The events of 13 March 1996

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3.18   The first police officers arrived from Dunblane Police Office at about 9.50 am in response to the telephone call from Mr Taylor. They immediately summoned further police assistance and these officers assisted in the gym and took steps to clear the way for the arrival of ambulances. By about 10.10 am senior police officers were on the scene, including the Chief Constable who had put into force the strategy for major incidents. In accordance with this a casualty bureau was set up at police headquarters in Stirling. The Chief Constable also delegated various tasks to his commanders. DCI John Ogg was appointed to be senior investigating officer. The police were faced with a very considerable task in dealing with the incident and its consequences. On 13 March over 100 police officers out of a total force of 658 were involved.

3.19   The first action of the police was to put a cordon around the school buildings with an outer cordon around the road access to the school, in order to restrict admittance to those who could be of assistance. By 10.30 am a considerable number of people had approached the school, not merely anxious relatives of school children but also representatives of the media. The emergency services had to make their way through some 200-300 people in proceeding to and from the school.

3.20   The police then gave priority to ensuring that the injured were taken to hospital. A deliberate decision was taken to refrain from noting their names before they left in order to ensure that they were given medical attention as soon as possible and in order to avoid insensitive intrusion. The next objective of the police was to endeavour to identify the deceased, then institute enquiries, followed by the appointment of production officers and the setting up of an administrative system.

3.21   As I have already indicated the task of identifying the victims was complicated by a number of factors. In addition it was found that two members of Mrs Mayor's class were absent that day. At one point it appeared that a particular child had been apparently identified as being at Stirling Royal Infirmary as well as lying dead in the gym.

3.22   In order to determine the identity of the dead it was necessary for the police to obtain identification of the survivors who had been removed to hospital. However, they had extreme difficulty in communicating with the hospital or the casualty bureau in the manner intended. Apart from a line in the library which was used for the internet facility there was only one telephone line into the school. This was engaged for virtually the whole time by calls from anxious parents or from the media. When the police used mobile telephones they soon found that they also became completely blocked. They decided not to resort to their radio system as the information in which they were interested was extremely sensitive and could have been picked up by scanners. The police did not receive information from the hospital until after mid-day when they obtained two or three names at a time with the use of mobile telephones. They requested British Telecom for additional telephone lines into the school but it was not until 3 pm that the first of these was installed.

3.23   In the meantime arrangements had to be made by the police for the relatives of children who attended the school. They were taken to a private house. From there the parents of children in Primary 1/13 were escorted to a second house before being transferred to a staff room at the school. The process of reuniting parents with children in other classes took up some 2-3 hours. As regards the parents of children in Primary 1/13, the police began to inform the parents of children who were injured and arranged for them to be driven to hospital. By about 1.15-1.30 pm all the injured children had been identified and the necessary information conveyed to their parents.

3.24   In order to communicate information to the parents of children who had died a family liaison team consisting of two police officers and a social worker was organised for each family. These teams required to be assembled and briefed before they spoke to the families and they were also instructed to provide them with continuing counsel and support. The police decided that they should be entirely certain as to the identity of the deceased children before informing their families lest any parents be misinformed. Their concern in this respect was increased by the fact that, as I have already narrated a child had been apparently identified as being both in the gym and at hospital. This necessitated a second round of physical identification of the children in the gym by members of staff. This served only to make their task the more harrowing. As this doubt had arisen the police took the deliberate decision to withhold information about any of the deceased until all of them had been identified.

3.25   Although these procedures were protracted for the reasons that I have explained the parents were not told of the problem and were given no explanation of the reason for the delay. The process of breaking the news to the parents of deceased children did not begin until 1.45 pm. It was not completed until about 3.30   pm. In the meantime doctors from the Health Centre at Dunblane had remained with the families in order to give them whatever comfort they could. The families of each child were called out of the staff room and then escorted by members of their liaison team to one of seventeen rooms which had been made available for the purpose of enabling news to be broken in privacy. The last family remained in the staff room with the members of their team. After the families had received the news they were escorted home by the members of their team who stayed with them as long as was required. It may be noted that at one stage before individual families had been informed there were broadcasts by the media as to the number of children who were thought to have been killed. This had a serious effect on the credibility of the work of the police.

3.26   Mrs Mayor's daughter, Esther, went to Stirling Royal Infirmary where she heard people enquiring about her mother's class at around 12.30 pm. She then left immediately for the school where she was put into the staff room with the parents. Mrs Mayor's husband arrived at the school about 1 pm and was taken to the school library. He was extremely upset and suspected from various media reports that his wife was among the dead. The police officer who escorted him knew that one teacher had been killed but did not know that teacher's identity. Mr Mayor threatened to obtain information from the media if the police would not provide him with it. The officer then left him alone in the library while he sought confirmation of the teacher's identity. After receiving confirmation of Mrs Mayor's death he returned to the library and broke the news to Mr Mayor. This was at least half an hour after he had arrived at the school. The officer then left Mr Mayor in the library in order to go to the briefing room where he was allocated as a member of one of the liaison teams. It appears that neither Mr Mayor nor his daughter was informed of the other's presence in the same building and that it was not until 2.45 pm that they were brought together and informed of what had happened.

3.27   A delay occurred later at Stirling Royal Infirmary where families and their supporters had to wait for some time before they were able to see their child in the mortuary.

Lessons from the Incident

3.28   Although the police had received training for emergencies and had participated in disaster planning they could never have envisaged an incident of such magnitude and involving such distressing circumstances as the massacre which Thomas Hamilton perpetrated. During the course of their evidence police officers who were concerned with the maintenance of access and communication to the school and with the provision of information to the parents of victims accepted that there were a number of lessons to be learned from what happened. In addition, during closing submissions, Mr James Taylor for Central Scotland Police presented me with a written submission by the Chief Constable dated 26 June. I have not thought it necessary to make any recommendations of my own in this respect but it may be of assistance if I draw attention to a number of matters which are to receive attention.

3.29   As regards the use of a cordon it appears to have been accepted that it would have been possible to move it further back from the school so as to enable police officers to speak to the families without their being under the gaze of the press and other members of the media. That was clearly desirable.

3.30   It is clearly better that the names of injured should be noted before they leave the scene of an incident involving multiple victims unless this creates a clear risk of prejudice to their treatment. This point has been noted in the Chief Constable's submission at 4.5.

3.31   A number of important points in regard to communications require future attention. In part 5 of his submission the Chief Constable refers to the importance of emergency services having the ability to limit the number of incoming calls in order that operators can continue to make outgoing calls; the use of a facility for re-configuring domestic telephones in order to give priority to outgoing callers; the dedication of several lines for use by emergency services at localised junction boxes; the value to emergency services of message pagers; the use by the police of encrypted radios; the use by family liaison teams of mobile telephones; the need for a communications vehicle for command purposes; and the need for a statement of best practice for adoption by the Association of Chief Police Officers of Scotland.

3.32   As regards the operation of the casualty bureau the Chief Constable has noted (at 9.3 and 9.4) that it is important for the future to ensure the recording of the times when casualties are positively identified and the times when relatives are notified; and that it would be of greater value to the police service if the processes of the casualty bureau were computerised.

3.33   A major incident puts a heavy premium on close co-ordination between the police and emergency services. I note from his submission at 4.8 that the Chief Constable considers that a closer liaison between his own press team and that of other emergency services would be beneficial.

3.34   However, the point which was of most concern to the families in the present case was the delay in their being informed of the fate of their children, and in particular the time which it took before the families of those who had been killed were informed of that fact. These delays were entirely unacceptable, especially when they were combined with the distressing effect of lack of any information, even an explanation that there was a problem and something was being done about it. It should be accepted that the provision of information even of a limited nature should be one of the aims in setting up adequate systems in the immediate aftermath of a major incident. I can appreciate that in the present case the police wanted to ensure that they were in a position to provide accurate information to the parents but the need, as they saw it, to wait until their information was considered accurate in every case, along with the time taken up by the formation of the liaison teams meant that a considerable time elapsed while the parents were left in what was described as a cramped and overcrowded room, experiencing intense frustration, concern and even anger. It is important not merely that as much information should be provided to relatives but also that the means by which that information is provided should be as sensitive and reassuring as possible. I note with approval that the Chief Constable intends (11.7 and 11.8) to consider allocation of officers with particular expertise for this purpose.

3.35   At the same time it is important to keep in view the general quality of the work which was done by Central Scotland Police. At the end of the Inquiry my attention was drawn to the letters in which the school board and Mr Taylor, the Head Teacher, had expressed their gratitude for the help, support and professionalism of the force. Further, as was made plain at the Inquiry the sensitivity and support which were provided to relatives by members of the liaison teams were warmly appreciated.

The firearms, ammunition and other equipment carried by Thomas Hamilton

3.36   It is now necessary for me to return to the scene of the shootings. Some time after 11.30 am Mr Malcolm Chisholm, scenes of crime officer and firearms examiner with the Tayside Police Force began a detailed examination of the area in conjunction with DC Donald Scobie, another member of the identification branch of that police force. The examination of the scene was interrupted for some time while the gym was checked for booby traps. The examination of the scene provided the Inquiry with a very detailed account of what was found. For the purposes of this report it is not necessary for me to go into every detail but to mention a number of findings which are of importance.

3.37   It was clear that Thomas Hamilton had with him two 9 mm Browning self-loading (or semi-automatic) pistols and two .357 Smith & Wesson revolvers. These firearms were found beside his body. They were in good condition and full working order. Thomas Hamilton was wearing four holsters of the right-hand draw variety strapped to his waist and a pouch over each of his shoulders. He had also brought with him a large camera bag.

3.38   As regards the pistols, Thomas Hamilton had used one of them in order to fire all of his shots at his victims. This pistol (pistol A) was a competition model with an extended barrel and barrel weight, and an adjustable rear sight. The spur of the hammer had been removed. The reason for its removal is not clear. It could have been done as a consequence of the pistol being damaged or to reduce the time for which the pistol had to be held on aim. In any event the absence of a spur did not impair its use in target shooting to any significant extent. Pistol A had a light trigger pull but not unusually so for a well-tuned competition model. The other pistol (pistol B) was a standard model which was fitted with a device which prevented it from being fired when the magazine was not fitted. As between the two revolvers there were only minor differences, including the fact that in one of them the standard wooden handgrips had been replaced with rubber handgrips.

3.39   The examination of the scene showed that Thomas Hamilton had fired 105 rounds of 9 mm ammunition by means of pistol A. He had with him 25 extended box-type magazines, each of which was capable of holding 20 rounds of 9 mm ammunition and suitable for use with either pistol. (The standard magazine for such pistols was capable of holding 13 cartridges.) Stickers had been attached to each magazine, a yellow sticker to the front and an orange to the back, presumably in order to ensure that it was inserted into the butt of the pistol the correct way round. The magazines were found to contain a total of 393 cartridges, 18 of the magazines being fully loaded with cartridges and 3 being partially loaded. The remaining 4 were empty. Mr Chisholm and DC Scobie reached the conclusion that Thomas Hamilton had arrived at the school with a total of 501 rounds of 9 mm ammunition which, with the exception of one round in the chamber of pistol B, were contained in the 25 magazines. They noted that in the majority of the magazines which still contained ammunition the cartridges had been loaded in uniform sequence - with metal jacket soft-nosed hollow point type at the bottom of the magazine; full metal jacket semi-wadcutter types in the middle; and full metal jacket round-nosed types at the top. In evidence Mr Chisholm and Mr Alastair Paton, another firearms expert, stated that they had never come across such an arrangement in the course of their experience. However Mr Paton accepted that putting round-nosed types at the top of the magazine could have been done with a view to avoiding the risk of a cartridge sticking between the magazine and the chamber.

3.40   Mr Chisholm and DC Scobie later carried out tests on the pistols at the firing range at the headquarters of Tayside Police. These included an exercise in which pistol A, in the cocked and ready to fire position, was used to fire off a full magazine of 20 shots as quickly as possible. The time taken to accomplish this was 5.46 seconds. Also, using pistol A and the 7 magazines which had been used by Thomas Hamilton and the appropriate number of cartridges, they carried out an exercise of firing off 105 rounds and ejecting 6 magazines in the course of doing so, all as quickly as possible. The time taken to accomplish this was 50.4 seconds. Too much should not be read into the evidence about 5.46   seconds. While he had not carried out a similar exercise Mr Paton gave evidence that in general terms it was consistent with his experience for a magazine of 20 rounds to be fired off in 5 or 6 seconds with some degree of accuracy. However, this depended on the expertise and physical make-up of the person firing. It would be unusual for 20 shots to be fired off at any one time. I accept Mr Paton's evidence as a broad indication. However, I note that Mr D J Penn, who is a highly experienced shooter, expressed the opinion that an averagely competent shot could not achieve 20 rounds of aimed fire in 5.46 seconds with an unmodified 9 mm Browning pistol: and that 10 to 12 shots in that time would be a more realistic figure. (This was expressed in a list of points submitted to the Inquiry after he gave his evidence.)

3.41   As regards the revolvers, an examination of the scene showed the presence of 230 live rounds of .357 magnum cartridges suitable for use in either of them. In addition each of the revolvers was fully loaded with six of such cartridges, apart from the single round which Thomas Hamilton had fired in order to kill himself.

3.42   It follows from the above that when Thomas Hamilton arrived at the school he had with him a total of 743 rounds of ammunition, consisting of 501 rounds of 9 mm and 242 rounds of .357 ammunition. He fired 105 rounds of the former and 1 round of the latter. At para 5.38 I will refer to evidence which was given in an interpretation of his intentions.