A look at the major recommendations from the TriData report, which states “many have already been implemented by Aurora”:
Unified or Single Overall Command: Police and fire officials did not establish a unified (joint) command nor a single overall commander until late in the first hour of the incident. Having a unified command might have resolved police-fire communications issues regarding getting ambulances in closer to victims, and clarifying the level of risk to fire/EMS personnel. This is not to imply that response actions in the first minutes should have been held up until a joint command was established; any such delay could have negatively affected the outcome.
Fire Department Incident Command: For the most critical period of the incident, an acting battalion chief was fire incident commander, without support from other chief officers. As a result, fire incident command was initially overwhelmed due to patient volume and geographical scope of the incident. Within the Incident Command System, an overall incident transportation coordinator was not appointed which might have alleviated some of the patient transportation problems.
Fire-Police Communications: In part due to the volume of radio traffic and dispatcher workload on police and fire frequencies, some critical messages were either not successfully relayed to recipients, or not understood between police and fire incident commanders. Police and fire must train with public safety communications personnel and communications systems in mass casualty exercises to ensure that all know how to communicate with each other in a large incident. It is part knowledge of communication systems and part human communications that need to improve.
Risk Assessment: The level of risk in the theater was not discussed between police and fire commanders. Fire did not know that police had arrested (redacted). Uncertainty of the risk might have delayed triage in the theater had it not been for the fortuitous circumstance of a police officer who was a SWAT paramedic being one of the initial officers on the scene. There needs to be clearer definition and care used to describe risk to paramedics at a mass shooting and to change the risk assessment if warranted as events proceed. There also needs to be better training of fire and EMS personnel for entering a warm danger zone under police protection. Another consideration is to train police officers in basic combat medic skills, and provide them with a tactical medical kit, which Aurora police now are doing.
Access to Victims: Police and fire need to work out procedures for better access to victims in such logistically complex circumstances. Emergency medical personnel were delayed and overloaded before getting to some of the critically injured victims because they were intercepted by the wounded streaming away from the theater. It was difficult to bypass them, especially with no overall transportation group having been established to coordinate transport. Police did not inform fire on how to reach some patients, despite one police car making multiple round trips to hospitals. No one considered having that unit or another lead an ambulance in after the first trip. Fire never asked police how their cars were getting through. As noted above, a transportation group should be established under ICS to deal with such issues.
Triage Ribbons: Triage ribbons indicating severity of condition (black, red, yellow) were not attached to victims, nor were patient tags used after treatment in the field. This made it more difficult for hospitals and EMS to identify and track the most seriously wounded. Notifications in Communications Center – Messages to the public safety communications senior managers did not result in getting senior communications managers back to duty soon enough. This contributed to a lack of adequate arrangements to bring in relief telecommunicators and to brief the next shift on incident status.
Emergency Operations Center: Some of the resource coordination and logistics that could have been facilitated through an activated emergency operations center did not occur. Aurora’s Emergency Operations Center (EOC) is a limited operation that needs improvement and greater visibility within the city’s structure.
First Responder Relief: Exhausted first responders who served during the theater and Paris Street responses were pushed to the limit by being required to serve as security for the Prayer Vigil and Presidential Visit. They could have been rotated out, using more officers from surrounding jurisdictions.
Victim Information: Providing information to families on the status of loved ones was problematic. Hospitals and victim advocates did not have adequate information to answer family questions in a timely manner.
