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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 second 20 minutes

Message from GMP Control to NWAS Control

At 22:51, GMP Control told NWAS Control that “all available ambulances” were needed.23 The “exact location”24 was identified to be “the booking office which is over the bridge to the main entrance”.25

NWAS Control did not act immediately to notify all ambulances allocated to the incident that they should go straight to the Victoria Exchange Complex. A number of ambulances had been sent to Manchester Central Fire Station. The message deploying them to the scene was not given until 23:00.

Further GMFRS NILOs mobilised

At 22:52, Station Manager Berry called NWFC and asked to mobilise three more NILOs. The extra NILOs requested by Station Manager Berry were not contacted by NWFC for at least 14 minutes. The GMFRS response was being severely hampered by delays and failures in communication.

The call by Station Manager Berry was an opportunity for NWFC to share its knowledge that ambulances were being deployed to the scene and that police officers were already there. This information was not shared. Station Manager Berry remained of the view that there was a risk that a Marauding Terrorist Firearms Attack was under way. GMFRS resources continued to be directed away from the scene, out of step with the other emergency services.

NWAS Advanced Paramedic Patrick Ennis’s first entry into the City Room

Patrick Ennis entered the City Room at 22:53. On that first visit to the City Room, he was there for nearly seven minutes. During this time, he spoke to Inspector Smith and ETUK personnel.

A minute after he entered the City Room, Patrick Ennis sent a METHANE message to NWAS Control. This was the first METHANE message sent by anyone. In the message, Patrick Ennis confirmed that it was a Major Incident and stated that there were at least 40 casualties and 10 deceased. He thought there were at least a dozen casualties in the P1 priority level of most seriously injured. He confirmed that ambulances were still needed at Hunts Bank.

NWAS Control replied to confirm that “everyone is now making their way to Hunts Bank”.26 However, for a number of ambulances already sent to Manchester Central Fire Station, it was to be another 12 minutes before they set off from that location to the Arena.

The METHANE message did not identify that GMFRS personnel were not present or that they were needed. NWAS did not share the METHANE message with BTP, GMP or NWFC. This compounded the earlier failure by NWAS to share its Major Incident declaration.

Arrival of the GMP ‘can-do’ team in the City Room

Two minutes after the arrival of Patrick Ennis, GMP officers from the Tactical Aid Unit, led by Sergeant Kam Hare, entered the City Room. Inspector Smith was grateful for their presence. He described them as a “can-do team”.27 These officers, like their BTP counterparts already present in the City Room, had received only basic first aid training.

Sergeant Hare directed his team to work in pairs and to give first aid. Reflecting his belief at the time, he reassured them that paramedics were on the way. That was not the case. The police officers did all they could, but they did not have the training of paramedics and there was a limit to what they could achieve.

Police explosives detection dogs

Just before the arrival of Sergeant Hare and his team, the Operational Firearms Commander, PC Richardson, made a request for explosives detection dogs. He made further requests for this to the FDO at 22:54 and 23:00. It was not until 23:47 that a BTP explosives detection dog arrived, 75 minutes after the explosion. A GMP explosives detection dog arrived only later.

The early attendance of explosives detection dogs would have enabled prompt confirmation that there was no secondary device in the City Room. It would have helped with the management of risk. It is very difficult, in circumstances such as existed in the City Room, to get that confirmation without the assistance of explosives detection dogs.

NWFC and the NWAS “Bronze Commander”

At 22:55, NWFC was informed by GMP Control that NWAS had a “Bronze Commander” on the scene. This was a reference to Patrick Ennis, who Inspector Smith had mistaken for the NWAS Operational Commander. This information was passed on to only one GMFRS officer, who failed to register it. It was not passed on to any other GMFRS officer that night.

Two minutes after this call, Station Manager Berry spoke to NWFC. He was not given this information. Had it been shared with Station Manager Berry at this point, he may have changed the course he had set GMFRS on. This was another example of a failure to ensure situational awareness for a multi‑agency emergency response.

Operation Plato and the City Room

By 22:55, Operation Plato had been running for eight minutes. Throughout most of this time, the City Room was secured against armed attackers by a significant number of well‑organised firearms officers.

No one save for the firearms officers knew of the declaration of Operation Plato. Given the relevance of this to the deployment forward of emergency responders, this lack of knowledge on the part of the emergency services generally was significant.

The Operational Firearms Commander, PC Richardson, and the Operational/ Bronze Commander, Inspector Smith, never spoke to each other. This is despite the fact that they were both in the City Room from 22:49. Inspector Smith was not told by anyone that Operation Plato had been declared for most of the golden hour.

Even if Inspector Smith had been told of the declaration during the early stages of the response, he would not have known what it meant because GMP had not given him any training about Operation Plato.

GMP Tactical/Silver Commander and GMP Headquarters

At around the time that Patrick Ennis was doing his first checks in the City Room, Temporary Superintendent Nawaz spoke to Assistant Chief Constable (ACC) Deborah Ford, who was the GMP Strategic/Gold Commander and Strategic Firearms Commander. She directed him to go to GMP HQ.

GMP was the lead agency and needed to ensure that it had a sufficient command presence at the scene both to organise its own officers, unarmed and armed, and to co‑ordinate with the other agencies.

Temporary Superintendent Nawaz’s departure to GMP HQ, without any other officer being sent to act as Tactical/Silver Commander at the scene, left a command vacuum at the Victoria Exchange Complex. This meant that important elements of the multi‑agency response were missed. No FCP was set up. Setting up an FCP was principally the responsibility of GMP. This, in turn, meant that there was no opportunity for shared situational awareness and joint assessment of risk by commanders at the scene.

GMP Force Duty Officer telephone line

By 22:57, the FDO was struggling to manage the different roles that he was required to fulfil. No action cards were available, which could have been used to delegate tasks from the FDO to others in the control room. It was difficult for anyone to reach the FDO. Answering the FDO telephone line in particular was not a good use of the FDO’s time.

A large number of people, including members of the press, were trying to make contact with GMP via the FDO line. This was bound to cause problems. Inspector Sexton instructed David Myerscough, a member of police support staff who had been a GMP radio operator since 2014, to answer the FDO line. Through no fault of his own, this was not a role David Myerscough had the skills and knowledge to perform. He was out of his depth.


Between 22:58 and 23:03, Inspector Dawson talked Sergeant Cawley through the elements of METHANE. This was the second METHANE message of the night.

Inspector Dawson explained that this was so that he could co‑ordinate and get support to the scene. In the course of receiving the METHANE message, Inspector Dawson stated: “[W]e’re just going to get as many ambulances and fire and all that to you as we can.”28

Despite the time spent obtaining this information and recording it in the BTP incident log, the METHANE message was not passed on to any other emergency service. It should have been. The passing on of a METHANE message is an essential part of the sharing and development of each emergency service’s situational awareness.

This had the most significant impact on GMFRS. At the time the BTP METHANE message was being passed from the scene, GMFRS was mustering at Philips Park Fire Station. If BTP had passed on the METHANE message to NWFC, it could have been relayed to Station Manager Berry. It was to be another 70 minutes before GMFRS considered it sufficiently safe to deploy firefighters to the scene.

Halfway through the golden hour

Halfway through the golden hour, there was still no common RVP and not one person involved in the response had even mentioned an FCP. No one in command roles in the other emergency services had recognised that GMFRS had decided to mobilise to a fire station three miles from the Victoria Exchange Complex.

GMP had an Operational/Bronze Commander in the City Room. The person who was to be the first NWAS Operational Commander, Daniel Smith, had just arrived at the Victoria Exchange Complex and was about to take up that role. There was no Bronze Commander for BTP. None of the BTP, GMP or NWAS Tactical/Silver Commanders had produced a tactical plan or communicated it to their Operational Commanders.

The two METHANE messages had not been shared with the other emergency services. Only one paramedic had been into the City Room.

Appointment of NWAS Operational Commander

Consultant Paramedic Daniel Smith arrived at the Victoria Exchange Complex at 22:59. He was not part of NWAS’s planned command structure for the night. Shortly after he arrived, he took up the role of NWAS Operational Commander.

There was an urgent need for paramedics to triage and provide life‑saving treatment to the injured in the City Room.

At 23:01, the only personnel Daniel Smith had immediately available for deployment were a doctor, a Senior Paramedic, two paramedics and a student paramedic. He chose to send the two paramedics and the student paramedic to Trinity Way. He did so on the basis that a police officer had told him there was at least one critically ill patient on Trinity Way. These NWAS personnel should not have been deployed until Daniel Smith had a better understanding of what was happening, particularly in the City Room. Only then could he assess where the paramedics could make the greatest contribution.

As those he had deployed to Trinity Way were leaving, Daniel Smith was approached on the station concourse by Patrick Ennis who had left the City Room at 23:01. In the course of the short conversation that ensued, Patrick Ennis informed Daniel Smith that there were police officers, members of the public, event healthcare staff and security staff in the City Room, helping casualties. He told Daniel Smith that people were in urgent need of medical attention and that there had been fatalities. They did not discuss whether the City Room was a safe place for non‑specialist paramedics, like Patrick Ennis, to work. They should have.

One of those immediately available to Daniel Smith was Derek Poland. Derek Poland was a Senior Paramedic. He was also one of the two on‑call Operational Commanders. He had been mobilised to the scene in that capacity. Derek Poland volunteered to go into the City Room to support Patrick Ennis. Daniel Smith instructed him to stay on the station concourse.

NWAS Advanced Paramedic Patrick Ennis’s second entry to the City Room

At the conclusion of his conversation with Daniel Smith, Patrick Ennis returned to the City Room. He re‑entered the City Room at 23:05. Daniel Smith did not direct Patrick Ennis to go back to the City Room, Patrick Ennis went voluntarily. Patrick Ennis’s expectation was that more paramedics would follow him. In the event, only two did, 10 minutes later.

Patrick Ennis had SMART Triage Tags in a bag in his vehicle. SMART Triage Tags allow casualties to be labelled with their priority level once they have been assessed. Patrick Ennis did not take these SMART Triage Tags with him into the Victoria Exchange Complex. He did not ask anyone to retrieve them for him or ask to use anyone else’s set once he was within the City Room.

As a result, when he commenced triage on his return to the City Room, Patrick Ennis had no clear and reliable method for identifying each casualty in terms of the priority level he had assessed them to have.

NWAS Operational Commander’s risk assessment of the City Room

Daniel Smith decided that non‑specialist paramedics should not be deployed into the City Room. He wrongly believed that he was prohibited from deploying any non‑specialist paramedics into the City Room.

Daniel Smith made this decision within a very short period of time of his arrival. He did not go up to the City Room to see the position for himself. He had not discussed it with Patrick Ennis. He did not attempt to find or speak to the GMP Operational/Bronze Commander.

Had Daniel Smith spoken to either Patrick Ennis or Inspector Smith about paramedics working in the City Room, he would have been told by both of them that they regarded it as a safe enough area to work in.

Daniel Smith should have sought to improve his situational awareness and conduct a joint risk assessment before making such an important decision.

BTP command

At 23:05, Chief Superintendent Gregory spoke to ACC Robin Smith, who was at home in the south of England. ACC Smith was the on‑call Gold Commander for BTP that night. Chief Superintendent Gregory informed ACC Smith that he was making his way to the BTP control room in Birmingham and that, once there, he would undertake the role of Silver Commander.

Chief Superintendent Gregory was rightly concerned about the lack of a BTP Bronze Commander. He concluded that the role of Bronze Commander needed to be undertaken by someone of seniority. As a result, his focus was not on finding a more junior officer to fulfil the role of Bronze Commander for BTP as quickly as possible. This was an error on his part.

Chief Superintendent decided to appoint Superintendent Edward Wylie as Bronze Commander. Superintendent Wylie was the sub‑divisional commander for the Pennine sub‑division. He was based in Manchester. Chief Superintendent Gregory called Superintendent Wylie at 23:08. Superintendent Wylie did not answer his telephone.

Having failed to get through to Superintendent Wylie, Chief Superintendent Gregory did not try to find out who of those already present at the Victoria Exchange Complex might take charge of the BTP response until a more senior officer arrived. He should have done so.

Manchester Central Fire Station

At 23:06, NWFC was informed by one of the fire crews who had left Manchester Central Fire Station and travelled to Philips Park Fire Station that ambulances were arriving at their home station as they departed. This was important information that NWFC failed to act upon. It was not passed on to Station Manager Berry.

At the time NWFC was being informed of this, those ambulances at Manchester Central Fire Station began to leave in convoy for Hunts Bank. The first ambulance in the convoy arrived at the Victoria Exchange Complex two minutes later.


At about the same time, the Team Leader of the C&M HART crew, Ronald Schanck, spoke to NWAS Control. It was agreed that the C&M HART crew would mobilise to Manchester. The C&M HART crew should have been mobilised to respond approximately 30 minutes before this time.

NWAS evacuation plan from the City Room

The staircase leading from the raised walkway to the station concourse presented a formidable obstacle to injured casualties being evacuated from the City Room. It was a challenge even for those injured who could walk. For those unable to walk, it was a danger. Daniel Smith was by now wearing an Operational Commander tabard and was located by the War Memorial entrance to the station. This gave him a viewpoint of the staircase.

From 23:07, Daniel Smith saw casualties being brought down from the City Room on makeshift stretchers. He could have had no idea when these materials would run out. He did not know what stretchers were available in or around the City Room. It did not occur to him to arrange to use the stretchers in the ambulances, which had begun to arrive in numbers at 23:08. The use of improvised stretchers was the product of the ingenuity of the police officers, members of the public and Victoria Exchange Complex staff. This should not have been necessary.

Daniel Smith believed that the evacuation was going well, and so he thought that he did not need to do anything further. He should have realised that the system for evacuation needed to be improved. Moving casualties in this way was a risk to them. It was painful for many. It risked making injuries worse. Although the stretchers in the ambulances ideally required training to use, they were significantly preferable to what was in fact used, even when used by those without training. The NWAS evacuation plan was inadequate.

Aside from the issue of stretchers, the evacuation plan was hampered by the fact that, between 23:05 and 23:15, there was only one paramedic in the City Room: Patrick Ennis. At 23:06, the first HART operative, Lea Vaughan, arrived at Hunts Bank. A minute later, two more HART operatives, Simon Beswick and Christopher Hargreaves, arrived. The arrival of the GM HART crew offered another opportunity to deploy medical resources into the City Room, where help was most needed.

NWAS Casualty Clearing Station

The area in which casualties receive treatment before being moved to hospital in a mass casualty situation is called a Casualty Clearing Station. In the course of his conversation with Patrick Ennis, Daniel Smith decided to locate the Casualty Clearing Station by the War Memorial entrance.

The first two casualties arrived at the Casualty Clearing Station at 23:07. One was on a makeshift stretcher; one had been assisted on foot down the raised walkway steps. By 23:10, there were four casualties in the Casualty Clearing Station. A total of 38 casualties were treated in the Casualty Clearing Station before being transported onwards to hospital.

GMFRS duty NILO and the METHANE messages

The NWAS or BTP METHANE messages were not shared with NWFC. Consequently, NWFC did not have them to share with Station Manager Berry. Station Manager Berry stated in evidence that, had he received either of these messages, GMFRS would “have responded straightaway”.29 I accept this evidence. It stands as a very clear example of the importance of METHANE messages being shared. It is also the reason why responsibility for GMFRS’s failure to attend within the first two hours does not rest solely with NWFC and GMFRS.

Because he was so far away, Station Manager Berry should have remained at home and mobilised another officer who lived closer to go to the scene. This should have been standard procedure.

GMP Tactical/Silver Commander’s arrival at GMP Headquarters

Temporary Superintendent Nawaz arrived at GMP HQ at about 23:10 and entered the room where the commanders were to be based. He was the first to arrive but, within a short time, many others joined him. By this time, Temporary Superintendent Nawaz had made no effective command decisions to influence what was happening at the Victoria Exchange Complex. He still did not know who the GMP Operational/Bronze Commander was. They would not speak for nearly another 25 minutes.

End of the second 20 minutes

By 23:10, one paramedic had been triaging for five minutes in the City Room. Alongside members of the public and others at the Victoria Exchange Complex, unarmed GMP officers and BTP officers continued their efforts to help the injured. With the exception of the firearms officers, who had ballistic protection, none of those working in the City Room was wearing personal protective equipment.

Inspector Smith was providing effective command to the unarmed police officers in the City Room. However, the responsibilities of that role meant that another senior officer was required to ensure that the JESIP requirements were being met. Someone needed to review the whole scene.

In particular, there was a need for an FCP, where commanders could co‑locate and communicate. This would have allowed them to share situational awareness and jointly assess risk. From this, they could have co‑ordinated their efforts most effectively.

Before the end of this period, if the mistakes I have identified above had not been made, NWAS and GMFRS would have been in a position to deploy resources into the City Room.

The failure to dispatch the ambulances already at and travelling to Manchester Central Fire Station meant that there were fewer resources available to the NWAS Operational Commander in the first five minutes of his command than there should have been.

The NWAS Operational Commander made his command decisions without reference to the superior situational awareness of GMP and BTP. His risk assessment was that the City Room was not safe enough for non‑specialists to work in. By contrast, both GMP and BTP considered the City Room safe enough for specialists, non‑specialists, employees of civilian organisations and members of the public to operate in.

As for GMFRS, its crews were mustered at Philips Park Fire Station in another part of the city.