Reducing the therapeutic vacuum: a qualitative study learning from experiences of care delivery during terror attacks in the UK over the past 20 years

BMJ Open. 2026 Jun 1;16(6):e108881. doi: 10.1136/bmjopen-2025-108881.

ABSTRACT

OBJECTIVES: The complex and dynamic care context of terror attacks must be better understood to reduce deaths. This study was designed to understand the tension between saving lives and maximising safety for emergency responders attending active terror incidents.

DESIGN, SETTING AND PARTICIPANTS: Qualitative study exploring the experience of survivors and emergency responders (armed and unarmed police, paramedics, doctors and fire officers) present in the hot (unsafe) zone of five major terror attacks in the UK since 2000. We used reflexive thematic data analysis to build qualitative case studies, comparing similarities and tensions between perspectives of different participant groups.

RESULTS: In our analysis of over 2000 min of interview data from 26 participants, we found a common view that the priority during a terror-related mass casualty event was to save lives. However, responder groups maintained distinct mental models that shaped their operational priorities regarding treatment for those injured within the hot zone. All responders expressed willingness to take self-assessed risks to save lives, but better interagency communication was noted to be required to achieve this safely. All responders felt it was vital to have experienced health professionals present to triage and facilitate urgent treatment and extraction decisions. Armed police commanders had dual responsibilities to achieve rapid care delivery while preventing further terrorist-inflicted injuries. Operationally, this was perceived as leading to a lack of shared mental models between responders regarding what is ‘unsafe’ due to zoning, rather than communication of risk, potentially delaying vital care delivery. There were mixed survivor perspectives regarding the risks that responders should be exposed to, but broad agreement that there was a notable absence of health professionals present in the hot zone during the immediate aftermath of attacks.

CONCLUSION: There is strong professional and public support for improving care delivery, including potential hot zone working, to minimise the therapeutic vacuum in active terrorist attacks. Better risk communication and better shared mental models are necessary to balance responder risk with care delivery to maximise lives saved as safely as possible.

PMID:42225364 | DOI:10.1136/bmjopen-2025-108881