How well did the 7/7 emergency services respond?
- 3 March 2011
- From the section UK
One of the key questions at the heart of the 7 July inquests is whether the emergency services could have responded faster and better.
The London Assembly had already reported that poor communications and a lack of basic medical supplies hampered the rescue operation. So what else has the inquests learned?
The hearings have focused on a number of key areas including:
- The ambulance service
- The fire fighters
- The police
- Overall command and control
LONDON AMBULANCE SERVICE
There was a delay of 52 minutes in getting ambulances to Tavistock Square, the scene of the bus attack where 13 people died.
Crews were only sent to the bus attack after reports of a second blast at 1040 - a controlled explosion of a suspicious package.
Jessica Ashford, the first paramedic to reach Tavistock Square, had in fact been despatched to Russell Square. She said the scene was devastating, with parts of bodies strewn across the road. Mrs Ashford alerted control at 0957 BST, performed a quick reconnaissance - and called again at 1005 demanding back-up.
The delays at Tavistock Square followed a separate half-hour delay in sending teams to Russell Square underground station, where 26 people died, the greatest loss of life.
Graeme Baxter was the first paramedic into the tunnel at Edgware Road. He called for eight more ambulances - but also told the inquests that he was frustrated to learn that crews from two stations nearby were not despatched.
Overall, only half of 201 London ambulances which were available on the day were sent to the attack scenes.
Crews who were stationed nearby were held back in case there were more attacks - and some of them were watching the events unfold on television.
At the same time, controllers were struggling to identify free ambulances to ferry the wounded to hospital. They eventually called on neighbouring ambulance services and volunteers to help at the scenes.
Helicopter Emergency Medical Service paramedic Lee Parker wrote in a debrief form that he found these decisions inexplicable.
"Due to the number of casualties involved, we had to utilise various medical staff who ended up creating more work," he wrote. "They did not understand triage and/or major incident procedures. Other medical staff should be kept as far away as possible from these incidents."
Jason Killens, deputy director of operations at the London Ambulance Service (LAS), told the inquests that it had been the "right decision on the day" to hold back some crews.
But in the closing days of the inquests, the coroner heard about "organised chaos" and shortcomings at the ambulance service's disaster control room at Waterloo.
Two people who were designated to crucial roles in the unfolding events were not trained for "Gold Command" events - the procedures used across the emergency services to co-ordinate the massive effort needed in a potential crisis.
Only one member of staff was logging all the emergency calls - and she was not a trained typist capable of doing it at speed. Others were writing down important information on scraps of paper. The employee in charge of the control room's white board could not reach more than halfway up it.
Staff brought into the disaster control room could not get to work immediately because ambulance service systems did not allow them to be logged into two computers at the same time.
Meanwhile, crews that had been despatched were not getting messages back to controllers because radio channels were blocked.
In other evidence, Coroner Lady Justice Hallett heard that the ambulance service had switched from using pagers to mobiles to transmit alerts.
Keith Grimmett, an officer in the LAS emergency planning unit, argued that pagers were more reliable in a disaster situation. During 7/7, the capital's mobile network became overloaded with many people finding it impossible to make calls. The service began using pagers again a week after the attacks.
Mr Killens accepted that the government's review of events was wrong when it had stated that rescue operations had not been hampered by poor communications.
LONDON FIRE BRIGADE
One of the key issues that emerged from evidence relating to firefighters was their own safety rules.
One group of firefighters said they could not enter the tunnel at Aldgate because they had not received official confirmation that the live electric rail had been turned off.
One police officer stood on the rail to prove that it was no longer live - but the crew insisted they still needed word from London Underground managers. Four other firefighters had already gone into the train.
The first crew reached King's Cross station at 0913 - but did not go to the scene until a second crew arrived at 0942. That was because their communication protocols demanded having a back-up teams available.
One police officer reported seeing firefighters waiting on the escalator for colleagues to arrive, as the walking wounded began to emerge from a tunnel.
The inquests heard that over at Edgware Road, Assistant Divisional Officer Alan Davies, then head of Paddington fire station, refused to allow his men into the tunnel because of the possibility of a dirty bomb.
Mr Davies told the inquests that his training had been to expect a chemical, biological, radiological or nuclear (CBRN) incident and he could not risk flooding the tunnel with personnel until the situation was clearer.
He accepted that evidence showed that police officers and paramedics went into the tunnel before specialist officers had chance to establish whether or not there was a CBRN risk.
Meanwhile, there were also tensions between the services operating amid the chaos at Aldgate.
One paramedic said he encountered hostility from firefighters who did not understand that his role was to assess the situation and report back before doing anything else.
The police had been switching to a new digital communications system - but at the time of the attacks, they still could not use their radios underground.
At one stage, the emergency services were using runners to get information from tunnels to the ticket halls.
In September 2003, London's emergency services staged a massive training exercise to test their ability to cope with a chemical attack on an underground station. That exercise concluded that none of the radio systems were adequate.
Some of these problems dated back to the horrific King's Cross fire of 1987.
Sir Desmond Fennell's report into that disaster made a string of recommendations including ensuring that communications worked underground - and that the emergency services and London Underground workers could all talk to each other on the same system.
But 18 years later, the Tube's system was still not fully compatible with the three services. The London Underground's system has been updated since 2005.
A succession of senior figures from across the capital's emergency services have appeared before Lady Justice Hallett - but on the final day of the inquests, she told them to use plain English, rather than refer to things like the "Conference Demountable Unit from the Management Resource Unit".
"Management jargon is taking over organisations," said Lady Justice Hallett. "When it comes to something like a major incident, people do not understand what the other person is.
"All you senior people from these organisations are allowing yourselves to be taken over by management jargon... You people at the top need to say 'We have to communicate with other people and we communicate with plain English'."
"I am sorry if that sounded like a rant but everybody who has been here for the last few months will know I have been building up to it."