Portsmouth Hospitals Major Incident Response Policy
Reference Number
15.8
Version
9v2
Name of responsible (ratifying) committee
PHT Emergency Planning Liaison Officer
Major Incident Planning Group
Date ratified
15.12.2009
Document Manager (job title)
Glen Hewlett. PHT Emergency Planning Liaison Officer
Date issued
16.12.2009
Review date
June 2011
Electronic location
Corporate Policies
Related Procedural Documents
Key Words (to aid with searching)
South Central Health Authority Major Emergency Plan
Civil Contingencies Act 2004
The NHS Emergency Planning Guidance 2005
Deliberate Release of Biological and Chemical Agents
Beyond a Major Incident DoH Guidance and Policy
(Dec 2004)
Portsmouth Hospitals Procedural Document Policy
Portsmouth Hospitals Business Continuity and
Business Contingency Planning Policy
Portsmouth Hospitals PHT Telecommunications
Equipment Policy
Hospital major incident policy; Emergency planning;
Responsible person; Responsible persons; discharge
major incidents; Casualties; Health; Emergency
planning officers; Emergency practices; Infection
control; Communicable diseases; Emergency planning;
Risk assessment; Information; Guidelines; Clinical
guidelines
Major Incident Response Policy Issue 9v2. 16.12.2009 (Review Date: June 2011)
Control Date: 05/02/2016
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CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
INTRODUCTION.......................................................................................................................... 3
PURPOSE ................................................................................................................................... 3
SCOPE ........................................................................................................................................ 3
DEFINITIONS .............................................................................................................................. 3
DUTIES AND RESPONSIBILITIES .............................................................................................. 4
PROCESS ................................................................................................................................... 5
TRAINING REQUIREMENTS ...................................................................................................... 6
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 6
DISTRIBUTION………………………………………………………………………………………….…6
APPENDICES
APPENDIX A: TERMS OF REFERENCE FOR MAJOR INCIDENT PLANNING STEERING GROUP
APPENDIX B: ANNUAL RISK ASSESSMENT CHECKLIST
APPENDIX C: STAFF INFORMATION LEAFLET
APPENDIX D: DECLARING A MAJOR INCIDENT
APPENDIX E: PROCEDURE FOR TRAINING AND EDUCATION
APPENDIX F: MAJOR INCIDENT PLAN - RESPONSIBLE PERSONS GUIDELINES
Major Incident Response Policy Issue 9v2. 16.12.2009 (Review Date: June 2011)
Control Date: 05/02/2016
Page 2 of 24
1. INTRODUCTION
The events listed below may generate large number of casualties; however there are other
events that may place a significant burden on local health services and/or impact on their ability
to deliver normal services. These include but are not limited to civil emergencies (e.g. petrol
crisis, flooding, terrorist threats, etc), public health scare, civil emergencies, etc, and in such
circumstances a major incident could be declared.
Examples of mass casualty incidents which could arise in Portsmouth & South East Hampshire
include:
-
major road traffic accident on M27, A3, etc.
an incident involving a ferry or other large vessel in the Solent
an air disaster over the area (Portsmouth is on the Gatwick/Heathrow flight path)
a radiation incident at Portsmouth Naval base
a significant incident on the local rail network
a major infection or infectious disease outbreak, or drinking water contamination
Most crises can be handled through extending normal day-to-day arrangements i.e. Business
Continuity/Contingency planning arrangements; and other trust emergency planning
arrangements; the emphasis should be on responding to an emergency regardless of its cause.
Flexible plans are in place to deal with a range of situations which are likely to increase in
magnitude, duration or complexity, and which may affect areas covered by more than one
health region. Specialist arrangements may be required in the event of unusual incidents, e.g.
communicable disease, chemical incidents and radiation.
There is a vast range for scenarios and it is not possible to have specific plans for them all.
Plans therefore need to be flexible and based on integrated emergency management which
means that the planning emphasis is on the consequences and not the cause of the incident.
See intranet links on the Business Continuity / Emergency Planning Home Page.
2. PURPOSE
This Policy sets out the arrangements that will ensure an effective response to a Major Incident
/ or Major Incident test by Portsmouth Hospitals NHS Trust. It follows with national guidelines
and procedures, and has been agreed with other statutory agencies in the Portsmouth and
South East Hampshire District, e.g. South Central Ambulance Services, Social Services,
Hampshire Partnership NHS Trust and the Primary Care Trusts.
3. SCOPE
Portsmouth Hospitals NHS Trust / Carillion Services Ltd, MOD staff
4. DEFINITIONS
Civil Contingencies Act 2004: The term ‘Major Incident’ is commonly used by emergency
services personnel to describe an emergency as defined in “the Act”. The definition of
“emergency” is concerned with consequences, rather than with cause or source. Therefore, an
emergency inside or outside the UK is covered by the definition, provided it has consequences
inside the UK. In this way, the Act narrows the range of events or situations to which the duties
apply to those, which test responders.
For the NHS, a major incident is defined as: “Any event whose impact cannot be handled within routine service arrangements and which
requires the implementation of special procedures by one or more of the emergency services,
the NHS, or a Local Authority to respond to it.”
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NHS organisations are accustomed to significant fluctuations in the daily demand for services.
Whilst at times this may lead to facilities being fully stretched, such fluctuations are managed
without activation of special measures by means of established management procedures and
escalation policies.
Major incident management in NHS organisations is therefore concerned with exceptional
events and increases in the demand for services.
The Department of Health has categorised major incidents on a scale according to their impact
on the NHS. These are:
Level 1 – incidents which individual ambulance trusts and acute trusts are well versed in
handling such as multi-vehicle motorway crashes. More patients will be dealt with, probably
faster and with fewer resources than usual but it is possible to maintain the usual levels of
service
Level 2 - much larger-scale events affecting potentially hundreds rather than tens of people,
possibly also involving the closure or evacuation of a major facility (for example, because of fire
or contamination) or persistent disruption over many days. These will require a collective
response by several or many neighbouring trusts
Level 3 - events of potentially catastrophic proportions that severely disrupt health and social
care and other functions (for example, mass casualties, power, water, etc) and that exceed
even collective local capability within the NHS
A major incident can be sudden (known as a “Big Bang” incident) such as a major transport
accident or a series of smaller incidents, which, cumulatively, test the capacity of the NHS to
respond. A major incident can also develop over a period of time (known as a “Rising Tide”
incident). Examples of a rising tide incident are a developing infectious disease outbreak or
progressively more serious flooding in an area.
5. DUTIES AND RESPONSIBILITIES
Legal Considerations
If a Trust fails to plan for, or respond effectively to, a major incident / or exercise, it could lead to
at best, adverse publicity and criticism at an inquest or public inquiry and at worst, a breach of
civil or criminal law and subsequent prosecution. To minimise the risk of litigation, PHT must
ensure that all of the requirements of this Policy are met and in particular, that staff that are
required to respond to a major incident / exercise are properly trained, briefed and supported.
The Chief Executive has overall responsibility for emergency planning and is accountable to
the Board or ensuring systems are in place to facilitate an effective major incident response.
Within Portsmouth Hospitals NHS Trust the Director of Operations, Nursing and Midwifery
has been nominated as the executive director with the responsibility for Emergency Planning
within the Trust at Trust Board level. A Non-Executive Director has also been nominated in a
similar role.
An Emergency Planning Liaison Officer (EPLO) has been appointed within PHT. The EPLO
has responsibility for co-ordinating emergency planning arrangements, including maintaining
the Hospital information & Co-ordination Centre which in the event of an incident or exercise will
be located in the Duty Hospital Manager’s office and acts as the named link (Responsible
Officer) with other Trusts/Agencies, the Strategic Health Authority (SHA) and with the Health
Emergency Planning Adviser
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The Portsmouth Hospitals Emergency Planning Liaison Officer (EPLO) is:
Glen Hewlett: Director of Development & Estates
Other PHT, Carillion Services Ltd, MOD staff (and PCT staff on PHT premises) that will take
part in the planning and execution of the major incident response as required, may include:
a)
b)
c)
d)
e)
f)
g)
Senior managers and other staff at PHT ’s Headquarters office
Clinical Directors
Radiation Protection Adviser
Estates Managers
Service Managers, On-Call Managers / On-Call Executives / Duty Hospital Managers
Children’s Services managers and staff
Secretarial and support staff
Major Incident Planning Group. This will be the forum where planning matters are raised,
discussed and agreed with relevant staff (e.g. senior management team meetings). The Terms
of Reference for this group are attached as APPENDIX A. Consultation will also include the
Governance Manager and the Chief Executive Officer.
The Lead PCT will co-ordinate a multi-agency Joint Health Emergency Planning Group
which meets every quarter to ensure local emergency planning arrangements are robust.
Relevant PHT staff will also be members of the LA (PCC) forum, which leads planning
for radiation incidents and develops the PORTSAFE plans.
6. PROCESS
The Trust is responsible for ensuring that individual members of staff understand what a Major
incident is, how the trust responds to a Major incident or Major Incident exercise, and how their
individual department responds. Each department within PHT that has major incident planning
arrangements has a Responsible Person (RP), whose designated role is to regularly review the
major incident action cards for their department and to do so in consultation with other
associated departments. See Appendix F. Annexe 1. Section 3.6.
All trust emergency planning action cards are available in hard copy folders in the On-Call
Manager’s cupboard in the Duty Hospital Manager’s office – for use by senior mgrs, and in the
Emergency Department Major Incident Control Centre – for use by Emergency Consultants. All
trust wide action cards are also available on the Intranet, via the Trust register within the
Business Continuity / Emergency Planning Home Page and where applicable, within individual
departments’/Specialty’s Home Pages. Not all of the Action Cards will be needed for every type
of incident, e.g. the Radiation Response Action Card is only activated in the event of a major
incident involving radiation exposure or threat of exposure
PHT RP’s will review the staff contact number/s that switchboard will call in the event of an
exercise or live incident; this information will be included in their emergency contacts numbers
monthly returns, they will also review their departmental staff contact call in-lists every 3 months
(or as the need arises) and individual departmental planning arrangements annually (or as the
need arises), and after each test/exercise or actual incident.
PHT will arrange for this policy to be audited by Internal Audit or District Audit periodically and
for an annual report presented to Trust Board.
PHT will also be required to submit annual returns to the Health Emergency Planning Adviser
on behalf of the Strategic Health Authority (SHA) and report on training, exercises and
response to actual exercises/incidents during the year. PHT will complete an annual risk
assessment jointly with other organisations locally, which will consider possible major incident
scenarios that could arise and their potential impact on local services.
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Each ward/department/area with a role in the implementation of the Major Incident Plan will
assess its compliance with this policy as part of the annual risk assessment process by
completing APPENDIX B of this policy (sent out annually). An Action Plan to address the
deficiencies identified on the risk assessment must be developed, implemented in each area
and reflected in reviewed action cards.
This policy will be reviewed annually, or as and when the need arises.
7. TRAINING REQUIREMENTS
PHT undertake 6 monthly communications exercises, a tri-annual trustwide major incident
exercise, other in-house exercises, and also participate with other agencies in joint / regional
exercises, etc., as and when the occasion arises. Individual specialties and Divisions are
advised to carry out table-top exercises, and if they do so, they must give advance warning to
the EPLO.
Please refer to the education and training procedure at Appendix E. Also Appendix C: The staff
information leaflet, and Appendix F: The Responsible Persons guidelines.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
See Related Procedural Documents on frontsheet
9.
DISTRIBUTION
Portsmouth Hospitals NHS Trust - Emergency Planning Liaison Officer
All PHT Policy Holders
EPLOs for Hampshire PCT and Portsmouth City PCT’
Hampshire Partnership NHS Trust
Social Services – Hampshire County Council & Portsmouth City Council
Regional Health Emergency Planning Adviser
South Central Ambulance Service – Emergency Planning Officer
South Central Health Authority – Director of Public Health
South Central Health Authority – Emergency Planning Development Manager
Portsmouth City Council Emergency Planning Officer
Hampshire County Council Emergency Planning Officer
Major Incident Response Policy Issue 9v2. 16.12.2009 (Review Date: June 2011)
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APPENDIX A: TERMS OF REFERENCE FOR MAJOR INCIDENT PLANNING STEERING
GROUP
Constitution
The Hospital Management Committee hereby resolves to establish a sub-group to be
known as the Major Incident Planning Steering Group. The Major Incident Planning
Steering Group is a non-executive sub group of the Hospital Management Committee and
has no executive powers, other than those specifically delegated in these Terms of
Reference.
Purpose/ Objectives
The purpose of this Steering Group is to:
1
Co-ordinate and monitor the development and regular updating of PHT’s major incident
plan;
2
Ensure that PHT’s planning arrangements are compatible with those of related agencies,
in particular social services and other local authority departments;
3
Ensure the regular testing of PHT’s plan is undertaken and, where appropriate, to test
planning arrangements on a cross-agency basis, identifying any internal and external
dependencies;
4
Assess the hazards and risks associated with Major Incidents and share lessons from
tests and actual incidents when all or some of the existing plans are implemented;
5
Ensure the local implementation of national and regional guidance and requirements
relating to emergency planning;
6
Identify issues requiring discussion with PCT’s, etc. and raise at local Joint Health
Emergency Planning Group meetings;
7
Ensure communications strategies and procedures deal with any incident within the
scope of a major incident and/or the trust’s services continuity/contingency planning
arrangements;
8
Identify training requirements and ensure effective training and testing programmes are in
place;
9
Effective review, refinement and performance monitoring procedures are in place;
10
Distribution control of all plans;
11
Ensure the provision of advice on Emergency Planning to the Trust Stakeholders as
appropriate.
Authority
The Major Incident Planning Steering Group is authorised by the parent Committee to
which it accounts to investigate any activity within its terms of reference. It is authorised to
seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Steering Group.
The Major Incident Planning Steering Group is not authorised to obtain outside legal or
other independent professional advice or secure the attendance of outsiders with relevant
experience and expertise without reference to the committee to which it is accountable.
Reporting
The action points of the meetings will be recorded by the Steering Group Clerk and where
appropriate submitted to the committee to which it is accountable at an agreed frequency.
The Chair of the Committee shall draw to the attention of the Committee to which
accountable any issues that require disclosure or executive action.
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Communication
The action points of the meetings will be recorded by the Steering Group Clerk and where
appropriate submitted to the committee to which it is accountable at an agreed frequency.
The Chair of the Steering Group shall draw to the attention of the committee to which the
Group is accountable any issues that require disclosure or executive action.
The members of the Major Incident Planning Steering Group will ensure timely
dissemination of information.
This will be via minutes to other group members; an annual report to the trust Board and
other establish fora.
Membership
The Major Incident Planning Steering Group will consist of the following members –
Director of Operations, Nursing and Midwifery - Chair
Non Executive Director
Director of Development & Estates (Trust Emergency Planning Liaison Officer)
Associate Director of Nursing
Divisional General Manager - Medicine
CD Consultant - Emergency Dept.
CD Consultant - Anaesthetics
Consultant Nurse - Infection Control
Nurse Practitioner - Emergency Dept.
Head of Risk Management
Head of Carillion Services Limited Facilities Management Team
Finance Manager – Medicine
Royal Hospital Haslar Representative
Duty Hospital Manager
Assistant to the Emergency Planning Liaison Officer
Department of Medicine for Older People Representative
Internal Emergency Planning Co-ordinator
Major Incident Planner (Pandemic Flu)
Secretary
Other members may be seconded to the Group as required. The Steering Group shall
change its membership and co-opt others as necessary to fulfil its objectives.
For information/invited as appropriate
Strategic Health Authority Emergency Planning Manager
Regional Health Emergency Planning Advisor
Lead PCT Representatives
Any person who is unable to attend must send a suitably briefed, nominated deputy
Attendance
Attendance is required at all meetings. Members unable to attend should indicate in writing
to the Steering Group Clerk 3 days in advance of the meeting (except in extenuating
circumstances of absence). Members are advised to nominate a deputy to attend who is
appropriately briefed to participate in the meeting.
Meetings
The Major Incident Planning Group will meet monthly for a maximum time of 2 hours. A
special meeting will be arranged to review lessons learned from any actual
incident/exercise when emergency plans are implemented.
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The meeting will have a predetermined agenda sent out with relevant papers a week before
the meeting. Items for consideration for the agenda should be sent to the Steering
Committee Clerk 3 weeks prior to the meeting.
Minutes of the meeting will be taken and distributed to the Steering Group for approval at
the following meeting.
Quorum
For that reason, a quorum of 5 members is required - which must include a member of
Director Status - before meetings can be convened
Other Matters
The Chair of the Committee will take advice on the content of the agenda and will be
responsible for ensuring actions are taken forward through appropriate dissemination of the
minutes.
The Group will be supported administratively by the Steering Group Clerk, whose duties in
this respect will include:
 Drafting of the agenda for the agreement of the Chair and collation of papers
 Taking the minutes and keeping a summary of agreed actions and a record of
matters arising and issues to be carried forward
 Advising the Steering Group on scheduled agenda items
 Inviting or co-opting attendees as required
Review
The Terms of Reference will be reviewed annually and ratified by the committee to which
accountable.
Updating
The Terms of Reference must be kept up to date between reviews for changes in
membership and purpose etc
Date agreed by group
Date agreed by committee to which accountable
Date to be reviewed Date is at next policy review or as and when the need arises
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APPENDIX B: ANNUAL RISK ASSESSMENT CHECKLIST
This checklist summarises the requirements of the Major Incident Response Policy and is to be
completed by the Responsible Person. On completion it is to be sent electronically as email
attachment to the PHT Trust Internal Emergency Planning Co-ordinator as and when requested
Delete as applicable
1.
2.
3.
4.
5.
6.
Is the role of the area in a Major Incident explained to all new staff
as part of their Induction with their Line Manager?
Are the specific departmental roles and responsibilities required of
individual members of staff clearly explained and understood by
these people? I.E. Managers/Supervisors, all other staff, and is
training regularly undertaken
Where applicable, are relevant staff offered any additional training
which may be required to help them fulfil their role in the event of a
Major Incident?
Are all staff contact number lists kept up to date at all times? This
includes the contact numbers that switchboard require to contact
staff informing them that a major incident has been declared, or a
major incident exercise is underway.
Is the location of the departmental Major Incident Plan/Procedures
known and accessible to relevant staff; both during and out of
office hours?
Is each element of the Major Incident Plan/Procedures reviewed
annually and following every test, exercise or actual incident?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
When was your Departmental Major Incident Response was last reviewed
……………………………………………
When was your Departmental Major Incident Response last exercised – include local desktop
exercises
…………………………………………….
When was your Departmental Major Incident Response Staff call list last reviewed
…………………………………………….
Your Department…………………………………………………………………………….
Your Name and Post…………………………………………………………………………
Your Contact Number……………………………………………………………………….
Date assessment completed…………………………………………………………………
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APPENDIX C: STAFF INFORMATION LEAFLET
Risk Management IT Systems and Policies Officer
Martin Smalley
Internal Ext. 7700 3480 / Fax 7700 6301
Email: martin.smalley@oporthosp.nhs.uk
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APPENDIX C: STAFF INFORMATION LEAFLET
(The nature and circumstances of the incident will
determine which staff are involved)
Switchboard will notify the Duty Hospital Manager, the On-Call
Manager, the On-Call Executive, all baton bleep holders,
other senior Clinicians and Managers asking them to
respond as per their agreed protocol, or in the case of
departments: with a Major Incident response plan – To
activate their plan.
The On-Call Manager and On-Call Executive will go to the
Hospital Information and Co-ordination Centre and make
contact with the Emergency department to determine the
detailed status of casualties.
All media enquiries will be handled by PHT
Communications Team
When deemed appropriate, the On-Call
Manager will ask individual departments to
stand down. The On-Call Manager will ask
the Trust as a whole to stand down via
switchboard and IT.
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APPENDIX D: DECLARING A MAJOR INCIDENT
1. In the case of casualty related incidents, it is usually the Ambulance Service that will declare
a major incident. Usually first at the scene, the Ambulance Service is responsible for
assessing the situation, and declaring a major incident by selecting and alerting the most
appropriate receiving hospital(s).
2.
Acute NHS Trusts also have the prerogative to initiate their own plans if the need arises e.g.
if the emergency presents via other sources, e.g. at the hospital itself or there is a public
health outbreak. Depending on the nature and circumstances, other agencies such as PCT’s,
the Police, Local Authority and Coast Guard could also declare a major incident. See
Standard Operating Procedures
3. Queen Alexandra Hospital (QAH) in Cosham is designated as the receiving hospital in
Portsmouth & South East Hampshire area for Major Incidents, although more than one
receiving hospital may be designated depending on the nature and location of the incident.
4. Whether it is the Hampshire Ambulance Service or PHT who declares the major incident, the
system of notification and cascade method is the same and once declared the Switchboard at
QAH will activate their cascade notification system.
5. Arrangements are in place to ensure other agencies can be alerted of a major incident at any
time. All members of PHT senior management on-call teams will be provided with access to
up to date copies of policies, procedures, telephone and contact lists to allow them to
effectively respond to a major incident/exercise alert.
6. The patient flows that will be instituted when a major incident or exercise is declared are available
in all Clinical / Key areas and also via the Intranet. This information is updated as and when the
need arise
PHT RESPONSE
There are five major roles for the receiving hospital during a major incident:
1 To provide on-site medical care and advice, to maintain communications with relatives and
friends of existing patients, the local community, the media and VIP’s
2
To ensure the hospital continues all its essential functions throughout the incident (Please
refer to the PHT Business Continuity and Contingency Planning policy).
3
To liase with the ambulance service, other hospitals and agencies in order to manage the
impact of the incident. This is particularly important for critical services such as Intensive
Care and Theatres.
4
QAH may also be required to provide a trained and equipped mobile medical team to attend
the site of the major incident. Strategic Health Authorities are responsible for ensuring that
arrangements are in place to ensure that ‘Medical Emergency Response Incident Teams’
[MERITS] can be sent to the scene of any incident on the request of either the Ambulance
Incident Commander or the Medical Incident Commander. Further details of the
requirements for MERITS can be found in the Department of Health guidance).

Where QAH is NOT nominated as the receiving hospital, it may be asked to contribute
to the district and if, necessary, Hampshire-wide incident management arrangements

As the incident (or exercise) draws to an end, a positive decision will be made to
‘stand down’. The Ambulance Service and Queen Alexandra Hospital (as the
receiving hospital) will normally liase to determine when the stand down is appropriate.
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The On-Call Manager will also liase with Emergency Department Consultants and other Key
departments, standing them down as appropriate.

Portsmouth Hospitals Switchboard at QA Hospital will on the advice of the On-Call
Manager ask all wards/departments and organisations on their laminated notification
sheets to stand down. PCTs’ in turn will notify their staff and services and GP
practices of the stand down.

Once the incident/exercise is at an end, ALL of those involved will be invited by PHT to
attend one or more debriefing sessions, organised by the EPLO. The purpose of
debriefing is to provide immediate post-incident/exercise reflection and discussion for
the staff concerned. Each aspect of the response to the incident/exercise will be
evaluated and discussed and actions may be agreed to address areas that may need
improvement.

Senior PHT staff will also be invited to attend external multi-agency debriefing
sessions.

In some circumstances, an independent facilitator may be asked to assist with the
debriefing process and individual support and advice will be offered to any member of
staff who feels they have been personally affected by the incident.
Communications, Media & Public Liaison
The emergency telephone number of PHT is protected under the Government Preferential
Telephone Scheme (GPTS). In the event that telecommunications infrastructures become
overloaded, provider companies can withdraw the facility to make outgoing calls from domestic
and commercial numbers. Only telephone numbers listed on the GPTS will retain normal
telephone and fax services. Migration to the ‘next generation networks’ is ongoing and it is
proposed that the whole of the UK be converted by 2011. GPTS will then be re-branded as the
Fixed Telecommunications Privileged Access Scheme (FTPAS).
An On-Call Manager Major Incident bulletin board is available as a source of information and to
rationalise communication channels – access is via the Major Incident link within the Business
Continuity / Emergency Planning Home Page. on the trust Intranet - this will be regularly kept
up to date by the Hospital Information & Co-ordination Centre.
All media and public enquiries received by PHT will be directed to the Communications and
Public Relations Team, who have a regularly reviewed action card.
Record Keeping
1. A Departmental Log Book and Best Practice Guidance for keeping a record of all
instructions received, action taken and other information that will enable PHT to assess the
success of the response, is to be referred to within all departmental planning arrangements.
All staff involved in a Major Incident response, be it exercise or real incident must complete
the log book appropriately. After any incident/exercise, all completed sheets must be
photocopied and forwarded to the EPLO for review and safekeeping.
2. The Emergency Planning Liaison Officer is responsible for preparing a report which sets out
what has been learnt from the incident/exercise within PHT, sharing with other relevant staff
and/or agencies, and updating the Major Incident Policy and Action Cards as appropriate.
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APPENDIX E: PROCEDURE FOR TRAINING AND EDUCATION
1.1
Major Incident Response Planning is available at Trust induction and explains the role
of local health services (and specifically PHT) in the event of a major incident or
exercise. New staff can discuss their role further with their Line Manager.
A Trust Major Incident Induction DVD is also available
1.2
Staff with a specific duty manager role (senior managers, bleep holders etc) will
receive appropriate training commensurate with their role in a major incident or
exercise.
1.3
Front line staff will also receive training through participating in exercises that test out
this plan, and in joint training events organised with other NHS organisations and
external agencies e.g. social services.
1.4
Key staff from PHT including Responsible Persons – See 1.5 will attend relevant
Emergency Planning Seminars and courses as required.
1.5
The person with departmental responsibility (nominated lead) for ensuring emergency
planning arrangements are in place, in the event of a major incident or major incident
exercise being called is referred to as the Responsible Person. See APPENDIX F.
1.6
PHT will conduct internal communications tests every six months.
1.7
PHT will participate in multi-agency communications tests and other exercises
including LIVEX (organised by the local authorities and emergency services) and the
multi-agency exercise organised every three years.
1.8
Following a Major Incident test, PHT’s ability to comply with each element of the policy
will be analysed and evaluated and the policy amended to reflect lessons learnt if
necessary.
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APPENDIX F: MAJOR INCIDENT PLAN - RESPONSIBLE PERSONS GUIDELINES
Annexe 1.
1. Purpose
This guideline outlines the responsibilities of the nominated leads for Major Incident planning to
ensure best business practice and continuity throughout Portsmouth Hospitals NHS Trust and its
associated partners
2. Definitions
The Responsible Person is the registered person with departmental responsibility (nominated
lead) for ensuring emergency planning protocols are in place, in the event of a major incident or
major incident exercise being called
3. Responsibilities: Responsible persons must:
3.1
Ensure they have access to a PC and e-mail and be proficient in their use. They must also
have had training in the ability to manage, edit/update their Specialty/Departmental electronic
local business continuity and contingency planning arrangements on their Sharepoint web
page. Please note special IT arrangements exist for Carillion Services Responsible
Persons, as they do not have direct access to PHT IT systems.
3.2
Maintain their department’s major incident planning files electronically on a suitable and trust
acceptable electronic storage device, or on their Sharepoint Web page (ensuring that staff
contact information is password protected). Clear reference as to the location of the electronic
files/spare hard copy should be on the front sheet within the MI sealed envelope and also
reflected within the Major Incident action card itself.
3.3
Ensure a nominated, adequately trained deputy is identified in the event of the absence of the
responsible person
3.4
Ensure that the departmental major incident planning protocols are always accessible to all
staff within the department either electronically or via hard copy, and that all staff receive
adequate training for dealing with Major Incidents and exercises; including methods of
communication within the department and with the rest of the hospital and its associated
partners. This includes ensuring that your designated fax machine is set up with all the
relevant sender’s information (inclusive of changing the settings from GMT to BST and viceversa)
3.5
The Departmental Responsible Person or their deputy must ensure that all staff are aware of
the need for the major incident envelope on the emergency planning board be ‘up to date’ and
sealed at all times. Especially following an exercise or actual major incident. See 3.2 above
and also annexe 4.1
Please ensure that the emergency planning board is not placed in a public area (due to the
confidential nature of the staff information that may be held here).
3.6
Regularly review in consultation with all associated departments, and amend as necessary,
all departmental Major Incident planning arrangements and the reflecting electronic file. This
especially refers to a relocation of a department or changes to its infrastructure (be it
temporary or otherwise). Please also refer to the trustwide register of locations/Specialties
etc. available via the Trust’s Business Continuity / Emergency Planning Home Page. The
departmental plan must follow the approved trust layout. See annexe 3 of this appendix.
Staff call-in lists need to be revised when the need arises and at least every three months and
the electronic file password protected. Also if there is no departmental baton bleep/24 on-call
contact number, regularly review those staff contacts to be contacted by Switchboard in the
event of a ‘real’ Major Incident or exercise, i.e. staff leaving or pro-longed absence - inform
Switchboard immediately of any changes. Please ensure the reviewed / issue date is in the
footer of all updated files.
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Always place an electronic copy of any updated protocol file on your Sharepoint web site (as
appropriate) – see the properties box on annexe 5. The Trust Polices Officer has set up
information update alerts within all known Sharepoint document libraries that have Major
Incident planning information / Business Continuity / Contingency Planning information /
Specialty guidelines and Policies, this is for audit purposes and also is to enable the
distribution of, and utilisation of Emergency Planning information by Duty Hospital Managers /
On-Call Managers, ETC. Responsible Persons must also ensure that their department also
sends the monthly emergency communications status report return to the Trust Policy
Officer – please see the Trust policy and protocol for all PHT telecommunications equipment
– Appendix B
3.7
Ensure all staff responsible for initiating any of the major incident protocols completes the
department log book (numbering all pages as appropriate) referred to/included within their
planning protocols, both after a declared incident or exercise. These need be
retained within the department and copies must be forwarded to the EPLO (Glen Hewlett) for
review and safekeeping. A Best Practice Guidance is also available.
3.8
Assess their department’s compliance with the PHT Major Incident Response Policy as part of
the annual risk assessment process (sent out annually). An Action Plan to address the
deficiencies identified on the risk assessment must be developed, implemented and reflected
in all relevant action cards. Any associated department or outside partner must be informed of
any changes immediately.
3.9
Ensure any changes to the Responsible Person details or their deputy are notified to the Trust
Policy Officer
Annexe 2: The Trust Policy Officer is responsible for
1. Maintaining the Trust major incident master hard copy folders for utilisation by Duty Hospital
Managers/ On-Call Managers / Emergency Department, the intranet web page for formal
trustwide access / updating external agencies to maintain local resilience continuity
2. Providing spare major incident plan envelope seals upon request
3. Ensuring any changes to the trust emergency planning arrangements are notified to
responsible persons for Major incident planning and business continuity and contingency
planning (See Responsible Persons Business Continuity / Contingency Planning Guidelines –
available via the Business Continuity / Emergency Planning Home
4. Providing any advice on these guidelines or any assistance with setting up electronic files,
Business Continuity web sites, etc.
5. The following links are available on the Business Continuity / Emergency Planning Home
page on the Trust Intranet and are useful in maintaining the up to dateness of your Major
Incident planning arrangements

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PHT Duty Managers’ Rota
Standard Operating Procedures
PHT web sites.
PHT Emergency Telephone Breakdown Procedure includes register of ‘fall back phones’
PHT Utility/Estates Services Failure action cards
PHT Major Incident action cards and generic Major Incident information
PHT Dangerous Substance or Bomb Found / Search Protocol
PHT Child/Infant Red Alert Protocol
PHT Emergency Planning help/advice contacts
Queen Alexandra Hazardous Materials (HazMat) Plan including CBRN (Green Plan) & annexes
PHT Automated Emergency Alert system guidance and information
The NHS Emergency Planning Guidance 2005
Emergency Planning Bulletins (DoH)
Pandemic Influenza
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


Hants and IOW Local Resilience Forum
PHT Units/ Divisions/Specialties and locations
Simple guidance for maintaining your document library on Sharepoint
Please note Intranet access to all confidential contact numbers is restricted by the On-Call Manager’s
password
Annexe 3
Major Incident Response Action Card ~ layout
1. Contact Point
Contact number/baton bleep number/ 24 on-call number for Switchboard to notify department of
Major Incident stand-by / declared, or exercise.
2. Key Staff and Roles
Key staff and action cards/points showing the roles that Key staff will take on within the
department during a major incident/exercise to facilitate/support items 3, 4 and 5 below, including
a role for efficient liaison and communications with the rest of the hospital. The location of your
departmental major incident manned control area must be clearly shown. Your departmental
major incident manned control area should also contain, where possible, your dedicated major
incident manned control telephones and fax machines. Numbers and locations of dedicated MI
manned control telephones and fax machines must be included in this section of the plan layout,
as too, where applicable, the location of the nearest red emergency telephone. Reference should
also be made here to the On-Call Manager’s Major Incident bulletin board as a source of up to
date information, thus reducing the need for calls to the Hospital Information & Co-ordination
Centre. (Available via the Major Incident Plan link).
3. Patient Decant/Discharge
These Departmental protocols should cover all aspects of the discharge/decanting of patients
including creating an escape bed, medical records, and the points of contact required within the
trust essential to achieve this efficiently i.e. Hospital Information & Co-ordination Centre,
Discharge Planning, Portering, Domestics, Medical Equipment library, if required, Pharmacy for
TTOs, Patient Transport Services, Social Services, etc.
4. Departmental protocols Receiving Major Incident Casualties
These Departmental protocols should cover the reception/treatment and continuing care of major
incident casualties, including Medical records and the maintenance/availability of Medical devices
that may be required and the points of contact within the trust essential to achieve this efficiently
i.e. Hospital Information & Co-ordination Centre, Portering, Pharmacy for TTOs etc., Catering,
Chaplains, Voluntary Services, Laundry and Linen, Medical Equipment Library, etc.
5. Patients Retained Within Your Department
These Departmental protocols should cover the continuing care/treatment/examination etc. of
those patients retained within your department.
Individual departments must consider, and plan for, any additional risks to their major incident
planning protocols. Advice is always available from the Emergency Planning department or the
Trust Policies Officer.
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Annexe 4.
Departmental Major Incident Protocols Sealed Envelope
These must contain:
1. Front-sheet (dated in footer please)– showing Department, Staff Assembly point, dedicated Major
Incident manned control location – see annexe 6, manned control telephone (NOT bleep) and
fax number/s, and the following statement: If this plan has been removed for any
purpose. Please ensure that it is replaced and re-sealed immediately Please
confirm this action ASAP to your Dept Manager / Major Incident Responsible
Person
2. Contents list (dated in footer please).
3. Departmental major incident response action card (dated and numbered e.g. 2 of 7, etc. in footer
please).
4. Departmental staff call-in list showing name, job title/grade, contact details and home location
area (dated and numbered e.g. 2 of 7, etc. in footer please).
5. Trust-wide dedicated manned control contact numbers directory (Major Incident communication
only).
6. M.I.1 Bed State forms as applicable.
7. Discharge Checklist (where applicable)
8. Departmental log book for keeping a record of all instructions received, action taken and
other information that will enable PHT to assess the success of the emergency response.
(Or reference within the MI plan to the Departmental log book. See Annexe 1. 3.7
9. Spare seals.
Note: 5 – 9 are supplied by the Trust Policies Officer and will be forwarded to all Major Incident
Responsible Persons, as and when the need arises. Please contact the TPO, if you wish to
amend any details on your MI1 forms.
Please note: some departmental major incident plans must contain additional information and
this must be reflected in the contents list. Any additional information must be dated and
numbered e.g. 2 of 7, etc. in footer please.
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Annexe 5.
All PHT Emergency Planning files must have a completed properties dialogue box;
1.
The properties box as shown must contain the following data:
The ‘Title’ field must be the same as the title of the file etc. I.E. Emergency Department Major
Incident action card – please see Annexe 4. 10.
2.
The ‘Author’ field must contain either the originating department or specialty in question I.E.
‘Emergency Department’.
3.
The ‘Manager’ field must contain the name of the Senior/Clinical manager of the department /
specialty at the time of either the file being created or when last updated.
4.
The ‘Company’ field must be that of the parent organisation I.E. ‘Portsmouth Hospitals NHS
Trust’.
5.
‘Category’ this must be the type of file I.E. Major incident action card, major incident staff
call list, etc.
6.
‘Keywords’ This section must contain keywords; supplied by the originator of the file – the
purpose being to enable easy retrieval of the document via the trust search engine.
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ANNEXE 6. MAJOR INCIDENT PLAN FRONTSHEET
Emergency Planning Arrangements for
Portsmouth Hospitals NHS Trust in
Dealing with Major Incidents
DEPARTMENT:
SMH CANCER WARD
ASSEMBLY POINT:
STAFF ROOM
MANNED CONTROL LOCATION:
WARD MANAGER’S OFFICE
TELEPHONE: (SMH) 6177
WARD MANAGER’S OFFICE
SAMPLE ONLY
FAX: (SMH) 7337
WARD MANAGER’S OFFICE
LOCATION OF NEAREST RED FALL BACK TELEPHONE AND ITS 6
DIGIT NUMBER: Ward Clerk Desk: 92 344203
If this plan has been removed for any purpose. Please ensure that it is replaced
and re-sealed immediately Please confirm this action ASAP to your Dept
Manager / Major Incident Responsible Person
Issue date: 22.06.2004
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APPENDIX G: CATEGORY 1 RESPONDER RESPONSIBILITIES
The Civil Contingencies Act 2004 having received Royal assent became law in November
2005. Around the same time the new The NHS Emergency Planning Guidance 2005 became
effective. In reality both of these documents are beginning to be used and indeed at the
beginning of July 2005 Portsmouth Hospitals were audited on our Emergency Planning
arrangements using them.
Both the guidance and the Act place obligations upon Portsmouth Hospitals as a category 1
responder.
These are: 1. Planning

An integrated emergency planning process is in place that is built on the principles of risk
assessment, co-operation with partners, emergency planning and communication with the public
and information sharing.

There is a major incident plan that is kept up to date, accessible, tested regularly and specifically
addresses any potential causes of a major incident for which the identified NHS organisation is
at particular risk.

Major Incident plans take account of the requirements of the Civil Contingencies Act 2004.

The need of vulnerable persons including children is taken into account.

Appropriate arrangements are in place to provide and receive mutual aid locally, regionally and
nationally.

Working as appropriate with DH, appropriate arrangements are in place to provide and receive
mutual aid nationally and internationally.

Planning is undertaken in conjunction with local partners in the independent healthcare sector
including ISTCs.
2. Preparedness

Boards receive regular reports including in NHS organisations annual reports a specific
statement relating to the emergency preparedness including reports on exercises, training and
testing undertaken by the organisation and that appropriate resources are made available to
allow discharge of these responsibilities. To support this arrangement an Executive Director of
the Board will be designated to take responsibility for emergency preparedness on behalf of the
organisation.
An appropriately resourced officer will also be designated, usually referred to as the Emergency
Planning Liaison Office, to take operational responsibility for emergency preparedness. It is
suggested that a Non-Executive Director of the Board is also nominated to support the Executive
Director lead in this role.

Mechanisms are in place to identify, select and train staff to participate in a major incident
ensuring that those staff:
Understand the role they are to fulfil in the event of an Incident.
Have the necessary competencies to fulfil that role.
Have received training to fulfil these competencies.
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Include in induction training an introduction to the role of their organisation in major
incident planning and response.

The resilience of its own estate, facilities and systems enables it to continue to provide core
services as appropriate to the circumstances of the major incident(s).

A high level of preparedness and planning is demonstrated in conjunction with NHS partners.
Working relationships are established and maintained with other emergency services, local
major organisations and other key stakeholders.
3. Reaction

A command and control structure is developed that allows appropriate linkages.

The health, safety and welfare of NHS staff, its patients and the public using NHS facilities and
services. This includes provision of appropriate personal protective equipment and of postincident welfare and debriefing for all staff involved in an incident.
4. Recovery

Major incident plans will link into the organisation’s arrangements for ensuring business
continuity.

Local communications mechanisms are developed that are consistent with central messages
and providing information and advice to the public and the media.
5. Response
In responding to a major incident, the roles and responsibilities of the Trusts are to:

Provide a safe and secure environment for the assessment and treatment of patients.

Provide a safe and secure environment for staff that will ensure the health, safety and welfare of
staff.

Provide a clinical response including provision of general support and specific/specialist health
care to all casualties, and victims and responders.

Liaise with the ambulance service, SHA, local PCO’s, (including GP’s, out-of-hours services,
MIUs and other primary care providers), other hospitals, independent sector providers, and other
agencies in order to manage the impact of the incident.

Ensure there is an operational response to provide at scene medical cover using, for example,
BASICS and other immediate care teams where they exist. Members of these teams will be
trained to an appropriate standard.

Ensure that the hospital reviews all its essential functions throughout the incident.

Support to any designated receiving hospital that is substantially affected including provision of
effective support to any neighbouring service.

Provide limited decontamination facilities and personal protective equipment to manage
contaminated self-presenting casualties.

Trusts will be expected to establish a Memorandum of Understanding (MOU) with their local Fire
and Rescue Service on decontamination.
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
Trusts will need to make arrangements to reflect national guidance from the Home Office for
dealing with the bodies of contaminated patients who die at the hospital.

Liaise with activated health emergency control centre and/or on call SHA/PCO Officers as
appropriate.

Maintain communication with relatives and friends of existing patients and those from the
incident, the Casualty Bureau, the local community, the media and VIPs.
6. Receptions and Treatment of Patients.

For the hospital to be able to manage the reception and treatment of patients effectively, it is
important to ensure casualties are routed appropriately on arrival. Wherever the local layout of
the hospital allows, there should be provision for a clean and dirty entrance and for triage to take
place at each point of entry established. Decontamination facilities will need to be co-located as
appropriate.
7. Protection of Patients

Providing alternative reception areas that are not immediately within the main Emergency
Departments, for example, to help ensure the protection of staff and hospital facilities in the
event of a CBRN incident; or, to deal with large numbers of patients presenting.

Identify potential holding areas adjacent to the receiving hospital.

Potential public health requirements for example, to keep certain categories of patients away
from others.

Access to Paediatric Intensive Care Facilities (PICU) including retrieval and stabilisation teams.

Determining what method of triage will be used at the commencement of the incident and during
an incident.

Arrangements for securing the Trusts’ facilities either in total or in part. This must include
isolating the Emergency Department and securing key areas. This will require multi-agency
input to the development of site-specific plans.
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