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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)

The final 20 minutes

The City Room at 23:11

By about 23:11, there were a substantial number of highly motivated police officers from GMP and BTP in the City Room. The unarmed officers were doing their best to assist casualties. This included by helping to carry them out. There were a significant number of members of the public and Victoria Exchange Complex staff offering their assistance.

At 23:12, Patrick Ennis approached Inspector Smith in the City Room. Patrick Ennis explained that the Casualty Clearing Station was being set up on the station concourse. This gave greater impetus to the evacuation of casualties. Between 23:12 and 23:42, when the last casualty arrived in the Casualty Clearing Station, 33 casualties were evacuated from the City Room. All but six of them were evacuated on makeshift stretchers.

The need for paramedics in the City Room was now acute. At 23:13, Sergeant Hare could be heard on video saying to another officer, “Paramedics mate, they need to be coming in droves.30 At the same time, three HART operatives were captured on CCTV on Hunts Bank, speaking to Daniel Smith.

Deployment of HART operatives at the Victoria Exchange Complex

At 23:15, two of those HART operatives, Lea Vaughan and Christopher Hargreaves, entered the City Room. They had volunteered to enter the City Room following a briefing with Daniel Smith in which he indicated that the scene had not been declared safe. They went into the City Room not knowing what the situation was. They did so without ballistic protection.

The third member of the GM HART crew at the scene, Simon Beswick, remained behind on Station Approach. He was a HART Team Leader. He should have deployed into the City Room to provide a command presence.

As Lea Vaughan and Christopher Hargreaves were entering the City Room, the three other members of the GM HART crew were arriving on Hunts Bank. Together with Simon Beswick, these three HART operatives were tasked by Daniel Smith to set up what he termed a Casualty Collection Point. The correct decision would have been for all four to have been deployed to the City Room.

In the City Room, Lea Vaughan and Christopher Hargreaves began to assist Patrick Ennis with the triage process. Both Simon Beswick and Daniel Smith stated in evidence that they were expecting to be told by the paramedics in the City Room if more paramedics were required there. Given how much the paramedics in the City Room had to do, this was an unrealistic expectation. Instead, Simon Beswick and Daniel Smith should have taken the initiative.

The three paramedics in the City Room needed a commander with them, such as the HART Team Leader, who could make an overall assessment of what was required and liaise with the police in the City Room. Lea Vaughan expected more paramedics to follow her into the City Room. They never came. She said in evidence that they were not needed, but in my view they were.

GMP Tactical/Silver Commander and NWAS Tactical Commander at GMP Headquarters

Annemarie Rooney arrived at GMP HQ at 23:12. Temporary Superintendent Nawaz was already there. ACC Ford arrived shortly afterwards. Temporary Superintendent Nawaz informed Annemarie Rooney that a suicide bomber was responsible for the Attack, that it was not a shooting incident. He told her that there were 20 fatalities at that time, including the bomber. This information was not passed on to Daniel Smith, who was allocating his resources at the scene on the basis that the City Room was not safe.

The conversation between Annemarie Rooney and Temporary Superintendent Nawaz did not reveal that their respective Operational/Bronze Commanders were taking a different approach to the risk in the City Room. Temporary Superintendent Nawaz did not even know who the GMP Operational/Bronze Commander was at that stage.

The conversation was not focused, as it should have been, on how GMP and NWAS could co‑ordinate their efforts.

Temporary Superintendent Nawaz did not look at the GMP incident log. Had he done so, he would have seen that Inspector Smith was making repeated requests for paramedics in the City Room. Accordingly, this was not something that he was able to discuss with Annemarie Rooney when they spoke at 23:15.

BTP Bronze Commander

By 23:10, no BTP Bronze Commander had been appointed. Having been unsuccessful in his attempt to contact Superintendent Wylie, Chief Superintendent Gregory contacted Superintendent Kyle Gordon. The two spoke at 23:12. Chief Superintendent Gregory directed Superintendent Gordon to travel to the scene and take up the role of Bronze Commander.

There was no appointment of a more junior officer as an interim Bronze Commander. In these circumstances, the appointment of Superintendent Gordon, who was in Blackpool at the time of this conversation, was a bad decision.

Chief Superintendent Gregory expected Superintendent Gordon’s journey would take about an hour. In fact, it took much longer. Superintendent Gordon had no access to a police vehicle or police radio. Having failed to secure a police vehicle to pick him up, Superintendent Gordon ordered a taxi to take him to the scene.

Superintendent Gordon did not arrive at the Victoria Exchange Complex until approximately 01:20. During the time he was travelling, he was unable to influence BTP actions or operational decisions. Even had the trip taken an hour, Superintendent Gordon would have arrived too late to make a meaningful contribution.

This meant that, throughout the critical period of the response, BTP did not have an on‑scene Bronze Commander.

Continued evacuation of the City Room

NWAS classified casualties for treatment by three priority levels: P1, P2 and P3. P1 was reserved for the casualties in most urgent need of care. In the City Room, by 23:17, one P1 casualty had been carried into the Casualty Clearing Station on a makeshift stretcher.

Two P2 casualties had been carried into the Casualty Clearing Station on makeshift stretchers. A P2 casualty was anybody who could not mobilise with minimal assistance. Some P1 and P2 casualties had also reached the Casualty Clearing Station without needing to be carried. A number of casualties remained in the City Room.

GMP Tactical Firearms Commander role

Following her agreement with CI Dexter, Temporary CI Buckle travelled to GMP HQ in order to take up the Tactical Firearms Commander role. Shortly before she arrived, at 23:10, she spoke to Superintendent Craig Thompson. Superintendent Thompson informed Temporary CI Buckle that he intended to take up the Tactical Firearms Commander role when he arrived at GMP HQ.

As a result, despite being in a position at 23:20 or shortly after to relieve Inspector Sexton of his role as Initial Tactical Firearms Commander, Temporary CI Buckle did not do so. Superintendent Thompson did not take up the Tactical Firearms Commander position until 00:18, very nearly an hour later.

GMP knew there was a risk of the FDO becoming overwhelmed. Given this, Temporary CI Buckle should have taken up the Tactical Firearms Commander role when she arrived at GMP HQ.

Redeployment of the GMP Force Duty Supervisor

In the latter part of the golden hour, the FDO was still overburdened and difficult to contact. At 23:20, this was compounded by a decision to send his Force Duty Supervisor from GMP Control. The role of the Force Duty Supervisor is pivotal in an Operation Plato situation. Inspector Sexton had an expert and experienced Force Duty Supervisor in Ian Randall that night.

Inspector Sexton made a decision that Ian Randall should travel to GMP HQ to set up the Silver Control Room. That was a mistake. Ian Randall’s replacement lacked his experience. As a result, Inspector Sexton lost a significant part of the limited support that had been available to him.

NWAS Tactical Advisor/NILO

At around this time, the NWAS NILO Stephen Taylor had still not been able to make contact with the FDO. At 23:22, he contacted NWAS Control and asked about using a multi‑agency radio talk group which was monitored by GMP. This was a sensible thing to do but should have been done much earlier.

Stephen Taylor should have also sought to make contact with BTP. He did not do so. He only sought to contact GMFRS and NWFC after 01:00 on 23rd May. This is an example of a significant communication failure that had set in to the emergency response.

There was little multi‑agency communication. This was either because there was not a good understanding of the systems to do this or because insufficient efforts were made to seek information from emergency service partners where it was missing.

Arrival of GMP Ground Assigned Tactical Firearms Commander at the Victoria Exchange Complex

At 23:23, CI Dexter arrived at the Victoria Exchange Complex. Once there, he took up the role of Ground Assigned Tactical Firearms Commander. This role placed him in charge of what he described as the “forward-facing” part of the response.31 That is to say, the part of the response focused on eliminating the threat from terrorists and keeping other responders safe.

Co‑ordinating the other parts of the response was not part of CI Dexter’s role. However, the command vacuum at the scene meant that CI Dexter had no choice but to involve himself in those parts of the response. It is to his credit that he did so.

CI Dexter entered the City Room at 23:25. He spoke to Inspector Smith. He then spoke to PC Richardson, the Operational Firearms Commander. CI Dexter was the first GMP officer to give real thought to Operation Plato zoning, although his ability to do so was affected by the limits of his understanding. He was also the first senior police officer at the scene who actively sought out others in a command position.

Second NWAS METHANE message

At 23:23, Daniel Smith provided a METHANE message from the scene. Daniel Smith did not inform NWAS Control in that message that GMFRS officers were not at the scene and that they were needed.

NWAS Control did not share Daniel Smith’s METHANE message with any other emergency service. Had it been shared with NWFC, it was capable of resulting in GMFRS personnel arriving at the scene much sooner than they did.

Stalling of GMFRS response

At 23:25, the Manchester Central Fire Station Watch Manager telephoned NWFC again. He told NWFC that he was with a firefighter whose wife was a paramedic. She was at the scene. This was important information: the other emergency services were co‑locating at the scene. NWFC did not pass this information on to Station Manager Berry. It was an opportunity, over 45 minutes after the Attack, for a step back to be taken. This would have led to a realisation, even at this late stage, that GMFRS had taken a completely different approach from that of NWAS.

At 23:28, Group Manager Carlos Meakin, who had been mobilised as a second NILO, called NWFC. He repeated the information that the Manchester Central Fire Station crews had seen ambulances pulling up there as they were leaving for Philips Park Fire Station. He was told that the deployment to Philips Park Fire Station was Station Manager Berry’s decision and that NWAS was aware that GMFRS was mustering at Philips Park Fire Station.

By 23:30, GMFRS had mobilised a significant number of senior officers. The Chief Fire Officer, an Area Manager and four Group Managers were all involved in the GMFRS response. Two of the Group Managers went to Philips Park Fire Station. The other senior officers made their way to GMFRS’s Command Support Room at GMFRS HQ. Each of them had a different level of knowledge about the incident.

The primary reason why no one from GMFRS had gripped the response by 23:30 was GMFRS’s approach to incident command. GMFRS’s policy at the time was that the Incident Commander was the most senior Fire Officer at the scene. The difficulty that policy created was seen in Station Manager Berry’s initial mobilising decision, which was that those responding should go somewhere other than the scene. That meant that, by 23:30, with no one at the scene, GMFRS did not have an Incident Commander. This was a significant gap in GMFRS policy. It was a gap that should have been identified and filled before the events of 22nd May 2017.

Those that knew of Station Manager Berry’s initial mobilising decision deferred to him, expecting him to get further information from the FDO. None of those who deferred to Station Manager Berry’s initial decision knew that he had been given an RVP near the scene by GMP and had rejected it.

By 23:30, GMFRS was still not on scene. Its response had stalled.

End of the golden hour

As the golden hour ended, there were 25 casualties in the Casualty Clearing Station. Six were P2 casualties, who had been carried out of the City Room on makeshift stretchers. There were still four P1 casualties, who needed to be carried out of the City Room to the Casualty Clearing Station. A concentrated focus on casualties is required during the golden hour. Despite the best efforts of those working selflessly in the City Room, the emergency response had failed to achieve effective evacuation.

By 23:30, the NWAS Operational Commander did not know how many casualties would require transportation to hospital. It was not until 23:34 that Daniel Smith reported to Annemarie Rooney an accurate estimate of the number who would require transportation to hospital. He should have established this figure from the paramedics in the City Room much sooner than this. This was so he could ensure that there were enough ambulances allocated to respond.

One hour after the explosion, the full structure of a co‑ordinated response was still not in place. BTP did not have a Bronze Commander on the scene. GMFRS had not started directing resources to the Victoria Exchange Complex. Only three paramedics were in the City Room, two of them for only the last 15 minutes of this period.

The FDO had not communicated his declaration of Operation Plato to other emergency services. Operation Plato zoning was only just under consideration. None of the GMP firearms commanders had reviewed the decision to declare Operation Plato at all.

None of the emergency services had gripped the response to the Attack as they should have. It would take a substantial part of the next hour of the response and beyond for that to happen.