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Coroner publishes recommendations from 7/7 inquest
Lady Justice Hallett says the recommendations "may save lives" in the future.
This morning the coroner raised concerns about the failure to implement recommendations made after the 1987 King’s Cross fire about underground radio communication by the time of the July 7 attacks. “I don’t want to make recommendations that go to the question of saving people’s lives and think that it’s going to lie on a shelf for 15 years.”
During the inquest a succession of witnesses had reported that the emergency services were overburdened by rules and regulations that prevented them reacting more quickly.
However, Hallett commented today that the evidence “does not justify the conclusion that any failings of any organisation or individual caused or contributed to the deaths"
The hearing heard that it was impossible to know if any of the 18 victims who survived the initial blasts but later died, could have been saved if they had received attention sooner.
Graham Foulkes, whose 22-year-old son David was killed by Khan at Edgware Road, is reported to have said in the Guardian that he hoped Lady Hallett would expose “the failings of the security service and the inadequacies of the emergency services."
The evidence at the inquest revealed the confusion of the emergency services and transport controllers as the full extent of the situation emerged on 7 July 2005.
There was a shortage of vital equipment, and mobile phones and radios did not work underground, the inquest was told.
The coroner heard about a delay of nearly 30 minutes in getting firefighters into King's Cross station and that they waited, thinking there could be a chemical or biological attack below, despite the fact that travellers who had made their own way out of the station showing no such signs.
Summary of Lady Hallett's recommendations
- I recommend that consideration be given to whether the procedures can be improved to ensure that “human sources” who are asked to view photographs are shown copies of the photographs of the best possible quality, consistent with operational sensitivities.
- I recommend that procedures be examined by the Security Service to establish if there is room for further improvement in the recording of decisions relating to the assessment of targets.
- I recommend that the London Resilience Team reviews the provision of inter-agency major incident training for frontline staff, particularly with reference to the London Underground system.
- I recommend that TfL and the London Resilience Team review the protocols by which TfL (i) is alerted to major incidents declared by the emergency services that affect the underground network, and (ii) informs the emergency services of an emergency on its own network (including the issuing of a ‘Code Amber’ or a ‘Code Red’, or the ordering of an evacuation).
- I recommend that TfL and the London Resilience Team review the procedures by which (i) a common initial rendezvous point is established, and its location communicated to all the arriving emergency services (ii) the initial rendezvous point is permanently manned by an appropriate member of London Underground.
- I recommend that TfL and the London Resilience Team review the procedures by which confirmation is sought on behalf of any or all of the emergency services that the traction current is off, and by which that confirmation is disseminated.
- I recommend that TfL (i) reconsider whether it is practicable to provide first aid equipment on underground trains, either in the driver’s cab or at some other suitable location, and (ii) carry out a further review of station stretchers to confirm whether they are suitable for use on both stations and trains
- I recommend that the LAS, together with the Barts and London NHS Trust (on behalf of the LAA) review existing training in relation to multi casualty triage (ie the process of triage sieve) in particular with respect to the role of basic medical intervention.
- I recommend that the Department of Health, the Mayor of London, the London Resilience Team and any other relevant bodies review the emergency medical care of the type provided by LAA and MERIT and, in particular (i) its capability and (ii) its funding.
Recommendations previously put forward by the bereaved families included:
Recommendation A: Inter-Agency Training
LAS, LFEPA/LFB, Metropolitan Police, COLP, BTP, TfL/LU, and HEMS to give urgent consideration to:
- (a) whether there is any insurmountable reason why inter-agency major incident training cannot be undertaken, at all levels including frontline staff; and
- (b) whether such training should be compulsory; and
- (c) the regularity of such training, and in particular whether it can be mandatory for all staff to attend within a specified period; and
- (d) whether the content of any existing inter-agency traning should be reviewed to ensure it is as practical as possible
Recommendation B: Language
All organisations which have been represented in these inquests to give urgent consideration to the use of ‘plain English’ in managing major incidents, and in particular to minimising the use of jargon and acronyms.
Recommendation C: Alerting Other Agenices to Declaration of Major Incident
Consideration to be given to a system/systems to alert all emergency services once a major incident is declared by one agency (and, if necessary and appropriate, transport services).
Recommendation F; RVPs [TfL]
It is recommended that form the outset of an incident the TfL station supervisor shall be responsible for ensuring that all members of the emergency services are met at a designated RVP; or for transferring them if necessary, either to the station control room or to another location (such as the Joint Emergency Services Control Centre). This shall be the supervisor’s responsibility, and, if not available, he/she shall deputise someone in his/her place to fulfil this role. The supervisor will ensure that the RVP is constantly attended throughout the continuation of the incident.
This recommendation must also be brought to the attention of the other emergency services.
Recommendation H: LUL Emergency Response Vehicles (‘ERVs’)
It is recommended that there should be providion of blue flashing lights for the five emergency response vehicles that attend any scene in rapid response to an emergency incident.
Recommendation U: LFB and Operational Discretion
It is recommended that the LFB consider whether its procedures might be amended to permit firefighters a greater degree of discretion when considering whether to proceed to the immediate site of an incident without delay.
Recommendation W: Record Keeping and Disclosure
It is recommended that:
(a) Following on from any major accident, personnel from each of the emergency services (and any other relevant institution) be directed:
- i) to retain any documentation created either during or in the aftermath of that incident; and
- ii) that they forward it to an identified individual within the institution concerned.
(b) Thereafter, such individual to be responsible for:
- i) collating the information; and
- ii) arranging for its safe storage.
(c) In the event of any future inquiry, all such material to be made available to the institution’s legal advisors, such that timely decisions on disclosure can be made.
Preventability
Computers and Databases
4. It is recommended that consideration be given to whether the existing computer systems and databases can be improved in order to ensure that strands of intelligence can be drawn together in a more efficacious manner.
Photographs
8. It is recommended that consideration be given to whether the procedures can be improved to ensure that human sources of intelligence who are asked to view photographs are shown copies of the photographs of the best possible quality, consistent with operational sensitivities.
To view the Coroner's recommendations in full, click here.
