Preparing for Emergencies Guidance

Section 7 - Preparing for Specific Incidents

This section sets out the requirements of Health Boards in relation to preparing for and managing a range of incidents of varying nature and scale. While this document remains strategic in scope, resources, and guidance for incidents with unique challenges are included here.

Communicable diseases

7.1 Increased international movement of people, animals, and goods in to and out of Scotland increases the exposure of the population to novel infections and diseases. The COVID-19 pandemic showed how easily an infectious disease can affect the entire world. Dealing with both imported high consequence infectious diseases (HCID) and more routine endemic infections and outbreaks requires constant vigilance and coordinated public health control measures. These factors, together with large-scale public/crowd events, combine to potentially heighten the risk of communicable infectious disease transmission events of varying type, scale, and impact in Scotland.

7.2 Health Boards have processes in place to deal with disease and infections, including those which may not have been previously recognised in a Territorial Health Board area.

7.3 A number of factors determine the impact of an infectious disease in terms of health, societal and economic costs. These include background levels of immunity (via natural infection or immunisation), infectiousness, virulence, and the availability of appropriate healthcare and/or preventative facilities. An important factor is the health status of the susceptible population, with a healthy, well-nourished, well- educated population less susceptible to outbreaks of infectious disease. The environment also plays an important role with hygienic (uncrowded) living conditions, clean environments at home and in healthcare and sufficient resources/facilities to support provision of healthcare reducing likelihood of outbreaks. These and other factors should be considered when planning an appropriate response to the particular condition.

7.4 Most infections requiring healthcare intervention are dealt with by primary care, with secondary care dealing with the more severe infections caused by organisms that may be more virulent and less common.

The identification of infection

7.5 The Public Health etc. (Scotland) Act 2008 provides the legal basis for notifiable organisms and notifiable disease. In conjunction with a wide range of topic specific guidance documents outlined in Appendix 5, it also provides the framework for action by Health Boards in relation to public health protection.

7.6 The Act also sets out the notification responsibilities of registered medical practitioners and places a duty on Directors of Diagnostics/Laboratories, where notifiable organisms are identified, to provide written confirmation to the relevant Health Board and Public Health Scotland no later than 10 days after identification, or sooner if the case is considered urgent. All healthcare professionals should be aware of local 24-hour arrangements for seeking the urgent advice of their Health Board’s Consultant in Public Health Medicine or Consultant in Public Health if they identify a situation that suggests a health risk state. In addition, there is a requirement for identification and notification of ‘health risk states’ (which are defined as (a) a highly pathogenic infection; or (b) any contamination, poison or other hazard which is a significant risk to public health).

7.7 Public Health Departments must be able to identify and respond quickly to new incidents and emerging public health threats, even if the precise cause of infection remains unknown. This is particularly relevant in the modern world of global travel and trade.

Responsibilities

7.8 Territorial Health Boards are responsible for public health protection, including surveillance, prevention, detection, treatment, and control of communicable diseases. They have a shared duty with local authorities and other national agencies (e.g. Public Health Scotland, and the Care Inspectorate) to support implementation of adequate standards by all service providers. In line with national guidelines, coordinated Incident Control Plans and Joint Health Protection Plans should be drawn up in collaboration with local authorities and any other public service organisations that may be required to participate in an outbreak response.

7.9 The appropriate response to an outbreak will depend on specific circumstances. Some outbreaks may not require an Incident Management Team (IMT) to be established, while others may require a locally based multi-agency IMT. However, in the case of a large-scale outbreak or significant public health incident, a coordinated national response will be required, necessitating local and national Major Incident Plans to be activated.

7.10 Some incidents may result in the activation of the Resilience Partnership. In such instances, the resilience partnership may request the local Health Board to convene and chair a Scientific and Technical Advice Cell (STAC Guidance). If so, the Health Board will retain responsibility for the investigation and management of the public health aspects of the incident, in line with Management of Public Health Incidents guidance, irrespective of a resilience partnership-led response.

7.11 The Health Board’s Director of Public Health should ensure that:

• the Territorial Health Board has a range of up-to-date plans (e.g. Business Continuity Plans, Incident/ Outbreak Control Plans etc.) and protocols that reflect national guidance and the requirements. These should detail measures to:
  • prev ent further spread or recurrence of the particular infection or incident
  • ensure that effective care and treatment is available to all those affected by the outbreak
  • put in place any necessary control measures including the dissemination of information to the public and appropriate external agencies
  • document the outbreak including its major epidemiological characteristics and causes
  • report on the outbreak
• the plans should be flexible enough to cope with the actual or potential incident from the simplest outbreak to more complex and widespread problems which cross Health Board boundaries and require multiple agencies to investigate and control them
• the Public Health Protection Team has adequate and appropriately trained staff and other relevant resources at its disposal to establish an effective IMT, when necessary to implement the actions outlined in the relevant guidance documents
• there are effective arrangements within the Public Health department for:
  • ongoing surveillance, including symptom surveillance at local level
  • receiving reports of relevant information from local health care providers and other local agencies
  • onward reporting of notifiable disease information or information on ‘health risk states’ (see glossary) into Public Health Scotland (PHS) for national surveillance purposes
  • communicating effectively and timeously with other Health Boards
  • debriefing following an incident and providing a lessons-identified report
• the Public Health Department has the necessary resources (including administrative support) available to simultaneously convene and lead a STAC, out of hours and over a sustained period if required and respond to the public health tasks associated with the incident
• relevant senior managers within Acute Services and Primary Care are made aware of the Health Board’s Public Health duties, the relevant (health protection) policies and plans for their respective service areas and their responsibilities for ensuring their implementation
• hospital managers implement the National Infection Prevention and Control Manual (NIPCM) and use the tools within it to ensure that IMTs are fully aware as to who they should inform and involve in the event of a localised (i.e. single ward) or larger scale outbreak or infection incident
• local plans and protocols are regularly exercised with multi- agency partners where appropriate to develop expertise and establish the necessary team working arrangements. Local plans should be reviewed and updated on a regular basis considering these revised guidelines

7.12 PHS’s responsibility will be to work in partnership with others (including the Health Board Public Health Protection Teams), to protect the Scottish public from being exposed to hazards which damage their health and to limit any impact on health when such exposures cannot be avoided. This will include (among other responsibilities), monitoring the hazards and exposures affecting the people of Scotland and the impact they have on their health, coordinating national health protection activity and facilitating the effective response to outbreaks and incidents.

7.13 This may result in PHS assuming responsibility for leading the overall management of the incident on behalf of an NHS Board/SGHSCD, coordinating surveillance, investigation, risk assessment and management, and risk communication.

Communication

7.14 As with all major incidents, internal and external communication is important. The issues to consider are covered in Section 5 of this guidance.

Hazardous Materials (Hazmat)/ Chemical, Biological, Radiological, Nuclear (CBRN)

7.15 All Category 1 designated Health Boards have a duty to provide care for people who may be contaminated with chemical, biological, radiological, or nuclear (CBRN) material or hazardous material (Hazmat) and a role in managing the consequences of such incidents. Contamination may result from accidental release of Hazmat or CBRN materials or because of a deliberate or malicious act. Accidental Hazmat incidents are more likely than those caused by deliberate release, and Health Boards should plan on this basis.

7.16 PHS and the UK Health Security Agency (UKHSA) Radiation, Chemical, and Environmental (RCE) hazards directorate have a role in providing advice and information to health professionals and first responder organisations during such incidents. In particular, UKHSA RCE have lead national responsibility for providing advice and support in respect of radiation and nuclear incidents.

7.17 Territorial Health Boards’ public health duties require that they respond to the health protection needs of people who are either exposed to, or worried about exposure to Hazmat or CBRN incidents, in line with the Management of Public Health Incidents guidance.

7.18 The term CBRN covers a distinct range of hazards:

(i) Chemical: poisoning or injury caused by chemical substances, including chemical warfare agents, or misuse of legitimate but harmful household or industrial chemicals

(ii) Biological: illnesses caused by the deliberate release of dangerous bacteria, viruses, fungi, or toxins (e.g. the plant toxin, ricin)

(iii) Radiological: illnesses caused by exposure to harmful, radioactive materials, possibly inhaled or ingested from food or drink

(iv) Nuclear: where the explosion of a nuclear device causes widespread effects due to blast, heat, and large amounts of harmful radiation

Chemical incidents

7.19 Chemical incidents, which commonly occur during the manufacture, storage, transport, or disposal of chemicals, may result in the direct contamination of people or indirect contamination via air, water, food, or property. Health services regularly provide treatment and care for patients following a range of chemical incidents. Information is available from various sources, such as weather information from the Met Office, TOXBASE, the poisons information database for clinical toxicology advice, or the Scottish Health Protection Information Resource (SHPIR), to support planning for chemical incidents. Some of these sources may not be publicly accessible and responsible officers may need to ensure they can be accessed when needed.

Biological incidents

7.20 Some biological agents, in very small quantities, can have a substantial impact on the health of a civilian population. Health Boards have established procedures for dealing with outbreaks of infectious disease, which are applicable to biological incidents. The effects of a biological release/ incident are likely to be delayed and prolonged as:

• people exposed may not know that they have been affected
• incubation periods between exposure and the development of symptoms can vary
• biological material dispersed may be deposited on clothing, equipment, and other surfaces; and when these are disturbed, secondary dispersal can occur

7.21 Urgent identification of infecting agents is critical to managing biological incidents. In the event of a biological incident impacting on a large proportion of the population, Health Boards may have to consider invoking a large-scale vaccination programme like the existing smallpox response plans.

Radiological and nuclear incidents

7.22 Radioactive material is widely used across industry, healthcare and research and may be released at or whilst in transit to or from such sites, or accidentally released from a nuclear reactor. Nuclear incidents may result from accidental leaks at nuclear sites or malicious acts with potentially widespread effects including blast, heat, and radiation. The response to the effects of an ionising radiation release from a radiological or nuclear incident and the measures required to mitigate them are broadly similar, although management of the consequences would differ significantly.

7.23 UKHSA have lead national responsibility for providing advice and support in respect of radiation and nuclear incidents, with additional incident management and support provided by Territorial Board Health Protection Teams and PHS.

Responsibilities

7.24 As Hazmat/CBRN incidents pose a threat of environmental contamination with public health impacts, Health Boards should undertake scenario- planning with relevant partner agencies to ensure they have the capability to respond to and/or mitigate the effects of any such incident.

7.25 Category 1 responders should ensure that:

• a strategic lead is responsible for ensuring that Hazmat/CBRN incident plans are in place and kept up to date
• Major Incident Plans appropriately reflect contingencies for providing care and treatment for the spectrum of CBRN-related casualties, including the identification, and monitoring of anyone, injured or not, contaminated with hazardous material (including ionising radiation)
• plans are proportionate and flexible to cope with hazards ranging from the simplest accidental incident to more complex or widespread incidents that cross Health Board boundaries and may require a variety of agencies to investigate and respond to them
• appropriate arrangements for risk assessment, risk management and risk communication are in place
• appropriate equipment, including Personal Protective Equipment (PPE) and facilities are available to support the plan, including provisions for compliance with Health and Safety requirements
• there are effective systems to enable primary care services to notify Public Health Departments and vice-versa of specified organisms, specified diseases, exposure to hazards and health risk states where there may be significant risk to public health
• there is access to suitable laboratory testing facilities, including procedures for the collection, transport, and processing of samples to assist with identification of the causative agent
• staff are trained for the roles they are expected to fulfil during a CBRN/ Hazmat incident
• staff have access to the relevant resources, advice and expertise required to provide care and treatment for casualties, including arrangements for decontamination of patients and distribution and administration of appropriate pharmaceutical supplies
• plans are regularly exercised and reviewed with multi-agency partners, including multi-agency training where needed (see Section 5)
• they develop plans for recovery to enable return to normal as soon as possible

7.26 Depending on the scale and impact of an incident, Territorial Health Boards should be prepared to:

• convene and chair a STAC, providing advice to the Resilience Partnerships on human health, risk management strategies, countermeasures, and longer-term health monitoring
• advise SAS and other first responders, other public bodies, the public and the media about effects of the incident on human health, and of countermeasures to those effects

7.27 In planning and preparing specifically for radiological and nuclear incidents, Territorial Health Boards should:

• develop specific arrangements for managing the health consequences of environmental contamination from a release of ionising radiation, as well as arrangements for controlling the distribution and administration of stable iodine tablets as appropriate; and notifying and informing Scottish Government HSCD and other Health Boards
• comply with their obligations under Radiation (Emergency Preparedness and Public Information) Regulations (REPPIR) to work with the operator of a nuclear installation in their area on the development of the Off-Site Plan for the nuclear installation, clearly outlining the health service’s roles and responsibilities, and be capable of responding to an incident, when required
• consider actions to be taken by a range of organisations in the event of an accident occurring during the transportation of nuclear weapons and special military nuclear material
• support the local authority and other partners in the implementation of pre-negotiated arrangements for Radiation Monitoring Units (RMU) and be prepared to assess and monitor longer term health effects on contaminated individuals and the public, including facilities for screening a potentially large number of people in the context of assessed risk
• have an external communications strategy to provide public advice to limit the impact of a Hazmat/CBRN incident

Further information on the role of some of the main organisations in planning for and responding to a radiological or nuclear incident is outlined in Appendix 6.

Decontamination

7.28 Decontamination is not an automatic or inevitable response to a Hazmat or CBRN incident. Decisions on decontaminating individuals involved in an incident will depend on the initial assessment of the nature of the emergency by first responders and subsequently by health professionals within the receiving Emergency Department. Health Boards should plan to accommodate a range of scenarios, ranging from those where casualties may be brought in by SAS (usually, although not always, already decontaminated) to contaminated individuals arriving independently by personal transport, and also consider scenarios where mutual aid may need to be deployed.

7.29 Territorial Health Boards should have a plan in place to facilitate the lockdown of areas in the hospital, or the entire hospital, if necessary, to prevent cross-contamination. This should be in accordance with national lockdown guidance.

7.30 To comply with the Health and Safety duty to protect staff and members of the public from risk to health, Health Boards must comply with the Provision and Use of Work Equipment Regulations 1998 (PUWER) regulations. By doing so this will mean that you must:

• carry out an appropriate risk assessment of decontamination arrangements
• provide staff with suitable facilities and equipment to perform their duties (including PPE)
• adequately train staff to fulfil their duties and use relevant equipment

The needs of children and young people

7.31 Health Boards should recognise the potential for children and/or young people to be among those affected in a Hazmat/CBRN and plan accordingly, considering their vulnerability and the need to keep families together and/or children with their carers.

7.32 Consideration should be given to the special requirements of children and young people during decontamination procedures. It will be necessary to reconcile any intention to use a designated general hospital to receive contaminated child casualties with existing protocols for reception of paediatric patients. Where child casualties are received directly at NHS care facilities, the feasibility and impact of ‘lockdown’ arrangements on children should be considered.

Recovery specific to a Hazmat/CBRN incident

7.33 The type, scale, and impact of a Hazmat/CBRN incident will dictate the potential length of time and the complexity of the recovery period, and these in turn will influence the level of resources required in response.

7.34 The local authority will normally be the lead agency for recovery. However, the scale of the incident will determine the level of involvement of international, national, regional, and local organisations. In addition, the cause of the incident may dictate whether the recovery is managed as a devolved or reserved matter by Government.

7.35 Hazmat/CBRN incidents present non-clinical challenges including the need for mutual aid and public communication, and intense media interest. Although these issues are addressed elsewhere in this guidance, consideration should be given to any specific issues that may arise and actions that need to be taken at various stages during the recovery period.

7.36 Health Boards with Category 1 responder status under the CCA (2004) should identify relevant procedures and resources to address the unique and potentially complex issues in the aftermath of a CBRN incident. The plan should ensure that healthcare facilities return to normal operations, following decontamination, in line with relevant guidance on Recovering from Emergencies.

Management of burn-injured patients

7.37 An incident involving critically injured burn patients can happen in any community or area in Scotland. Such incidents can arise from a major transport accident, an industrial or chemical fire, or a terrorist attack.

7.38 In contrast to many other injuries arising from a major incident, what may appear to be a small number of burn-injured patients has the potential to overwhelm the burn care capacity of a Territorial Health Board, region of Scotland, or the collective burns facilities in Scotland. As is the case with healthcare in general, in the event of demand for services exceeding or overwhelming supply, the underlying principle is to achieve best health outcomes for patients.

Incident-specific Responsibilities

7.39 The management of burn- injured patients in the event of a major incident should be coordinated through the Scottish National Burns Centre and utilise the Care of Burns in Scotland (CoBIS) Managed Clinical Network’s operational plan. Territorial Health Boards should ensure that arrangements:

• identify escalation triggers and responses
• are integrated and consistent with their Major Incident Plan
• take account of relevant legislation and guidance
• are consistent with local C3 structure and arrangements
• are appropriately and widely supported

7.40 The arrangements to transfer and move burns patients should be coordinated with:

• the Scottish National Burns Centre
• the Scottish Ambulance Service (SAS); and if necessary
• the National Burns Bed Bureau if transfers to England or Wales are required

In setting out their arrangements, Health Boards should aim to avoid secondary transfers by consulting and identifying suitable destinations for patients.

7.41 Given the nature of burn-related injuries and the potential impact this could have on continuing normal business; Health Boards should have business continuity plans that address arrangements for the recovery and restoration of critical services.

Territorial Health Boards with a Burns Centre

7.42 The Scottish National Burns Centre is located in NHS Greater Glasgow and Clyde. This Health Board should consider what constitutes a burns ‘major incident’ both locally and nationally as they will be expected to help manage patients from any major incidents occurring anywhere in Scotland. This information should be used as the basis for establishing triggers and escalation arrangements.

Territorial Health Boards with Burns Services

7.43 Health Boards with Burns Facilities (NHS Grampian and NHS Tayside) or a Burns Unit (NHS Lothian) service should consider what constitutes a burns major incident in the context of available capacity and capability, and this information should be used as the basis for establishing triggers and escalation arrangements. They will be expected to consult with the Scottish National Burns Centre where casualty numbers exceed local capacity.

Territorial Health Boards without Burns Services

7.44 Patients with burn injuries may be admitted to Emergency Departments anywhere in Scotland. The primary function of Health Boards without burns services should be to assess and stabilise patients and provide treatment and care in an Intensive Treatment Unit where clinically appropriate. Where injuries are severe or access to specialists is required, these Boards should transfer them to an appropriate burns facility or centre. Plans should set out arrangements for access to specialist and burns services in Scotland.

Scottish Ambulance Service (SAS)

7.45 The provision of care-at-scene and in-transit to the hospital is the responsibility of SAS. It is not expected that burn specialists would deliver care at the scene of an incident and pre- hospital care of casualties in a burns major incident should be provided according to the agreed pre-hospital arrangements between SAS and Territorial Health Boards.

Care of Burns in Scotland Managed Clinical Network (CoBIS)

7.46 Territorial Health Boards and SAS should:

• ensure that relevant personnel are aware of the role of CoBIS and raise awareness of this specialist network
• consider CoBIS plans, incorporating where needed the National Burns Centre in Glasgow, when developing local arrangements, especially where the incident is of such a scale that the numbers of injured patients is likely to be greater than can be managed in Scotland. In this situation, escalation plans will include the National Burn Bed Bureau to plan appropriate patient destinations.
• ensure that all staff are fully informed about planning and preparation for the management of burns-related injuries in the event of a major incident
• include the Scottish National Blood Transfusion Service in relevant communications, as skin tissue is also part of their service provision

Major Incidents with Mass Casualties

7.47 A MIMC for the NHS is defined as: ‘An incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services’ ability to manage’.

7.48 Category 1 and 2 responder Health Boards play a significant role in the multi-agency response to incidents resulting in mass casualties. The National Plan for Major Incidents with Mass Casualties outlines how Health Boards, Health and Social Care Partnerships and Scottish Government will work together at strategic and operational levels to deliver an effective response to major incidents which result in a large number of adult and/or child casualties.

7.49 Owing to the complexities and challenges involved in preparing for mass casualties, the local Major Incident with Mass Casualties (MIMC) plans should be regularly reviewed and exercised in line with guidance on other specific topics outlined elsewhere in this document.

7.50 Such incidents could result in hundreds of casualties, have the potential to overwhelm health services, disrupt business-as-usual arrangements of some health care facilities/services for several days; and require the activation of mutual aid arrangements. These circumstances will require Health Boards to undertake detailed scenario, capacity, and surge/escalation-planning.

7.51 Several smaller scale Incidents may combine, occur in quick succession to become larger, or be geographically diverse. This can require a MIMC response to be triggered due to the large volume of simultaneous casualties and the potential impact on one or more NHS Boards. For these reasons, the term MIMC is used throughout the National Plan.

7.52 The principles underlining the MIMC Plan are as follows:

• health boards will respond to a MIMC with a collaborative, unified and integrated approach, in conjunction with HSCPs
• there will be a consistent and standardised approach to a MIMC across statutory health and social care services in Scotland
• there will be a ‘whole system’ response to the treatment and care needs of patients following a MIMC, to secure the best possible outcomes for them
• the needs of children and adults are equally and appropriately addressed
• there will be a holistic approach that addresses patients’ physical and psychological care needs
• there will be partnership working with other responders, statutory and third sector services in accordance with Integrated Emergency Management
• Scottish Government and the responding Territorial Boards and HSCPs will work together to support a return to business as usual as soon as possible

Declaring a Major Incident with Mass Casualties

7.53 Any Category 1 Health Board may declare a MIMC. In exceptional circumstances, a Category 2 Health Board may make the declaration, but this will be rare in practice. As a ‘blue light’/first responder, the Scottish Ambulance Service (SAS) will usually make the declaration. If the organisation declaring is not SAS, they should immediately advise Ambulance Control Centre to cascade declaration of a MIMC to neighbouring Health Boards.

7.54 A MIMC should be declared by the Health Board Chief Executive or named Deputy based on a combination of factors. These include the number of casualties, the ability of local health services to cope with demand, and the potential of the incident to overwhelm the combined resources of Health Boards in a resilience partnership area. The ability of local services to cope with demand may itself be affected if an incident has a direct impact on NHS sites or staff (e.g. through evacuation).

7.55 Any arrangements for restricting access to NHS services due to a MIMC should only be implemented after a formal declaration of the incident has been recorded and approval has been granted by the Health Board Chief Executive/Executive–level Director or those with delegated authority such as a senior manager or on-call strategic lead.

7.56 A decision to declare a MIMC will primarily be influenced by casualty numbers and the potential impact and pressures on clinical services. However, other considerations may influence declaration of a MIMC including:

• media interest – which may be intense and reactive
• government interest – a situation- reporting cycle will be influenced or decided by central government information requirements

MIMC Responsibilities

7.57 The National MIMC plan requires NHS Boards to:

• minimise/mitigate the impact of a MIMC on its normal pattern of service provision
• identify and prepare an adequate level of resources on a stepped basis to respond effectively to a MIMC
• outline the arrangements required to support the organisation during a MIMC, where there is a potential for the incident to overwhelm the (lead responding) Health Board or other Boards/organisations in the local area. This may involve support for the incident response and for business continuity for defined periods.
• prioritise and coordinate resources to maintain optimal healthcare during the MIMC period

Activation

7.58 Within the first 2 hours of the declaration of MIMC, a Strategic Health Group (SHG) should be convened with the membership comprising of:

• the Chief Executives of all NHS Boards
• the Chief Operating Officer, NHS Scotland (previously titled Director of Performance and Delivery)
• a Senior Communications Manager
• a HSCP Chief Officer
• a representative from the Scottish Government Health Emergency Preparedness, Resilience & Response Division

Lockdown

7.59 Depending on the nature of the incident, ‘lockdown’ may be appropriate and Health Boards should ensure that this happens in accordance with national lockdown guidance. Health Boards should therefore ensure that arrangements are in place to cascade that message to all relevant services and that staff are familiar with these arrangements.

Mass Fatalities

7.60 Health Boards have an important role to play in working with other agencies through Resilience Partnerships to plan for an effective response when a major incident results in mass fatalities.

7.61 The term ‘mass fatalities’ is used to mean:

• deaths in large numbers that can or cannot be managed under the normal procedures of one or more agencies, or
• deaths where the number or fragmentation of bodies, taken together with the circumstances of the incident, require special arrangements for statutory investigation, or where the condition of bodies makes victim identification difficult, or
• deaths requiring the implementation of the following national policy on dealing with mass fatalities: Guidance on dealing with mass fatalities in Scotland

7.62 The duties of Territorial Health Boards in such circumstances are outlined in the Public Health (Scotland) Act 2008. These duties should be considered along with the specific issues (e.g. Equalities and Human Rights, integrated emergency management, business continuity and communication) covered in other parts of this guidance.

Responsibilities

7.63 By definition, mass fatality situations are likely to require the re- prioritisation of some health services and temporary changes to normal working practices of others. In these circumstances, it will be important for Health Boards to communicate any service changes to the public and to engage with patient groups to explain the reasons for any suspension of normal procedures.

7.64 Territorial Health Boards should:

• have a clear understanding of who the stakeholders are in planning for such emergency situations and engage with them either directly or via the resilience partnership
• be aware of the role and requirements of the Crown Office in relation to mass fatality situations
• have a clear understanding of their statutory duties in mass fatality emergencies and have in place business continuity management arrangements to address potential disruptions to the critical services that will be affected. Key stakeholders should be informed of these arrangements.
• collaborate with local authorities to plan for the provision of an adequate level of mortuary facilities in the local area
• assess and plan for the impact of the increased mortality on body-storage capacity. Such planning should address the possibility that Health Board staff may be required to be deployed within additional mortuary facilities, including away from the Board’s own.
• be aware of, and where necessary contribute to, local planning by death certification providers for service continuity during mass fatality incidents to avoid delays to the respectful handling of the dead which would result in difficulties for other responders
• ensure the provision of appropriate (role-based) training for the relevant staff, particularly mortuary staff, in conjunction with other key agencies
• develop and exercise plans using reasonable worst-case scenarios and ensure that the relevant staff participate
• maintain up-to-date pandemic plans in the light of lessons learned from exercises and ensure that their Mass Casualties and Mass Fatalities plans are consistent with each other