agencies such as the Commissioning Support Unit as required. The Incident Director will determine the attendance, frequency and venue (which may be virtual) for convening the group and will be responsible for chairing meetings, of which there should be minutes recorded.

5.0 Method

5.1 Triggers, Alerts, Activation and Stand Down

5.1.1 Triggers This plan can be triggered in several ways in response to an actual or potential significant/major incident in response to;

Declaration of a “Significant Incident” due to internal pressures within a provider trust, this may be caused by, but not limited to;

Increase in demand for services, including in response to an incident;

Building, equipment, utilities or infrastructure failure; and

Clinical safety, hospital acquired infections or staffing issues.

Declaration of a major incident “stand by” by a partner agency

Declaration of a “Major Incident” by a partner agency

External alert that a Tactical Coordinating Group meeting has been called

External alert that a Strategic Coordinating Group meeting has been called

In response to a National NHS England or Public Health England direction.



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5.1.2 NHS England Incident Levels

Alert Level Definition Incident Lead

Significant Incident

A significant incident is when a providers own facilities and/or resources, or those of its neighbours, are overwhelmed.

Provider/ MKCCG

Level One A health related incident that can be responded to and managed by local health provider organisations that requires coordination by the local CCG.

MKCCG

Level Two A health related incident that requires the response of a number of health provider organisations across an NHS England area team boundary and will require an NHS England Area Team to co-ordinate the NHS local support.

NHS England Area Team

Level Three A health related incident that requires the response of a number of health provider organisations across an NHS England area, and NHS England region and requires NHS England Regional co-ordination to meet the demands of the incident.

NHS England Regional Team

Level Four A health related incident that requires NHS England National co-ordination to support the NHS and NHS England response.

NHS England National Team

5.1.3 Alert Messages

The following alert messages may be used by the NHS, particularly by the Ambulance Service;

NHS Message Meaning Major Incident Standby

Alerts the NHS that a major incident may need to be declared. Organisations should make preparatory arrangements appropriate to the incident.

Major Incident Declared / Significant Incident Declared

Organisations need to activate their major incident plan and mobiles resources.

Major Incident Cancelled

Message cancels either of the above messages

Scene Evacuation Complete

Message from the Ambulance Service to confirm that the extraction of patients from scene is complete and there are no more casualties at scene; however some casualties may still be being conveyed.

Major Incident Stand Down

The (initial) response to the incident is now complete and arrangements can be stood down. It is the responsibility of all organisations to stand down at a time appropriate for them.

5.1.4 Casualty Classification

The Ambulance Service will triage casualties at scene and allocate them a classification for the prioritisation of treatment; Casualty Type Definition

P1 - Immediate Casualties requiring immediate lifesaving resuscitation, medical intervention/treatment e.g. surgery

P2 - Urgent Stabilised casualties needing urgent medical intervention/treatment where a short delay is acceptable

P3 - Delayed Casualties requiring non-urgent medical intervention/treatment where a longer delay is acceptable i.e. walking wounded.

P4 - Expectant* Severely injured casualties who are unlikely to survive even if treated aggressively

Deceased Deceased - No medical intervention/treatment required

* May only be invoked in mass casualty incidents



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5.1.5 METHANE Reports

Emergency Services generally use METHANE reports to provide the initial information pertaining to a situation/incident; M My call-sign or name and appointment / Major Incident Stand By or

Declared E Exact location (grid reference or GPS where available) T Type of Incident H Hazards, present and potential A Access to scene and egress route, helicopter landing site location N Number and severity of casualties / dead E Emergency services present and required. 5.1.6 Activation

The following individuals have the authority to activate this plan;

On-Call Director/Senior Manager

Chief Officer

Director Transformation and Delivery

Business Continuity and Resilience Manager Once the decision to activate this plan has been taken the incident cascade must be undertaken as per the On-Call Director/Senior Manager Action Card to inform, as a minimum;

NHS England Area Team (Thames Valley or Hertfordshire and South Midlands)

Milton Keynes General Hospital NHS Foundation Trust

Central North West London FT, (Milton Keynes community & mental health)

Milton Keynes Urgent Care Service

MKCCG Chief Officer

MKCCG Business Continuity and Resilience Manager

Triggers for activating the plan will most likely be received in the following ways, NHS England Top Down Activation:



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NHS Provider Trust Activation:



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Cascade of ‘major Incident Standby’ and ‘Major Incident’ from the Ambulance Service



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Due to the nature of major incidents an alert of activation may be received from a variety of sources, where possible before activating plans the information received should be verified. 5.1.7 Escalation and De-Escalation Escalation and de-escalation of an incident may not necessarily occur sequentially. It can be driven by the nature and scale of the incident and the appropriate response. Reasons for escalation and de-escalation may include (but not be limited to);

Criteria for Escalation Criteria for De-Escalation

Increase in geographic area or population affected

Reduction in geographic or population affected

Increased severity of the incident Reduced severity of the incident

Increased demands from government departments, the service or from partner agencies or responders

Reduced demands from government departments, the service or from partner agencies or responders.

Heightened public or media attention Reduced public or media attention

The need for additional internal/external resources

Reduced need for resources

Increased risk of harm/danger to staff, service users or the public

Decreased risk of harm/danger to staff, service users of the public

All changes in incident level must be agreed with the responding NHS England Area Team Incident Director and communicated to responding agencies, stakeholders and partners.

5.1.8 Stand Down It is the responsibility of the Incident Director to stand down the CCG response to an incident, once the demand for or impact on services has reduced to business as usual levels and can be managed under normal arrangements. Dependant on the scale and nature of the incident this may be some time after other agencies have stood down their response.

Stand down should be agreed with the responding NHS England Area Team Incident Director, and must be communicated to responding agencies, stakeholders and partners.

Following stand down Incident Debriefing and the collation of records should take place as per Sections 6.0 Administration.

5.2 Risk Assessment, Information Gathering and Decision Making

Gathering information to enable the assessment of the risks and impacts of the incident are an important factor in determining the level of the incident to enable a suitable response. As such this process is a dynamic one which continues and evolves as the incident does to ensure the most appropriate response.

5.2.1 Risk Assessment It is the responsibility of the On-Call Director/Senior Manager to undertake an initial risk assessment as per the On-Call Director/Senior Manager Action Card and Initial Risk Assessment Card. This process will enable the Director On-Call/Senior Manager to establish the severity and impact of the incident, and determine if it can be dealt with using business as usual/normal arrangements.



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Risk assessment should be dynamic and on-going and as such additional risk assessments should be documented when escalating or de-escalating the incident level or response. 5.2.2 Situation Reporting Situation reporting (SitRep) is the way in which the NHS gathers information from provider trusts, using the NHS England Standard SitRep. It is the responsibility of the Incident Director to ensure that the reporting requirements of NHS England are met by setting the internal SitRep requirements and frequency. Information may also be gathered from providers and responding agencies through the use of conference calls, similar to the daily system management calls. MKCCG’s teleconference details can be found in the EPRR Contact Directory.

5.2.3 Decision Making The Incident Director and Incident Recovery Director are responsible for making strategic and tactical decisions regarding the response. It is recommended that they follow the Joint Emergency Services Interoperability Programme Decision Making Tool; which uses a cyclical model where each step logically follows another, allowing continued reassessment of the situation or incident enabling previous steps to be revisited.

OODA Loop:

Observe: gather information and data from situation Orient: assess the situation and process the data about the current situation Decide: make a decision and then select the course of action Act: implement the selected course of action



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The NHS preferred method of assessing impacts and risks is using the ‘STEEPLE’ method which enables a range of factors to be considered;

Social Technological Economic Ethical Political Legal Environmental

All key elements of the decision making process must be recorded within the incident log. A simple way of recording decisions is to use the ‘DEAR’ method; Decision - What decision has been reached? Explanation - What is the decision? What do you expect the Outcome/impact to be? Alternatives - What alternative options where available? Rationale - What lead you to this decision? Why did you choose this option? 5.3 Incident Coordination Centre (ICC) During an incident a number of organisations may set up their Incident Coordination Centre, to provide a focal point for the management of the response. It is expected that for the majority of responses the MKCCG On-Call Director/Senior Manager will be able to mount a suitable response through business as usual arrangements, or from home. However dependant on the nature and scale of the incident the On-Call Director/Senior Manager has the ability to open the MKCCG Incident Coordination Centre. The Incident Coordination Room will be based in the Office of The Director of Transformation and Delivery. Any required support functions will use the desk space of the delivery team.

Alternatively it may be appropriate and suitable to co-locate within an NHS England, provider or multi-agency partner control room.

It may be advisable to set up the MKCCG ICC for prolonged and protracted incidents, and for large scale incidents such as mass evacuation, casualty or fatality incidents.

The On-Call Handbook provides further detail on how to set up the MKCCG ICC.

5.4 Shift Arrangements and Handover The response to an incident may occur at any time and require the Individuals to respond to work long periods out of normal office hours, including overnight.

In order to maintain a continued suitable response and consider the welfare of those responding it is essential that shift arrangements are implemented to ensure no individual responds to an incident for a period of more than 8 hours, especially if outside of office hours. Arrangements for the handover of responsibility should be considered and organised 4-6 hours into the incident response with the in-coming individuals receiving full handover briefings from out-going individuals, as per the Incident Director Handover Action Card. Any formal logs should also be closed, agreed and signed at the point of hand-over before being re-opened. Due to the intensity of the role, it is advised that where possible Loggists be changed every 4-6 hours.



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5.5 Press, Media and Communications The Greater East Midlands Commissioning Support Unit (GEM CSU) on call manager will assume the role of Communications Manager and is responsible for managing all external press and media relations, as well as internal communications to ensure staff are kept informed of the incident response and the impact to services. The Communications Manager will work with communication leads from other responding organisations in Milton Keynes as per the Milton Keynes Multi-Agency Media Response Plan.

In some circumstances it will be necessary to appoint a media spokesperson from the CCG. In such circumstances this is likely to be the Chief Officer or Chair, who will be fully briefed by the Incident Communications Manager.

5.6 Staff Welfare

MKCCG acknowledges that the health, safety and welfare of staff and visitors is at the forefront of any incident response and accepts that it has a duty of care to safeguard the well-being of all staff and visitors by employing all reasonably practicable measures. Staff will not be required to work beyond their competency or physical ability. Staff are encouraged to raise any concerns regarding medical conditions or personal circumstances with the Organisational and Workforce Development Lead. Dependent on the nature and scale of any incident varying degrees of staff welfare may be required, with assistance provided from GEMCSU Human Resources.

5.6.1 Staff Counselling and Support

Welfare and trauma support will be made available to staff responding to an incident, irrespective of their role. This support will be available from the very outset or as soon as is practicable during the early stages of the incident. The responsibility for identifying the need for welfare support rests jointly with individuals, their managers and the Incident Director. During and following an incident, staff welfare is of paramount importance. The following measures will be in place for staff:

A designated area for staff will be identified. This will be an area where staff can get refreshments, talk to each other, sit quietly etc.

Details of support available from Occupational Health will be made available to those who wish to speak to a counsellor confidentially in the days and weeks after the incident.

5.6.2 Family Counselling and Support

Dependent on the nature and scale of the incident it may be necessary for MKCCG to consider providing support and advice to families of staff who have been bereaved or are adapting to life changing injuries. Where suitable and practicable MKCCG will establish family liaison to assist them in seeking the professional support they require.

5.7 Vulnerable People It is not easy to define in advance and for planning purposes individuals that will be deemed a vulnerable person during an incident response or recovery, as this will vary dependant on the nature and scale of the incident. The following groups, (but not limited to) should be considered as the potential to be vulnerable;

Children & older people

Individuals with impairment (mobility, mental/cognitive or sensory);



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Individuals supported by health or local authorities;

Temporary or permanently ill individuals;

Individuals residing in care/nursing or residential homes, or being cared for by family members;

The homeless;

Pregnant women;

Minority language/non-english speaking individuals (including tourists); and

Travelling communities;

5.8 Helplines MKCCG does not have any formal plans in place for the activation of Help Lines during an Emergency. In the first instance existing arrangements such as Patient Advice and Liaison and 111 should be utilised. It is also expected that responding agencies will establish dedicated phone lines such as Casualty Bureau via the Police Force. Where existing arrangements are insufficient to manage demand or provide sufficient advice (such as in a pandemic) it may be necessary to set up additional NHS health line services. This decision should be taken by the Responding NHS England Area Team, with support to implement plans from MKCCG.

5.9 Financial and Budget Arrangements During the response to or recovery from an incident additional costs may be incurred either through the procurement of additional supplies and services or through the alteration of existing contracts. It is the Incident Director’s responsibility to agree any additional expenditure and ensure that all additional costs are captured. During an incident all expenditure in relation to the incident will be tracked using Cost Centre ‘332836 Emergency Planning’, subjective codes will vary dependant on the item/reason for expenditure.

It is accepted that to be able to respond effectively during an incident in the first instance costs will be the responsibility of the organisation within which they occur; however costs may be reimbursed or cross charged following resolution of the incident.

5.10 Legal Advice During an incident or the recovery phase it may be necessary for the Incident Director to seek legal advice. MKCCG does not hold any formal arrangements for receiving legal advice; however this is in the process of being procured and this section and the EPRR Contacts Directory will be updated accordingly.

It is not anticipated that the CCG will require urgent out of hours legal advice; however should it be required during an incident this can be arranged via NHS England.

5.11 Mutual Aid Health organisations have entered into Mutual Aid Agreements with NHS England; any requirement to activate or broker mutual aid should be via the Responding NHS England Area Team. 5.12 Recovery The Recovery Phase of an incident is as important as the Initial Response Phase, and may last considerably longer dependant on the nature and scale of the incident.



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In producing strategic intentions for recovery the following themes should be considered;

Humanitarian - physical and psychosocial impacts.

Economic - economic and business continuity.

Environmental - effects on the communities; and

Infrastructure - loss of NHS facilities, resources etc.

The recovery phase may also be a suitable opportunity to review the performance/configuration of services as it may enable re-design.

5.12.1 Recovery Planning Assumptions Planning assumptions are based on worse case credible scenarios, as such the perceived impacts on the recovery from an incident are likely to be caused by, but not limited to the following:

Increased NHS activity/demand for - surgical procedures; - ventilated or critical care beds; - specialist beds, e.g. burns and paediatric; - blood, blood related and skin products; - physiotherapy; - body storage; - repatriation of patients; - community services due to the rapid discharge of patients; - health monitoring and surveillance; - NHS resources, equipment and replenishment of supplies; and - re-scheduling cancelled elective procedures and out-patient

appointments.

Increased external activity/demand for - body storage; - funeral services; - temporary/long term accommodation; - Press, Media and Journalism; - VIP visits; and - repairing, rebuilding or make safe infrastructure and the environment.

Psychosocial impacts; - increased demand for trauma/bereavement counselling; - key anniversary dates; and - enquiries or inquests.

6.0 Administration

6.1 Incident Documentation Those individuals with responsibility for managing the response to an incident should ensure that suitable records and documentation are maintained, including Incident Logs, Decision Logs and minutes of any incident management meetings. On stand down all documentation and records must be submitted to the Business Continuity & Resilience Manager for review and retention. Following incident stand down or at the point of hand over formal logs must be closed, agreed and signed, before being re-opened.



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6.2 Post Incident Debrief and Reporting

MKCCG will adopt the following debrief and reporting protocol;

asap Hot debrief (within 24 hours)

Incident + 1-2 weeks

Formal Debrief

Incident + 4 weeks

1st draft report completed and agreed by Essex CCG Emergency Planning Group for submission to next CCG Board.

Incident + 12 weeks

Action Plan Update report submitted to next CCG Board.

The requirement and need for MKCCG to produce a full Incident Report may be superseded where NHS England Area Team lead incident debriefing and reporting arrangements.

6.2.1 Hot Debrief All MKCCG operational areas/individuals involved with the incident response should undertake a hot debrief brief immediately (within 24hrs) following stand down. The aim of undertaking a hot debrief is to ensure that immediate lessons are identified and good practice is captured for feedback at the post incident debrief. Hot debriefing also allows any concerns, impacts and risks requiring immediate mitigating actions to be put in place to be highlighted. Any actions requiring immediate mitigating actions should be discussed with the Business Continuity and Resilience Manager following the hot debrief.

6.2.2 Post Incident Debrief Unless NHS England Area Team are leading on incident debriefing and reporting a formal structured post incident debrief, chaired by the Business Continuity and Resilience Manager, with all key personnel will be held within 2 weeks of any activation of this plan to identify areas for improvement and good practice; to increase MKCCG’s emergency preparedness and resilience. It should be noted that at the time of debriefing the recovery phase may still be on-going, and as such a secondary debrief may be required to capture any further learning from the recovery phase once stood down. Typically the Post Incident debrief will include:

Nature of incident and response including a timeline

Involvement of MKCCGs

Involvement of other responding agencies

Implications for incident management within the NHS

6.2.3 Multi-Agency Debrief After some incidents it may be necessary for a multi-agency debrief to be held. It will be the responsibility of the Business Continuity and Resilience Manager and the Incident Director to represent MKCCG; capturing areas where learning may be applied.

6.2.4 Post Incident Report Where NHS England Area Team are leading the incident debrief and reporting process they will be responsible for producing a post incident report.



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However the Business Continuity and Resilience Manager should ensure a MKCCG report is written to capture the Corrective Action and Preventative Action log/plan capturing all of the mitigating actions against any areas for improvement. All actions identified will be entered onto the EPRR Lesson & Issue Log. Approval of the report will follow MKCCG governance arrangements as outlined in the Business Continuity Management System Scope and Policy. Once approved at MKCCG Board Level the report will be submitted to the Milton Keynes Health Resilience Group, NHS England Thames Valley/Hertfordshire & South Midlands (as appropriate) Area Team and shared with any external agencies as required. Incident Reports may be subject to FOI requests and may require some information to be redacted; as such a public report may also be produced and published at this time.

6.2.5 Storage and Retention of Documentation

An essential element of any response is to ensure that all records and data are captured and stored in a readily retrievable manner as these records will form the definitive record of the response and may be required at a future date as part of an inquiry process (judicial, technical, inquest or others). Such records are also invaluable in identifying lessons that would improve future response. All documentation relating to the incident including logs must be submitted to the Business Continuity and Resilience Manager within 72 hours of incident stand down for review and retention in line with Corporate Information Governance Arrangements. It is expected that incident documentation including log books will be retained for a minimum of 25 years.

7.0 Associated Documents In addition to individual agency/organisation plans the following documents are associated with this plan:

Internal:

EPRR Scope and Policy (Including On call Arrangements)

MKCCG Business Continuity Plan

MKCCG Escalation Framework

MKCCG On-Call Director/Senior Manager Manual External:

Hertfordshire and South Midlands Plan for Infectious Diseases at Pandemic Level (With specific reference to Pandemic Influenza)

Thames Valley Resilience Forum Multi Agency Procedures for Emergencies

Thames Valley Resilience Forum Mass Casualties Plan

Thames Valley Resilience Forum Mass Fatalities Plan

Thames Valley Resilience Forum Fuel Disruption Plan

Milton Keynes Hospital Foundation Trust Major Incident & Business Continuity Plans.



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8.0 Glossary / Lexicon

Abbreviation Primary Term Definition

Bronze See ‘Operational’

CBRNe Chemical, Biological, Radiological, Nuclear & Explosive

Incident type involving the intentional release of a chemical, biological, radiological, nuclear or explosive material – may be real of a hoax.

CCA Civil Contingencies Act 2004

The Act which outlines statutory duties for Emergency Preparedness, Resilience and Response.

CCG Clinical Commissioning Group

Category 2 NHS Organisation responsible for commissioning services.

CNWL NHS Central North West London Foundation Trust

Provider of Milton Keynes Community and Mental Health Services

DsPH Directors of Public Health Local Authority Director of Public health responsible for health promotion and protection of local communities.

ECOSA Emergency Coordination of Scientific Advice

Virtually established group of experts to provide specialist advice in the initial stages of a counter terrorism incident.

ED Emergency Department Department of an Acute Hospital also known as Accident and Emergency.

EPRR Emergency Preparedness, Resilience & Response

The Emergency Planning and Business Continuity work stream.

FOI Freedom of Information Disclosure of information under the Freedom of Information Act 2000.

GEM CSU Greater East Midlands Commissioning Support Unit

Commissioned service provider for Communications and Information Technology.

Gold See ‘Strategic’.

HART Hazardous Area Response Team

Specialist team within the Ambulance Service trained and equipment to manage hazardous/challenging incidents such as those requiring working at height or in confined spaces or with hazardous materials.

HAZMAT Hazardous Material incident

Incident type involving the unintentional release of a chemical, biological, radiological, nuclear or explosive material.

HSE Health & Safety Executive Government body responsible for health and safety.

ICC Incident Coordination Centre

Designated and equipped control room from which incidents can be managed.

LHRP Local Health Resilience Partnership

Statutory health meeting co-chaired by NHS England and Public Health England.

LICC Local Incident Coordination Centre (NHS England)

NHS England Local designated and equipped control room from which incidents can be managed.

LRF Local Resilience Fora Statutory multi-agency emergency planning meeting.

MACA Military Aid to the Civil Authority

Agreement under which the armed forces can be requested to assist in the response to incidents where there is a danger to human life or a breakdown in essential services.

MK Milton Keynes

MKCCG Milton Keynes Clinical Commissioning Group



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Abbreviation Primary Term Definition

MKHFT Milton Keynes Hospital Foundation Trust

The Acute Hospital for the Geographical Area of Milton Keynes.

NHSBT NHS Blood and Transplant

National Specialist Health Authority responsible for the collection and supply of blood, blood related products, organs and skin.

NICC National Incident Coordination Centre (NHS England)

NHS England National designated and equipped control room from which incidents can be managed.

Operational The level (below tactical level) at which the management of ‘hands-on’ work is undertaken at the incident site(s) or associated areas, equating for single agencies to Bronze level.

P1 Priority 1 Casualty requiring immediate lifesaving resuscitation, medical intervention/treatment e.g. surgery.

P2 Priority 2 Stabilised casualty needing urgent medical intervention/treatment where a short delay is acceptable.

P3 Priority 3 Casualty requiring non-urgent medical intervention/treatment where a longer delay is acceptable e.g. walking wounded.

P4 Priority 4 Severely injured casualty who is unlikely to survive even if treated aggressively.

PHE Public Health England The National Statutory Body with responsibility for protecting Public Health.

PSED Public Sector Equality Duty

Statutory duties placed upon organisations under the Equality Act 2010.

RICC Regional Incident Coordination Centre (NHS England)

NHS England Regional designated and equipped control room from which incidents can be managed.

SAGE Scientific Advisory Group for Emergencies

Established group of experts to provide specialist scientific and technical advice to the government during the response to or recovery from an incident.

SCG Strategic Coordinating Group

The Strategic multi-agency group chaired by the Police, responsible for overall command of the incident response and recovery.

Silver See ‘Tactical’.

STAC Scientific and Technical Advice Cell

Established group of experts, chaired by PHE to provide specialist scientific and technical advice to an SCG during the response to or recovery from an incident.

Strategic The level (above tactical level and operational level) at which policy, strategy and the overall response framework are established and managed. Also Known as Gold.

Tactical Level (below strategic level and above operational level) at which the response to an emergency is managed. Also known as Silver.

TCG Tactical Coordinating Group

The tactical multi-agency group chaired by the Police, responsible for coordinating and delivering the tactical response to and recovery from incidents.

TVEA Thames Valley Commissioned provider that undertakes basic level



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Emergency Access system management and data collection.

Action Card 1 - On Call “Initial Call / Stand-By”

Accountable to - Area Team Incident Director

Responsible for assessing the initial information received in respect of a potential or actual incident and escalating to NHS England Area Team

No. Action Time Completed

1. In the event of a potential or actual significant / major incident the MKCCG Director/Senior Manager will usually be notified by;

Provider Trusts (MKHFT or CNWL/MK Community & Mental Health)

Responding NHS England Area Team

Milton Keynes Council

Any other partner agency

2. Start a personal log (using initial call log) detailing information received and actions taken. Ensure formal logging of your actions/decisions.

3. If necessary, verify the information received via the on call arrangements of the alerting agency.

4. Obtain as much information about the incident as possible (METHANE) and begin to complete the initial risk assessment and formal log.

5. Advise the Area Team On Call and determine the severity of the situation and potential impact to the local health economy and consider action to be taken.

Hertfordshire & South Midlands Area Team:

Significant / Major incident in a MK Health Organisation

Health Escalation Incident in a MK Health Organisation

Thames Valley Area Team:

Major Incident occurring in MK Geography (but not in a MK Health Organisation)

6. If activating the Incident Response Plan go to Action Card 2.

7. If the situation can be dealt with by business as usual arrangements (not activating the Incident Response Plan) inform MKHFT, MKCHS and MKUCS, CCG Business Continuity and Resilience Manager; GEM CSU Communications Manager and relevant CCG departments of the current situation.

8. Continue to reassess the situation as information becomes available and determine if any additional action is required. If there is any increase in scale or impact reassess the risks and escalate as needed.

9. Complete all logs and documentation and submit to the Business Continuity and Resilience Manger.



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Action Card 2 - Incident Director “Incident Declared”


Responsible for managing the incident as tasked by the Area Team incident Director (when Activated) If a TCG is called the CCG Director may be required to attend on behalf of the local

NHS.


1. On receiving Major Incident Declared Message or deciding to activate plans, inform and establish liaison with the following organisations;

Communications Manager, GEM CSU – see Action Card 5

Milton Keynes Hospital Foundation Trust

Milton Keynes Community Health Services

Milton Keynes Urgent Care Services

NHS 111 Provider


South Central Ambulance Service

TVEA


Public Health England

MKCCG Internal Staff

2. Confirm the relevant command and control structures have been implemented across the health economy.

3. Confirm the AT Incident Directors aim and objectives for responding to the incident and the strategy to achieve these.

4. The following actions may be incident dependent;

Convene a teleconference with key NHS organisations

Brief out to local NHS & clinical networks

Collate Situation Report to responding NHS England Area Team

5. Identify the battle rhythm dependant on:

TCG and SCG meetings (if called)

NHS teleconferences/meetings

Reporting requirements of the responding NHS England Area Team

6. Establish an Incident Management Team (if required) and open the MKCCG Incident Coordination Centre (if required) contacting MKCCG Loggists.

7. Consider the need to establish shift and handover arrangements.

8. Where indicated by the type of incident, establish broader membership consisting of all responding organisations.

9. As directed by the responding NHS England Area Team implement and support the media and communications strategy.

10. Ensure response to all TCG determined actions.

11. Continue to reassess the situation as information becomes available and determine if any additional action is required. If there is any increase in scale or impact reassess the risks and escalate as needed.

12. In consultation with the Area Team, determine when stand down should be declared (taking advice from partners as necessary) and go to Action Card 03.



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Action Card 3 - Incident Director “Incident Stand Down”


When the stand down command is given by the Area Team Director, the Incident Director will:


1. Ensure a process is in place for an appropriate return to business as usual internally and externally across the local NHS.

2. Support the multi-agency recovery phase if required.

3. Inform the following agencies (and any others activated during the course of the incident)

GEM CSU Communications Manager

Milton Keynes Hospital Foundation Trust

Milton Keynes Community Health Services

Milton Keynes Urgent Care Services

NHS 111 Provider


South Central Ambulance Service

TVEA


Public Health England

MKCCG Internal Staff

4. Undertake ‘hot debrief’ of all MKCCG staff involved in the response.

5. Agree when MKCCG staff involved in the incident may return to their normal duties, considering any welfare requirements.

6. Complete and sign the incident/decision log and ensure all related paperwork is provided to the Business Continuity and Resilience Manager for retention.

7. Participate in any further formal debriefing as required to support the production of a Post Incident Report.



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Action Card 4 - Loggist Aide Memoir

Accountable to - MKCCG Incident Director or the person for whom they are logging

Responsible for recording and documenting all issues/actions/decisions made by the Incident Director. If the Incident Director attends the TCG they will be accompanied by a loggist if possible. Within the ICR, a loggist will

always be present working direct to either the Incident Director.

1. Attend the Incident Coordination Centre as required. On arrival ensure staff in attendance are identifiable and ask for clarification of who is present and their title. All persons must be recorded in the log.

Best Practice for Record Management:

Logs must be an ‘original note’ - the term used to describe the written evidence made at the time of an occurrence or as soon as reasonably practicable after the decision, action or event is witnessed.

• The log must be produced in a robust form where the pages are sequentially numbered and

professionally bound.

• The log must be in hard copy, therefore hand written notes must be clear, intelligible and accurate.

• Correctly compiled notes defend against allegations of improper alteration, deletion or addition.

Logs must be a permanent record and therefore must be in ink.

Format:

• Dates are to be recorded using the full DD/MM/YY format.

• Times are to be recorded using the 24hr clock HH:MM

• Ensure that letters and numbers are written clearly to differentiate between them e.g. letter O - number

0, number 1 - number 7 and number 6 - letter b.

• The Use Of Abbreviations And Acronyms Must Be Explained At First Use e.g. London Ambulance

Service (LAS).

• All log entries should be numbered in brackets. E.g. (1)

• Always leave a line between entries.

Cross through mistakes with a single line and initial so text remain legible.

Opening a Log:

• Enter your name and initials at the start of the Log with details of the incident.

• First Entry should detail;

- Start time

- Location

- Individuals present

Closing a Log:

• Check your log and make any annotations.

• Rule of Space.

• Get Gold to sign off your log.

• Rule of any further space.

• Close log with a signature and date.

• Retain for 7 years in case of enquiry.

2. Always close a log when handing over duties to another Loggist

Remember: NO

Erasures

Leaves torn out

Blank Spaces

Overwriting

Writing between lines

Statements in direct speech

If it isn’t written down - it didn’t happen



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Action Card 5 - Incident Communications Manager


Providing communication co-ordination, advice and support to the Incident Director


1. Confirm with Incident Director that an incident is taking place.

2. Contact the Area Team communications and join any MK multi-agency teleconferences to agree who will be leading on communications on the incident.

3. Commence a personal log.

4. As requested issue pre-arranged public health / safety messages in conjunction with Public Health England within the first hour of becoming aware of the incident.

5. If requested to do so by the responding NHS England Area Team communications lead/MK comms leads, assume responsibility for managing all public information and media communications. (Note that if a SCG/TCG is established all media responses are controlled and coordinated by them so communications input/feedback should be fed upwards into the SCG/TCG).

7. Provide TVEA* with ‘standard response’ messages for the public and ensure these are amended as required throughout the incident. (TVEA will be responsible for passing these messages on to 111/DOS amendment)

8. Deal with all media enquiries/draft statements/organise press conferences and interviews as agreed by the Incident Director

10. Identify communications officer/ admin support to log media calls and develop rolling question and answer brief as necessary.

13. On stand down, ensure that all original documentation (including notes, flip charts, e-mails etc.) are kept. Close personal log.

14. Attend Hot and Formal debriefs.

15. Manage any on-going media interest in the CCG response, including social media and updating of information on the MKCCG website

*TVEA 24/7 Access Manager: 08712 374 974



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Action Card 6 - Initial Risk Assessment

Undertaken by the Incident Director

Questions to consider Information

Collected?*

What is the size and nature of the incident?

Area and population likely to be affected - restricted or widespread

Level and immediacy of potential danger - to public and response

personnel

Timing - has the incident already occurred or is it likely to happen?

What is the status of the incident?

Under control

Contained but possibility of escalation

Out of control and threatening

Unknown and undetermined

What is the likely impact?

On people involved, the surrounding area

On property, the environment, transport, communications

On external interests - media, relatives, adjacent areas and partner

organisations

What specific assistance is being requested from the NHS?

Increased capacity - hospital, primary care, community

Treatment - serious casualties, minor casualties, worried well

Public information

Support for rest centres, evacuees

Expert advice, environmental sampling, laboratory testing, disease control

Social/psychological care

How urgently is assistance required?

Immediate

Within a few hours

Standby situation

Action Required by Area Team?

Establish ICC

Activate ICC Plan

Activate IRP

Liaise with other agencies to monitor the situation

Other Actions Required (Give Detail)

*Key √ = Yes X = no ? = Information awaited N/A = Not applicable



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Notes on Initial Risk Assessment

In making this assessment, it is important to distinguish between:

Events that can be dealt with using normal day to day arrangements.

Events that can be dealt with within the resources and emergency planning

arrangements of the NHS England Area Team and local NHS commissioned

services.

Events that require a joint co-ordinated response from the organisations across

an NHS England Area Team.

Events that require a strategic level co-ordinated multi-agency response across

an NHS England Area Team (or wider) health community.



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Action Card 7 - Incident Director Hand-Over

Outgoing Incident Director to Incoming Incident Director

Please maintain a personal copy, key decision makers to ensure actions formally logged.

Outgoing Incident Director Incoming Incident Director

Name: Name:

Date: Date:

Time: Time:

Location: Location:

Situation: Nature of the incident / outbreak / etc.

Background: Key issues, actions taken, current situation

Assessment: Risks and threats associated with the incident

Recommendation: Actions to be taken / considered

Review: Does this need to be reviewed / date / time etc.

Any other comments to note:



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NHS Situation Report (Sitrep)

Please complete all fields. If there is nothing to report, or the information request is not applicable, please insert NIL or N/A.

Organisation: Date:

Name (Completed by): Time:

Telephone number:

Email Address:

Authorised for release by (Name & Title)

Exact location of Incident

Type of Incident (Name)

Resources Deployed1

(e.g. Ambulance, Air Ambulance, HART)

Incident Casualties2 Location P1: P2: P3 P4: Disch Dead

Pre-Hospital

Receiving Hospital # 1




Total at Receiving Hospitals

Impact on Critical Functions4

Capacity Issues5a

Capability Issues5b

(e.g. major

trauma, burns)

Impact on business as normal

6

Mutual Aid Request Made (Y/N)

7

Current / Potential Media Messages

8



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Notes to aid completion of SITREP 1. Resources Deployed:

Resources deployed at scene of incident. 2. Incident Casualties:

P1: Casualties requiring immediate life-saving resuscitation and/or surgery. P2: Stabilised casualties needing early surgery but delay acceptable. P3: Casualties requiring treatment but a longer delay is acceptable. P4: Expectant category – confirm if invoked.

3. Fatalities in hospital:

Number of patients arriving at hospital and subsequently dying at/or in hospital.

4. Impact on critical functions:

Implications on Category “A” Ambulance response times.

Critical Care capacity. 5. Capacity/capability issues:

This section provides a forward look for the NHS and the Department of Health.

6. Impact on business as normal:

Cancellation of elective activity should be covered here.

Any other service reduction as consequence of incident.

7. Mutual aid request:

Confirm details of mutual aid requested, and from whom requested. 8. Media:

Indicated media interest shown/reported.

Provide key messages for media, also provide details of lead media contact.



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NHS England Situation Report

Note: Please complete all fields. If there is nothing to report, or the information request is not

applicable, please insert NIL or N/A.

Organisation: Date:

Name (Completed by): Time:

Telephone number:

Email Address:

Authorised for release by (Name & Title)

Type of Incident (Name)

Organisations reporting serious operational difficulties

Impact/potential impact of incident on services / critical functions and patients

Impact on other service providers

Mitigating actions for the above impacts

Impact of business continuity arrangements



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Media interest expected/received

Mutual Aid Request Made (Y/N) and agreed with?

Additional comments

Other issues

Incident Coordination Centre contact details:

ICR:

Name:

Telephone number:

Email:

OFFICIAL MARKING - ONLY available to MKCCG Staff and Partners in the MK Local Health Resilience Partnership


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Mass Casualty Incidents

1.0 Introduction Mass Casualty Incidents will involve an increase in the demands that are made on response Capabilities, whereby doing more of the same is unlikely to be adequate and organisations will need to adopt a different approach. The objective in a mass casualty incident is to make the best possible use of available resources, save as many lives as possible and concentrate on those who can be saved. The arrangements below are written to be in line with the DH (2007) “Mass Casualty Incidents: A Framework for Planning” and Thames Valley LRF Multi-Agency Mass Casualties Framework (2013). Even in the event of a mass casualty incident being declared, if the incident is a potential or actual Chemical, Biological, Radiological, Nuclear or Explosive (CBRNe) incident, responding organisations will activate CBRNe plans, to ensure that all patients undergo suitable decontamination either before leaving the scene or before entering the hospital building. Treatment standards should be expected to be the same as those applied to the single patient with the same injuries, but it is acknowledged that in mass casualty events this may not be possible (Planning for the Management of Blast Injured patients, Department of Health 2007) 1.1 Definition of a Mass Casualty Incident The definition of a mass casualty incident is defined by the Thames Valley Local Resilience Forum Multi-Agency Mass Casualties Framework (2013) as: “a disastrous single or simultaneous event(s) or other circumstances where the normal major incident response of several NHS organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response”

By definition, such events have the potential to rapidly overwhelm or threaten to exceed the local capacity available to respond, even with the implementation of major incident plans. 2.0 Preparing for a Mass Casualty Incident Mass Casualty Guidance requires that the following actions are considered in the planning for and response to a Mass Casualty Incident; Acute Capacity:

Ensure arrangements are in place to increase and maintain extra capacity, including procedures for ceasing all elective activity, identifying patients available for rapid discharge, supplementing available equipment and alternative use of specialist/day care beds.

Ensure arrangements include using existing capacity more intensively to create extra capacity for a higher level of dependency. For example, some community or intermediate beds could be used to deliver acute care, or general acute beds used to create additional capacity for critical care or burns cases (with specialist staff).

Consider and discuss the use of non- acute NHS facilities (to supplement maximum bed capacity available in hospitals), any independent sector capacity and/or the pre-identification of suitable accommodation that could be utilised if required in conjunction with Local Authorities (DH 2007).

Identify unused physical capacity which could be brought into use in an emergency. This might include disused wards within NHS hospitals or intermediate care or community

OFFICIAL SENSITIVE MARKING - ONLY available to MKCCG Staff and Partners in the MK Local Health Resilience Partnership


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beds, or capacity in the independent or private sectors or other locations identified with the help of local authorities.

Ensure integrated plans are in place to set up and provide facilities - preferably away from acute hospital sites - to assist in the triage, diagnosis, treatment and support of those patients who are not obviously seriously ill or injured.

Ensure contingencies are in place to maintain patients in the community and limit or avoid referrals to acute hospitals as far as possible. Contingencies should also include active measures to supplement maximum bed capacity available in acute hospitals.

Ensure plans are in place with the Local Authority to assist in expediting appropriate early discharge regionally in both acute and community care areas.

Ensure sufficient plans for increased patient transport services.

Ensure sufficient plans for the delivery of diagnostics and pathology, including the maintenance of critical supplies.

Ensure sufficient plans for the delivery of pharmacy and medicines.

Ensure sufficient plans for the management of blood and blood related products.

Staffing Capacity:

Ensure that Business Continuity Management plans reflect the need to maintain critical clinical and managerial functions during periods of disruptive challenges.

Ensure arrangements are in place for senior clinical leaders to temporarily re-align treatment protocols to reprioritise patient care, if necessary (DH, 2007).

Ensure clinical input to identify the scope for adapting “normal” clinical practices, which must recognise that in these circumstances, extraordinary measures will potentially mean doing something outside normal practice (DH, 2007).

Ensure plans are in place to deploy community staff to supplement acute services if that is required.

Ensure contingency plans also focus on pre-identifying (and enhancing) the emergency care potential/skills of all staff, directing staff effort to key emergency roles, and sustaining activity levels well beyond the initial response phase.

The Public and Casualties

Ensure that robust mechanisms are in place for managing a significant number of people making contact either in person or by telephone and internet.

Ensure plans are in place, in association with local police forces, to share information with the Casualty Bureau that the police will establish.

Ensure that receiving hospitals have the necessary facilities for teams of police officers rained to document casualties to ensure that all known casualty information, including details of the deceased, is passed to the casualty bureau.

Ensure that plans and procedures consider the needs of disabled and vulnerable casualties, as applicable.



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3.0 Planning Levels / Capacity Milton Keynes Hospital Foundation Trust currently has the following system capacity; Emergency Department:

PRIORITY DESCRIPTION COLOUR AREA NOS.

1 Immediate Red Resuscitation Room 5 2 Urgent Yellow Majors 11 3 Delayed

(ambulatory) Green Minors

Paediatric Emergency Department 10 6

Theatre Capacity: Emergency (Phase 1) - 4

Planned (Phase 2 ) - 8 Critical Care: 9 (Number of beds dependent on level of patient, that is, ventilated or

high dependency) Bed Stock: 450 Inpatient Beds (including Critical Care) and 34 Day Case Beds Mortuary: Capacity for 108 Emergency Treatment Centres - None CLIO Barcoding and Patient Tracking - None of these – patients who are booked into the Emergency Department are issued with a unique MRN (Medical Record Number)



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Mass Fatality Incidents

1.0 Introduction Following in an incident resulting in mass fatalities, there will be a range of physical, evidential, safety and psychological challenges to those organizing and directing the response. The recovery of fatalities is taxing for those involved and is generally an emotive issue. This section gives guidance about arrangements for mass fatalities. These arrangements below are written to be in line with the Thames Valley Local Resilience Forum “Mass Fatalities Management Plan” (2013) and the Home Office (2004) “Guidance on Dealing with Fatality in Emergencies”. In the event of a mass fatalities incident is confirmed or suspected to be involving Chemical, Biological, Radiological, Nuclear or Explosives (CBRNe) event then the challenges are further complicated by the presence of contaminating agents on and around the fatalities which present potential health risks. The aim is to provide an integrated emergency response to a mass fatality incident in providing options for dealing with incidents involving large numbers of human fatalities. It may also be used in response to an incident overseas which calls for the identification and repatriation of large numbers of UK nationals. Hospital mortuary facilities may be considered but should not be relied upon when considering the designated mortuary for a mass fatality incident. The issue of capacity should be an important factor. Public or temporary mortuaries offer advantages in some cases. Deaths that occur en route to hospital in an ambulance or at a hospital would normally be placed in a hospital mortuary. However, in the event of a mass fatality incident, it may be required for the NHS to transfer victims to the designated mortuary. Four Key Principles (Lord Justice Clarke, 2001)

The provision of honest and as far as possible accurate information at all times, at every stage

Respect for the deceased and the bereaved

A sympathetic and caring approach throughout

The avoidance of mistaken identity.

The Safe Handling of Contaminated Fatalities. 1.1 Definition of a Mass Fatality Incident The definition of a mass fatalities is defined by The Home Office 2004 ‘Guidance on Dealing with fatalities in Emergencies’ as: “any incident where the number of fatalities is greater than normal local arrangements can manage”

By definition, such events have the potential to rapidly overwhelm or threaten to exceed the local capacity available to respond, even with the implementation of major incident plans. 2.0 Considerations Arising During a Mass Fatality Incident

A Casualty Bureau (police led) may be established to collage and pass onto police relevant data about person who have been reported as missing.

The bodies of victims may require storage for significant periods of time in order to assist with evidence for criminal investigations and in order to allow time for the Coroner to confirm the identities of those who are deceased.



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In some cases it may not be possible to identify victims at all.

Normal infrastructures e.g. communications, utilities, transport, may suffer disruption.

Severe pressure may affect established procedures including those for identification, post mortems and burials.

Media and political interest is likely to be intense: there are likely to be exceptional demands for public information.

There is potential for confusion over the numbers of missing people.

Human aspect requirements relating to victims, the bereaved, survivors, witnesses and responders will be significant.

There may be multi-national, multi-cultural and multi-religious aspects.

There may be long term implications following a mass fatality incident linked to: - On-going identification and investigation requirements, inquiries and proceedings - Legal issues - Human aspects and social impact

3.0 Planning Levels / Capacity There are 3 levels of planning for mass fatalities;

Enhanced Current Arrangements - Increasing the capacity of existing mortuaries

Local Response - setting up an emergency temporary mortuary when enhanced arrangements would lack capacity to cope.

National Response - requesting the use of National Emergency Mortuary Arrangements (NEMA).

4.0 Thames Valley Mass Fatality Plan

The Thames Valley Local Resilience Forum Mass Fatality Plan may be invoked when a incident occurs where the number of fatalities is greater than normal local mortuary arrangements can manage. The plan may also be activated in response to an incident overseas which calls for the identification and repatriation of large numbers of UK nationals.

A Mass Fatality Co-ordination Group (MFCG) will be established and chaired by the relevant Coroner. Membership is likely to be as a minimum: - HM Coroner (Chair) - Thames Valley Police Senior Investigation Officer - Thames valley Police Senior Identification Manager - Lead Pathologist (Acute Trust) - Local Authority Emergency Planning Officer - Local Authority Finance Officer

The MFCG will select the most appropriate mortuary option to manage the incident. The option chosen will need to be scalable. The MFCG will decide whether Thames Valley’s mortuary capacity has been exceeded and if to request deployment of National Mortuary Emergency Arrangements (NEMA). 5.0 International Dimension The Foreign and Commonwealth Office (FCO) are able to respond and/or assist in fatality incidents involving either foreign nationals who have died or have been killed in the UK or British nationals who have died or been killed whilst overseas. The UK Disaster Victim Identification Team (UKDVI) is managed by the Association or Chief Police Officers (ACPO) and has the ability to be deployed should this be requested by the Police Service.



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Chemical, Biological, Radiological, Nuclear & Explosives Incidents

1.0 Introduction Following in an incident involving the accidental or malicious release of a Chemical, Biological, Radiological or Explosive (CBRNe) substance, responding agencies will need to activate specialist arrangements for the management of those involved, the injured and the deceased, in line with the Joint Emergency Service Interoperability Programme (JESIP) Initial Operational Response document. There are a number of substances which could be effectively released in a variety of different forms, for example; powder, liquid, gas or contamination of food / water supply. Some substances may be covertly released, therefore it may not be immediately apparent that an incident is one involving a CBRNe agent and in some circumstances it may take a number of hours / days for symptomatic patients to present. During a CBRNe incident a key priority is the containment of the substance and those individuals which have come into contact to reduce the spread of the contamination. 2.0 Decontamination at the Scene Where it is suspected or known that a Major Incident has a CBRNe element, those involved, injured or deceased will undergo decontamination before leaving the scene. The Ambulance Service Hazardous Area Response Team (HART) is provided with the suitable equipment including personal protective equipment to assist in the search and rescue, treatment and decontamination of contaminated casualties. It is the responsibility of HART to ensure all casualties undergo appropriate decontamination before leaving the scene of the incident and being conveyed to hospital. The Fire Service is provided with suitable equipment including personal protective equipment to undertake the search and rescue of contaminated casualties and the deceased. The Fire Service also has the ability to undertake mass decontamination of those individuals who are uninjured, but who may have been affected by a release. It is the fire service responsibility to ensure the general public involved but not injured undergo appropriate decontamination before leaving the scene of the incident. 3.0 Decontamination at Hospital Due to the nature and scale of incidents it may not be possible to contain all individuals at the scene, and some ‘walking wounded’ casualties may make their own way to the nearest hospital for treatment. Those casualties self-presenting at Emergency Departments are unlikely to have undergone suitable decontamination. It is the responsibility of the hospital to ensure they have suitable and sufficient plans to;

Undertake appropriate decontamination of self-presenting casualties before they enter hospital buildings.

Ensure suitable and effective hospital site lock down to restrict the access of contaminated patients to hospital buildings.

Generally decontamination at the hospital will require the erection of the CBRNe tent and use of Powered Respirator Protection Suits by trained staff. Hospital Trusts have been provided with RAM GENE monitors for use in the detection of radiation and contamination.



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4.0 Mass Prophylaxis In some circumstances such as in incidents where substances have been released covertly or it is not immediately apparent that the incident is of a CBRNe nature it may be necessary to undertake Mass Prophylaxis of those in the vicinity of the incident or the injured. In this situation Mass Prophylaxis Plans will be activated across the health economy and is likely to require the activation of National Emergency Plans. 5.0 Information and Advice Public Health England is responsible for providing advice relating to CBRNe incidents to the NHS and the general public, with the ability to provide specialist clinical advice via the Centre for Radiation, Chemical and Environmental Hazards (CRCE) and National Poisons Information Service (NPIS).

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