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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 first 20 minutes

First 999 calls

By 22:30, the Ariana Grande concert was nearly over. Members of the 14,500‑strong audience had already begun to make their way out of the Arena, many via the City Room. Just one minute later, SA walked towards the departing crowd and detonated his deadly device. He did so near to the exit doors from the Arena concourse. He intended to kill and injure as many people as possible.

At 22:31:52, Greater Manchester Police (GMP) received the first of many 999 calls from the public. Those calls started to reveal the horror of what had happened. A member of the public in the City Room made that first emergency call. He said that there had been an explosion, in the foyer near the old McDonald’s restaurant. He said that 30 or 40 people were injured.

At 22:32, North West Ambulance Service (NWAS) received its first 999 call. It was in similarly stark terms: a bomb had gone off near the box office. A graphic description was given of the impact it had caused.

Many other 999 calls followed. Not all the emergency calls were as clear. A small number referred to shooting or gunshots. The situation was chaotic. That was not surprising. JESIP expected the emergency services to be able to respond to such an incident. It provided the framework for a multi‑agency response. JESIP should ensure that the chaos of an unfolding incident is gripped as soon as possible.

BTP officers at the Victoria Exchange Complex

Four British Transport Police (BTP) officers were in Manchester Victoria Railway Station. They heard the bomb go off. They immediately made their way to the City Room. As they did, they encountered some of those affected by the explosion. Showing considerable courage, the first three BTP officers entered the City Room fewer than two minutes after the explosion.

Those first officers reported to BTP Control what they could see and hear. The lights in the City Room were on. There were many casualties. Police Constable (PC) Jessica Bullough messaged BTP Control from the City Room at 22:33 to confirm that a bomb had been detonated. She requested ambulances. BTP Control confirmed that multiple ambulances were being requested and contact was being made with GMP.

Three minutes after the explosion, four BTP officers were in the City Room. Seven minutes after the explosion, nine BTP officers were in the City Room or on the raised walkway. Some brought first aid bags with them. During this time, the first person from Emergency Training UK (ETUK), the Arena’s event healthcare provider, entered the City Room. Together with the BTP officers and members of the public, they began to try to assist casualties.

BTP officers were also sharing their situational awareness with BTP Control. It was the start of what should have been an effective, co‑ordinated multi‑agency response to the Attack. Unfortunately, that is not what happened.

GMP Control

The GMP Force Duty Officer (FDO) on the night of the Attack was Inspector Dale Sexton. He was based in GMP Control. This was some distance from GMP Headquarters (GMP HQ). His role was to take initial command of an incident such as the Attack until other commanders assumed command. This meant that, until he handed each of them over, he held a number of command roles simultaneously. Inevitably, this placed him under a considerable amount of pressure.

At 22:34, Inspector Sexton became aware of an incident at the Arena. At that point, he became the Tactical/Silver Commander and the Strategic/Gold Commander for the incident. When he deployed firearms assets, he also became the Initial Tactical Firearms Commander and the Strategic Firearms Commander.

Inspector Sexton quickly became overburdened by the number of tasks he had to undertake. This had a direct impact on the effectiveness of the emergency response. It affected who received information, what resources were made available and the decisions of other commanders.

Inspector Sexton made a significant mistake in the early stages: he failed to declare a Major Incident. This omission was duplicated by other GMP commanders during the critical period of the response. It was not rectified until nearly 01:00 the following morning.

North West Fire Control

At about the same time that Inspector Sexton became aware of the Attack, North West Fire Control (NWFC), which provided the control function for Greater Manchester Fire and Rescue Service (GMFRS), was informed by GMP Control of “an explosion in the city centre”.7

The NWFC Control Room Operator created an entry on the NWFC system in readiness to mobilise GMFRS resources straight to the scene of the Attack. That mobilisation order was not given by NWFC, as a supervisor intervened and decided that the GMFRS duty National Interagency Liaison Officer (NILO) should be consulted before any mobilisation took place.

BTP Control and Major Incident declaration

BTP had a similar role to GMP’s FDO. BTP called that position ‘the Force Incident Manager’. At 22:35, the Force Incident Manager, Inspector Benjamin Dawson, declared himself in command of the incident. Within four minutes, he declared a Major Incident. BTP communicated that declaration to NWAS at 22:41. It did not, however, communicate it to either GMP or GMFRS at any relevant stage. This was an error and an early example of many failures in communication that were to emerge across the multi‑agency emergency response.

The BTP incident log reveals that BTP Control did try to contact GMP Control at an early stage. At 22:37, the BTP incident log records “still on hold with GMP”.8 The GMP incident log indicates that contact was made by BTP at 22:39. BTP was in the 999 queue along with many others. BTP had failed to appreciate that it did have better means of communicating directly with GMP, using a radio channel reserved for police services to contact each other.

NWAS Control

At 22:36, NWAS Control called GMP Control. NWAS Control was on hold for over two minutes. When they spoke, the NWAS operator stated: “We’re 10 minutes away – we’ve got quite a lot of ambulances coming.”9

Later in the call, NWAS Control stated that they had “five at least” ambulances on the way and that more were being contacted.10 GMP Control informed NWAS Control that there were “probably at least 20” police officers on the scene.11

As the call between NWAS Control and GMP Control was taking place, another operator in NWAS Control called NWFC. NWAS Control informed NWFC that a bomb had gone off at the Arena. In that call, NWFC was not told that NWAS was in the process of deploying personnel to Manchester Central Fire Station, less than a mile from the scene, and to the scene itself.

Deployment of GMP firearms officers

At 22:36, Inspector Sexton directed the dispatch of firearms officers to the Victoria Exchange Complex. Shortly afterwards, he granted formal authority for the firearms officers to deploy with their weapons. This was an important and sensible step.

Mobilisation of NWAS Advanced Paramedic Patrick Ennis

NWAS Advanced Paramedic Patrick Ennis was on duty at Central Manchester Ambulance Station. He quickly became aware of the 999 calls to NWAS Control. Commendably, he decided to deploy directly to the Arena. At 22:38, he told NWAS Control that he was on his way to the scene.

The City Room shortly after the explosion

At the Victoria Exchange Complex at 22:36, BTP officers were doing their best to help the casualties.

Situation updates were provided to BTP Control from the City Room. However, none of the BTP officers in the City Room declared a Major Incident. None of the BTP officers in the City Room provided a METHANE message. This was due to a failure by BTP to prepare them adequately for the situation they were confronted with.

BTP officers worked alongside members of the public, SMG and Showsec staff and ETUK. ETUK was contracted by SMG to provide healthcare services at the Arena for the concert. There were 14 people on duty from ETUK on 22nd May 2017. A number of those ETUK employees entered in the minutes following the explosion. They showed courage in doing so.

However, ETUK had not adequately prepared to deal with a Major Incident response. There were not enough staff with necessary clinical qualifications, skills and experience on duty. Some staff were not sufficiently qualified to provide healthcare at events. ETUK’s Major Incident Plan expected ETUK to provide a METHANE message to NWAS. This would have given NWAS situational awareness at an early stage. ETUK failed to do this.

Overall, ETUK’s provision of a healthcare service on the night of the Attack was inadequate.

Rendezvous Points

GMP Inspector Michael Smith understood the need to grip the unfolding response. He was notified about the Attack by GMP Control at 22:34. He acted with impressive speed. Within minutes, he started to make his way to the Arena. As he did so, at 22:36, he informed GMP Control that the RVP should be “the… parking area outside the Cathedral”.12 This RVP was recorded on the GMP incident log as the “Cathedral car park”.13 It was passed on to NWFC at 22:40. It was also given to GMFRS by GMP Control much later, at 23:54. It was never used by any agency.

At 22:40, Inspector Smith contacted GMP Control again. Having heard that there was already a GMP officer on scene, Inspector Smith said he wanted all officers to go to the scene directly. Inspector Smith intended this to be understood as the new RVP. It was not passed on as such to NWFC and GMFRS.

Before the arrival at the scene of Inspector Smith, BTP Sergeant David Cawley was one of two Sergeants present. One of his first actions was to reject a request made at 22:40 by a BTP Sergeant in Liverpool for an RVP. Sergeant Cawley said that it was not possible to identify an RVP because of the need to focus on treating casualties. This was an error. It was his responsibility as a supervising officer to assess the situation and to identify how best to co‑ordinate the response on the ground with the resources he had. It is a difficult thing to do. It requires training and experience. A multi‑agency RVP was urgently required. It was an important step that would have helped to co‑locate resources for the emergency response.

NWAS had decided that Manchester Central Fire Station would be used by its ambulances as an RVP. NWAS Control informed BTP Control of this decision about the RVP at 22:41.

Three minutes later, at 22:44, BTP PC Carl Roach declared an RVP at the Fishdock car park. This was an area on the Corporation Street side of the Victoria Exchange Complex. The BTP incident log records that the RVP should be passed on to GMP. I have seen no evidence that this RVP was ever communicated by BTP to GMP or NWAS. This RVP was never used by any emergency service during the critical period of the response.

In the first quarter of an hour after the Attack and thereafter, there was substantial confusion over the location of an RVP. Each emergency service chose its own. In some cases, this was passed on to other agencies. In others, it was not.

There should have been a concerted effort to agree a multi‑agency RVP where all the emergency services could co‑locate.

At the time of the Attack, the emergency services operating in Greater Manchester were in the process of setting up a radio talk group that allowed the control rooms for each emergency service to communicate with each other directly and simultaneously. It should have been operational by 22nd May 2017, but it was not. One of the issues it would have helped to resolve was a multi‑agency RVP.

GMP duty Superintendent

Temporary Superintendent Arif Nawaz was GMP’s duty Superintendent that evening. In this role, known as Night Silver, he was expected to become the Tactical/Silver Commander in the event of a Major Incident. GMP Control notified Temporary Superintendent Nawaz about the Attack at 22:39. He was told that 20 to 30 people had been injured.

Temporary Superintendent Nawaz decided to check the incident log and find a copy of the GMP contingency plan for the Victoria Exchange Complex. Given the important role he had to play, he should have delegated this task to someone else.

NWAS Tactical Commander and the Hazardous Area Response Team

At the same time, NWAS Control contacted Annemarie Rooney, the NWAS on‑call Tactical Commander. She was told that there were reports of a bomb explosion at the Arena. At 22:39, Annemarie Rooney told NWAS Control, “[W]e need to get HART.”14 HART stands for Hazardous Area Response Team. HART is an NWAS specialist resource with training and equipment that enable it to work in hazardous areas.

NWAS Control had known since 22:32 that a bomb had been detonated. The need for HART should have been identified before 22:39. The sooner HART is notified of an event such as a bomb explosion the better. NWAS had two six‑person HART crews on duty that night: one covering Cheshire and Merseyside (the C&M HART crew) and one based in Greater Manchester (the GM HART crew). At the time Annemarie Rooney spoke to NWAS Control, the GM HART crew were closest to the Victoria Exchange Complex.

Annemarie Rooney took some other important steps. At 22:41, she telephoned Consultant Paramedic Daniel Smith. In that call, they agreed that he would travel to the scene. She also spoke to Neil Barnes, the NWAS on‑call Strategic Commander for Greater Manchester. Neil Barnes asked for a further update when a METHANE message was available. The situation required him to be more proactive. It was already apparent that a complex, multi‑agency response was required, and quickly.

GMFRS duty NILO contact with NWFC

At 22:40, NWFC informed the GMFRS duty NILO, Station Manager Andrew Berry, of the Attack. He decided to discuss what was happening with the FDO. Although now out of date, Station Manager Berry was informed of the Cathedral car park RVP declared by Inspector Smith three minutes earlier. Station Manager Berry rejected that RVP because he was not confident that it was safe.

Instead, Station Manager Berry directed NWFC to mobilise GMFRS resources to Philips Park Fire Station, three miles from the Victoria Exchange Complex. He should not have done this. Station Manager Berry’s rejection of the Cathedral car park RVP set in motion a series of events that resulted in GMFRS not arriving at the Victoria Exchange Complex until over two hours after the Attack occurred.

The effect of Station Manager Berry’s decision to mobilise to Philips Park Fire Station was that the fire appliances at Manchester Central Fire Station drove away from, not towards, the incident. While driving away from the incident, the Manchester Central fire appliances drove past ambulances travelling in the opposite direction.

At the same time that PC Roach was declaring an RVP at the Fishdock car park, the BTP Senior Duty Officer Chief Inspector (CI) Antony Lodge contacted the BTP divisional commander for the area in which the Arena was located, Chief Superintendent Allan Gregory. Chief Superintendent Gregory made his way to the BTP control room in Birmingham. In due course, he would take over from Inspector Dawson as the BTP Silver Commander, but that was not until 23:34.

Arrival of GMP firearms officers at the Victoria Exchange Complex

The first firearms officers arrived at the Victoria Exchange Complex eight minutes after the explosion. Initially, the FDO was told that reports of an explosion were a false alarm and that it was nothing more than fireworks. It quickly became apparent that that was wrong. By 22:41, a GMP firearms officer outside the Arena, PC Lee Moore, updated the FDO that there were “major casualties”.15

The FDO authorised an emergency search at 22:42. This was a specialist tactic that involved locating and neutralising any threat. At about the same time, PC Lee Moore again confirmed to GMP Control that there were casualties. He indicated that it was believed a ball bearing device had caused them. He ended his radio message, “Operation Plato, Operation Plato”.16

At 22:43, a pair of firearms officers, one of whom was PC Lee Moore, entered the City Room from the raised walkway. Approximately one minute later, they emerged onto the Arena concourse, having crossed the City Room. During their walk through the City Room, they conducted a “raw check” for any gunmen who might be present.17 No such threat was identified by them. Two minutes later, those two firearms officers had joined three other firearms officers at the doors to the City Room on the Arena concourse.

NWAS Major Incident declaration

At 22:46, NWAS became the second emergency service, after BTP, to declare a Major Incident at the Victoria Exchange Complex. The declaration was not shared with any other emergency service despite the requirement that it should be.

Following the declaration, a series of calls were made to notify local hospitals of the Major Incident declaration, giving approximate casualty numbers. NWAS records indicate that, by 23:00, six hospitals had been informed of the Major Incident declaration.

GMP Tactical Firearms Commanders

Around the same time as the NWAS Major Incident declaration, GMP’s CI Mark Dexter was notified about the Attack. He placed himself on duty and immediately began making his way to the Arena. En route, CI Dexter spoke to Temporary CI Rachel Buckle. Temporary CI Buckle was the on‑call Tactical Firearms Commander. They agreed that CI Dexter would travel to the Victoria Exchange Complex to take up the Ground Assigned Tactical Firearms Commander role. They further agreed that Temporary CI Buckle would travel to GMP HQ to take up the Tactical Firearms Commander role.

The Ground Assigned Tactical Firearms Commander role is a firearms role. However, in the absence of any tactical command of the unarmed officers at the scene, CI Dexter also assumed the role of Tactical/Silver Commander for those officers following his arrival at the scene. He arrived at 23:23. In the 52 minutes before that, there was no GMP Tactical/Silver Commander at the scene. There needed to be.

Arrival of NWAS Advanced Paramedic Patrick Ennis at the Victoria Exchange Complex

By 22:46, Patrick Ennis was on Station Approach outside the Victoria Exchange Complex. At 22:47, he asked for at least four ambulances to go to “Victoria Station”.18 He entered the Victoria Exchange Complex at 22:50 and updated NWAS Control that the best access was via Hunts Bank.

GMP PC Grace Barker approached Patrick Ennis as he entered the station. She informed him: “Every NWAS. They want every NWAS there … At the booking office which is just … upstairs.”19 Patrick Ennis began to make his way to the City Room.

GMP Operation Plato declaration

At 22:47, Inspector Sexton declared Operation Plato. In 2017, Operation Plato was the emergency services’ designation for the response to an attack by a marauding terrorist with a firearm. Although, as it turned out, there were no armed terrorists within the Arena or wider area, this was a reasonable decision. There had been some reports of gunshots.

In 2017, there was a focus within counter‑terrorism on such attacks because of incidents elsewhere in the world. Inspector Sexton could not discount the possibility that a Marauding Terrorist Firearms Attack was under way. That was understandable.

The next step for Inspector Sexton was crucial. He should have ensured that the declaration of Operation Plato was communicated to the other emergency services. The GMP plan required this. Inspector Sexton failed to do this. The burden of his responsibilities as FDO meant that he overlooked it.

GMP had no contingency plan for this, despite knowing that the FDO role was likely to come under enormous pressure during an incident such as the Attack. As a result, no one prompted Inspector Sexton to communicate the declaration of Operation Plato or checked whether he had done so.

The failure to communicate the Operation Plato declaration had significant consequences. It affected the ability of the emergency services to work together by jointly understanding the risks.

Communication was not the only failure in relation to Operation Plato. The declaration of Operation Plato required zones to be applied. The purpose of the zones is to ensure emergency responders are protected from any terrorists who may be present. There was a substantial failure by GMP at every level of armed command in relation to the zoning of the Victoria Exchange Complex during the golden hour.

Arrival of GMP Operational/Bronze Commander at the Victoria Exchange Complex

At about the same time as the declaration of Operation Plato, Inspector Smith entered the City Room. He assumed the role of GMP Operational/Bronze Commander, a role that he performed to a high standard. At 22:47, Inspector Smith contacted GMP Control. He directed that a GMP officer should meet the arriving paramedics.

The GMP radio operator then broadcast: “Any staff, please, start making to the booking office.”20 This was a reference to the City Room. The GMP incident log was updated to the effect that all available officers should go there.

At 22:50, Inspector Smith radioed GMP Control stating, “The booking hall is the seat of the explosion. It’s not the Arena itself.”21 By this time, Inspector Smith knew what he was dealing with. He knew this because he was in the City Room. He could see for himself. He had immediate, direct access to those already on the scene.

Intervention of NWAS Consultant Paramedic Daniel Smith

At the same time, Consultant Paramedic Daniel Smith radioed NWAS Control. At that time, he was travelling to the Victoria Exchange Complex. He told NWAS Control to maintain the RVP at Manchester Central Fire Station pending his arrival at the scene.

By 22:50, there were two ambulances on the forecourt of Manchester Central Fire Station. A third ambulance arrived there at 22:53, a fourth at 22:56, a fifth at 22:59 and a sixth at 23:02. This intervention by Daniel Smith was an error. It was made at a time when Daniel Smith was not part of the command structure. It would not be until 23:00 that NWAS Control issued an instruction to the ambulances at Manchester Central Fire Station to deploy to the scene.

GMP firearms officers’ ‘spiky bubble’

As unarmed police officers, personnel from ETUK and members of the public continued to assist casualties, GMP firearms officers worked quickly to secure the City Room. Two officers had already done a raw check. A second sweep of the City Room was undertaken. At 22:46, firearms officer PC Edward Richardson entered the City Room. By this point, he was the Operational Firearms Commander. This placed him in operational command of the firearms officers within the Victoria Exchange Complex.

By 22:48, the firearms officers were confident that there was no firearms terrorist threat in the City Room. They could not be sure that there was not a secondary device, although there were no obvious signs of one, and they had not checked all of the Arena for gunmen. PC Richardson deployed firearms officers to create a “spiky bubble”22 around the City Room. This resulted in firearms protection on the Arena side of the City Room and the railway station side of the City Room.

By 22:50, the City Room had been secured by firearms officers against any marauding terrorist with a firearm. There was also nothing positively to indicate the presence of a secondary device.

Further contact between GMFRS duty NILO and NWFC

At 22:48, Station Manager Berry spoke to NWFC. He said that he could not reach the FDO. In contrast to what the firearms officers in the City Room knew, he was told that, in addition to there being over 60 casualties, there were reports of an active shooter.

Station Manager Berry was not told that ambulances were being deployed and that the police were on the scene, with more officers on the way. By this time, Station Manager Berry had mobilised the GMFRS Marauding Terrorist Firearms Attack specialists to Philips Park Fire Station. The GMFRS response had already diverged from the other emergency services. The requirements of JESIP were not being met.

NWAS Tactical Advisors/NILOs

Jonathan Butler and Stephen Taylor were the NWAS Tactical Advisors/NILOs on the night of 22nd May 2017. At 22:49, Jonathan Butler was contacted by NWAS Control and mobilised to the scene. He lived approximately 45 minutes from Manchester City Centre.

Immediately after his call with NWAS Control, Jonathan Butler contacted Stephen Taylor. It was agreed that Jonathan Butler would travel to the scene and Stephen Taylor would provide cover from home while he did so. This was a sensible arrangement. Stephen Taylor then tried on numerous occasions to contact the FDO. Like the GMFRS officers, he could not get through.

GMP Tactical/Silver Commander and Operation Plato

At 22:50, Temporary Superintendent Nawaz spoke to the FDO, Inspector Sexton. In this conversation, Temporary Superintendent Nawaz became the GMP Tactical/Silver Commander. He was told that Operation Plato had been declared. Temporary Superintendent Nawaz had no idea what Operation Plato was. He did not reveal this critical lack of knowledge. Instead, he gave the impression that he did know what Operation Plato was. Temporary Superintendent Nawaz should have asked the FDO to explain what Operation Plato meant.

Temporary Superintendent Nawaz was responsible for the unarmed officers at the scene and developing a tactical plan. He could not do this without knowledge of a central aspect of the police response. Temporary Superintendent Nawaz kept from everyone that he did not know what Operation Plato was.

Because of his lack of understanding of Operation Plato, Temporary Superintendent Nawaz was not competent to perform the role of Tactical/Silver Commander of the response on the night of the Attack.

GMFRS duty NILO’s departure for Manchester

At around 22:48, Station Manager Berry decided to set off from his home to Philips Park Fire Station. This was a journey of more than 20 miles. In the course of it, he became lost due to diversions. At the time he set off, he was not to know that he would encounter the difficulties he did.

However, it should have been obvious to Station Manager Berry that his geographical location meant that a substantial amount of time would be spent driving, rather than being devoted to developing and advancing the GMFRS response. The GMFRS response was already significantly out of step with that of BTP, GMP and NWAS. Travelling at such a critical time was not going to improve that.

Station Manager Berry should have given his undivided attention to progressing the GMFRS response to the incident. He had great difficulty contacting the FDO. It is a striking feature of the evidence that he made no attempt to contact the NWAS NILOs. Nor did he make any effort to contact BTP, despite the Attack occurring within a transport hub.

Instead, he spoke only to NWFC and GMFRS officers during his drive to Manchester. In the course of these conversations, he learned nothing new about the incident. These conversations served to recycle existing knowledge about what had happened, not to increase his situational awareness.

The NILO role was not a command role. However, for reasons I will give when I consider the second hour of the emergency response, Station Manager Berry was effectively in charge of the GMFRS response throughout the entire time he was driving.

BTP Control’s request for a METHANE message

Inspector Dawson, on behalf of BTP, was still trying to gain an understanding of what was happening at the scene. He made a number of requests for a METHANE message to be provided to him. At 22:50, he tried again and broadcast a request over the radio for someone to provide a METHANE message. Sergeant Cawley agreed to provide one, but was not able to communicate it to Inspector Dawson for another seven minutes.

By 22:50, a METHANE message should have been provided to BTP Control and then disseminated to all other emergency services.

The City Room at 22:50

By 22:50, more unarmed officers were arriving in the City Room. A minute earlier, seven officers from the Tactical Aid Unit had run into the Victoria Exchange Complex. They made their way towards the City Room. Their help was desperately needed but the real urgency in the City Room was for paramedics.

With no tactical plan from Temporary Superintendent Nawaz, Inspector Smith formed his own plan. He decided that, first, the casualties needed expert treatment and evacuation. That was the priority. Second, once lives had been saved, steps needed to be taken to preserve the area as a crime scene.

Inspector Smith communicated the need for ambulances within seconds of arriving in the City Room at 22:48. He repeated the request again at 22:50 and 22:51.

No one had yet zoned the City Room for the purpose of Operation Plato. By 22:50, the City Room was in fact a cold zone. In 2017, under the national Operation Plato guidance, a cold zone was an area where it was assessed that there was no immediate threat to life from a terrorist armed with a firearm. By 22:50, the GMP firearms officers were confident in their assessment that no such threat existed in the City Room.

That did not mean that the City Room was entirely safe for those responding. However, it had been assessed by Inspector Smith to be “safe enough” for non‑specialist emergency responders and members of the public to be in. Not only should this have been the view across the emergency services, based on the available information, but it was in fact correct, as is now known for certain.

End of the first 20 minutes

Within 20 minutes of the explosion, a concerted effort had been made by those at the scene to ensure that the City Room was secure from further threat and to help the casualties in that location.

However, a great deal had already started to go wrong. Only BTP and NWAS had declared a Major Incident. Neither declaration was shared with all the other emergency services. There was no clear multi‑agency RVP and there had been no discussion about an FCP. GMFRS had rejected the GMP RVP and decided to muster on its own, some distance from the Victoria Exchange Complex. NWAS Control had not deployed to the scene ambulances that were close by.

Despite efforts by Inspector Dawson, no METHANE message had been passed from the scene. ETUK also failed to pass a METHANE message to NWAS.

Operation Plato had been declared by GMP, but not communicated to other emergency services or the unarmed GMP officers. No consideration had been given by GMP to the zoning of the scene as required under Operation Plato.

Had the response proceeded as it should have, GMFRS would have had personnel at, or very close to, the Victoria Exchange Complex by 22:50. This could have been achieved had any one of the following been done.

First, this could have been achieved through the use of the multi‑agency control room talk group, had it been progressed to an operational stage more quickly than it was. The system in operation on the night of the Attack involved each emergency service making a call to another emergency service and waiting to be connected in order to pass on information. Inspector Smith made a request at 22:40 for all officers to come straight to the scene. If all the control rooms had been communicating with each other on a single radio channel, this information could have been disseminated to all other emergency services at that time.

Second, this could have been achieved through a METHANE message passed to NWFC in the first 15 minutes stating that GMFRS was required at the scene. Realistically, at this stage, this could only have originated from BTP officers or ETUK.

Third, it could have been achieved through the duty NILO initially accepting the GMP RVP, or through the duty NILO accepting the GMP RVP once he found that he could not get through to the FDO.

As it was, another 1 hour and 45 minutes would have to pass before GMFRS had any personnel on the scene.