Skip to main content

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 hour

The second hour began with the emergency services focusing their efforts at three locations. Police officers from both GMP and BTP were in the City Room. With them, from NWAS, were three paramedics. NWAS’s focus was on the station concourse and Station Approach, where paramedics and doctors were managing 25 seriously injured casualties. GMFRS had mustered its resources three miles away.

At 23:31, many casualties remained in the City Room.

British Transport Police

Officers in and around the City Room

The activity of the BTP officers continued. A significant number of casualties still needed to be evacuated. The BTP officers in the City Room continued to do their best to help, and were assisted by others. At 23:39, the final living casualty was evacuated from the City Room. As the critical period of the response ended, there was still an enormous amount of work to be done. That casualty arrived in the Casualty Clearing Station at 22:42.

At 23:47, a BTP explosives detection dog arrived at the Victoria Exchange Complex. This was the first time an efficient and safe means of ensuring that there were no secondary devices became available. This response time is something that needs to be improved in the future.

Bronze Commander

Shortly after the start of the second hour, Chief Superintendent Gregory relieved Inspector Dawson of his role as Silver Commander. This was the point of formal handover. However, since becoming aware of the incident, Chief Superintendent Gregory had been sharing some of the responsibilities with Inspector Dawson. He had made decisions around the appointment of the Bronze Commander.

At 23:31, there was still no BTP Bronze Commander at the scene. Fortunately for BTP, CI Andrea Graham had become aware of the Attack shortly after 23:00, put herself on duty and made her way into the centre of Manchester. By 23:56, she was at the Victoria Exchange Complex. Upon learning of CI Graham’s presence, Chief Superintendent Gregory’s plan was that CI Graham take up the role of Bronze Commander until Superintendent Gordon arrived.

CI Graham was spoken to twice about becoming Bronze Commander after she arrived at the Victoria Exchange Complex. A breakdown in communication meant that she did not end either of those calls understanding that this was her role. While she did view herself as in command of the BTP officers and she did liaise with GMP, she did not undertake the Bronze Commander duties as envisaged by JESIP. She did not liaise with the NWAS Operational Commander or take any steps around establishing an FCP.

CI Graham would have been a reasonable choice for appointment as Bronze Commander at an early stage. Her home was sufficiently close to the Victoria Exchange Complex for her to be able to get there within a reasonable period of time. The attempts to appoint her into that role only occurred after it became apparent that Superintendent Gordon’s journey was taking a long time and after she had self‑deployed. At 00:30 on 23rd May 2017, Superintendent Gordon was still 40 minutes away from arrival at the Victoria Exchange Complex.

Greater Manchester Police

Officers in and around the City Room

As with BTP officers, GMP officers helping in the City Room continued their work, under the supervision of Inspector Smith.

The City Room continued to be secured by firearms officers. Other firearms officers continued their work of ensuring that all of the Arena was clear of threats.

At around 00:11 on 23rd May 2017, a GMP explosives detection dog arrived. Again, this response time is something that should be improved if possible.

Commanders at GMP Headquarters

ACC Ford, the GMP Strategic/Gold Commander, made a conscious decision to replace Temporary Superintendent Nawaz of the Tactical/Silver Commander role. She did not regard him as competent to act as Tactical/Silver Commander in an Operation Plato situation.

At 00:00 on 23rd May 2017, Temporary Superintendent Christopher Hill arrived at GMP HQ. He relieved Temporary Superintendent Nawaz of the role of Tactical/Silver Commander. Temporary Superintendent Hill did not immediately enquire whether a Major Incident had been declared. Approximately one hour after he took over as Tactical/Silver Commander, when he did become aware that there had been no declaration of a Major Incident by GMP, Temporary Superintendent Hill made that declaration.

At 00:18, Superintendent Thompson relieved Inspector Sexton of firearms command. Superintendent Thompson took up the role of Tactical Firearms Commander. This meant that Inspector Sexton had acted as Initial Tactical Firearms Commander for approaching two hours. This was too long for anyone in that role.

By 00:30, a decision had been taken to hold a Strategic Co‑ordinating Group meeting. As Strategic/Gold Commander for the lead agency, this was ACC Ford’s responsibility to organise. The Strategic Co‑ordinating Group meeting did not take place for nearly another four hours. It took place too late to have any impact on the immediate emergency response.

North West Ambulance Service

Operational Commander in the Casualty Clearing Station

At 23:57, Daniel Smith was relieved of the role of Operational Commander by Stephen Hynes. Stephen Hynes was a senior member of staff within NWAS. Contrary to policy, he self‑deployed and, without reference to the Tactical Commander, took over from Daniel Smith.

By the time Stephen Hynes took over, the City Room evacuation effort was over. That is not to say that Stephen Hynes did not have a challenging role to perform. He did. In the course of doing so, he was able to address some of the earlier JESIP failings.

As Operational Commander, it was Stephen Hynes’ responsibility to organise the transportation of casualties to hospital. At the point he took over, only one casualty in the Casualty Clearing Station had left for hospital.

By 00:01 on 23rd May 2017, two casualties had left the Casualty Clearing Station for hospital. There were still 36 casualties in the Casualty Clearing Station. By the end of the second hour, nine casualties from the Casualty Clearing Station had left in ambulances for hospital. There were still 29 seriously injured casualties to move. Of those 29, 11 were assessed to be the highest priority of casualty. It was not until 02:50 on 23rd May 2017 that the final casualty left the Casualty Clearing Station for hospital.

To those who experienced it, this period of time will have seemed interminable. It must not happen again.

Tactical Commander at GMP Headquarters

Annemarie Rooney was not told of the Operation Plato declaration until approximately 00:15 on 23rd May 2017. When she was told, she did not ask about Operation Plato zones. She did not pass on the fact that Operation Plato had been declared to anyone at the Victoria Exchange Complex until after 00:30.

By the time Annemarie Rooney passed this on, a misunderstanding connected to Operation Plato had occurred involving Stephen Hynes.

Strategic Commander

At approximately 23:40, Neil Barnes, the NWAS Strategic Commander, was told that there was a Strategic Co‑ordinating Group meeting at GMP HQ. Until that point, he had remained at home and had not spoken to the Strategic/Gold Commanders of any other emergency service.

Shortly after he was notified about the Strategic Co‑ordinating Group, he set off from home. It should have been apparent to him from what he had learned of the incident at a much earlier stage that such a meeting was inevitable. He should have set off earlier than he did. Had he done so, he would have been able to speak to the GMP Strategic/Gold Commander, ACC Ford, in person sooner than he did.

The NWAS Strategic Commander made no significant or meaningful contribution to the emergency response.

Greater Manchester Fire and Rescue Service

By 23:40, Station Manager Berry had reached Philips Park Fire Station. Also present was Group Manager Ben Levy. At approximately 23:45, Group Manager Levy declared himself to be the Incident Commander. This was the right thing for him to do. This was an attempt to grip the GMFRS response. It did not have the effect that Group Manager Levy was intending.

Following Group Manager Levy’s self‑appointment, Station Manager Berry got through to GMP on the FDO telephone line. He did not speak to the FDO. The person he spoke to had been asked by Inspector Sexton to answer the FDO telephone line. Through no fault of his own, that person was not competent to answer the FDO telephone line during the emergency response to a terrorist attack.

Station Manager Berry asked for the location of an FCP. During an unsatisfactory conversation, Station Manager Berry was initially told: “I think they’ve been liaising at the Cathedral.32 This was a reference to the RVP, which Inspector Smith gave at 22:37, but which he superseded at 22:40. Station Manager Berry was then given a location of “the old Boddingtons car park”.33 Dissatisfied with the information he was being given, Station Manager Berry rejected that location and said that GMFRS was going to go to Manchester Central Fire Station.

Following this call, Group Manager Levy called Chief Fire Officer Peter O’Reilly. Group Manager Levy wanted to go forward to the Victoria Exchange Complex. Chief Fire Officer O’Reilly did not realise that Group Manager Levy had appointed himself the Incident Commander. A misunderstanding between them resulted in Group Manager Levy believing that he had been told that he must not go further than Manchester Central Fire Station. GMFRS resources at Philips Park Fire Station moved forward to Manchester Central Fire Station.

At 00:12 on 23rd May 2017, Chief Fire Officer O’Reilly spoke to the NWAS Operational Commander, Stephen Hynes, whom he knew. Stephen Hynes, who did not know about the Operation Plato declaration, told Chief Fire Officer O’Reilly that the GMFRS Operation Plato specialist resources were not required. Stephen Hynes requested 12 non‑specialist firefighters and a commander.

Following a debate in the GMFRS Command Support Room, Chief Fire Officer O’Reilly directed that the resources requested by Stephen Hynes should go forward. In the course of that mobilisation, a GMFRS officer learned of the Operation Plato declaration by GMP. He did not ask about the zoning, but did pass on the fact of the declaration. This did not lead to the deployment of the Operation Plato specialist resources. It should have caused Chief Fire Officer O’Reilly to send forward the specialist firefighters.

At the end of the second hour, GMFRS resources were still seven minutes away from arriving at the scene.