Major incident in Kent: a case report

A major incident was declared after a road traffic accident involving 150 cars and 200 people in Kent, England. The emergency services oversaw coordination of the scene, recovery and triage of casualties and transfer of patients to hospital. The crash was one of the worst seen on British roads and it has been hailed as a miracle that there were no deaths and very few serious injuries. This case report is a retrospective analysis of the regional health system’s response to the crash. The structure is based on the content of a report submitted using an online open access template for major incident reporting (Scand J Trauma Resusc Emerg Med 22: 5, 2014; http://www.majorincidentreporting.org). A more comprehensive analysis of the incident has also been the theme of a Masters thesis (Hardy S. Reporting Major Incidents in England: Putting Theory into Practice. England: Queen Mary’s University of London; 2014).


Introduction
On 5th September 2013, a road traffic accident occurred on the Sheppey Crossing bridge in Kent. It happened at 07:15 under thick fog where visibility was reduced to 25 yards. As the fog lifted, it was evident that the pile up involved cars extending across most of the 1270 metre long bridge. There were 69 casualties but no fatalities occurred. Although declared a major incident, there was minimal disruption to the routine emergency and healthcare services.

Pre-incident data
The Isle of Sheppey is an island in the district of Swale off the North coast of Kent in England (Fig. 1). It has an area of 36 square miles and a population of 37,852. The population density of Swale is 3.49 people per hectare. Many of the inhabitants commute over one of two bridges that connect the Isle of Sheppey to mainland Kent. The Kingsferry Bridge is a combined single carriageway road and railway bridge and was the only connection to the mainland until the Sheppey crossing bridge was built in 2006. The Sheppey crossing runs alongside the Kingsferry Bridge and carries the A249 trunk road. It has 4 lanes with a 70mph speed limit and does not have a hard shoulder. It is unlit and has no matrix warning signs. Telecommunications are a vital part of England's infrastructure and are managed by competitive, commercial companies. As category 2 responders, telecommunications "fixed" and "mobile" network providers can be called upon for cooperation during major incidents.

Emergency Medical System (EMS) background
Emergency medical response in the UK is provided by local ambulance services known as National Health Service (NHS) trusts. The South East Coast Ambulance (SECAmb) service NHS trust covers Brighten & Hove, East Sussex, West Sussex, Kent, Surrey and North east Hampshire, an area of 3600 square miles. Emergency (999) calls are put through to one of 3 Emergency Operations Centres (EOCs). From here they are triaged to provide an appropriate response. As soon as initial reports indicate that a major incident may have occurred, the senior person on duty at the EOC will initiate the major incident plan. Figure 2 shows EMS background data from the online report [1].

Incident characteristics
Despite heavy fog and low visibility some drivers approached the Sheppey bridge at speed and without lights. This culminated in a pile up involving over 150 cars. The crash continued for 10 min as vehicles continued to hit each other. More than 200 people were assessed at the scene and 37 of these required hospital treatment. A further 32 people presented to minor injuries units. The Bridge was closed for 10 h following the incident to allow for assessment and treatment of casualties and for a full investigation and clear up operation to be carried out. As the fog lifted, the 30°C heat and the prolonged period stranded outside began to put those remaining on scene at risk from dehydration, lack of food and exacerbation of pre-existing illnesses (Fig 3).

EMS response data
The first ambulance responders on scene reported that hundreds of cars were involved with some priority 1 (P1) casualties (Fig 4). The incident response lasted for just over 10 h (Table 1) and the Sheppey Crossing was re-opened to routine traffic at 17:30 that day.

On-scene EMS work
There were hundreds of people milling around on the bridge which, in addition to safety issues, made it difficult to assess and triage casualties. The first AIC liased with senior counterparts from the police and fire services and asked them to clear everyone that was still walking, off the bridge and to a Casualty Clearing Station (CCS). A practitioner paramedic (PP) was assigned to triage the walking wounded at the CCS while ambulance crews were sent in teams of 3 to triage the casualties who remained on the bridge. Each team was assigned a car, each of which by this point had been numbered by the police. They were to be involved in extrication and stabilisation on scene if necessary and then transport the casualty to an awaiting ambulance. An ambulance parking officer was assigned to control the ingress and egress of ambulances.

Triage
The Sieve and sort method of triage [2] was used for casualties on site and tagging was carried out using cruciform cards and wrist slappers. Although SECAmb crews were ordered to stabilise casualties before transport, there were no reports of invasive procedures or interventions. Due to a lack of a loggist on scene during triage and recovery, there is a paucity of official information on this.
Two Hazardous Area Response Teams (HART) were deployed to the incident and assisted with triage. It was felt by both the first Ambulance Incident Commander (AIC) and the designated AIC who arrived later that a medical incident officer (MIO) or Medical Emergency Response Improvement Team (MERIT) were not needed. The triage and transport of patients was under control and their aim was to get the injured away form the scene and to hospital as soon as possible.

Medical communication difficulties
Prior to the arrival of the silver manager on scene, senior command was finding it difficult to obtain any hard information about the incident. It wasn't until 11:00, when the communications officer had been set up and the last casualty had been transported from scene (11:05) that accurate information started to come through. The NHS commissioning board recommends the formation of a Strategic Coordinating Group (SCG) for large or widespread incidents that require multiagency discussion and coordination [3]. This is usually formed and chaired by the police but the police did not hold a SCG meeting until 14:00. This meant that there was no designated meeting point for all the agency tactical and strategic levels to assemble and coordinate a formal command and control response.

Structure of medical incident command during the major incident
The NHS commissioning board has published a framework for command and control structure in response to a major incident [4]. It follows the nationally recognised structure of bronze (operational), silver (tactical) and gold (strategic) command [5].
The bronze manager is normally the first level of command to be established. In this case, it was the first paramedic of enough seniority on-scene who established herself as the temporary AIC. A number of other bronze managers were allocated specific roles on-scene following this (eg. casualty clearing officer, communications officer). The silver manager develops a tactical plan to achieve the objective set out by the gold command. In this case, there were 2 silver managers: one on-scene who took over the role of AIC from the first bronze manager on scene and one off-scene who established himself at one of the EOCs. The gold manager has overall control of the organisation and liases with gold command of other task forces.

On-scene resources
Over 200 members of the public were involved in this incident. It was attended by 24-30 policemen (12-15 police vehicles) and 31 firemen (6 fire vehicles). There were approximately 20 ambulance crew members and in addition to this, 5 paramedic practitioners (PPs) and 3 critical care paramedics (CCPs). One air ambulance crew and 2 HART crews were also deployed. The council and various charity organisations provided food and water.
Hospitals receiving patients 37 casualties were taken to receiving hospitals by the emergency services. A further 32 casualties attended one of two local minor injuries units. The receiving hospitals, the relative distribution of patients, the distance from the incident scene and the type of Hospital are detailed in Table 2.
Casualties arriving at the Medway Maritime Hospital (MMH) were triaged by the Emergency department registrar into either the resuscitation area or the trolley area. They were not given a formal category (expectant, immediate, observation, wait and dismiss) as advised in the hospital's major incident plan. At the William Harvey Hospital, casualties were triaged on arrival by the nurse looking after them into 4 categories (immediate, urgent, delayed, fatality) according to the hospital's major incident plan. There is no information on the triage system used in the other receiving hospitals.
The ambulance service is responsible for casualty distribution and alerting the receiving hospital(s). Casualty distribution is a dynamic decision based on injuries, capacity, access and egress. Fig. 4 The CHALET mnemonic is used to report a major incident