Christchurch terror attack inquest: Emergency response like trying to put together 1000-piece jigsaw puzzle

9:02 pm on 29 November 2023
29th November 2023 Iain McGregor/The Press/Pool
Christchurch Masjidain Attack Coronial hearing.
Witness Dawn Lucas - St John command & control.

Former St John dispatcher Dawn Lucas. Photo: The Press / Iain McGregor

The St John staffer responsible for dispatching ambulances on the day of the Christchurch terror attack has apologised for mistakenly alerting police to an active shooter at the hospital's emergency department.

On Wednesday, the inquest into the deaths of 51 worshippers at Al Noor Mosque and Linwood Islamic Centre heard that early in the emergency response on 15 March 2019, an ambulance crew reported over the St John radio that people with gunshot injuries had turned up at Christchurch Hospital's ED.

Dispatcher Dawn Lucas misheard the transmission at 1.54pm, thinking it meant a shooting was happening at the ED.

"I am sorry for my mistake," she told the Coroners Court.

Lucas reported this to her manager who in turn, notified police of the shooting.

Earlier evidence in the inquest showed Armed Offenders Squad (AOS) members responding to the mosque shootings diverted to the hospital when this information was relayed.

AOS members said it was quickly evident no shooting had occurred at the ED, although some time was spent at the hospital confirming no shooting had taken place.

Lucas said she should have further clarified if there was indeed a shooting at the ED to prevent the possibility of resources being wasted.

27th October 2023 Iain McGregor/The Press/Pool
Christchurch Masjidain Attack Coronial hearing.
Abigail van Echten - Counsel assisting the Coroner cross-examines witness Constable Dara Taylor (Police).

Counsel assisting the coroner Abigail Van Echten. Photo: Iain McGregor

Under cross-examination by counsel assisting the coroner Abigail Van Echten, Lucas was asked about the delay in getting ambulances to both mosques.

Lucas said she was never aware of all the requests made by police to get ambulances to the scenes.

With regard to Al Noor Mosque, details coming into St John by 1.54pm showed it was aware of people having been shot, dead, and that more than 100 people were injured.

Lucas dispatched just one ambulance to the scene in the early stages.

Van Echten asked if it was clear by this time that "significantly" more than one ambulance was needed at the scene. Lucas said yes.

She could not answer why more ambulances were not sent to the designated safe forward point.

She later told St John counsel James Wilding staff could have been "sitting ducks" if all lined up near the scene as the number of offenders was not known.

Lucas confirmed no ambulances were sent to Linwood mosque until 2.27pm despite being aware that it was the scene of another shooting by 2pm - and further information about people being deceased came in just minutes later.

Police had never provided a safe forward point and never informed St John it was safe for paramedics to go to the scene, Lucas said.

She earlier told the court she would not send ambulances to a scene without confirmation that it was safe for them to attend.

Lucas said she was prompted to send ambulances to the scene after St John's Special Emergency Response Team member Dale Muller called from the scene asking for them.

When asked why she did not ask police for a safe forward point, Lucas said: "I don't know."

She accepted 27 minutes was a long time not to send an ambulance to Linwood mosque, but time flew, she said.

"I keep saying it but it was busy. In real time, time went. And I was very focused on the radio traffic and the crews and what they were relaying to me as well.

"Time went very quickly. It was very busy."

Lucas confirmed she had never received training on an active shooter situation, or how to work with police in one.

29th November 2023 Iain McGregor/The Press/Pool
Christchurch Masjidain Attack Coronial hearing.
Coroner Brigitte Windley.

Deputy chief Coroner Brigitte Windley. Photo: The Press / Iain McGregor

Emergency response like trying to put together 1000-piece jigsaw puzzle

A senior police tactical commander has likened the emergency response to trying to put together a 1000-piece jigsaw puzzle dumped upside down on the floor.

The Armed Offenders Squad (AOS) officer, in the role of Zero-Alpha, quickly moved from the squad room to sit alongside incident controller Senior Sergeant Roy Appley in the Southern Communications Centre as the crisis unfolded.

The policeman told the inquest that he was working very hard.

"It was like someone had dumped a thousand-piece jigsaw on the floor and all those pieces were upside down and each piece of that jigsaw was a relevant piece of information that we had to know, but I'd pick each one of them up and put it in the jigsaw and try and figure out where it fit within the picture," he said.

"We tried our very best to pick each piece up and put it where it should go."

The commander let an AOS team leave the scene of the first shooting at Al Noor Mosque for Linwood, despite a police officer saying there were already enough people in Linwood Avenue, because he believed there could be more gunmen.

An AOS team leader previously told the inquest he regretted leaving injured victims at Al Noor to attend the Linwood scene.

The Zero-Alpha officer told the Coroners Court he heard over police radio that there were six armed offenders at Linwood and the terrorist had falsely claimed there were nine other shooters in Canterbury. He was also concerned about the possibility of an offender going to Eastgate Mall nearby.

Given what had occurred at Al Noor, the officer said the possibility of six armed gunmen at Linwood was a "catastrophic thought".

It was "certainly my thinking" that more than just one tactical unit was required at Linwood, he said.

Communication between AOS members were not recorded during the terror attack because their vehicle had a flat battery and they could not use the usual cassette tape system.

Recording the radio channel no longer required using a cassette tape.

Asked by deputy chief Coroner Brigitte Windley what could have made his job easier, the officer said he wondered if the presence of a St John commander at the Southern Communications Centre would have helped.

He did not know if there was much that could have been done to improve his response, although he did wish the AOS tactical radio had been recorded.

The inquest will examine the following 10 issues over six weeks:

  • Events of 15 March 2019 from the commencement of the attack until the terrorist's formal interview by police
  • Response times and entry processes of police and ambulance officers at each mosque
  • Triage and medical response at each mosque
  • The steps that were taken to apprehend the offender
  • The role of, and processes undertaken by, Christchurch Hospital in responding to the attack
  • Coordination between emergency services and first responders
  • Whether the terrorist had any direct assistance from any other person on 15 March 2019
  • If raised by immediate family, and to the extent it can be ascertained, the final movements and time of death for each of the deceased
  • The cause of death for each of the victims and whether any deaths could have been avoided
  • Whether Al Noor Mosque emergency exit door in the southeast corner of the main prayer room failed to function during the attack and, if so, why?

The inquest continues.

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