The lack of planning and coordination by the mass gathering event organizers involving other stakeholders, especially from the health sector, caused mass casualty incidents which could not be managed in a timely manner and resulted in many victims. This was worsened by the fact that the nearest health facilities to the mass gathering event did not have a disaster management plan such as a hospital disaster preparedness plan which, if any, was not operational. No firm regulation forced, monitored, and evaluated the necessity of high-risk mass gathering events to have such a preparedness plan yet in Indonesia.

Using a case study qualitative research method by conducting media observations and listening to webinars on experiences with health workers involved in handling the social disaster of the Kanjuruhan tragedy. Supported by analysis of policy reviews and in-depth interviews with the involved stakeholders on the field.

This is ongoing research, the results have not been finalized. However, from the information that has been obtained so far, it can be concluded that there is no synergy between the plans prepared by the football match organizing committee, police, local government, and nearest referral health facilities. This was identified by the absence of a medical director at the referral health facility, the absence of in and out access for the medical team to the mass gathering event location, and the absence of crowd management at the site of the incident resulted in 720 injured and 135 of them dead. This made the incident the second worst football stampede incident in history.

Specific mass gathering regulation specific to football matches is required as Indonesia has a risk of hooliganism in some areas. This will be mandatory for the organizing committee to comply with and involve relevant stakeholders, especially the local health sector.