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

Volume 2 is divided into two sub-volumes: Volume 2-I and Volume 2-II. Volume 2-I is 695 pages long. Volume 2-I begins with a Preface and then continues with Parts 9 to 16. Volume 2-II is 189 pages long. It contains Parts 17 to 21 and the Appendices. A list of the names of the twenty-two who died is at page vii of Volume 2-I and at page iii of Volume 2-II.
A large format version combining Volume 2-I (ia, ib and ic) and Volume 2-II is also available.
Volume 2-I (standard format)
Volume 2-II (standard format)
Volume 2 (large format)

Part 10: What went wrong


Significant aspects of the emergency response on 22nd May 2017 went wrong. This should not have happened. Some of what went wrong had serious and, in the case of John Atkinson, fatal consequences for those directly affected by the explosion.

In this Part, I will look at the key events in the chronology of the emergency response on the night of the Attack and the areas in which I have found the response to be inadequate. I do so by reference to the first two hours of the response. For the first hour, the golden hour, I will set out the problems as they developed by reference to 20‑minute periods.

There are a number of things this Part will not do. It will not be an exhaustive review of everything that went wrong. It will not be a complete recitation of what people did or did not do. It will not set out the analysis or evidence by which I have reached the conclusions I have. All of that is deliberate.

In the Parts that follow, I have provided comprehensive footnotes, following the approach I set out in Appendix 4 in Volume 1 of my Report. In this Part, I have intentionally limited the footnotes only to direct quotations. That is because I am often summarising findings based on a substantial body of evidence and footnoting is impractical. The reader should look to subsequent Parts in this Volume of my Report for the detail that provides the evidential basis for the conclusions I set out in this Part. A plan of the Victoria Exchange Complex can be found at Figure 37 in Part 13.

There are two introductory matters before I turn to the key events. First, I will introduce four key phrases which are used in Volume 2. Second, I will briefly explain key concepts relevant to an emergency response in 2017.

Key phrases

Golden hour

The first hour of an emergency response will determine its overall success. As a recognition of this period’s importance, some emergency responders refer to it as ‘the golden hour’.1 In my Report, the term will be used to refer to the period from 22:31 to 23:30. In using this term, I recognise that one hour is an arbitrary period of time. The time it takes to respond will be dependent on many Grip factors, as determined by the incident itself. However, ‘the golden hour’ is a useful way of communicating the urgency with which the emergency services should be acting from the start.


The aim for the commanders in the golden hour should be to gather information and decide what needs to be done, putting in place structures that bring order to the inevitable chaos as quickly as possible. Where there is a threat, this should be swiftly contained and neutralised. There should be a concentrated focus on rescuing victims as quickly as possible. For those who are critically injured, minutes or seconds can count. Witnesses described the process of bringing order to the chaos by using the word ‘grip’: commanders needed to ‘grip the situation’ or ‘grip the incident’. In my view, ‘grip’, used in this way, efficiently communicates what was required. I shall use it in this Volume of my Report.

Muscle memory

Another phrase commonly used by emergency responders was ‘muscle memory’. This captures the idea that a particular way of behaving has become ingrained and is instinctive. To create ‘muscle memory’ requires effective training and exercising. I shall use this phrase in this Volume of my Report.

The critical period of the response

Finally, I shall use the phrase ‘the critical period of the response’. Unlike ‘the golden hour’, which can be applied to all Major Incidents, this period is specific to events on the night of the Attack. It covers the time from the explosion to the removal of the final living casualty from the City Room: 22:31 to 23:39. This period should have been shorter than it was.

Key concepts

The framework under which the emergency services were expected to operate in 2017 was called the Joint Emergency Services Interoperability Principles or ‘JESIP’. I will outline this in more detail in Part 11.

JESIP’s origin can be traced back to the Prevention of Future Deaths report by Lady Justice Hallett, following the inquests into the deaths caused by the terrorist attack on 7th July 2005. That report, and others which followed, identified that there were repeated failures by the emergency services to work together effectively. Despite this, many of the problems that JESIP was created to resolve recurred on 22nd May 2017.

By 2017, JESIP was well established. There had been at least two years for the emergency services operating in the Greater Manchester area to understand what was required of them and to ensure that their personnel knew how to implement JESIP.

The overarching aim of any response to an emergency is saving lives and reducing harm. This should be the most important consideration throughout every decision‑making process.2 The five main principles for achieving this, known as the “Principles for joint working”, were: communication, co‑location, co‑ordination, shared situational awareness and joint understanding of risk.3

There were significant failures in relation to each of these principles for joint working on the night of the Attack.

The core guidance document for the application of JESIP in practice was the Joint Doctrine: The Interoperability Framework (the Joint Doctrine). The Joint Doctrine set out how an emergency response should be structured. I set out below a summary of four aspects of that structure.

First, the declaration of a Major Incident. A Major Incident was defined within the Joint Doctrine as “an event or situation with a range of serious consequences which requires special arrangements to be implemented by one or more emergency responder agency”.4 Every responder agency should declare a Major Incident as early as is justified by the information it has. Every responder agency that declares a Major Incident should communicate that fact to all other responder agencies “as soon as possible”.5

Second, METHANE messages. The METHANE message provides a structure into which key information is placed. It allows for information to be shared in a recognised format: “M/ETHANE is a structured and consistent method for responder agencies to collate and pass on information about an incident.”6 METHANE is a mnemonic, with each letter standing for a different piece of information to be gathered and relayed. I set out what METHANE stands for in Figure 23 in Part 11.

Third, the three levels of command: Strategic, Tactical and Operational. These levels are sometimes described as Gold, Silver and Bronze. The Strategic/Gold Commander sets the strategic direction, co‑ordinates and prioritises resources. The Tactical/Silver Commander interprets the strategic direction, develops the tactical plan and co‑ordinates activities and assets. The Operational/Bronze Commander executes the tactical plan, commands his or her service’s response and co‑ordinates actions.

Fourth, there are two key locations that are central to a successful multi‑agency response: the Rendezvous Point (RVP) and the Forward Command Post (FCP).

The RVP is a single place to which all responding agencies should travel and co‑locate. The RVP needs to be identified and then communicated as early as possible. The RVP brings all the responders together in a single place. It reduces the risk that each responder agency will operate on its own, rather than together.

The FCP is the place where commanders at the scene from each responder agency meet as soon as possible. It should be a jointly agreed location. Co‑locating commanders is essential. When commanders are co‑located, they can perform the functions of command, control and co‑ordination face to face.