I: It’s Monday November the 12th 2012. I’m Richard Barratt, I’m here today with Trish Willis at the Association of Anaesthetists to interview Dr Andrew Hartle. Andrew thank you very much for coming along today, primarily we want to talk about the events that happened seven years ago and has now become known as 7/7. Perhaps you could give us some background beforehand; you work at St Mary’s?
P: Yes I’ve been a consultant at St Mary’s since 2001, principally at that stage an anaesthetist but who did intensive care on call, but most of what I did was anaesthetics. And in July 2005 I’d just taken over as the Service Director orLlead Clinician for anaesthesia at St Mary’s. Just a month before I’d taken over from William Harrop-Griffiths. So I was a relative new Lead Clinician just coming to terms with what that entailed.
On the 7th of July it was just an ordinary working day and I was quite looking forward to doing an operating list, actually going and anaesthetising some patients, because that was quite a good way of escaping from all the emails and correspondence of Lead Clinician.
I: What time did you learn that things weren’t going to be a normal working day?
P: The operating list was supposed to start at half-past-eight, as I’m afraid was quite a common occurrence at that stage. There were no beds for the patients to get into so we were twiddling our thumbs. I think we finally got the first patient into the anaesthetic room about quarter-past-nine and I had a trainee with me who happened also to be on call so they had one of the cardiac arrest bleeps. The two of us had just gone through the double doors into the anaesthetic room when the trainee’s pager went off, and I sort of rolled my eyes ‘cause I was assuming it was going to be cardiac arrest somewhere, the trainee was going to disappear and I wouldn’t see them again for a couple of hours. But it actually said, ‘Major incident at St Mary’s’ which wasn’t what I was expecting and maybe turned a bit cold. He sort of looked at me and I just said, ‘Go straight to Resus’ because I knew the Major Incident plan pretty intimately so I knew that was where they had to go. I clearly wasn’t going to start the case, I can’t even remember if I said anything to the patient or if I apologised but I think I just left. And about the same time my air-call pager went off and gave me the text message, ‘Major incident at St Mary’s.’
I think the first thing I did was walked up and down the main theatre corridor to make sure that each and every theatre knew that the Major Incident alert had gone out and to make sure that no one who hadn’t started did start. And in fact we weren’t being very efficient that day ‘cause at least half the theatres hadn’t started, and also to make sure that anyone who finished a case didn’t start anything else. And that probably took me five minutes. And then I went to Resus, which is three floors down and it was already getting quite busy, lots of people not quite running around but lots of activity, a bit of a hubbub but at that stage still no real news about what it was.
I: So we’re now about half-past-nine?
P: Yeah I think probably 20 or 25-past-nine by the time I get into Resus. And I remember meeting William, my predecessor, and Nicola Batrick who is one of the A&E consultants and a very good friend of mine, a colleague I know very well, and Trish Ward, another one of the A&E consultants. And the four of us had a sort of huddle, you know, “What’s going on?” . I’m fairly certain that they said something about bombs going off on the Tube. BBC news was talking about power surges but I’m pretty certain that almost as soon as I arrived in Resus someone mentioned bombs and that all of a sudden the very cold reality check that that’s not the sort of thing people make up, that’s not a rumour. And I can remember a conversation between William and me as to which of us should do what. William I think had been running Resus for St Mary’s last major incident and St Mary’s, of all the London hospitals, has probably had more major incidents over the years than the others, partly because it’s next door to the railway station. And we agreed that I would stay in Resus and that William would go up to the fourth floor to theatres and man the phone in the office and he would be my point of contact so that the Emergency Department could stay in touch with theatres so they knew what was coming.
I: So at that stage everything was just clicking into place for a major incident?
P: The main Resus bay at St Mary’s has four trolleys, four areas so the first thing we did was to make sure that we had an anaesthetist in each bay, and interestingly enough of course the first two people that turn up are the two trainees with cardiac arrest bleeps. So the first two bays have a senior house officer and a registrar in, and then as consultants begin to arrive they filled up bays three and four and then we staffed a separate bay in paediatrics; and then there’s another room which is the old plaster theatre, which is also set up for resus. So we had six bays, one notionally for children. It became quite apparent to me that the first patient was going to go into bay 1, which at the moment just had a slightly anxious looking senior house officer. But the noise had settled down, I think people were beginning to expect this was real and the word ‘bombs’ had been mentioned now and that’s what we were expecting.
Everything was in place, everyone had checked their equipment. I’d done lots and lots of rehearsals and if you’re doing drills and things certain things actually happen and other things say, ‘At this point this would happen’ but at this point the haematology staff actually did turn up with ‘cool boxes’ of blood. And again, this is real now. And then there was a few moments of calm, sort of calm before the storm, because everything was ready, I was at the far end of Resus which is where the patients would come in where the first bay is. And we were all just waiting and no one knows anything, it’s the sense of the unknown and also sense of anxiety because although I’d been in the military and I’d done… I seem to have spent vast amounts of my career doing exercises and practising for major incidents, I’d never actually done one. Although St Mary’s had done quite a few over the years I’d never actually been there when it happened. There was a lot of anxieties, what is it actually going to be like for real when we have real patients and how are we going to do, am I going to make a complete fool of myself?
The next thing I remember is that the door, the double doors opened and a chap in a suit covered in soot walked in. So he’d clearly come from some sort of incident but he wasn’t in the right bit, he was obviously walking-wounded and he was ushered away. And there was sort of a moment of relief there that that was not the moment. And then the next thing that happened is our very first patient arrives and there’s so many different bits of that mental picture that I can’t forget. So the first thing is I’ve never seen anything like it, I could tell you it was a male and he was a big chap. He was covered in soot and smoke and black from top to bottom, absolutely devastating injuries, just to the naked eye one leg almost completely severed, the other one hanging off almost certainly not going to survive and that was the first thing you saw. And the other thing I remember very clearly is the paramedic who I knew quite well, I’d actually trained him, when he was doing his paramedic course I’d actually… he’d spent quite a lot of time with me in theatre learning how to cannulate and how to intubate. And he was a very sensible chap, the sort of guy you would want to be there and he just looked unlike I’d ever seen him before. He had his day-glow jacket which was, again, covered in soot and dirt and whatever, and he was bright red in the face and the sweat was pouring off him and he clearly… he was in control, don’t… but he wasn’t the normal calm, whatever he’d been to and seen was clearly utterly different from anything he’d ever seen before.
That patient goes into the first bay and resuscitation starts and he’s conscious at that stage. I can remember thinking oh my God if that’s the first one what’s the rest of them going to be like? What you’re taught is that the first patients that arrive aren’t the sickest. That team seemed to be getting on with things pretty well, in fact about that time another consultant turned up and I directed him into that bay because at that stage there was still a fairly junior trainee on their own. And Resus seemed to fill up really quite quickly, I think number two and number three were both lower limb injuries – most of what we were dealing with was lower limb injuries and certainly at least one other patient who was obviously going to lose a limb. And then the fourth patient didn’t come straight into Resus, the fourth patient had actually been triaged into majors but they had facial burns, flash burns and were re-triaged into Resus. So we’ve got all four Resus bays full now and I can remember it was beginning to get a bit uncomfortable, I was constantly liaising with Nicola Batrick as to how long do we keep them here and how quickly do we get them upstairs? And we wanted to get the leg injuries upstairs as fast as possible. We still didn’t have a feel about how many patients we were going to get and how sick they were going to be. And what we didn’t want to do was fill up the empty theatres with patients who could wait and because you don’t know what’s coming it’s a bit of a balancing act.
I was moving up and down Resus making sure everyone was OK, that they had what they wanted, that they didn’t need anything else and bays 2 and 3 were fine. The girl with burns, I can remember having a conversation with the anaesthetic consultant there about whether we should intubate her and both agreed that we should do it now before the facial swelling got any worse. So everyone seemed to be fairly contained, self-contained, they knew what they were doing and no one was any trouble. And then I was aware of the commotion back in bay 1 with the really sick guy with the multiple injuries and he’d had a cardiac arrest; and I think I actually said very loudly… ‘cause the noise was beginning to creep up, ‘Cardiac arrest bay 1’ which brought silence to Resus. He was resuscitated quite quickly, he was intubated. And then we weren’t quite sure what his injuries were, he certainly had devastating lower limb injuries and he had presumably blunt injury, he didn’t have any open injuries to his chest or abdomen but he had facial injuries where his pupils was dilated and we began to worry that he’d got blunt chest trauma. Professor of Cardiology turned up and did an echocardiogram there and then and it showed that his heart was fine. It became pretty obvious that this guy was bleeding to death. It’s quite interesting to compare what we were doing in 2005 to what we’re doing now, ‘cause in 2005 the civilian practice in this country had yet to learn from the military, from Iraq and Afghanistan. And we weren’t using tourniquets, although interestingly at the inquest a member of the public, he’s still absolutely adamant that he put tourniquets on his patient, I didn’t see any tourniquets so people’s recollections can be clouded. But this guy was bleeding to death and he needed to get to theatre, he needed to get his legs off. One of the consultant orthopaedic surgeons turned up at that stage, ‘cause we knew one leg was off and we didn’t know whether the other one would survive – he just took one look at it and said, ‘It needs to come off.’ And that actually makes life easier.
So we began shipping patients up to theatre and I was staying in contact by phone. And the other thing we did was we were very concerned about this dilated pupil and St Mary’s, at the time, didn’t have neurosurgery, it was before we were a trauma unit. And I don’t know who made the call but someone phoned Charing Cross, and again, at that time Charing Cross was a completely different Trust to St Mary’s, we’re all merged now but at the time they were just another hospital. And we arranged for a neurosurgeon and the neuroanaesthetist to be ferried across to St Mary’s in case we ended up doing a craniotomy. So he went upstairs to theatre. And I think at one point we had all six Resus bays filled, but all with adults, we didn’t have any children, and certainly grateful we didn’t have children. The timing of the bombs, 10-to-9, hopefully most kids would’ve been at school that day but otherwise the risk of attack on the public transport network, the odds of children being involved were very high, it was just that little bit later in the day.
So we were getting slightly anxious that we’d reached our maximum capacity but in fact we managed to move people up to theatres quite quickly.
I: Can I just ask how you know what’s the rate-limiting step, is it in the Emergency Department where you’re receiving patients or is it in theatres or does it go beyond?
P: I think it depends on the major incident because no two major incidents are the same, each will have its own pattern of injury. So talking to colleagues who’d been at St Mary’s for the Ladbroke Grove rail crash, most of the injuries they had were relatively minor trauma, orthopaedic trauma, but burns principally. This was a bombing in an enclosed space so we were seeing predominantly lower limb injuries. Getting that balancing act right so we’re not clogging up Resus but then also not clogging up the operating theatres, that was where communication between Resus and theatres was crucially important. The timing worked enormously in our favour, because it was the beginning of the day and an awful lot of operating theatres hadn’t started and a lot of those that had started weren’t doing particularly big cases. And in fact in one case there was a major cancer case, oesophagectomy, where they put the patient to sleep but hadn’t started and the surgeon and anaesthetist made a decision, which I think was quite right at the time, to wake the patient up and not start operating because that theatre would then have been out of use for probably 12 or 15 hours. And in that very early 30 minutes when we had no idea how many patients were going to come I think that was the right decision. . In retrospect that patient could actually have had his operation and it wouldn’t have affected things, but you only know these things after the event.
So we got up to six priority one patients, but quite quickly we began to clear Resus. And there’s one moment that really sticks in my mind, when the first patient left the first bay and went up to theatre, a huge gaggle of people around them, that Resus bay was just absolute carnage. I mean the floor was soaked in blood and clothes and bandages and dressings and all sorts, it was just… and I can remember the cleaner turning up with his mop and bucket and he just got on and started cleaning the bay ready for the next one and we didn’t know whether there would or wouldn’t be another one. So in the middle of all this chaos this guy was basically just doing his job, which to say so, we were all just doing our jobs, we were just doing slightly not the job we’d expected to do when we got there.
As Resus began to clear I can remember doing some rounds in majors because there were patients, majors who were going to need to go to theatre but there weren’t any anaesthetists out there. So I actually did some preoperative assessments on some patients so that they would arrive in theatre having been seen and assessed, and phoning upstairs and telling them what’s coming up. I can remember seeing a young American girl, and I can’t remember what her injuries were, I suspect it was lower limb and she was in a lot of pain and she had a drip in and they were giving her IV morphine. I can remember having a discussion with the nurse because she said she’d had 10 milligrams of morphine and she couldn’t have anymore, ‘I don’t care how much she’s had if she’s still in pain she can have some more.’ And one of my colleagues jokingly said after the event it was probably the first acute pain round that had ever been done in a major incident.
So they soon began to move upstairs and I remember that there were all sorts of other things that were just odd about it. Firstly, virtually none of the patients could hear you, they were all deaf, an awful lot of them had got eardrum injuries; and it so happened that the list I was doing, or was supposed to have been doing, was an ENT list so I knew the ENT surgeons weren’t doing very much. And interestingly enough ENT surgeons don’t have a big role in a major incident. So I got hold of them and they came round and started seeing all these patients with tympanic injuries. So they all got their ENT review really very quickly.
I remember when the police arrived, I think it actually was the Antiterrorism Branch, it was one of the SO groups, it was either the National Protection Group or SO19. I think it was a bit random who you got on the day because obviously this was just such an immense thing. But one of the early messages I can remember being given by the police, and this was a chilling message, I can remember phoning upstairs, is not to forget that anything that came off a patient was evidence: clothes, personal effects, limbs, anything that they debrided, shrapnel, all had to go into evidence sacks not pathology sacks or pathology pots. So obviously a crime but we’re not treating it as… we’re treating patients and the police are already looking at this in a completely different way.
I: Did you by this stage have any idea of the scale of the blast, because you’re obviously only seeing patients as they come through the door, but did you have any idea of what was going on outside?
P: It’s funny; we were reliant entirely on the BBC news. We had an Ambulance Service Liaison Officer who was supposed to be telling us what was happening, but we were very much in the dark; we knew little more than somebody sitting at home watching the television. We weren’t the only incident, it’s thought there were more incidents than there actually were because of patients coming out of two ends of tube trains, the trains that had stopped between stations. So whatever we were dealing with was obviously a major event. We began to get some word about what was happening outside, I mean we knew that these victims had come from Edgware Road, which is literally walking distance, I mean we were almost on top of the tube line in the hospital. I’m not quite sure how it happened but we ended up, I think just because some of the hospital staff were passing as people began to emerge and they set up a makeshift clearing station in Marks & Spencer next to Edgware Road and that’s where all the walking-wounded went. And they were then moved by the police because Marks & Spencer is on top of the tube train. The train was halfway between Edgware Road and Paddington so the train with the bomb on it was underneath Marks & Spencer; so that was decided not to be a very good place to be in case of a secondary device. So everyone was evacuated from Marks & Spencer, and rather than moving them all the way to Mary’s, they took them into the Metropole on the corner of Edgware Road and Praed Street. So the temporary casualty clearing station was sent there. So quite how the communications got through but we sent staff and bandages, we sent the Professor of Obstetrics and the Professor of Medicine amongst others, were all sent down Praed Street. And an awful lot of the walking-wounded never even came to St Mary’s, they were all treated and triaged and sent home from the Metropole, which of course meant that the Accident Department at Mary’s was relatively quiet because we’d got lots of priority ones, lots of really sick people and the priority twos but we saw very, very few walking-wounded. So there were an awful lot of people who didn’t really do very much on the day, the obstetricians, the gynaecologist often do the walking-wounded, were standing there expectantly and didn’t see a single patient. That was one of those things that you would never plan for but on the day just worked really well, ‘cause the vast majority of people on the train were uninjured or were shocked or were upset, but only really people in the carriage were injured. So I think the pattern of injury was really very different from this incident to many other rail crashes, so that was an entirely fortuitous thing. And the patients stopped coming quite quickly, I don’t think we had any more patients after about half-past-ten and then there was this sort of eerie calm in Resus because we didn’t know what was coming, there was this sense of isolation.
One of the things I’ve thought about recently is that with a major incident like this, each hospital becomes very introspective, you know what’s going on at your place but you’ve no idea what’s happening at Charing Cross or Hammersmith or Chelsea and Westminster. The mobile phone network had completely crashed, which was probably predictable, and so we improvised quite a lot for communication within the hospital, were the reasons why I’d got William Harrop-Griffiths sitting at a phone extension number and I knew that extension number and he knew my phone extension number, obviously we were heavily reliant on landlines. But an awful lot of us had forgotten what the phone number of x, y or z was and we used runners; lots of medical students turned up to help and I think they quite wanted to be on the action but we had more than enough doctors and nurses but they were incredibly useful for carrying messages. And I think they were perhaps a bit disappointed that that’s what they were used for, I could say, ‘Go to doctor so-and-so, tell him this and then come back and tell me what the answer is.’ And of course not everyone was at the end of a phone, so the use of runners goes back to ancient times on the battlefield. And it has to be said medical students are a slightly better calibre of runners because the message doesn’t get garbled, they were very effective at…. But normally you’d expect to be stood down. Talking to the A&E consultants normally once the patients stop coming in and I think the Ambulance Service told us relatively early that there would be no more patients from Edgware Road, you would be stood down but we weren’t because ‘Gold Command’, centrally, still didn’t really know what had happened. I think the fact that the bus bomb had gone off an hour after the tube train bombs and no one really knowing what was going on, no one had any way of knowing that this wasn’t going to keep going throughout the day.
So no hospital was stood down. So we’d cleared the Emergency Department of all the patients and everyone was then just sitting there waiting and not knowing. And rumour control becomes incredibly powerful, because the only information we’d got coming in from the outside is what you can see on television and they didn’t know an awful lot. But rumour control was amazing, I think on a number of occasions we heard rumours which went through the hospital like wildfire, and I don’t know where they started from but there were bombs at Paddington Railway Station, there were bombs at the Sorting Office and these were the buildings we were next to so slightly uncomfortable feeling that… and it made perfect sense at the time that there might be a bomb at Paddington Railway Station; there might be a bomb at the sorting office. I wouldn’t say there was a hysteria but there was a general unease of not knowing what’s going on.
I: How were the staff around you coping at this stage, because this coming out of the blue as it did, you can imagine this period of high adrenaline that there would be a slump afterwards?
P: I think there was, and one of the things that we were very aware of was that we had to keep people focussed because, as you say, you’ve had major incident alert, everyone’s turned up, everyone’s done a superb job. We weren’t used to doing trauma. It would be completely different now because we’re so accustomed to turning up for an adult or paediatric trauma call, it’s just routine now but in 2005 it wasn’t. It was quite apparent that people were beginning to drift away and so the teams were getting a bit incomplete. You can understand why: the surgical SHO quite wanted to go and see what was going on in theatre. I’m afraid I think that’s when the ex-military in me came out and I can remember giving quite clear briefings and speaking slowly but clearly and loudly and probably the phrase, ‘Listen up!’ probably came in which is not how you normally talk in the NHS. But certainly there was one point I said that we began to release teams one at a time to go and eat, and food began to appear, I’ve not idea where it came from, I think the Friends or somebody turned up with sandwiches or drinks. But I can remember saying very clearly, ‘Look, team one can go have a break but you go together and you stay together and you come back together and you come back at this time.’ And then I let team two go and it was stated, ‘You don’t go for anything else, you are still trauma team one and trauma team two until we tell you that you’re not.’
I’m trying to think how long I’d been out of the Air Force at that stage, probably seven years, but it all came back to me and it was amazing how people responded: no one argued, which is slightly unusual for the NHS. So I think in that setting people responded to being told what to do. But it turned into quite a long afternoon when nothing else was happening and so I was staying in touch with what was going on in theatres and we began to start having ‘hospital command’ meetings, so the Chief Executive and the Head of Nursing had set themselves up right next to Resus and they headed ops. And then we would have two-hourly meetings, I think it was in the canteen, of ‘This is where we’re up to, this is how many patients we’ve got, this is how many Resus bays we’ve got, this is how many theatres we can use, how many ICU beds we can use and what do we know.’ And that was updated fairly regularly and then by this stage I’d been popping up to ICU and popping up to theatres to make sure that they were all coping and basically everybody was coping ‘cause we’d got the capacity to deal with the patients we had, and we’d cleared patients out of ICU so we had enough ICU beds and we’d cleared the wards.
I: Was the hospital closed to anything else, broken legs or motorcycle accidents?
P: We would still have taken them because although we were obviously the main receiving hospital for the Edgware Road bombing, every hospital in London was on Major Incident standby. Now most did nothing at all, they sat there all day. And interestingly enough we didn’t know that, so the girl I talked about that we intubated because she had facial burns, we’d assumed that Chelsea was taking all the major burns and given that there’d been an explosion it was a reasonable assumption that there were some nasty burns going on. And I think we made that up, I don’t think anyone ever told us that, I think we’d assumed that London Ambulance Service would take major burns direct to Chelsea, but in fact they didn’t, Chelsea and Westminster were stood up for Major Incident at twenty-past-nine and didn’t receive anything. So it was very late in the afternoon that we started making phone calls to Chelsea and saying, ‘We’ve got this patient with facial burns and there’s someone with a burnt hand.’ And we’d assumed that we’d try and get them across tomorrow or when they’d calmed down and they’d done nothing at all and were very keen to get those patients and a bit upset that they hadn’t. And that, again, it was the introspection, the isolation, we’d assumed what was going on outside but didn’t actually know, although whether the Ambulance Service would’ve been able to transfer a patient in the middle of all this, again, we‘d assumed that inter-hospital transfer, unless they were lifesaving, weren’t going to happen.
I remember having a conversation with the Chief Executive about what are we going to do tomorrow, because I had assumed that we would cancel all elective operating because I knew there was going to be a huge tail of patients that still needed to go to the operating theatre for debridement would have to go back to theatre. And I can remember him clearly saying, ‘We are going to work as normal tomorrow, we are not going to let terrorists shut us down.’ I’m not sure I necessarily agreed with him, I didn’t think anyone would turn up and actually I don’t think anyone turned up for their elective operation the next day.
I: Because a terrorist attack is so infrequent in the scheme of things that the police and the other Security Branches would be heavily involved because you wouldn’t know presumably whether or not you had the terrorist as a patient, was that the case?
P: I don’t remember that as clearly, I think it was such a major incident that the police didn’t arrive until after we’d started shipping patients up to theatre. I think there were police attached to patients, but only in the same way that whenever someone’s been involved in a major incident a policeman stays with them through their course of stay. So I don’t know who they… I wasn’t up in the operating theatre, I don’t think we ever seriously believed that we had terrorists amongst our patients but I think that thought only crossed my mind after the event. I don’t think I really started thinking about this as a terrorist attack until sometime later, I was just dealing with it as a major incident, although you couldn’t escape the fact that this was almost certainly a terrorist incident because, as I say, the police had turned up and it was the Terrorist Branch. And obviously we had vast amounts of press, Praed Street was full of broadcast crews and reporters trying to get into the hospital, which is what always happens on these occasions. The number of people who turned up and said, ‘I am an orthopaedic surgeon’ or a nurse or a plastic surgeon, ‘and I’m coming to a meeting at Paddington, I can’t get anywhere, do you need any help?’ That was quite a difficult thing to deal with, ‘cause one…. actually we didn’t need any help and we didn’t know who these people were and I’m sure they were all completely and utterly genuine. But one always had at the back of the mind, actually you’re just someone’s who’s making something out… you’ve seen it on the television but you’re not qualified in any way. And we just decided that we would decline all offers of help. But there were quite a lot of people who just spontaneously turned up and offered to help.
I: Stocks of blood at this stage was that a problem?
P: I don’t think it was, I don’t remember that we had difficulty, I mean one patient, the first patient had a huge amount of blood, I think he had something like 60 or 80 units in the first 24 hours, but it kept coming, I don’t think we ever ran out. So the Blood Transfusion Service… we weren’t using any blood anywhere else that day ‘cause we weren’t operating on anybody else. No, that all came through and that bit worked really well. St Mary’s was incredibly lucky, one this wasn’t the first major incident we’d had so there were more people who’d been through it before, you know I was the novice. An awful lot of my colleagues had been here before so the general principles were not completely new. We were really lucky in the timing because we had everybody there and then also the pressure was taken off us by this quite fortuitous casualty clearing station. I know that other hospitals, as well as getting the same number of very seriously ill patients, some of whom were being resuscitated on route and did not survive, also got double-decker buses full of walking-wounded. So they were really stretched. We got off relatively lightly on the day. And one of the things I’m particularly proud of, even after all these years, each patient that got to St Mary’s survived, no one died. Although people just did very sadly die on the train at Edgware Road, they all died instantly on the train, no one that got out of the train tube station then died.
I: But when did it begin to dawn on you that perhaps there was no more and you could begin to stand down?
P: I think we began to feel that in the early afternoon, but the decision to stand us down is not made by the hospital, it’s made by Ambulance Control and I think that was not until half-past-four. I mean I wasn’t privy to the decisions but I think there was a lot of anxiety about whether there had been planned attacks for the evening rush hour, and of course by this stage we knew that the entire public transport network was down, but I think about half-past-four we were formally stood down. And then you start looking at other logistic aspects of what is going on because people have got to get home, people who are on nights have got to come in and then we were very seriously concerned that there was still something to happen. We looked at who was supposed to be on call that night and where they lived and how would they get in if something happened and there’s a whole clutch of us who happen to live within walking distance. So we completely rejigged it so that, although the on call consultant was still on call, there were about five or six of us who could be in in 15 minutes if we had to be and in immediate debrief in Resus. And actually everyone seemed perfectly fine, no one seemed to have any particular issues.
The theatres were still going fairly busily, there were still lots of patients needing debridement going on and the Orthopods were busy. I probably went home about half-past-six. It all calmed down very, very quickly, it seemed quite odd to go but I wasn’t on call and as far as I can see theatres had everything under control. I can remember phoning my counterpart at UCH who I knew reasonably well and had his mobile phone number, because I thought well we’re all calm and we’ve got beds and theatres and ICU beds, UCH looks as if it’s more in the middle of things and I phoned them up and said, ‘Look, are you OK?’ Because again, there wasn’t much communication between hospitals and they were already in the pub, so they obviously didn’t need our help so we felt much happier at standing people down. And walking home through Paddington was really… it was busy, there was an awful lot of people who weren’t going to catch a train home, but there was just a… it was complete silence, the streets were really busy with people walking home and you heard all sorts of stories about people walking enormous distances to get home but I remember absolute silence.
I: And then when you got home you must’ve been replaying it all in your mind?
P: A sense a disbelief really, this has actually happened, this really, really did happen. Quite a sense of relief, to my mind it had gone well, that sounds a crass thing to say but actually there was quite a lot of pride that we’d done a good job and that everyone was still alive. And I think was beginning to change my focus from what had happened at St Mary’s and began to really appreciate the enormity of the whole incident, ‘cause my day had been very much focussed in the Resus room, I barely got out of that one room for most of the day, with occasional visits to the debrief and trying to find some food at one point ‘cause I suddenly realised it was three o’clock and I hadn’t eaten. Beginning to get a sense of the enormity and then you start seeing pictures of the Prime Minister and?????? at St Andrews, but all the other incidents going on and you realise that what I’d seen had been replayed over and over. And then also just the pictures of London, however many million people trying to get home without public transport and people just trudging through the streets, but still anxiety that it was going to happen again. But nothing happened.
I remember I got phoned by an Orthopaedic Surgeon who was having a tantrum about the number of operating theatres we were running, and in retrospect actually I think he was probably right, although at the time I was probably quite defensive ‘cause although I was the Lead Clinician I wasn’t actually on call. And people were tired by that stage and actually probably we did need to rely on a second operating theatre. But although we’d put extra people on call in case there was another incident, what I hadn’t actually done, I hadn’t put extra people to be in that night to keep the operating theatres open, we just had the normal on-call team and actually that was a mistake, we should have made arrangements to be able to run additional theatres so that they weren’t running all night and that all the patients could get their debridement done. And the orthopaedic surgeons had been in theatre for most of the day amputating and debriding so they had probably had a far more difficult day than I had, ‘cause actually my clinical experience, my shock, had been very focussed in the first 30-40 minutes so they’d been exposed to it all day. God forbid that I ever have to do it again, though very often with major incidents you focus on what happens in the Emergency Department and Resus and then the immediate live saving at surgery, but you forget that there’s a whole tail of patients with lesser injuries or patients who go back to theatre, that the knock-on effect for theatres is for days and days afterwards. And in fact after that night we did put on extra emergency lists and we arranged for extra people to be available through the weekend to allow for open and closed laparotomies and people going back for further debridement.
I: How about the Ambulance Services, did they cope as well as you can imagine, because presumably they were trying to treat on the spot or in the most awful circumstances down in the tunnels or in the trains?
P: It’s very difficult, I mean it was quite clear… and this has been the subject of a lot of debate, there was a lot of discussion at the 7/7 Inquests what the Ambulance Services standard procedures were, that they shouldn’t have gone into the tunnels for fear of a secondary explosion. There has been a lot of criticism of the health and safety environment; but similarly I don’t think I could criticise someone, who if you genuinely thought there was another bomb going off, you wouldn’t send your personnel in. And we actually know that it’s a very tried and tested terrorist tactic. It was used a lot in Iraq, it was used a lot in Afghanistan, you set off one device, injure a couple of people and then you wait an hour and you set off a second device to take out the rescuers and the medics and everyone that’s come in. I think it was a very natural apprehension and I think the Ambulance Service could probably answer for itself. And I do know that the guys that I saw I consider genuinely were heroes because they knew what they were… or they were pretty certain what they were going down to and it’s quite clear to me that certainly the first patient would not have survived if the paramedics hadn’t gone in and got him out because he would’ve had his cardiac arrest not in Resus bay 1 at ten-past-ten, but in a tunnel and he wouldn’t have survived. So he certainly owes his life to some very, very brave paramedics who did their jobs and got him out, but put themselves at considerable personal risk.
I: When did you start putting together a report on this that would put all the parties together and go through a more formal debriefing?
P: It was over days and weeks. We had immediate debriefs on the day and they were a mixture of, ‘Is there anything that hasn’t worked well?’ And I think we were much more conscious that the odds of this happening again tonight were much higher, the odds of having two train crashes on the same day, you sort of feel that although statistically that makes no sense, the odds are it’s not going to happen tonight, it’s not going to happen tomorrow. That clearly wasn’t the situation here that we need to be able to do this again tonight or tomorrow so we had to get on to replenish everything that we’d used so that we could do it again. That sort of debrief, very hot debrief was happening almost straightaway. The other bits were mostly…..so things about learning to keep theatres open were just conversations that I was having within the Anaesthetic Department. Because it was quite by chance that on the day of the bombing the newly appointed Lead Clinician, who happened to have been in the military happened to be free; statistically the next time it happened I wouldn’t be, I’d be in theatre, I wouldn’t be on site. So that sort of informal learning I was sharing quite quickly.
The North West London Critical Care Network had, from early afternoon, been emailing round everybody in its email list which ICUs had how many beds. That happened on the day, that wasn’t part of a plan that was, I think, a fairly spontaneous thing, so it was a bit like the Emergency Bed Service but it was just for Critical Care. And the email of course was robust so another way of learning on the day: how do you get messages out? Well email works very well because email is robust, that’s how email was set up. And we would put messages on the Trust website about transport and accommodation and food and stuff like that ‘cause some people couldn’t get home. So those things were happening relatively informally and I do remember a series of other meetings about hospital evacuation; I think we had taken the risk to St Mary’s because of its physical location next to the train station quite seriously. So we looked at: is it possible to evacuate the hospital? And the answer is no. So what do you do and what do doctors do and what do nurses do? So we were looking at slightly different elements of major incidents, what if we were now not just receiving the casualties but were part of the major incident? Because the proximity of the Tube lines and the train station just made us think a bit more carefully about how we would do that sort of thing.
And then there was a slow learning process. I think I gave a talk at the Winter Scientific Meeting, maybe 18 months after, of learning. But most of the systems had worked: getting people to Resus, getting people to theatre, all that had worked. But there were elements about this that were different. One of them was about shrapnel. We’re used to dealing with shrapnel injuries but what we’re not used to dealing with is human shrapnel injuries, but there was no doubt that some of the shrapnel injuries were parts of other victims, just the mechanics of a bomb going off in an enclosed space – one patient still carries some coins in his buttocks that we can’t get out. That was one of the reasons why there was so much need for taking people back to theatre and debridement. And then there was some other issues which arose in the next week or so which was about blood born viruses and the Healthcare Protection Agency got quite anxious that if you sit on your average tube train in the morning and look around, who in the cabin’s got HIV or hepatitis B or hepatitis C? And then if you set a bomb off in that and spread blood and bone and everything around what is the risk of transmission in that case? And the answer is we don’t know, we just can’t assess it. I’m pretty certain that all the survivors were offered hepatitis immunisation, and then again that was something that was completely new and different about this.
And then we talked about the fact that everyone was deaf, which is apparently absolutely typical for a bomb, particularly a bomb in an enclosed space and if you talk to the Israelis they would’ve told you that straightaway but we hadn’t even thought about it that you couldn’t really talk to these patients. So ENT had a big role on the day which they weren’t expecting.
I: Was identification of patients a problem given that they were unrecognisable because of the head-to-toe soot, loss of clothing and now deafness as well?
P: I don’t think that was a problem, I mean there was only one patient who wasn’t conscious to start with, the rest of them were all… one was anaesthetised electively because of facial burns but I think we knew who they all were. And of course at this stage we’re still using their Major Incident identification, although we may or may not know who they are, in terms of their hospital records and notes they are still whatever code we were using on the day because you don’t convert them to being Joe Smith or Joe Blogs, they are still Alpha 2 or Alpha 4 because all their notes on all their blood results and all their cross matching and their x-rays are using a completely separate but parallel system.
I know one of the concerns the Police had was about joined up reporting of patient numbers, so I don’t think the hospital said how many patients it had received and what state they were in, that was all being coordinated by the Police Casualty Bureau. And as we know, quite a lot of people were missing or were missed by families and it wasn’t clear where they were, although obviously not on the scale of 9/11 in New York. All of our patients were identified and family contacted by the end of the working day, but I wasn’t part of that process so I think it could’ve been a problem but wasn’t in practice for us.
I: When you realised it was a bomb, was there a moment when you maybe thought is there a chemical aspect to this explosion?
P: I don’t think we were ever concerned on this occasion about biological or chemical or nuclear, but that’s a decision made on the scene by the Incident Commander. The Major Incident Plan is modified and it’s something that we have practised and we started practising very seriously after 9/11. What the Major Incident Plan says is supposed to happen is that the causalities should be decontaminated on scene; dirty causalities shouldn’t present to the Emergency Department but we’ve always assumed that we had a high chance of patients turning up… there is the inflatable decontamination kit and there are Emergency Department staff trained to put on the really high protection suits and decontaminate people but we didn’t do that on the day.
I: Maybe we’re now days three or day four and the hospital is more or less back to normal. How were the Emergency Department staff coping, do they need support at any level?
P: I’m not aware that anybody had any particular issues. It was always the view that it was unlikely to be the Emergency Department staff that would actually have a problem because they, although it wouldn’t sit on that scale, do see that sort of injury fairly regularly, I think it’s part and parcel of being in the Emergency Department. I suppose my anxiety were people who don’t normally work in that environment that were put down to work there, but actually they all seemed to cope remarkably well, I mean I’ve never seen injuries as severe as the ones I saw that day and they are seared in my mind. I think I was able to sort of distance myself from it, that’s what happens; that’s what I’m here for; that’s what I’m trained to do so I think people coped quite well. We did have the obligatory royal visit the next day, I was having a lie-in on the Friday, it was before I was on AAGBI Council so I didn’t do anything on Friday. So I was having a lie-in and I got this frantic phone call saying, ‘You’d better be in the Emergency Department in 35 minutes, looking smart, because the Prince of Wales is coming.’ So I did what I was told, met the Prince of Wales and Camilla and they were in Resus, which of course was empty, there was still quite a lot of activity going on in theatre.
After he’d moved on to go and see other staff, I have to confess, I nipped out the back of Resus for a fag, which I’d done a couple of times the day before as well. And I was standing there and I suddenly noticed… ‘cause we were right next to the canal path, that there was a bag sitting there with no one with it, a sports bag looking quite full by the back entrance to A&E. So <chuckles> I put my fag out, sidled back into the Emergency Department, went up to the Protection Officer and said, ‘I don’t want to worry you, but there’s a bag on its own outside the back of the Emergency Department.’ And very, very subtly I have to say, I was very, very impressed, he just moved their Royal Highnesses through to the far end of the building. And I went out to the back of Resus to look at where this bag was and I was astonished how many police cars and police vans came screaming up the ambulance ramp within seconds. So nerves were obviously fairly fraught on the day, but that was about as much excitement we had on the next day.
I: When did you come to the point of saying, let’s really look at our Major Incident Plan and what went well, what didn’t go quite so well and how we can plan for the future?
P: Starting the next week, again, mostly informal discussions but then there were a series of formal meetings of the emergency planners which is the A&E Consultants and then key people like me, as the Lead Clinician for Anaesthesia, the Lead Clinician for ICU, the ops people. And actually our conclusion was we didn’t change anything, apart from making… well the things we did, we made much more point about communications: don’t like mobile phones ‘cause we all become very blasé about mobile phones, but emphasizing the need for communication within the hospital to avoid Chinese whispers; so putting out regular bulletins from the Chief Executive and communication with your neighbours. So I think in terms of in-house did we do anything different? No, we actually decided that it had worked, for Ladbroke Grove had worked, for the 7th of July, the basic skeleton of the Major Incident plan was fine. It was much more about what would we do differently for an attack on London rather than just a single incident and that was all about communicating within networks with the Ambulance Service, so email distribution lists were set up so that you could communicate in a robust manner. So we didn’t make big changes to the nuts and bolts of the Major Incident Plan because it essentially worked.
I think on a personal level I think quite a lot of people suddenly realised how entirely reliant on the mobile phone network we are, to the extent that actually you don’t know people’s phone numbers because you just hit their name in the A-to-Z list on your phone. I think a lot of people thought quite carefully about how they would be contacted, how they would be traced and so on and then an awful lot of people started using ICE – In Case of Emergency entry in their phone. I think I learnt a couple of things about the anaesthetic response, the fact that we rely on our first responders being trainees, so that on this occasion the sickest patient went to the most junior SHO. I think as a whole the hospital’s Major Incident Plan now is entirely consultant-based because the trainees are on shifts so they’re either in at work or at home and about to come to work – if there are trainees there then they’re a bonus but it should be consultant-based. And the other learning point for me, although it actually wasn’t a problem on the day, is that one of the first things you should do as an anaesthetist is send a Consultant Obstetric Anaesthetist to the Labour Ward. Because about the only thing you can’t stop in a major incident is obstetrics and the last thing you need in the middle of a major incident is a phone call saying, ‘I can’t get the epidural in’ or ‘there’s a crash section’ or something. So the bits you can’t stop, and labour is about the only one, you’ve got to make self-sufficient. So it might not be what that consultant wanted to do in a major incident, isn’t deemed quite as glamorous, but actually it’s really important because what you couldn’t have is somebody coming to harm having a baby because we’re all doing something else in Resus.
I: How did you cope with the press because they must’ve been very keen for stories?
P: They were generally pretty well behaved I have to say, the British press behaved quite well, but they generally didn’t try and get into the hospital. There were some rules that we… we had the briefing centre and again the Chief Executive would issue some statement every two hours, it may not say very much but they didn’t feel that we were hiding anything. So the Chief Executive would meet the press, most queries were of course referred to the Metropolitan Police. Some of the overseas press did not behave quite as well; we had some overseas Commonwealth patients on the ICU and some of their journalists did try and get into ICU. There was the old grabbing a white coat and calling yourself a doctor trick, which of course doesn’t work anymore ‘cause none of us wear white coats so that doesn’t really help. I suspect it’s even more difficult now than it would’ve been then because of course everyone has swipe-card access, so even just wearing an ID badge that looks convincing isn’t actually going to get you in. But our security staff were very good, I mean they were on all the exits and we ‘locked down’ so not all the entrances were open and Security were there and if you didn’t have your hospital ID badge on you didn’t get in and it worked. We kept that going for several days. But generally speaking, and I didn’t have any, thankfully, direct press contact in those first couple of days.
I: And has it changed you at all?
P: My attitude to the attacks did change, on the day it was something that happened to other people and I’d been in and done my job. I think my attitude certainly changed because I suddenly stopped thinking about it as just a doctor who treated some patients and I began to think about it as someone who lives in London. Now quite by chance on the Monday, Tuesday and Wednesday of that week I had been on a district line train going through Edgware Road Tube station at ten-to-nine – going in the opposite direction; I wouldn’t have been on that train. And I don’t normally do that but I’d been at interviews and I’d been in another meeting and so I had been… I always assumed this wouldn’t happen to me ‘cause I walk to work, I live close enough, I walk to work, but actually I analysed and said, actually you do travel on the Tube and who’s to say it hadn’t been the Wednesday or the Tuesday or whatever. The impact it had on London was astonishing, the one bit of the Tube I use regularly didn’t reopen for three months and I began to think of it much more as an attack on London and on me, than I had done on the Thursday.
I can remember a very, very emotional moment the following week on the 14th when of course I was doing the same operation list I had actually started and that was when they were going to do the two-minute silence. And I was up in the operating theatres which at St Mary’s are on the fourth floor and overlook the canal and look out on the whole new Paddington Basin and development. I didn’t know who would respond, I knew I wanted to go and have my two minutes. And I wasn’t really quite sure what the public response to this would’ve been and I can remember being completely gobsmacked looking out over Paddington Basin and just seeing hundreds, hundreds of people, possibly even thousands, but just emptying out of all the office buildings and just a sea of people there and very, very moved, got slightly tearful that this was the public response. And that was mirrored across the whole of London; the whole of London had responded to this and I think it was viewed by most people that this was an attack on London and there were 50-something very unlucky victims who died and many hundreds of people who were injured. But this could’ve been any of us and I think there was a sense of vulnerability; this could have been me. And again, St Mary’s was very lucky in that we didn’t lose any members of staff and no members of staff were injured as far as I know, but that wasn’t the case certainly I know at UCH and Great Ormond Street, both had members of staff who were injured or killed in the attack.
And there was still this sense of unease, is it going to happen again? There was the failed attempt, again, four bombings on the Tube and buses which thankfully the bombs didn’t go off. When the bleeps went off, again on the first day, ‘Major Incident Alert’ and that adrenaline surge, oh God not again! I can’t believe it’s actually happening again. And of course we got stood down reasonably quickly that time because we had no patients, but there was just this sense of anxiety, is this what it’s going to be like, is it going to keep happening? And you were thinking about what was happening in Baghdad and Basra and places like this that it becomes a part of life. And that sense of unease I think remained for quite a long time and I can’t remember when it was but I can remember being very conscious of my first Tube journey, as I suspect everybody else was. And people don’t chat to each other on the Tube train but you were very conscious that everybody was watching everybody else. Yeah I was quite conscious about where I stood in the Tube train and I think that took quite a long time… it doesn’t bother me now, I just get on the Tube and I don’t think twice about it, just occasionally I’ll think ooh who’s that over there or whatever, but it’s now just come back to being just getting on the tube and it’s not seen as a high risk event but it took quite a long time for that to subside.
And I’m not sure that it ever did completely because it was 2005 and then you think it was the day after we’d been awarded the Olympics, so the only thing that anyone had been talking about on the way to work on the 7th of July was the Olympics. And I wasn’t actually a great fan, I wasn’t hugely supportive, I thought it was going to be a huge disaster and that London, or Britain, didn’t have a great tradition of delivering major public works on time or on budget and that the public transport system would grind to a halt and it would all be a shambles, and I didn’t really want it and I was planning to go away for the whole of the Olympics. And the difficulty was that that classic same footage of Jacques Rogge announcing the award of the games and the crowd going absolutely bonkers in Singapore and in Trafalgar Square was the clips that have just been shown over, and over, and over, and over again, and then I went to work and then the bombings happened. So those two things were just linked. And as we got closer and closer to the Olympics those clips kept being shown and I couldn’t separate them, and I’ve been accused by some of having PTSD – it wasn’t PTSD, it wasn’t flashback it’s just that there was an association between that film and that event. And yes, there was a lot of anxiety that the Olympics would be used as a vehicle for another terrorist attack, and I’m not a great sportsman, I’m not a great sports fan, in previous Olympics I’ve watched the opening ceremony and not much of the sport.
And then David [59:11 Zigmond] asked me, David Zigmond was then a consultant at the Hammersmith, who was running the Emergency Medical Centre, he asked me if I’d volunteer and quite frankly nothing had been further from my mind. But I thought about it and decided that you either got the hell out dodge or you threw yourself into it, so I did, I volunteered. And I didn’t really know what David wanted me to do, I sort of thought he wanted me to do a ‘command and control’ job, that’s sort of what we talked about because I was ex-military and I had this experience on the 7th of July and I could use a radio and went through exactly the same application as all the other games-makers, but because years ago in the Air Force I’d been the Medical Officer for the amateur boxing I was put ringside for the entire amateur boxing competition, which wasn’t at Stratford, it was down at ExCel and I was a bit disappointed, but then I figured hey, it’ll be good. But I think it was three years between applying and the games coming.
Just when the ‘Torch’ hit London and people got really quite excited, what the atmosphere was like in Paddington walking home from the bombings, that there was just something in the air that again was quite different to anything I’ve ever experienced, and particularly on the Friday when the Games were going to open and who was going to open them and what was going to happen. And I can remember just this sense of excitement and quite emotional feeling, I couldn’t explain why it was, maybe it was that this journey seven years in the planning and whatever was coming over. And I sorted of realised, I had a good cry at the Opening Ceremony, I don’t know why but there were tears streaming down my face. And then I went to the ExCel the next day, first day the sports started, and it was quite cathedral-like, I can remember going up there ridiculously early and was wandering around this enormous arena and I kept having to pinch myself and say, ‘You are actually here, this is the Olympics.’ But all the anxiety had gone, it wasn’t about the bombings anymore.
A rather strange coincidence of my life was I was on the Tube travelling to ExCel on the Monday morning, a stop after me Sebastian Coe got on the Tube train and I didn’t even recognise him and I thought, he looks familiar. And again, bizarrely Central Line, quarter-past-nine in the morning, third day of the Games, the carriage is empty, there are seats and everything. And so we nodded to each other than he came over and chatted to me and then we moved apart, and then I rather school-boyishly asked him for his autograph in my Games Makers log book. So we started talking again and he said thank you for being a volunteer and I said thank you for bringing the Games to London and making it such a success and we sort of danced backward and forward about who was thanking who. And I actually said, ‘I think this has been really important to me because I was there on the 7th of July and this has been a huge success and this has been closure and it’s shown that London is not just about the bombings, London is about something fantastic.’ But I genuinely meant it and there had been something missing, LOCOG, the Olympic Committee had said that there’d be a tribute to 7/7 in the Opening Ceremony but you had to look really hard and know it was there ‘cause it was a bit non-specific. And I think quite a lot of people felt some disquiet that the Olympics were almost ignoring the 7th of July, ‘cause I think for many people those two events were completely linked. I think quite a lot of us thought that if the bombings had happened on the 5th of July and not the 7th of July London wouldn’t have got the games and it would have gone to Paris.
So we were on the tube train, we got chatting and actually I started chatting to Seb’s Protection Officer, ‘cause he had two Police Protection Officers, and they talked about their experiences, one of them had been on duty at Downing Street and heard one of the bombs. So it wasn’t just me, they… I then got off the Tube and went off to ExCel and bounced into work and said, ‘You’re never going to guess who I’ve met, Seb Coe and here’s his autograph.’ And everyone thought that was quite good and I thought that was going to be one of the highlights of my Games. And then little did I know that obviously whatever I’d said had made quite an impact on Lord Coe because he then mentioned me in an interview on Radio 5 Live, the middle weekend of the Games. And he described meeting me on the train as one of the moments of Games. Now I’m a cynic and it could be that I actually did have that effect or he spotted a superb PR opportunity or a press opportunity. He just mentioned my first name and he mentioned that I was an anaesthetist at a London hospital, he very carefully didn’t identify me, but he did say I worked at the boxing and it was actually my day off. So apparently the boxing control phone went off all day and then The Times managed to find out who I was, they pieced it together and did some guess work.
So the next thing I know I’m doing all sorts of press interviews and stories and stuff, which was interesting and I have some interesting stories to tell and I was saying lots and lots of nice things about the Games Makers ‘cause the Olympics was a truly amazing experience. But I did feel slightly fraudulent ‘cause I didn’t do anything during the Olympics, I just expressed an idea that I think resonated with a lot of other people. But then it obviously did make an impact because Seb Coe then talked about that in his closing speech and his Made In Britain speech at the Paralympics, which I thought was a much more London event because I know nobody who was at the Olympic Closing Ceremony but I know an awful lot of people who were at the Paralympic Closing Ceremony. And that story and what I’ve said has meant an awful lot to a lot of people, so I think I just put into words what an awful lot of people were thinking. After seven years I can now separate the Olympics, because they’ve actually happened and they were better than we ever imagined from the 7th of July, but I suspect I will still, if I see that film clip, think about them but the Olympics now stand in their own right.
I: I think that’s a perfect place to end it, Andrew, thank you very much indeed.