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The Manchester Arena Inquiry has now concluded. The closure notice from the Inquiry Chairman is available here.

Volume 1: Security for the Arena
Volume 1: Security for the Arena (large format)

Security patrols

Key findings

  • There was confusion between SMG and Showsec as to whether, during events Showsec was required to undertake security patrols/pre-egress checks of the entirety of the City Room which included a counter-terrorism element. SMG thought that Showsec was undertaking a patrol of this nature; Showsec did not think it was part of its role to do this.
  • As a result of the confusion, Showsec did not generally undertake security patrols of the entirety of the City Room including the mezzanine. Showsec should have made sure their staff properly checked the mezzanine during pre-egress checks.
  • Primary responsibility for the confusion lies with Showsec. However, SMG should have checked whether Showsec was doing what SMG expected it to do.


A key element of the security arrangements at the Arena was regular patrols. There was confusion between SMG and Showsec about how these patrols were conducted during events, and in particular about what the pre-egress checks in the City Room entailed. This led to a missed opportunity to identify SA as I set out in Part 1.

The facilities management agreement required SMG to undertake Deister Patrols655 24 hours a day, 7 days a week.656 The patrols looked for obstructions, spillages and leakages, as well as ensuring doors were locked if appropriate. One purpose of these patrols was counter-terrorism, specifically looking out for “suspicious activities (anything out of the ordinary or any person found loitering)”.657 At least eight patrols were to be done in any 24-hour period.658 The Deister Patrol route covered the City Room mezzanine and included the location where SA hid on 22nd May 2017.659

On event days, the SMG facilities management team had many more tasks to do.660 As a result, they did not carry out Deister patrols during the event itself, when Showsec staff were present.661


Showsec’s Counter Terrorism Awareness 2017 document, as set out above, stated that:

“The building operations include various different patrols to ensure it is constantly being checked. On a Non-event day or out of event hours the patrols are undertaken by the SMG Whisky control room staff. These checks span the whole of the venue and cover all key/vulnerable areas such as entrances and/or lifts.

During events these patrols are undertaken by Showsec Security staff. The Access Control/IRT Teams are redeployed to patrol around the venue and ensure it is secure and for public safety…”662

Some of the SMG facilities management team assumed that Showsec carried out similar patrols during events, albeit not using the Deister equipment, but it seems there was never an explicit conversation about exactly what this would entail.663

Although SMG knew that the primary focus of Showsec on event days was on public access and egress, SMG thought that the pre-egress checks by Showsec would have included the City Room mezzanine.664 SMG produced a pre-egress check sheet for Showsec staff to use, and this specified that the check needed to cover the “entire City Room area including McDonalds and JJ Williams Entrance”.665

Michael Cowley, SMG’s Director of Facilities Services in May 2017, thought this was unambiguous and simply meant “wall-to-wall in all directions, the entirety of the City Room.”. He expected the Showsec staff to go up one set of stairs, along the mezzanine, and down the other stairs as part of the check.666 He also understood Showsec’s patrols to be discharging a counter-terrorism function in the same way as the Deister Patrols.667 Miriam Stone had the same understanding and said, “it never occurred to me” that Showsec could have thought the pre-egress check meant something different.668

The pre-egress check of the City Room carried out by Jordan Beak on 22nd May 2017 consisted of walking through the City Room with a brief glance towards the McDonald’s side stairs up to the mezzanine to see if they were clear. Jordan Beak did not accept that this was insufficient, or that it was incompatible with the pre-egress check sheet wording. His interpretation of the phrase “McDonalds and JJ Williams Entrance” was that it referred to the stairs leading on to the mezzanine. He did not consider the mezzanine area to be part of the City Room.669 He thought his responsibility was to see if there was anyone sitting on the stairs and, if so, to ask them to move. He said he was able to fulfil that role by looking across from the other side of the City Room.670 He did not think it was his job to look for anyone suspicious on the mezzanine. Even when it was pointed out to him that he had gone onto the mezzanine earlier that evening671 he maintained that it “wasn’t part of our jurisdiction or our check area”.672

There was one witness, Jonathan Lavery who was a Showsec member of staff, who said he routinely went onto the mezzanine, including when conducting pre-egress checks.673 Kyle Lawler said he had seen Showsec staff going on the mezzanine. He thought they were checking it.674 There was evidence of Showsec dealing with a suspicious package on the mezzanine at a Disney on Ice concert on 14th October 2016.675

However, Jordan Beak’s interpretation of the extent of the pre-egress check was more common. Thomas Bailey acknowledged that the natural meaning of the words on the pre-egress check sheet included the mezzanine, but said, “our understanding of it was the bottom of the steps.”676 David Middleton also accepted that the literal meaning of the pre-egress check sheet included the mezzanine,677 but like Jordan Beak he had understood in practice that the pre-egress check applied only to the stairs, and that the mezzanine area was not Showsec’s responsibility.678 Daniel Perry thought that pre-egress checks involved looking at the stairs, but not the mezzanine level itself.679 In contrast to Jordan Beak, David Middleton680 and Daniel Perry681 both thought that part of the purpose of the pre-egress check was to look for any kind of suspicious behaviour, but only within the main City Room space, not the mezzanine.

The City Room pre-egress check sheet had been reviewed, along with all the others, in early 2015 by Thomas Bailey and Lucy Hunt, who was an Event Manager at SMG between 2010 and 2016.682 At no point in their discussion was the difference in understanding about whether the pre-egress check included the mezzanine clarified. As Thomas Bailey put it:

“I wouldn’t have brought it up with Lucy because I thought we were just going to do what we usually do. She didn’t bring it up with me because she thought we went up on to that mezzanine. So it was never discussed because we both must have had an understanding that each of us thought we were doing the same thing.”683

The Security Experts were of the view that the check sheet was clearly written.684 They also thought that SMG had a responsibility to ensure that the security work they expected to be done by Showsec, including the pre-egress checks, was in fact being carried out.685 They commented that they would not have expected SMG to be ignorant of the fact that for a considerable period of time before 22nd May 2017, Showsec staff were simply looking at the bottom of the stairs in the City Room rather than patrolling the mezzanine.686

It seems extraordinary that two large and commercially successful companies had such a fundamental misunderstanding of what they had agreed. Showsec characterised what happened as a “breakdown in communication between the two companies”.687 SMG say that any breakdown of communication was “internal to Showsec and entirely of its own making”.688

On the one hand, the obligation under the facilities management agreement lay with SMG to provide regular patrols at all times. While it was open to them to agree that Showsec should conduct those patrols during events, they were under a duty to ensure these were being carried out and should have checked. Such a check would have been straightforward and could have been done by simply viewing the CCTV. The closure of the McDonald’s restaurant at the end of January 2017,689 which had a significant impact on how busy the mezzanine area was during events, also presented an opportunity to review the pre-egress checks and confirm they were being done in an adequate manner. This opportunity was not taken.690

On the other hand, the primary responsibility for the confusion about the pre-egress checks lies with Showsec. The wording of the check sheet was clear. It was reasonable for SMG to think that the pre-egress checks did include the mezzanine. It is difficult to see how the check sheet could properly be interpreted by Showsec staff as simply looking up the two sets of stairs leading to McDonald’s and JD Williams from the bottom and clearing people away from the stairs if necessary. Showsec should have made sure their staff properly checked the mezzanine level and should have made sure that Jordan Beak did so on 22nd May 2017.

By agreeing to complete the pre-egress check sheet, Showsec was under an obligation to carry out a security patrol of the mezzanine. I regard the failure to do so as being Showsec’s, rather than that of its employees on the ground. This security patrol included being vigilant for the threat from terrorism.

In Part 1, I have addressed what I consider is likely to have occurred had a security patrol taken place at the time of the pre-egress check.