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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 Joint Doctrine

Key findings

  • The Joint Emergency Services Interoperability Principles (JESIP) were established in 2015 following a number of reports that consistently found failures by the emergency services to work together in response to a Major Incident.
  • The Joint Doctrine: The Interoperability Framework (the Joint Doctrine) set out guidance essential for joint working by the emergency services.
  • The version of the Joint Doctrine in force at the time of the Attack was published ten months before 22nd May 2017. There was sufficient time for it to be fully embedded.
  • The Joint Doctrine set out five principles for joint working: co‑location; communication; co‑ordination; joint understanding of risk; and shared situational awareness.
  • The most important of these is co‑ordination. The other four principles should support a co‑ordinated response.
  • A Major Incident declaration should occur as early as possible, as it sets in train important structures, which take time to be put in place.
  • A METHANE message should be issued as early as possible from the scene. It should be shared promptly with the other emergency services.
  • A dialogue between the emergency services’ control rooms should be established as soon as possible.
  • Frequent discussions between control rooms should include: covering what information each emergency service holds; what hazards and risks are known by each agency; and what assets have been deployed by each agency.
  • Commanders at the scene should co‑locate at a Forward Command Post as early as possible.


On 6th May 2011, Lady Justice Hallett issued her Prevention of Future Deaths report following the inquests into the terrorist attacks in London on 7th July 2005 (the 7/7 attack).9 The report sets out what went wrong with the emergency response to that atrocity. This included: a lack of adequate information‑sharing between the emergency services; failures in communication; basic misunderstanding between the emergency services as to their respective roles and operations; and difficulties resulting from the lack of a common Rendezvous Point.

Those who have followed the Inquiry will immediately recognise that, on the night of 22nd May 2017, almost exactly six years after this Prevention of Future Deaths report and nearly 12 years after the 7/7 attack, these same things went wrong again.

In 2012, after Lady Justice Hallett’s report, steps were taken to create the Joint Emergency Services Interoperability Programme. The main driver for this was the recommendation from the Blue Light Interoperability Programme Report in April that same year.10 This report recommended the formation of a joint programme to improve multi‑agency working between the emergency services.11

In October 2013, as part of the Joint Emergency Services Interoperability Programme, the Joint Doctrine: The Interoperability Framework was published.12 This set out what was expected of the emergency services as they worked together to respond to emergencies.

Also published in October 2013 was a review by the Cabinet Office’s Emergency Planning College of 32 joint emergency responses between 1986 and 2010. This identified the following common causes of failure: inadequate training; ineffective communication; no system to ensure that lessons were learned and staff taught those lessons; and previous lessons/reports not being acted upon.13

Again, the evidence heard in this Inquiry shows that those same issues recurred on the night of 22nd May 2017.

In 2015, the programme was relaunched as the Joint Emergency Services Interoperability Principles (JESIP).14 Governance was provided by an Interoperability Board with members of the emergency services and local and national governmental organisations. There was ministerial oversight of the Interoperability Board.

A year later, in July 2016, a second edition of the Joint Doctrine: The Interoperability Framework (the Joint Doctrine) was issued. It built upon the principles of the first.15 The second edition was the applicable version in the months leading up to and at the time of the Attack. When I refer to the ‘Joint Doctrine’, I am referring to the content of the second edition.

The review that led to the second edition concluded that it was essential for the emergency services to view JESIP training as a continual requirement.16

The Foreword of the Joint Doctrine stated:
“This guidance remains essential to the effective interoperability of emergency services and other responder agencies and will be subject to future changes and improvements as it is tested and incorporated into business as usual. We need to make sure that the ethos of ‘working together’ becomes embedded, not only within our own organisations at every level, but within that of the other responder agencies.”17

The Foreword went on to state that the Joint Doctrine “should be embedded in individual organisation policies and procedures and in their training and exercise programmes, for all levels of response staff”.18

The evidence heard in the Inquiry has confirmed the importance of almost all of what is said in the Joint Doctrine. I have set out below the parts relevant to the Attack, although not necessarily in the order in which they appear in the document.

Principles for joint working

The five principles for joint working were introduced in this way:
“The need for a joint response is not new. The findings and lessons identified by public inquiries and inquests have highlighted cases where the emergency services could have worked better together and shown much greater levels of communication, co-operation and co-ordination.”19

In light of this introduction, it is disappointing that so much went wrong with joint working on 22nd May 2017. That does not mean that there were not any good examples of joint working on the ground. But at a command level, things went badly wrong. This Inquiry comes at the end of a line of inquiries and inquests which have identified similar problems. Those inquiries and inquests made recommendations, which it was hoped would bring about change. It is clear that in Greater Manchester those recommendations did not result in JESIP being sufficiently well embedded before the Attack. If unnecessary loss of life is to be avoided in the future, it is important that a change in knowledge, culture and attitude takes place.

The principles for joint working, as presented in the Joint Doctrine, are shown in Figure 22.

Figure 22: The principles for joint working in the Joint Doctrine20

The Joint Doctrine stated: “They [the principles for joint working] will often, but not always, be followed in the order in which they are presented.21 This suggests that co‑location will often be the first act guided by JESIP. I do not consider this statement to be necessarily helpful.

In many cases, communication between control rooms ought to be possible before responders are able to come together at a scene. This ought to be a priority action for every control room at an early stage.

Later in the Joint Doctrine, this very point was acknowledged: “A dialogue between control room supervisors should be established as soon as possible”22 and “Control room supervisors should engage in multi-agency communications and carry out the initial actions required to management [sic] the incident.”23 I agree with both of these statements.

Adequate communication between control rooms focused on achieving a co‑ordinated response was a major failing on the night of the Attack. I am concerned that there was insufficient emphasis on the importance of immediate and ongoing contact between control rooms. This is a subject I will look at in more detail in Part 12.

Principle 1: Co-location

The Joint Doctrine stated:
“When commanders are co-located, they can perform the functions of command, control and co-ordination face-to-face. They should meet as early as possible, at a jointly agreed location at the scene that is known as the Forward Command Post (FCP). This allows them to establish jointly agreed objectives and a co-ordinated plan, resulting in more effective incident resolution. The benefits of co-location apply equally at all levels of command.”24

It went on:
“Co-locating commanders and face-to-face exchanges will always be the preferred option … The lead responder will suggest a location for commanders to co-locate in the early stages of a multi-agency incident when operational commanders may be travelling to the scene.”25

The Joint Doctrine stated: “If there is any delay in commanders co-locating, interoperable communications should be used to begin establishing shared situational awareness.”26 This statement could be better phrased. It is possible to read it as suggesting that only if there is a delay should the control rooms be used to establish shared situational awareness.

Control rooms should begin sharing information at the earliest possible stage, in parallel with commanders seeking to co‑locate. Shared situational awareness is a dynamic process.27 An ongoing dialogue from the very start is required between control rooms. There should not be a delay to see if commanders can co‑locate in a timely way. Other parts of the Joint Doctrine recognised this.28

On the night of the Attack, BTP Control received accurate information from its officers at the Victoria Exchange Complex within seconds of the explosion.29 During the first ten minutes, the only emergency service with personnel in the City Room was BTP.30 BTP should have been sharing that situational awareness with the other agencies as a priority. The most straightforward way for this to occur was via a multi‑agency control room radio channel. This did not occur on the night of 22nd May 2017.31 In Parts 12 and 13, I shall provide more detail in relation to this.

Principle 2: Communication

The Joint Doctrine stated:
“Meaningful and effective communication between responders and responder agencies underpins effective joint working.”32

It also stated:
“Using terminology that either means different things to different people, or is simply not understood across different services is a potential barrier to interoperability.”33

On the night of the Attack, GMP’s Force Duty Officer (FDO) declared Operation Plato. This declaration was not communicated outside GMP during the critical period of the response, by which I mean the period from the explosion at 22:31 to the removal of the final living casualty from the City Room at 23:39.34 However, had it been communicated to GMP’s unarmed officers at the scene, including the Operational/Bronze Commander, it would have meant nothing to them as they had not been trained in what the declaration of Operation Plato meant, and what actions were required as a result.

There was also the potential for confusion in terms of the language used around zones. Operation Plato uses the terms hot, warm and cold to describe zones.35 Some NWAS personnel referred to a system used at Major Incidents that were not Marauding Terrorist Firearms Attacks, which also used the terms hot, warm and cold zones.36 Although the terms are identical, they mean different things within the two systems. The use of the same terms to mean different things is a practice that must stop, if it has not already. It gives rise to the possibility of misunderstanding.

Principle 3: Co-ordination

The Joint Doctrine stated:
“Co-ordination involves commanders discussing resources and the activities of each responder agency, agreeing priorities and making joint decisions throughout the incident. Co-ordination underpins joint working by avoiding potential conflicts, preventing duplication of effort and minimising risk … For effective co-ordination, one agency generally needs to take a lead role.”37

Given that the responders on 22nd May 2017 were responding to a terrorist attack, it was widely recognised that GMP should take the lead role. This made the ability for other agencies to make contact with the FDO extremely important. It also placed a very substantial burden on the FDO.

GMP was the lead agency. GMP had two Operational/Bronze Commanders in the City Room from a very early stage: Inspector Michael Smith and Police Constable (PC) Edward Richardson.38 Inspector Smith was responsible for the unarmed officers and PC Richardson for the firearms officers. The fact that GMP was the lead agency meant that contact by other Operational/Bronze Commanders with the GMP Commanders at the scene was essential. BTP did not have a Bronze Commander at the scene during the critical period of the response.39 Neither did GMFRS. The NWAS Operational Commander was at the Victoria Exchange Complex from 23:00, but he did not try to contact the GMP Operational/Bronze Commander or Operational Firearms Commander, either directly or indirectly.40

I regard co‑ordination to be the most important of the principles for joint working. A fully co‑ordinated response is likely to produce the best outcome. The other four principles are very important, but they are the means by which co‑ordination is achieved.

Principle 4: Joint understanding of risk

The Joint Doctrine stated:
“Different responder agencies may see, understand or treat risks differently. Each agency should carry out their own ‘dynamic risk assessments’ but then share the results so that they can plan control measures and contingencies together more effectively.”41

Later, it stated:
“Commanders jointly assess risk to achieve a common understanding of threats and hazards, and the likelihood of them being realised. This informs decisions on deployments and the required risk control measures.”42

The different approaches to risk were starkly apparent on the night of 22nd May 2017 and were reflected by the locations in which each emergency service was prepared to operate.

BTP and GMP went directly to the City Room and many officers from both police services remained in the immediate vicinity of the explosion for substantial periods of time. Any risk assessment consciously performed by those officers was not until after they were in the City Room. Inspector Smith reached the conclusion that the City Room was “safe enough” after he had entered.43

The three NWAS paramedics, including those from the Hazardous Area Response Team (HART), who went into the City Room during the critical period of the response did so voluntarily, as opposed to being deployed into that area. The remainder were deployed on the station concourse and Station Approach.

GMFRS did not consider the vicinity of the Victoria Exchange Complex to be sufficiently safe until long after the critical period of the response had ended.44

The police, NWAS and GMFRS each made their own risk assessments separately. They each reached different conclusions. This was unsurprising because they each had different levels of situational awareness. Had a joint assessment of risk occurred, it is likely that there would have been much closer alignment between the responders as to which areas were safe enough to work in.

Principle 5: Shared situational awareness

The Joint Doctrine stated:
“‘Shared situational awareness’ is a common understanding of the circumstances, immediate consequences and implications of the emergency, along with an appreciation of the available capabilities and the priorities of the emergency services and responder agencies.”45

It is a striking fact that, on the night of the Attack, those at the scene did not regard it as significant that GMFRS was not present. The only realistic reason for this is that there was insufficient realisation on the part of GMP, BTP and NWAS of the important contribution that GMFRS could have made on the night. GMFRS’s specialist capabilities included its Specialist Response Team, which was trained and equipped to work alongside HART in an Operation Plato warm zone. In addition, all firefighters were trained in rescue and first aid. The addition of the rescue capability of GMFRS would have resulted in the safer and faster extraction of the severely injured from the City Room to a location where they could receive clinical care.

Early stages of a multi-agency response or Major Incident

The Joint Doctrine devoted a section to the early stages of a multi‑agency response to a Major Incident:
“Applying simple principles for joint working are [sic] particularly important in the early stages of an incident, when clear, robust decisions and actions need to be taken with minimum delay, in an often rapidly changing environment… In the early stages of an incident, employees of one service may arrive before employees of another and, as a result they may carry out tasks that are not normally their responsibility. If this happens, command and control arrangements for the relevant service should start as soon as the right personnel are in place in sufficient numbers.”46

The Joint Doctrine continued:
“Recognising that an incident will involve working with other emergency services and/or other responder agencies is very important. The earlier other responder agencies are notified of the incident, the sooner joint working arrangements can be agreed and put into place. … In order to help all agencies gather initial information about an incident in a consistent manner, a common approach is recommended. The ‘METHANE’ model brings structure and clarity to the initial stages of managing any multi-agency or major incident.
A major incident is defined 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.47

The Major Incident declaration is no mere formality. An early declaration ensures that structures that may take time to set up are initiated as soon as possible.


Before JESIP was introduced, the emergency services operated a mnemonic which was used to capture key information from the scene. METHANE replaced that mnemonic. The Joint Doctrine provided as follows:
“The METHANE model is an established reporting framework which provides a common structure for responders and their control rooms to share major incident information. It is recommended that M/ETHANE be used for all incidents. … Each responder agency should send a M/ETHANE message to their control room as soon as possible. The first resources to arrive on scene should send the M/ETHANE message so that situational awareness can be established quickly. The information received through multiple M/ETHANE messages will gradually build to support shared situational awareness in those responding to the incident and between control rooms.”484

Figure 23: METHANE mnemonic from the Joint Doctrine49

The Joint Doctrine went on:
“It is important that all individuals who could be first on scene for their respective responder agency are able to declare a major incident, and that they understand the implications of declaring one. They must also be able [to] convey incident information using the M/ETHANE model. Declaring a major incident begins the process of activating relevant plans.”50

BTP and NWAS personnel provided METHANE messages to their respective control rooms.51 In BTP’s case it took longer than it should have, despite Force Incident Manager Inspector Benjamin Dawson’s best efforts. I will set out Inspector Dawson’s role in Part 13. Neither BTP nor NWAS shared their METHANE messages with other responder agencies. At no point did anyone from GMP ask for or provide a METHANE message, whether from its own responders or any other agency.

During the critical period of the response, GMFRS was not at a location from which a useful METHANE message could have been passed. At no point did NWFC ask any other agency if they had a METHANE message to pass on.

BTP declared a Major Incident. This declaration was shared with NWAS. Separately, NWAS declared a Major Incident. Neither BTP nor NWAS informed GMP, NWFC or GMFRS that they had declared a Major Incident. GMP, NWFC and GMFRS did not declare a Major Incident during the critical period of the response. They did not enquire of any other responder agency if that agency had declared a Major Incident.

Control rooms

The Joint Doctrine stated:
“Control rooms play a vital role in managing the early stages of a multi- agency incident. There cannot be a co-ordinated multi-agency response or effective communication if control rooms do not deliver a swift and joint approach to handling them. … Control rooms generally operate from separate fixed locations and therefore cannot feasibly co-locate. They can, however, help in co-locating responders and commanders by jointly agreeing the initial multi-agency rendezvous points. … A multi-agency discussion between control room supervisors in the affected control rooms at the earliest opportunity starts the process of sharing information about the incident.”52

It went on:
“Discussions between control rooms should be frequent and cover the following key points:

  • Is it clear who the lead agency is …? If so, who?
  • What information and intelligence does each agency hold …?
  • What hazards and risks are known by each agency …?
  • What assets have been – or are being – deployed …?
  • …  At what point will multi-agency interoperable voice communications be required, and how will it be achieved?”53

On 22nd May 2017, the question of what assets had been or were being deployed was an important one for NWFC to ask of the other emergency services. At no point was there a concerted and organised effort by NWFC staff to find this out. Once Station Manager Andrew Berry decided not to mobilise GMFRS resources to the scene, it was a question that needed to be robustly pursued. Had it been, GMFRS would have realised much earlier than it did that all other responders regarded the scene as being sufficiently safe to deploy to. I will set out Station Manager Berry’s role on the night of the Attack in Part 15.

The Joint Doctrine continued:
“Control room supervisors should be ready to set up multi-agency interoperable voice communications for commanders if and when required … when each service has allocated a commander to the incident, the value of making interoperable voice communications available should be considered.”54

There was a failure to establish effective multi‑agency voice communications on the night of the Attack. This is a topic to which I will return in Part 12.


The Joint Doctrine stated:
“Operational commanders will be working with colleagues from other responder agencies. This will most likely be at, or close to, the scene of the incident. … Communication and co-ordination between commanders is critical. Tactical commanders should be located at a mutually agreed location where they can maintain effective joint command of the operation … The fire and rescue service tactical commander will be located where they can maintain effective tactical command of the operation, invariably they will be in attendance at the scene …The tactical commander is likely to be in place before the strategic commander and is also likely to be the first senior officer taking command of the incident. In the early stages of an incident, the tactical commander is likely to set priorities before the strategic commander has set a strategy.…The strategic commander from each agency has overall authority on behalf of their agency. They are responsible for the resources of their own agency and for formulating their single agency strategy for the incident.”55

On the night of the Attack, GMFRS did not have a commander of any kind at the scene for over two hours. The NWAS Operational Commander did not work with the GMP Operational/Bronze Commander. Although they were both in the City Room for much of the critical period of the response, the GMP Operational Firearms Commander and the GMP Operational/Bronze Commander did not speak to each other. BTP’s nominated Bronze Commander did not arrive until after 01:00 on 23rd May 2017.

The Joint Doctrine stated: “The joint decision model is designed to help commanders make effective decisions together.”56 I will deal with the Joint Decision Model next.

Joint Decision Model

The Joint Doctrine stated:
“One of the difficulties facing commanders from different responder agencies is how to bring together the available information, reconcile potentially differing priorities and then make effective decisions together. The Joint Decision Model (JDM) … was developed to resolve this issue.”57

Figure 24 shows the Joint Decision Model process:

Figure 24: Joint Decision Model58

The most important consideration, throughout the decision‑making process, is “to save lives and reduce harm”.59 Every stage of the decision‑making process should have this as its focus.

The Joint Doctrine states:
“When using the joint decision model, the first priority is to gather and assess information and intelligence. Responders should work together to build shared situational awareness, recognising that this requires continuous effort as the situation, and responders’ understanding, will change over time. Understanding the risks is vital in establishing shared situational awareness.”60

When making his initial command decisions, the NWAS Operational Commander should have worked with GMP to gather and assess information and intelligence.61 This would have developed his situational awareness and improved his decision‑making.

The Joint Decision Model was explained to me by the Fire and Rescue Expert, Matthew Hall.62 He assured me that, once a person has been trained in using it, it was an effective way of making decisions. I can readily accept that in theory it is a very good way of ensuring that all relevant considerations are taken into account. However, in practice, when under enormous pressure in an emergency, the Joint Decision Model will be much harder to follow. It needs to be part of the ‘muscle memory’ through training and exercises, so that it becomes instinctive.

It is clear to me that use of the Joint Decision Model is of greatest value when commanders come together and jointly make decisions, as it provides a framework for a short and focused discussion.

Joint organisational learning

The Joint Doctrine stated:
“The lessons identified from de-briefing activities are now at the forefront of many key changes in emergency services policy and practices. Issues have frequently been identified but not successfully acted upon to improve effective joint working. It is essential that joint organisational learning is accepted as the standard for multi-agency learning and is adopted by all response agencies to ensure interoperability is continually improved. … It is important to capture lessons while events are fresh in the minds of those involved. … To continually improve emergency response interoperability, all responder agencies must capture lessons identified from incidents, exercises and training … Following any incident, exercise or training, those involved should ensure appropriate de-briefs are scheduled and that all those involved in the response are represented.”63

In Part 12, I will consider the key multi‑agency exercises that took place in the period prior to the Attack. There were significant failures to make necessary changes identified by those exercises. In relation to one in particular, Exercise Winchester Accord, there remains a stark disagreement between GMP and other participants as to what areas for improvement ought to have been identified.