Intended for healthcare professionals


Are British hospitals ready for the next major incident? Analysis of hospital major incident plans

BMJ 1996; 313 doi: (Published 16 November 1996) Cite this as: BMJ 1996;313:1242
  1. Simon Carley, Royal College of Surgeons of England Hillsborough research fellowa,
  2. Kevin Mackway-Jones, consultanta
  1. a Department of Emergency Medicine, Manchester Royal Infirmary, Manchester M13 9WL
  1. Correspondence to: Dr Carley.
  • Accepted 26 September 1996

Although major incidents are uncommon, they require careful planning and preparation if they are to be managed well.1 2 In 1990 guidelines were issued for health service arrangements for major incidents.2 These required regional health authorities to ensure that comprehensive plans were in place for all health service responses to an incident. We examined hospital major incident plans to assess the level of compliance with these guidelines.

Methods and results

The major incident plan was requested from all 224 British hospitals with an emergency department receiving more than 30 000 patients a year. Altogether 142 (63%) were received and analysed. The number of plans complying with different aspects of current guidance are shown in table 1.

Table 1

Number of emergency plans that contained specified elements of planning

View this table:

Although 119 plans used action cards, in only 65 were these comprehensive enough to include all staff likely to be involved in the response to a major incident. In only 106 were cards for the hospital coordination team (senior nurse, senior manager, and senior doctor) available. Overall only six (4%) plans complied fully with health service guidelines.


Clear directions were given in 1990 for the formulation of hospital major incident plans,2 but these findings, six years later, show that few plans conform to the guidance given. Action cards act as aides-memoire and are essential to inform staff rapidly of their duties during a major incident. Although many hospitals used action cards, most had too few to instruct all staff. Concern at alerting procedures has been expressed following many major incidents in Britain.1 3 4 The ambulance service will usually notify hospitals of a major incident using a specified form of words,2 designed to avoid confusion between agencies. Yet the correct form of words was specified in fewer than half the plans analysed.

Many people may arrive at a hospital during a major incident. Plans were generally in place for the management of the press, relatives, and volunteers, but few arranged for the management of visits from people such as politicians or royalty; these may be disruptive to a receiving hospital in the days after an incident and should be planned for.2

As well as the actions specified in the official guidance plans also need to pay attention to practical matters such as the management of traffic flow, staff children, staff reporting areas, and ambulance communications. Few plans covered these subjects.

Major incidents require good interservice liaison.1 This is provided through police and ambulance officers despatched to the receiving hospital. Although most plans cater for the police, few plans made arrangements for the ambulance liaison officer (who may be the only means by which the hospital can communicate with the scene).

Insufficient training and preparation have repeatedly been cited as problems in the preparation for major incidents,5 yet few plans specified plans for audit or the training of staff. Few plans specified procedures for the management of children, and when they were included they typically consisted of the use of a paediatrician to help in the triage and treatment of paediatric casualties. This is unlikely to be adequate in an incident resulting in large numbers of injured children.

Health service guidelines state that plans should be reviewed at regional level. The small number of plans conforming with current guidance shows that this review procedure is not effective. Most hospital major incident plans need revision, and methods of reviewing plans should be strengthened in the light of these results.


  • Funding SC's fellowship is funded by the Hillsborough Fund.

  • Conflict of interest None.


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