Major Incidents at Events

The Joint Emergency Services Interoperability Principles define a major incident as an event or situation with serious consequences requiring special arrangements to be implemented by one or more emergency responder agencies. Note what that does not say. It is not a casualty count, and it is not primarily a statement about your resources.

Declaring one is a formal act, made by the statutory responder agencies under their own plans. Under the Civil Contingencies Act those are the Category 1 responders, the emergency services and the other core agencies, and a private event medical team is not one of them and does not need to be. What it does is recognise the threshold, activate the event's internal escalation plan, and get a structured message to the emergency services immediately. Waiting to be sure is the failure mode; sending the message is not a declaration and costs nothing.

The message is M/ETHANE, and the slash is the point. The M asks whether this is a major incident, yes or no, and it is a question rather than an announcement. If the answer is no, you send an ETHANE message instead and keep reviewing in case it escalates. It may also be a major incident for one service and not for another, which is precisely the position an event medical team can find itself in.

The rest: Exact location, as precisely as you can, including a location referencing service where that is understood. Type of incident. Hazards present, suspected, or that could arise. Access, meaning the routes that are safe to use, the rendezvous point, and the egress, because the ambulance service will be coming and going with casualties. Number of casualties, with the level and severity of injuries if you can manage it. Emergency services required or already there.

The first resources on scene should consider their own safety and then send it. At an event, that is usually you.

This is the part most people have not caught up with. Following a review by the NHS England Emergency Preparedness, Resilience and Response Clinical Reference Group, two tools replaced what came before, with NHS England requiring full implementation and replacement of previous methodologies by 30 June 2024.

The NHS Major Incident Triage Tool is used by NHS responders. It is a single algorithm for adults and children, used at the scene and in hospital, and it replaced the triage sieve, the triage sort and the paediatric triage tape outright. If your team was trained on those, your team was trained on something that has been withdrawn.

Ten Second Triage exists because of the care gap. It is designed for responders with little or no clinical training, to be used before the NHS clinical response arrives, or under their direction once it does. That means stewards, security staff and first aiders working to the same tool and the same language, which is the point: it gives a shared mental model consistent with the interoperability principles. Adopting it is an organisational decision with training and governance attached rather than something an individual picks up.

One feature is worth understanding rather than memorising. Ten Second Triage does not categorise a casualty as dead. Open the airway if you are able to; if they are still not breathing, they are recorded as not breathing, with resuscitation only if resources allow. That last clause matters, because a mass casualty response is precisely the situation in which resources usually do not allow, and the tool is not an instruction to start cardiopulmonary resuscitation on everyone who needs it.

Geography matters here as it does elsewhere in this subcategory. These tools were issued by NHS England. A private event team should be working to the tool agreed with the statutory ambulance service for their event and their jurisdiction.

The gap between reading this and being useful is training, and the plan is where that gets arranged.

Your clinicians train on the tool the arriving services will use. Retraining a team that learned the sieve is not optional maintenance; it is the difference between speaking the same language as the people arriving and not.

Ten Second Triage's design has an implication most events miss. It is built for people with little or no clinical training, which at an event describes the stewards and the security team, and those are the people standing closest to a crowd. Whether they are trained in it is a question for the event rather than for the medical provider, and it is worth asking out loud at the safety meeting rather than discovering the answer on the day.

Then the ordinary things that fail. Somebody has to be able to send an M/ETHANE message under pressure, which means having said one before. The internal escalation route has to be known by the people who would use it. And the casualty surge plan, which belongs in the medical plan from the start, is what carries you between recognising the problem and anybody else arriving.

An event doctor is expected to have completed an approved major incident course and to be trained in major incident triage in line with ambulance service clinical guidelines. That requirement is not a certificate for the file; it is what this page describes.

• •The Joint Emergency Services Interoperability Principles define a major incident as an event or situation with serious consequences requiring special arrangements by one or more emergency responder agencies, and set the M/ETHANE reporting model, which becomes an ETHANE message for incidents below the major incident threshold.
• •The Manchester Arena Inquiry identified the care gap in its volume 2 report, and its recommendations led to the development of new triage tools.
• •Following a review by the NHS England Emergency Preparedness, Resilience and Response Clinical Reference Group, the Major Incident Triage Tool and the Ten Second Triage tool were made available from April 2023, with NHS England requiring full implementation and replacement of previous triage methodologies by 30 June 2024. The Major Incident Triage Tool replaced the triage sieve, the triage sort and the paediatric triage tape.
• •Ten Second Triage is intended for responders with little or no clinical training, before the NHS clinical response arrives or under its direction once present. These tools were issued by NHS England.

• •A major incident is an event with serious consequences needing special arrangements by responder agencies.
• •M/ETHANE: the M is a question, and a no makes it an ETHANE message.
• •Exact location, type, hazards, access and rendezvous, number and severity, emergency services.
• •The Major Incident Triage Tool replaced the sieve, the sort and the paediatric tape.
• •Ten Second Triage is for responders with little or no clinical training.
• •It records 'not breathing' after opening the airway, with resuscitation only if resources allow.