Poor communication and equipment shortages hindered 999 response

Police, firefighters, paramedics and transport workers all experienced problems as they descended into dark, smoke-filled tunnels and tried to save passengers trapped in the wreckage of the three bombed Tube trains.

Ambulances and equipment were delayed by the chaos, which was exacerbated by the communication problems, Lady Justice Hallett said.

While the failures did not cost lives, they “did impede effective management of the scenes”, she said. Many members of the public and passers-by stepped in instead, providing “considerable assistance” to victims.

In light of this, the coroner urged Transport for London to “reconsider whether it is practicable to provide first aid equipment on underground trains”.

The coroner said she could not accept that the police, fire and ambulance services could not do more to improve the situation and highlighted the lack of a single rendezvous point where commanders could meet

When the three bombs on the Tube went off at 8.49am, there was “inevitably, confusion throughout the control centres of London Underground”, she said. But it was surprising that even making allowances for the “inevitable confusion and chaos”, that it took the Tube’s network control centre until about 9.40am to be sufficiently certain that the incidents were terrorist-related so as to order an evacuation.

Lady Justice Hallett also called for better inter-agency training and awareness of how emergency services should work to tackle high numbers of casualties in a major incident.

Rescuers at the scene of the bus attack in Tavistock Square had to use tables and a window from the vehicle to move the injured and dying, using sticky tape and pieces of plastic as a makeshift splint.

Only half the 201 ambulances available in London on July 7, 2005, were used in responding to the attacks and some casualties were treated by paramedics from outside the capital.

Chaos in the control room meant there were long delays. Victims of the bombing between King’s Cross and Russell Square had to wait 40 minutes before the first paramedics arrived.

An ambulance accidentally came across the Tavistock Square devastation within minutes of the attack, but it was almost an hour before further crews were despatched.

The coroner added that she was “concerned” there was no “uniform system” by which all the emergency services could confirm the track current was off on the London Underground.

She also voiced concerns the network-wide “code amber” alert issued on the day was not brought “directly and clearly” to the attention of transport agencies and the emergency services by London Underground.

The chief constable of the British Transport Police, Andy Trotter, said his force would “take time” to read the coroner’s recommendations.

“The memory of that day will be seared on the minds of all of us,” said Mr Trotter.

London Ambulance Service chief executive Peter Bradley said after the hearing: “I am pleased that the coroner recognised the bravery and care shown by our crews.

“I recognise that certain aspects of our response should have been better.”