In Part 1 of our review of major incident management, we focused on management at the disaster scene. In Part 2, we will focus on how hospitals respond to the declaration of a major incident and manage the potentially large number of casualties that can arrive in the aftermath.


Major incident plans

NHS bodies, including hospitals, are Category 1 organisations under the Civil Contingencies Act 2004. They, therefore, have a legal obligation to plan and prepare for major incidents. Written major incident plans are at the core of this preparedness. They fulfil two broad functions: to act as the official organisational policy on major incident planning and to be a reference document for staff on the actions required during a major incident.

A typical major incident plan includes the following:

The core major incident plan – this sets out the organisational arrangements for major incidents and explains these in detail. This will include information on how the Trust board delegates planning responsibilities and who the accountable officer and planning lead. There will also be information on how major incident alerts are received from external agencies, and how a major incident is declared within the organisation.

Action cards – these explain what each person’s role involves when a major incident is declared. There will be an action card for each key role identified in a trust’s major incident plan.

Specialist plans – these deal with specific types of incidents that may occur, e.g. those involving hazardous chemicals or radiation, large numbers of children, or those involving large amounts of patients with burns.


Declaring a major incident

The Ambulance Incident Officer (AIO) usually contacts the hospital switchboard to notify them of a major incident alert. Three messages may be received by the hospital switchboard relating to a major incident, these are:

  • Major incident standby
  • Major incident declared, activate plan
  • Major incident cancelled


Major incident standby – when the standby message is received, the switchboard notifies a core group of management and operational staff within the hospital. At this point, extra staff are not yet called in, but the strategic team involved are now ready to step up the response if the major incident is declared.

Major incident declared, activate plan – this message is relayed when the hospital is required to move to its full major incident response. The switchboard then alerts key members of staff within the that a major incident has been declared trust via a call-out cascade. These key staff members then contact others within their area, and so on, until everybody is informed. At this stage, the Emergency Department is cleared, and staff and equipment are prepared to deal with patients.

Major incident cancelled – this message is relayed when further assessment at the scene results in the conclusion that there does not need to be a major incident response initiated. A cancelled message is then passed on to the management and operational staff that were placed on standby.

Within a hospital, a fourth message, major incident stand-down, may be issued when the hospital response is complete. This will come from the hospital control team when they have decided that the hospital response is finished.


Organisation of the hospital major incident response

The organisation of the hospital major incident response is similar to the gold-silver-bronze structure used at the scene of the major incident.

Gold (Strategic):

In this hospital setting the Gold Command is undertaken by Chief Executive and Trust board. This strategic team can approve the release of funds for equipment and supplies; they also work with other regional agencies to oversee the incident’s impact in the wider community.

Silver (Tactical):

In this hospital setting the Silver Command oversees and co-ordinates the teams providing patient care. They maintain an overview of the situation within the hospital and can make decisions about the allocation of resources. They liaise with tactical teams in other services to share information.

Bronze (Operational):

In this hospital setting, the Bronze Command are the front-line teams directly involved in patient care. This will typically include the treatment teams in the Emergency Department, trauma and emergency medical and surgical teams, anaesthetics and theatres. It also includes the teams that provide the essential resources to allow this to happen, e.g. sterile supplies departments, portering, radiology and laboratory services.


The role of the Emergency Department

Within the Emergency Department, a triage team will assess patients on arrival and decide on their triage category. Usually, this is a senior nurse and a senior doctor at the entrance. The first patients to arrive are usually the least severely injured because they are the most mobile and require minimal stabilisation before transfer. The more severely injured patients typically take longer to stabilise and transfer and usually arrive later.

A different triage system is generally used in the hospital setting to the one used in the field at the scene of the incident. There is no uniform system currently in use, but a common classification is resuscitation, major and minor.

There will also be the usual flow of non-casualties from unrelated events in the Emergency Department. These patients are usually directed to different hospitals, but some may be asked to visit their GP. It is obviously inappropriate to send away someone with a serious medical need just because he or she is not a victim of the major incident, and some patients may need to be kept at the hospital and put through the same triage procedures as those from the major incident.


Header image used on licence from Shutterstock

Thank you to the joint editorial team of for this ‘Exam Tips’ blog post.