Injury (1990)21, 3 7-40

Printed in Great Brifuin

37

The Clapham rail disaster K. L. H. Stevens Consultantin Accidentand Emergency

Richard Partridge Smior Registrarin Accident and Emergenry

St George’s Hospital, London, LJK

At 0814 on 12 December 1988 the 0614 train from Poole travelling at 51 miles/h ran into the back of the 0718 Basingstoke to Waterloo train which had stopped for the driver to report a faulty set of signals. A few seconds later a third empty train from Clapham Junction ran into the wreckage. Thirty-three people died immediately. The emergency services were alerted and senior ambulance officials reached the site within 6 min. St George’s hospital was put on stand-by alert at 0823 and this converted to a full alert at 0848. A Site Medical Team was requested from St Stephen’s Hospital at 0830 and a Site Medical Officer and team from St George’s at 0835. Queen Mary’s, Roehampton, St Stephen’s Hospital and St Thomas’ Hospital were alerted. The site was a difficult one, being effectively divided into three parts, that between the roadside embankment and the trains, that between the trains, and that of the far embankment which abutted the grounds of Emanuel School. Ladders were needed to clamber from area to area over the trains and there were difficulties extricating the patients and then transporting them up the embankment to the road and waiting ambulances. The Site Team from St George’s Hospital left at 0856, the Site Medical Officer following shortly afterwards. The role given to the Site Medical Officer in our hospital Major Incident Plan is the coordination of all medical arrangements at the scene of the emergency, liaison with all hospitals involved, the effective deployment of teams and the formulation of a casualty evacuation plan in conjunction with the Ambulance Incident Officer, including organization of the labelling of triaged casualties and recording any treatment administered. His responsibilities also included the organization of a pathologist to certify death on site, establishing a senior officer as a point of contact to organize volunteers, keeping forensic evidence and giving the standdown signal in collaboration with the ambulance incident officer. On the 12th this role was hampered in many ways. First, communications from team members on the site to the Site @) 1990 Butterworth & Co (Publishers) Ltd 002O-1383/90/010037-04

Medical Officer were limited to relayed shouted messages or scrambling back to the Emergency Control Vehicle which could take 0.25 h. Second, the London Ambulance Service (LAS) did not set up radio links between the Emergency

Figure 1. Accident

scene at Clapham.

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Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.1

Control Vehicle and hospitals until the incident was well established and there were difficulties in using the cell phone in the Emergency Control Vehicle. The Site Medical Officer communicated by sending a team member to the call box in a local public house. We had then at St George’s Hospital no definite infomration on the expected casualty numbers, and indeed the only message received was at 1030 when we were asked if we could take more casualties (numbers unspecified) or would like to stand down. At this stage we had taken 117 patients. We said we could take more major cases but no more minors. We did not know that there were only four patients left on site. Third, by the time the Site Medical Officer was in position the London Ambulance Service had effectively triaged most patients and the first wave of severely injured reached us at 0900. The Site Medical Officer’s role in triage then was limited. Fourth, documentation was poor, our mobile team took triage labels but these were largely irrelevant. We did receive information on the treatment given to patients on site from our own team members returning with the patients, but virtually no information on fluid administration, analgesia, position of the patient in the train or on-site triage category was forthcoming from any other source on site. By 1000 another three mobile teams and some doctors from BASICS were present. By this stage there was virtually one doctor per patient and the main role was certifying and labelling for the temporary mortuary. The three teams were from St George’s Hospital, Queen Mary’s, Roehampton and St Thomas’; in all cases the request relayed informally in person by an LAS officer. In retrospect it appears that it was not intended to request more than one more team. The LAS have since stated they did not formally request the BASICS attendance. Such a plethora of teams, outfits and systems made for confusion at the site. Most team uniforms were yellow with white labels and were not easily distinguishable from those of the emergency services. Our recommendations for site work are that: 1. With large sites, casualty clearing sub-bases

2.

3.

4. 5.

6. 7.

are set up with a Doctor and Ambulance Officer in charge, reporting back to the Site Medical Officer and Ambulance Incident Officer in the Emergency Control Vehicle by means of two-way radios. Communication from site to main hospital and between hospitals must be set up early and be functional. Triage labels with treatment recording labels should be carried by the ambulance service, available immediately at site and used for all patients. Site medical teams should have a distinctive uniform. Call-out of extra manpower or supplies must be at the behest of the Ambulance Incident Officer and Site Medical Officer and made directly to the hospital concerned by the o&&l channel radio links. The evacuation of casualties must be in the order authorized by the Site Medical Officer. All medical and paramedical staff on site must accept this disciplined structure. Most important, we recommend that these provisions be nationally standardized.

There has been much discussion on the identity of the Site Medical Officer. Our experience is that it is very helpful to have a Site Medical Officer from the main receiving hospital, he will know about local resources and can discuss the site situation in context. There are, of course, disasters in sites

such as Lockerbie with no large hospital nearby. For these sites national or regional teams should be provided to be called on at short notice. Teams must be of a high standard of education and expertise, quickly available in all areas of the country, and provide a permanent and predictable pool. They cannot be dependent on volunteer support. With regard to the alerting of four hospitals in the same area, there has been much debate about the correct use of several hospitals in disaster planning. On the positive side if there is a wide distribution of patients each hospital may be able to assess their patients more thoroughly. On the negative side, not all hospitals in the area will be equally suited to major trauma work. Certainly the scenario where, as happened here, hospitals go on to full alert, clear accident and emergency departments and cancel lists and outpatient clinics and then receive few or no patients, is not satisfactory. The normal service for the local population must be continued. Part of the responsibility for this lies with each hospital and its interpretation of the correct response to a warning alert. However, we would recommend that the primary alert goes to the main hospital only and that this is backed by a full picture of the incident provided by Ambulance Incident Officer and Site Medical Officer. The main hospital then decides on the necessity for backup and whether to distribute patients u priwi or after a set load is taken. Good communications to site and between hospitals are indispensable to this decision-making process. By 0900 we received the first casualties at St George’s Hospital. By 1010 we received 119. One was dead on arrival and 41 were admitted. St George’s Hospital is a 100O-bed hospital with a brand new Accident and Emergency Department, opened 1 week before the incident. The Accident and Emergency Department contains three operating theatres, a five-bay resuscitation room, stretcher provision in the majors and children’s areas for 21 patients and sitting accommodation in the minors areas for 16.In addition there is a l&bed day surgery unit which we used for treating the walking wounded. The hospital contains three sets of main operating threatres and includes cardiothoracic, faciomaxillary, paediatric and plastic surgical provision. Neurosurgery is provided within the hospital group at Atkinson Morley’s Hospital, 2 miles away. In this context the 10 patients needing immediate airway management represented two throughputs of the resuscitation room, the other 31 major cases, just under two throughputs of the major areas and the 78 minor cases four throughputs of the minor area and one of the day ward. All patients had been assessed, the minors treated and the majors stabilized and mostly warded or taken to theatre by 1100. The hospital reception plan separates the role of Triage Officer from that of Hospital Medical Officer. The consultant in Accident and Emergency is Triage Officer and has responsibility for clearing and preparing the department, calling in Accident and Emergency medical staff and is then stationed at the entrance to receive and triage casualties as they arrive. The Hospital Medical Officer is responsible for the allocation of hospital medical staff to areas in the Accident and Emergency Department, the mobile team and to the wards. They coordinate the transfer of live casualties to the casualty receiving ward, ITU and theatres. The only problem with triage on the day was the opening of a side entrance door by non-Accident and Emergency staff, which allowed two mini-buses of casualties from the Emanuel School to bypass the triage point. Two patients then needed transfer from the minors area to the majors area.

Stevens and Partridge: The Clapham rail disaster

Within the department teams of anaesthetist, surgical registrar (SR), house physician and nurses were assigned to each resuscitation bay, being replaced as they sent each patient to the ward or theatre by a standby team who received the next patient. A nurse and a doctor were assigned to each stretcher cubicle and at least six doctors under the control of the SR in Accident and Emergency to the minors area. This worked well as a system except that the numbers of people involved meant that better identification of the doctor or nurse in charge of each section or team was needed, and control of the Brownian motion of junior medical staff was difficult to maintain. There was also a reluctance of senior nursing and clerical staff to accept a junior position in the context of a major incident. For the future we have tabards designating personnel in charge and arm bands indentifying all our accident and emergency staff. All other hospital staff and volunteers within the department will also be required to wear such identification as a safeguard against unauthorized and media intrusion. Documentation problems continued into the department and indeed into the wards. Only Accident and Emergency doctors seemed familiar with the major incident printed record form or used it routinely. The recording of baseline observations in the inpatient notes was poor and on occasions patients became separated from their notes and/or radiographs. A nationally standardized major incident record card would perforce become familiar to medical and other staff which does not happen where each Accident and Emergency Department keeps its own version. The problems of communication pursued us into the hospital and continued well into the night. Many enquirers found the police information lines either unobtainable or unhelpful and rang our department directly. This meant that the afternoon and night clerical and nursing staff were perpetually bombarded by calls from distressed people who they were often impotent to help. For many staff this was the worst experience of their day. We have now written some protection for them into our hospital plan in the setting up of a helpline number, manned by an administrator or psychiatrist, which will be activated in the event of disaster. The main responsibility for this area must, though, remain with the police and there are obviously deficiencies needing revision. Of the patients admitted three died and three were left mentally or physically disabled. Amongst those admitted there were 19 chest, 20 head, II: spinal, 8 pelvic, 7 visceral injuries and 26 fractures and dislocations. Of those discharged, there were 10 fractures, 21 lacerations, 17 abrasions, 39 contusions and 5 whiplash injuries. Amongst those who died one had an Injury Severity Score of 50, one of 43, and one of 24. The latter was a diabetic with chronic obstructive airways disease who died of multisystem failure and sepsis. Twenty-one operations were performed on the 1st day, 5 on the second and there were 17 later operations; 5 patients had multiple operations. Seven significant injuries were missed or underestimated on the first assessment in the Accident and Emergency Department, many being picked up during the afternoon ward round. These cases illustrate the absolutely essential importance of a systematized approach to the multiply-injured patient with emphasis first on respiratory and circulatory sufficiency and the cervical spine, second on intra- and retroperitoneal injuries, head injuries and the rest of the spine and lastly on faciomaxillary, genitourinary and limb injuries. In no case was it thought that the patient’s long-term outcome was affected, but our

39

policy of systematized assessment had not been fully observed. All patients in a major incident should be checked before decisions about their subsequent management are made by a doctor trained in the assessment of the multiply-injured patient. All major hospitals should encourage their surgical staff to attend an Advanced Trauma Life Support Course. Lastly the aftermath. This fell into two areas. First, VIPs and the media. It must be remembered that a major incident represents a significant disruption of a hospital’s work. It takes at least a week to stabilize the disaster patients and resume normal working for all the other patients who continue to attend the Accident and Emergency Department, outpatients and wards. At St George’s Hospital we only closed the Accident and Emergency Department to other patients for 2.5 h in order to receive the Clapham patients. Our work was disrupted for 4 h on the subsequent 2 days by visiting dignitaries, and there were also several other lower key visitors who caused less disruption to activity. Against this it may be good for the morale of patients and staff that such visits happen. We would recommend that into the present melting pot of thoughts around disaster planning is put consideration of the style and timing of such visits. Generally, fact finding visits are best delayed until the staff concerned have had a chance to debrief and analyse the problems and successes of the events. From the media perspective it is wrong that clinicians have to interrupt their treatment of a patient to safeguard the patient’s confidentiality by evicting the press. We need to come to a civilized agreement where information is made easily available for the media by hospital, emergency and other agencies so that the harassment of patients, individual members of the public and clinical staff is stopped. If such a national agreement cannot be made and kept as a matter of honour, then we feel there may need to be some legislative control. Second, the psychological aftermath. We arranged experience-sharing sessions for all staff involved in the reception of the casualties from Clapham on Friday, 16 December. These took the form of groups of from 10 to 16 staff of mixed grade and type, with a facilitator external to the episode. Individual follow-up was also offered if wished. The ambulance service were offered similar groups by the department of psychiatry; their uptake of this offer was variable. We have concluded that staff should off-load and that this is best built into standard incident protocol as a routine debriefing session. Counselling can be offered on an individual basis as well. From the public perspective: the children of Emanuel School who helped rescue patients were offered help by a psychotherapist with children at the school; the patients were all sent a leaflet on the possible after-effects and offered individual counselling either in their locality or at St George’s Hospital. Groups were also run at St George’s and in the locality. Patients were sent questionnaires on depression, anxiety and the Impact of Events Scale at I week, 1 month and 3 months and the results of these analysed. From the results some patients were actively encouraged to seek counselling if they had not already done so. Although these arrangements seem to have worked well they came together partly as a result of certain research work already under way in the Accident and Emergency Department and partly from the deliberations of a rapidly constituted steering group of Accident and Emergency Consultant, Psychiatrist, social services and chaplaincy. We recommend the institution of a National Crisis Advice Group similar to that of Norway

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Injury: the BritishJournalof Accident Surgery (1990)

where a small team of psychologists, social workers, etc., are available to help those involved in a major incident to provide convalescent advice. In summary it must be said that tribute must be paid to the speed and efficiency of the rescue services and to the commitment and skill of the hospital staff and all those carers whose work in Dorset, Hampshire and Surrey continues. We have dwelt on the problems which arose as it is from these

Vol. 21/No. 1

that we have learned lessons which have led us to revise our policies and which are hopefully useful pointers from the national perspective.

Requesfs for reprints

shodi be adhstd to: Dr K. L. H. Stevens, Consultant in Accident and Emergency, St George’s Hospital, Blackshaw Road, London SW17, UK.

The Clapham rail disaster.

Injury (1990)21, 3 7-40 Printed in Great Brifuin 37 The Clapham rail disaster K. L. H. Stevens Consultantin Accidentand Emergency Richard Partridg...
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