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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)

Greater Manchester Police preparedness




Key findings

  • The effect of austerity cuts was greater on Greater Manchester Police (GMP) than some other police services. This principally affected GMP’s Planning Department and Firearms and Policy Compliance units.
  • GMP had a Major Incident Plan. This plan should have been rewritten in light of the Joint Emergency Services Interoperability Principles (JESIP). It was written in the expectation of the GMP Tactical/Silver Commander attending the scene. It had not been updated to reflect GMP’s practice in 2017 of the Tactical/Silver Commander attending GMP Headquarters.
  • GMP had a site‑specific plan for the Victoria Exchange Complex. It had not been updated to take account of the extensive refurbishment and rearrangement which took place in 2014.
  • GMP had a Silver Commanders Guide. It had not been updated to reflect JESIP. It had not been updated to reflect the Joint Operating Principles and Operation Plato. It had not been read by the Tactical/Silver Commander on duty at the time of the Attack.
  • By 22nd May 2017, there were three potentially applicable Operation Plato plans. The process by which those plans were created and managed was unsatisfactory.
  • By 2017, GMP was well‑aware that, in the event of an incident such as occurred on 22nd May 2017, the Force Duty Officer could become overwhelmed or overburdened. GMP failed to take adequate steps to address this problem.
  • With the exception of the Tactical/Silver Commander between 22:50 on 22nd May 2017 and 00:00 on 23rd May 2017, all GMP commanders who had a role in the response were competent for the role they performed.
  • The Tactical/Silver Commander between 22:50 on 22nd May 2017 and 00:00 on 23rd May 2017 was not competent to perform the role he was required to perform in response to the Attack.
  • GMP failed to embed JESIP adequately in its officers and staff prior to the Attack.
  • GMP failed to train its unarmed officers in what Operation Plato was. Neither the Operational/Bronze Commander nor the Tactical/Silver Commander for the period 22:50 on 22nd May 2017 to 00:00 on 23rd May 2017 knew what Operation Plato was.
  • GMP frontline officers were not adequately trained in first aid. This was a national issue and not the fault of GMP.
  • Firearms officers should have received more training in when they should use their enhanced first aid skills.
  • Firearms offices were not adequately trained in Operation Plato zoning.
  • GMP dedicated an appropriate level of resources, time and commitment to exercising.


In common with other sections in this Part, I shall consider GMP’s arrangements for the infrastructure, its planning, the training of its officers and exercising.

Unlike other sections in this Part, it has been necessary to set out the detail of the analysis, most notably in relation to GMP’s approach to Operation Plato plans. The reason for this is simple. As the evidence emerged, it was clear that GMP had caused a situation to develop in which there were multiple plans in operation by 22nd May 2017. How that came to be is instructive for how such a situation can be avoided in future.


GMP Control

The Operational Communications Branch within GMP was responsible for the collation of information received by GMP. It had two Operational Control Rooms from which radio traffic was managed. Neither of the Operational Control Rooms was based at GMP HQ. There was also a Contact Management Call Handling Centre which managed telephone calls.232 I shall refer to these collectively as GMP Control.

The FDO was based in the larger of the two Operational Control Rooms. This building was approximately 15 to 20 minutes’ driving time from GMP HQ.233 On the night of the Attack, the FDO was Inspector Dale Sexton. The FDO’s role included responsibility for initially acting as the Tactical/Silver Commander in response to an incident. In the event firearms were deployed, the FDO would also take up the role of Initial Tactical Firearms Commander. There was a dedicated telephone line for the FDO.

The FDO was supported by the Force Duty Supervisor. The Force Duty Supervisor sat next to the FDO in the Operational Control Room. On the night of the Attack, the Force Duty Supervisor was Ian Randall.234 There was a dedicated telephone line for the Force Duty Supervisor.

Force Command Module

GMP’s Force Command Module was a large room with three separate areas at GMP HQ. GMP HQ was based in the Central Park business park in the Newton Heath area of Manchester. The Force Command Module could be activated as part of GMP’s response to a Major Incident. The space could be sub‑divided into three rooms using intersecting doors. One area was for the Strategic/Gold Commander. It was referred to as the Gold Control Room. The other two areas were for the Tactical/Silver Commander(s). These were referred to as the Silver Control Room(s).235

The Gold Control Room and Silver Control Room had allocated spaces within them for representatives of other emergency services and responders.236 Personnel only occupied these rooms once they were activated. For these rooms to become operational, it was necessary to power up the facilities in them, such as the computers and radio terminals.237

On the night of 22nd May 2017, the Strategic/Gold Commander, ACC Deborah Ford, took the decision not to sub‑divide the Force Command Module. This meant the multi‑agency strategic/gold command and tactical/ silver command operated in a single space. Despite this, some of those responding on the night referred to this space as the ‘Silver Room’ or the ‘Silver Control Room’.

Approach to planning generally

The financial crisis of 2008 led to a period of economic recession in the UK. In 2010, that led to the introduction of an austerity programme by the Conservative and Liberal Democrat coalition government. The period that followed is often called the ‘age of austerity’. Indeed, that is the way in which David Cameron, then Prime Minister, publicly characterised it.238 This period was marked by a drive to reduce public expenditure by billions of pounds each year.

Whether the age of austerity was a necessary policy and whether it was successful are issues beyond the scope of my terms of reference. Nothing I say in this Report should be interpreted as expressing a view about those issues. Nonetheless, austerity has been referred to by a number of GMP witnesses as having had an impact upon that police service’s ability to do everything that it must have recognised it was important to do. It is therefore essential that I address this issue.

A number of GMP officers gave evidence about the impact of austerity upon their work. At a corporate level, both former Chief Constable Ian Hopkins239 and DCC Pilling240 gave evidence about the level of savings that it was necessary for GMP to make. Between 2010/11 and 2017/18, GMP’s income fell substantially from £632,987,763 to £545,394,197.241 The number of officers fell by 25 per cent from 8,219 to 6,159. Staff posts and PCSOs were also lost.242 The decrease in income and personnel is striking.

In further detail, the figures for the reduction in GMP’s total income, and for the reduction in number of officers, between 2010/11 and the financial year the Attack took place are shown in Figures 25 and 26.

Figure 25: Reduction in GMP’s total income from 2010/11 to 2017/18243

Figure 26: Year-on-year decrease in establishment figures (the number of officers for whom funding is available) from 2010 to 2018244

GMP experienced a significantly greater cut in income than was the average across all police services in the same period. The difference arose because GMP, in common with other metropolitan police services, receives a lower portion of its income from council tax revenues than non‑metropolitan police services. Consequently, a larger portion of its income comes from central government than is the case for non‑metropolitan police services.245

As a result, the reductions in central government funding hit GMP and the other metropolitan police services disproportionately hard.246 I do not know to what extent this was taken into account by the Home Office in the decisions it made. I recommend that the Home Office consider the different arrangements for funding police services if a similar programme of budgetary cuts and austerity occurs in the future.

This diminution in funding was bound to have an impact upon policing within Greater Manchester, and it did. I accept that GMP had to make hard decisions about where such substantial cuts should be made.

Just as it is not for me to make a judgement about whether austerity was an appropriate policy, so it is not for me to make a judgement about whether the decisions made by GMP in this regard were appropriate. That would be outside the Inquiry’s terms of reference, and, in any event, the evidence does not enable me to make such assessments. However, what I can and will do is make observations about what the impact of this was, as a matter of fact, on the issues that are within the terms of reference.

In my view, the cuts did have a significant impact on the ability of GMP to provide an adequate public service in certain respects.

DCC Pilling said in evidence that GMP did not seek to use austerity and the cuts it necessitated as a reason or excuse “for many of the areas where we should have done better”.247 I am certain he is right to make that concession, but that does not mean that the cuts were irrelevant.

DCC Pilling explained that GMP decided it needed to maintain frontline staff but that this made it necessary to make reductions in other areas. That included cuts to the Planning Department, and the Firearms Training and Policy Compliance units.248 Those cuts had a significant impact upon the matters relating to the emergency response that I considered in evidence.

Police Constable (PC) Katrina Hughes worked in the Specialist Operations Planning Unit of GMP from 2007.249 For many years prior to the Attack, she was responsible for the maintenance of the operational planning database of GMP. Her focus was on the planning for GMP’s response to an emergency.250 From 2012, cuts to her department meant that she was struggling to keep plans up to date.251

In the end, it became impossible for her to achieve the aims of her department. PC Hughes raised this with a senior colleague in 2015. Nothing changed. In 2016, she escalated this to a Chief Inspector within the Specialist Operations Planning Unit. Nothing changed, save that her workload increased.252 I will deal with the specific impact that this had on the Arena contingency plan (the site‑ specific plan) and the Major Incident Plan within paragraphs 12.167 to 12.210. For now, it will suffice to observe that the evidence of PC Hughes serves to illustrate the impact that the cuts had on planning within GMP.

Further evidence of this was provided by Inspector Simon Lear.253 He was a long‑serving operational firearms officer. In 2014, he moved from an operational firearms team to assume responsibility for the Policy Compliance Unit.254 The Policy Compliance Unit was set up as part of the Firearms Training Unit, as a result of action taken following the unlawful killing of a police officer in 2008.255 It was separate from and independent of the operational firearms teams. That division was deliberate and was designed to enable the unit to act independently.256

The responsibilities of the Policy Compliance Unit included the maintenance of firearms policy and conducting compliance checks on those policies.257 It was an important role. The policies were ones that concerned police operations involving the potential for lethal force to be used. The policies ought to have been kept up to date. They ought to have been comprehensive and comprehensible. They ought to have been understood by all officers likely to be involved in their implementation. For that to be achieved, the Policy Compliance Unit needed to be adequately staffed and resourced.

Inspector Lear explained that, when the Policy Compliance Unit came into existence, a Chief Inspector was in charge, supported by an Inspector, a Sergeant and three or four other members of staff.258 When he inherited the unit in 2014, cuts meant that he was supported only by a Sergeant and then, after about a year, he lost that officer, too.259 This was a very significant reduction in personnel.

To compound the strain he was under, Inspector Lear then inherited the Firearms Training Unit as well. To that point, the unit had had its own Inspector. This created a workload for Inspector Lear that was unmanageable and placed him under an intolerable degree of pressure. By the end of 2017, it had made him unwell and it became necessary for him to move away from a firearms role altogether.260

I was grateful to Inspector Lear for his considerable candour on this issue and other issues. His evidence served to illustrate in very stark terms the impact of austerity and the cuts it generated upon planning within GMP in the years leading up to the Attack. In simple terms, as Inspector Lear said, the Policy Compliance Unit was not adequately resourced to perform its important function properly while he was there between 2014 and 2017.261

Superintendent Leor Giladi was part of the Specialist Operations Branch with responsibility for the Firearms Training Unit and Policy Compliance Unit during the period I considered.262 He explained that he was aware of the pressure that Inspector Lear was under. He agreed that the impact of the cuts was significant.263 When asked what he had done to address the pressure upon Inspector Lear, he said:
“Unfortunately, we were operating in a wider review of constant reviews and constant cuts. I don’t remember a specific occasion where I would have flagged up my concerns, but no doubt I would have, not in a formal meeting, but maybe with my line manager or others, but it was beyond my capability to, unfortunately, provide him with that extra support that was needed and the reviews were just constant throughout the branch. Throughout my time at the branch there was review after review after review, reshuffle after reshuffle, so it was [a] very, very difficult environment in which to operate.”264

I have quoted this evidence directly because it encapsulates what was happening within this part of GMP in the lead‑up to the Attack. Superintendent Giladi was an experienced and competent senior police officer. It was plain to me from his evidence that he cared about his staff. Ultimately, the financial pressures were such that there was nothing he could do to help Inspector Lear or to alleviate the difficulties that were developing in the Policy Compliance Unit.

Other witnesses who worked within the area of GMP planning expressed similar concerns about the cuts, including CI Michael Booth265 and Sergeant David Whittle.266

I have no doubt that the cuts that resulted from austerity had a damaging impact upon GMP’s planning for all emergencies. Whether that is an area in which cuts should not have been made is not a matter for me. However, cuts appear to have landed very heavily in this area, to the detriment of policing within Greater Manchester.

The result is that a vital function of policing in GMP was not operating as well as it should. As I will explain in this Part and in Part 13, this had real consequences. There was confusion about which version of the Operation Plato plan was in place. Even more significantly, no action cards had been introduced into GMP Control by the date of the Attack.267 I am confident the removal of resources from the planning function of GMP played a part in this, although that does not provide a complete explanation.

I do not consider that it is appropriate or possible for me to make a recommendation in this area. The most I can say is that, while frontline policing is, of course, of vital importance, the evidence has demonstrated to me that the value of those involved in planning for policing should not be underestimated. This is an issue upon which I invite His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), the College of Policing and the Home Office to reflect. The events in Manchester demonstrate the critical role of planning in effective policing, and the consequences or potential consequences if that does not occur.

Major Incident Plan

GMP maintained a Major Incident Plan. It was originally compiled in 2011. It was subsequently revised a number of times. The most recent update prior to the Attack was in March 2017. This update added the Major Incident definition, references to JESIP and updates in relation to the Tactical and Strategic Co‑ordinating Groups.268 It was 225 pages long. The Major Incident Plan was too long to be useful to anyone when responding to the early stages of a Major Incident.269

The Major Incident Plan described itself as a “generic” plan for use in responding to any Major Incident. 270

The Major Incident Plan made clear that it was not to be read prescriptively but as a guide.271 It went on to state: “The response to a Major Incident should be flexible and tailored to reflect the specific circumstances of the incident. Crucial to the effective management of a major incident by GMP is a robust command and control system that is quickly put into place.272 This is an appropriate approach for GMP to take. The emphasis is rightly on gripping the incident swiftly.

Role cards

The appendices to the Major Incident Plan provided a description of the duties of the “Core Roles”.273 It referred to these as “Role Cards”. These are not the same as action cards. Action cards were created for Operation Plato and were less detailed.274 I will consider the Operation Plato action cards in paragraphs 12.219 to 12.310 when looking at the GMP Operation Plato plans.

Laminated hard copies of the role cards were stored by GMP in the Major Incident boxes within the Major Incident trailers.275 Consequently, unless the Major Incident trailer was deployed, these hard‑copy role cards would not be available to anyone responding to a Major Incident. Even if the Major Incident trailer were deployed, it is unlikely it would have been on scene and accessible early in a no‑notice incident. To be useful, role cards needed to be immediately accessible from the outset to those responding whose role justified access.

It was suggested by DCC Pilling, who gave evidence on behalf of GMP, that the role cards could be read out over the radio.276 While this provides a potential safety net, on the night of the Attack, no one thought to ask for these cards to be read out or offered to read them out. I found this unsurprising. There was no evidence that considering the role cards in the early stages of a response formed part of the way in which GMP commanders were trained to respond. There is a risk that important steps are overlooked if available prompts, such as role or action cards, are not used.

GMP should give consideration to developing and utilising simple and focused action cards similar to those produced by the National Ambulance Resilience Unit (NARU). This would provide commanders with a reminder of the key actions. The cards should be immediately available to commanders, whether in hard copy or electronically. I will deal with the NARU action cards later in this Part at paragraph 12.450, when I turn to address NWAS’s preparedness.

Treatment of JESIP

A section specific to JESIP was included in the Major Incident Plan. It stated: “For larger or major incidents the responders should co-locate at the Forward Command Point where they can communicate and coordinate the response … a METHANE message (which will be an appraisal of the situation) should be used to inform Gold Control and the partner organisations.”277 A number of JESIP concepts were set out on the following page.278 There were hyperlinks embedded in the text for those reading online.279

I recognise that JESIP informed a number of parts of the Major Incident Plan, beyond the one and a half pages which are exclusively dedicated to it.280 However, the introduction of JESIP, which had been well established by March 2017, demanded a comprehensive rewrite. JESIP was not a bolt‑on. It was fundamental to all aspects of a Major Incident response.

Major Incident declaration

The Major Incident Plan included a section which dealt with what a Major Incident is. Nowhere in this section is a statement of the need for a Major Incident to be declared early. The Joint Doctrine stated: “It takes time for operational structures, resources and protocols to be put in place. Declaring that a major incident is in progress as soon as possible means these arrangements can be put in place as quickly as possible.281

The METHANE message was dealt with in a number of places across the Major Incident Plan. One of those places was under the initial actions of the first officer on the scene.282 As its first component, the person delivering the METHANE message is required to ask whether a Major Incident has been declared. The question of whether a Major Incident has been or needs to be declared was also listed as one of the initial actions of the Tactical/Silver Commander.283

As no one from GMP delivered a METHANE message on the night of the Attack, the opportunities to think about whether a Major Incident had been declared as part of the composition and receipt were missed.

A clear statement of the importance of an early declaration of a Major Incident was absent from the section of the Major Incident Plan dealing with what a Major Incident is. It should not have been.

On the night of the Attack, GMP failed to recognise the importance of declaring a Major Incident early. It was not declared by any of the first officers on the scene. It was not declared by Temporary Superintendent Arif Nawaz who took up the role of Silver Commander from the FDO. GMP did not declare a Major Incident until 00:57 on 23rd May.284

Forward Command Post

The Major Incident Plan provided a description of what an FCP was and how it should be selected. It described the FCP as “the management post for the incident officer (officer in charge at that time) and the central point of contact for all emergency and support services engaged at the scene”.285 While this did not contradict the JESIP approach to an FCP, as set out in the Joint Doctrine, it failed to capture the fundamental importance of this location and the need to establish it as quickly as possible. This section of the Major Incident Plan was silent on this point.

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).”286

The Major Incident Plan failed to capture the importance and urgency of establishing an FCP as expected by JESIP. This is an example of the need for a comprehensive rewrite of the Major Incident Plan incorporating the Joint Doctrine.

On the night of 22nd May 2017, there was a failure by all emergency responders, including GMP, to recognise the importance of an FCP and the need for it to be established early. The way in which the Major Incident Plan was drafted in relation to FCPs put insufficient emphasis on the FCP’s importance to a successful response.

Tactical/Silver Commander

The Major Incident Plan used the terms ‘Silver Commander’ and ‘Tactical Commander’ interchangeably. For this reason, I will use the term ‘Tactical/Silver Commander’ when referring to a GMP commander in that role. I will adopt this approach to the ‘Strategic/Gold’ and ‘Operational/Bronze’ Commander roles, for the same reason. Reference solely to ‘Strategic’, ‘Tactical’ or ‘Operational’ will be to the firearms commanders with those roles.

The Major Incident Plan anticipated that the FDO would initially assume the role of Tactical/Silver Commander. It envisaged that the FDO would identify an appropriate officer to take the role of Tactical/Silver Commander. At night this was expected to be the person undertaking the Night Silver role. The Strategic/ Gold and Tactical/Silver Commanders were then expected to identify the other core roles that are necessary.287

The Major Incident Plan stated: |
“The overarching aim of the tactical commander is to ensure rapid and effective actions are implemented that save lives, minimise harm and mitigate the incident.”288

This aim is achieved by, among other things, establishing “a common view of the situation between the responder agencies”289 and identifying and agreeing “a common multi-agency forward control point for all operational commanders and remain[ing] suitably located in order to maintain effective tactical command of the incident or operation and maintain shared situational awareness”.290 I understand the term “forward control point” to mean the same as ‘Forward Command Post’.

Temporary Superintendent Nawaz was notified of the Attack at 22:39 on 22nd May 2017.291 He spoke to the FDO at 22:50.292 He was relieved of the role of Tactical/Silver Commander at 00:00 on 23rd May 2017.293 During that time, he failed to establish a common view of the situation between responder agencies. He did not contact the Tactical/Silver Commanders from BTP or GMFRS. His conversation with the NWAS Tactical Commander at around 23:15 failed to identify the differing approach to entry to the City Room by the two organisations.294 He failed to identify and agree a common multi‑agency FCP.

The issue of where the Tactical/Silver Commander should locate themselves is important for the events of 22nd May 2017. Under the heading Operational (Bronze) Commander”, the Major Incident Plan stated: “It is important that both operational and tactical commanders are easily identifiable on the ground by means of identification tabards.”295

As shown in Figure 27, “Command and Control” was displayed pictorially in the Major Incident Plan. One of the entries was “Scene Tactical Commander and Silver Control”.296Figure 27: Annotated Command and Control diagram from the Major Incident Plan297

Appendix B to the Major Incident Plan was an entry specific to the role of Tactical/Silver Commander. The heading is as shown in Figure 28.
Figure 28: Appendix B within the GMP Major Incident Plan298

The entry continued by stating: “Wear your Incident Commander Tabard (JESIP) so that you can clearly be identified.”299 Further on, it stated:
“Together with the Fire Incident Officer, and Traffic Management Officer identify a common approach route for emergency services attending the Marshalling Area … The sighting [sic] of the FCP must be decided following liaison between yourself and the Fire Incident Officer in attendance.”300

Taking the Major Incident Plan as a whole, the expectation communicated by the various entries above was that the Tactical/Silver Commander would go to the scene.301 I recognise that the Major Incident Plan made clear that it was to be treated as a guide and operated flexibly. However, in taking the approach it did, the Major Incident Plan failed to recognise that a very important early decision was likely to be whether or not the Tactical/Silver Commander went to the scene or to GMP HQ.

The Major Incident Plan did not set out the factors which might be relevant to that decision. Nor did it recognise and allow for circumstances in which any provision was made to cover the actions expected of the Tactical/Silver Commander at the scene.

By May 2017, the culture which had developed within GMP was that the Tactical/ Silver Commander would go to GMP HQ because of the facility there.302 This approach was not reflected anywhere in the Major Incident Plan. It should have been. Had the Major Incident Plan contemplated this decision, it is likely that careful consideration would have been given to the risk of a command vacuum at the scene in the event the Tactical/Silver Commander deployed to GMP HQ.

The culture of going to GMP HQ rather than the scene was not something of which Temporary Superintendent Nawaz was aware.303 It is a matter of significant concern that the Night Silver on 22nd May 2017 did not know where GMP expected him to go in the event of a Major Incident. Had he travelled to the scene, which is where he believed he should go, immediately upon notification, he would have unwittingly acted contrary to the expectations of others within GMP.

Operational/Bronze Commander

Section 3.1.3 of the Major Incident Plan set out the “Operational (Bronze) Commander” role. A list of initial actions was included.304 The role of Operational/Bronze Commander was not identified in the list of “core roles” in the appendices.305 It should have been, as it was intended that laminated hard copies would be available for use during incidents. The roles of Inner Cordons Manager and Outer Cordons Manager were included.306 On the night of the Attack, Inspector Smith assumed the Operational/Bronze Commander role for GMP. In evidence, he confirmed that he was not undertaking either the Inner or Outer Cordons Manager role on the night.307

The absence of an Operational/Bronze Commander role card in the appendices did not make any difference on the night of the Attack. This was because Inspector Smith did not seek to consult the role card relevant for his position. However, had Inspector Smith sought to do so, as DCC Pilling envisaged might happen, there would not have been one available. Given its importance, the Operational/Bronze Commander should have been included in the “core roles” section of the appendices.

Treatment of GMFRS

The Major Incident Plan had a section devoted to GMFRS. It spoke of GMFRS’s role in “firefighting, rescue and salvage operations”.308 It identified seven responsibilities. While it did identify “[l]ife-saving through search and rescue”309 as the first responsibility, the Major Incident Plan should have been much clearer about GMFRS’s capability of working with NWAS to treat and move casualties within an incident scene to an area in which they can receive care.

None of the GMP officers at the scene recognised that GMFRS was not present during the critical period of the response.310 This was despite the challenges those in the City Room were experiencing in the emergency treatment and movement of casualties. The GMP Operational/Bronze Commander, Inspector Smith, stated in evidence: “I don’t think I realised that many, if not all, of the Fire Service personnel were trauma trained.”311 He stated that he did not know that NWAS’s Hazardous Area Response Team (HART) and GMFRS’s Specialist Response Team trained together.312

The way the Major Incident Plan was drafted was consistent with the general lack of understanding of the importance of GMFRS’s potential contribution among GMP frontline officers. This is an important area for improvement across all areas of GMP planning and training.

Site-specific plan

GMP held a plan entitled “Contingency Plan – Phones 4U Arena” (the GMP Arena contingency plan). It was dated June 2013.313 It was updated to reflect the name change at the Arena in December 2013.314 It was marked for review in June 2016.315 It had not been reviewed by the time of the Attack, 11 months later.316 The need for review had been identified by GMP’s Contingency Planning Unit. The intention was that a joint plan for the entire Victoria Exchange Complex would be created.317 Steps had been taken to progress this, but there was work still to be done by 22nd May 2017.318

In 2014, the Victoria Exchange Complex underwent a substantial refurbishment.319 As a result, the internal layout changed. The plan of the configuration of the Victoria Exchange Complex contained in the GMP Arena contingency plan showed the arrangement before the refurbishment and in very little detail.320

The preface to the GMP Arena contingency plan stated:
“This is a site specific plan designed as an aide to assist officers responding to an incident. It must be used in conjunction with the GMP Major Incident Plan.”321

It went on to say that “GMP is the lead agency in the preparation of this plan and all Category 1 responders have been consulted in its preparation.” 322

On the fourth and fifth pages, a Major Incident checklist was provided.323

The GMP Arena contingency plan provided useful background information in relation to the Arena. It provided maps, contact numbers and evacuation procedures. It provided suggested RVPs.

Overall, the GMP Arena contingency plan was a potentially useful document to anyone responding to an incident, despite being in need of review. On the night of the Attack, only one person accessed it: Temporary Superintendent Nawaz. He did not find it easy to locate.324 He was unable to recall how much of it he read.325 He did not use the Major Incident checklist. He did not refer to the suggested RVPs or the maps.326

A large venue such as the Arena should have had a multi‑agency site‑specific plan. GMP commanders should have been informed of its existence and trained in a system that allowed them immediately to access it.

Silver Commanders Guide

All Superintendents in GMP were expected to be on the Night Silver rota.327 Being a qualified public order Silver Commander was not a mandatory requirement for being a Superintendent.328 There was no specific training for the role of Night Silver. Officers who were required to undertake it were expected to ensure that they addressed training gaps themselves. They also shadowed more experienced officers.329

GMP produced a document entitled ‘Silver Commanders Guide’. The copyright date on this document was given as 2010.330 It did not contain any reference to JESIP, from which I infer that it was not updated after JESIP was introduced. It should have been. The document was aimed at providing support to Superintendents when undertaking the role of Night Silver.331

Before 22nd May 2017, Temporary Superintendent Nawaz had not read the Silver Commanders Guide.332 He should have done, although it would not have given him assistance with some matters which were important on 22nd May. Temporary Superintendent Nawaz was not sure whether he even knew of this document’s existence before 22nd May 2017.333

The introduction to the Silver Commanders Guide began:
“The night silver superintendent provides an active role within the force and attends any serious, major or unusual events; ensuring incidents are effectively managed and properly resourced.”334

The use of the word “attends” mirrored what can be found in the Major Incident Plan: GMP’s plans were based upon an approach in which the Tactical/ Silver Commander went to the scene. The assumption that the Tactical/Silver Commander would travel to the scene was reinforced in a number of places throughout the document.

Nothing in the Silver Commanders Guide provided any direct assistance to a Tactical/Silver Commander in relation to the factors relevant to the important decision of whether they should or should not go to the scene. This is a significant omission in light of GMP’s practice by 2017 of Tactical/Silver Commanders not going to the scene. As with the Major Incident Plan, this should have been updated.

The Silver Commanders Guide had a section entitled “Terrorism”.335 That section said nothing about Operation Plato or what the Night Silver should do in the event Operation Plato was declared. Given the complexity of a Marauding Terrorist Firearms Attack, this was an area which should have been covered by the Silver Commanders Guide.

Aside from the Silver Commanders Guide and in any event, every officer who undertook the role of Night Silver should have been trained in Operation Plato. As I shall address shortly, this was not the case.

Operation Plato plans

Over four days between 26th and 29th November 2008, ten members of a violent Islamist extremist group called Lashkar‑e‑Taiba launched a series of terror attacks on civilian sites in Mumbai, India. They did so in a co‑ordinated way, using automatic weapons and hand grenades. At least 174 people were murdered. This was a shocking development in global terrorism.

At this time, a body named the Association of Chief Police Officers (Terrorism and Allied Matters) (ACPO (TAM)) was responsible for delivering and co‑ordinating national counter‑terrorism policing and strategy in the UK. In due course, ACPO (TAM) became Counter Terrorism Policing Headquarters (CTPHQ).336

In the aftermath of what happened in Mumbai, ACPO (TAM) conducted a major review of UK planning, preparedness and response to a Mumbai‑style attack.337

In 2012, as a result of that review, ACPO (TAM) issued guidance.338 The purpose of that guidance was to assist individual police services to create a plan for responding to what was termed a Marauding Terrorist Firearms Attack. In order to ensure that common terminology was used across all police services and, indeed, across the emergency services more generally, it was agreed nationally that the operational name for such a response would be Operation Plato.

Following this national guidance, the Specialist Operations Branch of GMP devised its own Operation Plato plan. The Specialist Operations Branch had responsibility for a wide range of specialist policing activity, including firearms policing and therefore Operation Plato.339 As I have explained, Superintendent Giladi was part of the Specialist Operations Branch with responsibility for the Firearms Training Unit and Policy Compliance Unit during the period I considered.

GMP’s Operation Plato plan was initially called Standard Operating Procedure 47 (SOP 47).

Standard Operating Procedure 47 v.1 to v.3

The first version of that plan, SOP 47 v.1, was created by Inspector Andrew Fitton on 18th July 2012 and approved on 25th July 2012. It was given a review date of 25th July 2013.340

The review took place earlier than that date. The second version of the plan, SOP 47 v.2, was created by Inspector Fitton in late December 2012.341 The changes between v.1 and v.2 were minimal. Indeed, the only substantive change was to include a short section at page 5 that is sensitive but also irrelevant to the issues for my consideration. SOP 47 v.2 was given a review date of 25th December 2013.342

Again, the review took place rather sooner than was scheduled. Inspector Roby, whose position I will address in paragraph 12.231, reviewed and updated SOP 47 in April 2013. GMP was unable to locate a copy of SOP 47 v.3 for the Inquiry. However, I heard evidence from Inspector Roby about it.343 Before dealing with her evidence on this issue, I will introduce the role of the FDO in greater detail as that role plays an important part in SOP 47.

Force Duty Officer

In the event of the declaration of Operation Plato, the FDO has a vital and pivotal role to play, certainly in the early stages of the response. I will deal with this in further detail in Part 13. Obviously, therefore, each version of the GMP Operation Plato plan ought to have dealt clearly and comprehensively with the discharge by the FDO of their responsibilities.

All police services operate a control room. The control room provides the hub of the police response to incidents 24 hours a day and 365 days a year. Police control rooms typically have a hierarchical management structure, with the FDO in charge. In some police services, such as BTP, the FDO is known as the Force Incident Manager. Where any Major Incident occurs, the FDO will provide the initial tactical/silver command function. That includes acting as the Initial Tactical Firearms Commander.344 It is obvious that, in the event of a Major Incident, the FDO role will be demanding.

The Operational Communications Branch was responsible for the functioning of the control rooms, which were known as Operational Control Rooms. As I have said, I refer to this collectively as GMP Control.345

Inspector Roby joined GMP in 1987. Between 1998 and 2000, as a Sergeant, she worked within GMP Control.346 During this period, it became necessary for Inspector Roby to understand the role of the FDO so that, in the event of a Major Incident, she could ensure the person in that role was supported. As a result, she became aware of the “massive responsibilities placed on the shoulders”347 of the FDO in such a situation. She believes that GMP as an organisation was aware of that burden.348 I accept her evidence. It follows that GMP had been aware at an organisational level of the burden that would fall upon the FDO in the event of a Major Incident occurring since the late 1990s, nearly 20 years prior to the Attack.

Another very experienced officer, Sergeant Whittle, described the role of the FDO as “an impossible task … it would be almost like being hit by a tidal wave”.349 He was describing knowledge that both he and his colleagues had had for many years.

Inspector Roby could not recall having updated SOP 47 v.2, so as to create SOP 47 v.3. She explained by reference to her general approach that she would not have had the authority to put v.3 into circulation.350 Instead, she would have made any amendments to v.2 that seemed to her to be necessary before sending it on for approval. She stated that prior to doing this work, she had received no training in Operation Plato and had no experience or training as a firearms officer. Moreover, she thought it unlikely she would have considered the role of the FDO in the work of review that she did.351

Inspector Roby, for all her experience and obvious qualities, was plainly not the right person to review the Operation Plato plan. She was unable to recall to whom, if anyone, v.3 was sent.352 Her expectation was that someone with firearms experience would have considered v.3 before it was approved by Superintendent Giladi for release. I have seen no evidence that this occurred or that there was any procedure in place that would have required it to happen. This is a criticism of GMP as an organisation, not of Inspector Roby.

All policies should be reviewed regularly. They should be reviewed by those with the skills and experience to assess them properly so as to make meaningful improvements. Where changes are made to a policy, they should be clearly visible and the fact that there has been a change should be apparent. I recommend that the College of Policing, the Home Office and HMICFRS consider issuing guidance to this effect. The problem with the development of v.3 was replicated throughout the course of GMP’s approach to its Operation Plato policy.

Standard Operating Procedure 47 v.4

SOP 47 v.3 appears to have remained in operation for a period of 18 months. It was then reviewed by Sergeant Simon Wright in October 2014. He produced SOP 47 v.4.353 He made only limited changes to v.3, although v.4 did give the FDO the additional responsibility of notifying particular assets of the incident.354

SOP 47 v.4 was given a review date of October 2015.355 That review did not occur. Superintendent Giladi said that was down to a lack of staff in the Policy Compliance Unit.356 I accept that evidence. This provides a clear example of how cuts were having a real effect within GMP.

Standard Operating Procedure 47 v.5

The next significant event in the relevant chronology involved a counter‑ terrorism inspection by HMICFRS. Andrew Buchan was an Associate Inspector and led HMICFRS’s specialist inspections programme over the period that I considered.357 He was responsible for a nationwide inspection known as Counter‑Terrorism Policing Part 2 or CT2.358

This inspection was focused on police services’ preparedness for a terrorist attack, particularly a Marauding Terrorist Firearms Attack. A number of police services were visited between October 2016 and March 2017, including GMP. The visit to GMP was scheduled for between 31st October and 4th November 2016, and the evidence indicated that it did take place between those dates.359

In 2016, Catherine Hankinson was a Chief Superintendent within GMP. On 1st October 2016, she commenced a period of temporary ACC duties. She assumed responsibility for the Specialist Operations portfolio. Shortly after her appointment, Temporary ACC Hankinson became aware of the impending visit of HMICFRS. She received an email from the Inspectorate on 14th October 2016 which made clear that the inspection would look at how well set up police services were to respond to a Marauding Terrorist Firearms Attack. Other emails made clear to her that a focus would be on how the FDO coped with the first four hours of such an attack.360 These were matters within her area of responsibility.

Understandably, Temporary ACC Hankinson set about preparing for the visit of HMICFRS. At 14:35 on Sunday 30th October 2016, as part of that work, Temporary ACC Hankinson emailed Superintendent Giladi and another senior officer, stating:
“Not sure who’s in order Monday, but need one of you to action this. All forces received a letter from ACC Chris Shead NPOCC [National Police Coordination Centre] in August dated 10th Aug relating to National Armed policing spontaneous mobilisation update. It reiterated the instruction that if we were dealing with an MTFA [Marauding Terrorist Firearms Attack] type incident, that neighbouring forces would send [X] ARVs [Armed Response Vehicles] to the affected force. It specifically requires us to review our Op Plato plans to take account of this and ensure our commander’s and FDOs are aware. Our Plato plan seems to need review and this needs to be done urgently given HMIC [Her Majesty’s Inspectorate of Constabulary] are here Tuesday. Can you ensure its [sic] updated and then circulate to relevant people …”361

The email refers to a need to review SOP 47 v.4 for a particular purpose, namely to address the issue of cross‑border co‑operation. However, by this stage, a review of the plan was a year overdue, and in that period the third edition of JOPs had been issued. JOPs 3 was of obvious relevance to GMP’s Operation Plato plan. In these circumstances, a comprehensive review of SOP 47 v.4 was called for. That is what should have happened. It did not.

Ultimately, Superintendent Giladi assumed responsibility for the review of SOP 47 v.4. He endorsed v.5 to indicate that it was the product of a review and update in October 2016.362 It appears, therefore, that he conducted his work over the course of Sunday 30th October 2016 and/or Monday 31st October 2016 so as to ensure SOP 47 v.5 was ready, as instructed, by Tuesday 1st November 2016. He produced SOP 47 v.5 by making only limited changes to SOP 47 v.4.363

There are a number of troubling aspects to the circumstances in which SOP 47 v.5 was created. First, Superintendent Giladi had never worked as an FDO or received any training in that role. He did not recall anyone ever pointing out to him that, in the event of the declaration of Operation Plato, the FDO might be the single point of failure. He accepted that in October 2016 he did not fully grasp the pressures the FDO would be under in such a situation, even with support.364

Given the central role the FDO had in the response to a declaration of Operation Plato, the person reviewing the plan needed to have a detailed knowledge of what that role involved or the support of someone else who did. Superintendent Giladi had neither. He was not an appropriate person to carry out this work. I do not regard either Superintendent Giladi or Temporary ACC Hankinson as being at personal fault in this regard. Each had been put in a position they should not have been in. The fault is GMP’s at a corporate level.

Second, Superintendent Giladi was required to produce SOP 47 v.5 under a pressure of time that was unrealistic and unreasonable. As Superintendent Giladi accepted, the pressure of time meant that the policy was not reviewed in the detail that was required. He recognised that there ought to have been a thorough review of the whole document. The timescales made that impossible.365 Once more, the fault in this rests with GMP corporately. Neither Temporary ACC Hankinson nor Superintendent Giladi should have been placed in this position.

Third, someone who lacked the experience to review the Operation Plato plan was required to conduct that review in a timescale that would have been inadequate even for an expert. In considering that unacceptable state of affairs, it is relevant to note that the plan in question was not one of limited importance.

It was a plan designed to eliminate a terrorist threat and protect innocent life in the event of an attack by marauding terrorists with firearms. It could hardly have been more important. That gives rise to the question of why something so significant was being dealt with in such an unsatisfactory way. The answer is clear. SOP 47 v.5 did not represent a meaningful attempt by GMP to reassess the Operation Plato plan. It was designed to ensure that HMICFRS did not identify a failure by GMP to have an up‑to‑date plan. It was window dressing.

Findings of HM Inspectorate of Constabulary and Fire and Rescue Services Inspectors

As GMP intended, the hastily prepared SOP 47 v.5 was the plan that HMICFRS was provided with and which it considered during its inspection.366 One of those who carried out the HMICFRS inspection was John Bunn. He prepared a review of the plan, which contained the following relevant findings.

In relation to the FDO, John Bunn found:
“The evidence indicates that the FDO is expected to control the early stages of a Plato and to call out and inform various roles, ranks and units. This evidence is set out in bullet points, with no narrative. The number of tasks the FDO is expected to perform, in all likelihood are so many that it may be that some will not be completed or at least not in the order expected which is acknowledged in the force plan. One point the force plan makes is the pressure the FDO is going to be under including transfer of command to a Cadre Tactical Firearms Commander. This is raised in a paragraph as ‘will bring its own challenges’ but there is no resolution to this question and it is left unresolved.”367

He assessed the impact of this as follows:
“Such apparent vagueness may cause confusion or doubt in a live scenario. There is a need to provide the FDO with more immediate support or resources to assist with all the functions expected of that role.”368

John Bunn also found that the plan lacked:
“… details and relevant information and is very tactical dealing in large part with the armed roles of ARVs [Armed Response Vehicles], OFCs [Operational Firearms Commanders], TFC [Tactical Firearms Commander] cadre, SFCs [Strategic Firearms Commanders] and the FDO. Initial response to a possible Plato by first responders, unarmed is a gap that requires to be covered. There is no question that the FDO is being overloaded with tasks in the initial stages of a potential Plato and will require urgent help. No Referencing to imaging transfer. No specific reference to the initial information/intelligence gathering within the FCR [Force Control Room].”369

Those findings were unsurprising and correct. Andrew Buchan described the following in evidence. First, SOP 47 v.5 was very tactical and focused on the roles, responsibilities and tactics of firearms officers and firearms commanders. There was no mention in the plan of working with other agencies responding to the incident, although there were isolated, bullet point references to JESIP. The plan included the stay safe guidance but did not identify how this would be communicated to those responding to a terrorist attack.370

Second, HMICFRS was well aware of the extreme burden that the FDO would come under in the event of the declaration of Operation Plato. HMICFRS considered that SOP 47 v.5 placed an over‑reliance on the FDO to complete a significant number of functions in the early stages of a terrorist attack. It was the view of HMICFRS that GMP needed to provide more support to the FDO, allowing that person to focus on commanding the initial response.371

SOP 47 v.5 also contained obvious errors. It contained a list of reference documents.372 It was, in any event, undesirable to cross‑reference a series of other documents in a plan that should have been internally comprehensible by someone likely to be operating under considerable pressure. What is more, the list was inaccurate. It referred to the second edition of JOPs, when the third edition was by then in force. This seems to me likely to represent a gap in Superintendent Giladi’s knowledge for which he is not to blame, as opposed to being a typographical error. Furthermore, the plan referred to a regional policy that had never been in force.373

HMICFRS’s report at the conclusion of Counter‑Terrorism Policing Part 2 was not available to GMP until after the Attack. However, at the conclusion of the inspection within GMP, Andrew Buchan conducted a “hot debrief” with Temporary ACC Hankinson. This took place on 3rd November 2016. Andrew Buchan explained in evidence that at this debrief he had described to Temporary ACC Hankinson the evidence that had been gathered during the inspection.374 He was clear that this included informing her about the risk that the FDO would become overburdened in an Operation Plato situation and the need for something to be done about this urgently within GMP.375

Temporary ACC Hankinson was unable to recall this meeting with Andrew Buchan.376 She accepted, having regard to a handwritten note she had made377 and to an email she sent to her Chief Officer colleagues on 3rd November 2016,378 that the hot debrief had taken place that day. She accepted, too, that the role of the FDO had been raised with her. Indeed, in her handwritten note, she had written: “[I]s there enough resilience around FDO[?]”

Before giving evidence to me, Temporary ACC Hankinson had attempted to work out or reconstruct what her note and email meant she had been told by Andrew Buchan. The view she initially came to was that what was being communicated to her was not a risk that the FDO would become overburdened or overwhelmed, but instead the importance of support for the person in that role.379 It was further her initial view that, in any event, she was not being told of something that required urgent attention.380

While I do not doubt that Temporary ACC Hankinson was doing her best to help me, I have come to the conclusion that Andrew Buchan is correct in his evidence that he briefed her about the risk of the FDO becoming overburdened and of the need to address this urgently.

First, HMICFRS went in to its inspection of GMP with a concern that, in an Operation Plato situation, the FDO would become overburdened and came out of the inspection of GMP with that concern reinforced. The issue of the FDO was raised in the hot debrief, and I can identify no credible reason why Andrew Buchan would have done anything other than set out the full intensity of the concerns of HMICFRS in that meeting. In evidence, Temporary ACC Hankinson realistically accepted this logic.381

Second, when questioned in the oral evidence hearings, Temporary ACC Hankinson ultimately accepted that it was likely that what was being communicated to her by Andrew Buchan was indeed the issue of whether the FDO would be able to cope in the event of an Operation Plato declaration and that what was being described was something that in fact required urgent attention, even if she did not accept that Andrew Buchan had emphasised the need for urgency.382 This was a fair and realistic concession by Temporary ACC Hankinson.

To her credit, Temporary ACC Hankinson did take action in response to what she was told in the hot debrief. At 19:36 on 3rd November 2016, the day of the meeting itself, she sent an email to the GMP Chief Officers.

Her email makes clear that a number of issues had been raised by Andrew Buchan, including the absence of training of unarmed staff in Operation Plato, an issue to which I will turn in due course. The FDO issue was also raised. The first “area for development” identified by Temporary ACC Hankinson was in the following terms:
“Is there enough resilience around the FDOs in the event we have an MTFA [Marauding Terrorist Firearms Attack] style incident? This wasn’t really about numbers of people, but about people having specific roles in specific seats. Our FDOs were able to evidence that they had picked this up from exercising during summer and they were on with producing guidance and crib cards for colleagues. HMIC [Her Majesty’s Inspectorate of Constabulary] did accept that our current IT hampered us but are aware this is being upgraded.”383

What this email does not do is make clear the extent of HMICFRS’s concerns about the risk of the FDO being overwhelmed. Nor does it state the need for urgent action that I am satisfied Andrew Buchan explained to Temporary ACC Hankinson. Temporary ACC Hankinson could not recall sending the email384 and was therefore unable to explain from memory why her email had not achieved these two important aims. The explanation, in my view, is complex.

At the time of her appointment, Temporary ACC Hankinson had no recent experience of the Specialist Operations Branch and was unaware of GMP’s corporate knowledge of the risk that the FDO would become overburdened in an Operation Plato situation.385 That was not her fault. Again, this was the position she had been placed in by GMP. Had she had such knowledge, I am satisfied that Andrew Buchan’s indication of urgency would have struck home in a way that it did not.

Temporary ACC Hankinson plainly also thought that what was being described to her was a national problem; indeed, she said as much in her email. As a result, she thought that the solution would be a national one and not something for GMP to address individually.386

In any event, her understanding was that work was already under way within GMP to ensure that, in the event of an Operation Plato situation, the FDO would be properly supported by staff around them who would understand, through the use of action cards, the tasks that had been delegated to them.387 It is understandable that Temporary ACC Hankinson should have thought that, although she acknowledged that something had ultimately gone wrong, namely that action cards had not been embedded,388 an issue to which I shall turn towards the end of Part 12.

Temporary ACC Hankinson was right to email her senior colleagues, but she should have made clear in her message the extent of the risk and the need for urgent action. Moreover, given her responsibility for the Specialist Operations Branch, she should have done more to follow up what was being done to address the issue within GMP. These failures are mitigated by the matters I have set out, but only in part.

GMP, as an organisation, bears the main responsibility for the lack of action. It had longstanding corporate knowledge of the risk that the FDO would become overburdened in the event that Operation Plato was declared. Here, in the hot debrief, was confirmation by HMICFRS of that risk. There was a need for urgent action. The necessary action included, but went beyond, the introduction and embedding of action cards. The necessary action did not occur.

One of the things that should have happened was that information about the inadequacies identified by HMICFRS in SOP 47 v.5 should have been communicated beyond the Chief Officer Group. In particular, the Policy Compliance Unit should have been informed, given their central role in the review of plans. That did not happen.

Inspector Lear, who as I have explained headed the Policy Compliance Unit at this time, stated that if the views of HMICFRS had been communicated to the Policy Compliance Unit promptly after the 3rd November 2016 hot debrief, then work on reviewing SOP 47 v.5 would have started immediately.389 Given the pressure on the Policy Compliance Unit, I doubt work would in fact have started straight away, but I do accept that this issue would have moved up the list of priorities. I accept that the work of review would have started long before it in fact did on 2nd May 2017.

Counter Terrorism Policing Headquarters Operation Plato guidance

At the same time as HMICFRS was undertaking its fieldwork as part of Counter‑ Terrorism Policing Part 2, CTPHQ (as it had become) was reviewing the original ACPO (TAM) Operation Plato guidance. Both Andrew Buchan and CI Richard Thomas, CTPHQ’s Head of Specialist and Counter‑Terrorism Armed Policing, explained that during this period, their two organisations co‑ordinated.390 HMICFRS wanted to ensure that CTPHQ had knowledge of its findings prior to publication of the Counter‑Terrorism Policing Part 2 report, which did not happen until August 2017.391 That was good practice.

In March 2017, CTPHQ published its refreshed Operation Plato guidance.392 This took into account the findings of Andrew Buchan’s HMICFRS team, even though the Counter‑Terrorism Policing Part 2 report had not by that stage been published.

On 23rd March 2017, the refreshed guidance was circulated to all UK police services.393 This was accompanied by a letter dated on the same day from Chief Constable Francis Habgood, the National Police Chiefs’ Council Lead for this policy area.394 The National Police Chiefs’ Council had by this stage succeeded to the role and responsibilities of ACPO. The day before the letter, the Westminster Bridge terror attack had taken place: an attacker had driven a car into pedestrians, killing four and injuring many others; he then left the vehicle and fatally stabbed a police officer, before being shot dead by a firearms officer.

The opening paragraph of Chief Constable Habgood’s letter read:
“My purpose in writing to you, is to share with you the new national PLATO guidance for UK policing. In light of the terrorist attack in London yesterday, I would encourage you to commission an urgent review of your local PLATO response plans against this new national guidance (attached). You will see that the refreshed guidance includes sections relating to operational staff and supervisors, control room staff and firearms commanders (including control room based initial commanders).”395

The Whittle Plan

An email chain shows that the following then happened within GMP.396 At 14:58 on 28th March 2017, Chief Constable Hopkins emailed DCC Pilling and ACC Robert Potts to suggest that they task officers to ensure GMP’s Operation Plato plan contained what CTPHQ considered it should contain. His email made plain that he expected a formal report then to be made to the Chief Officer Group. Chief Constable Hopkins was acting promptly, which is to his credit, but he did not follow up on this important issue. He should have done.397

At 16:17 the same day, ACC Potts delegated this task to Superintendent Giladi who, for reasons I have explained, was ill‑equipped to perform it personally. Superintendent Giladi confirmed in evidence that he understood he was being instructed to ensure that the Operation Plato plan was in proper order and report back to the Chief Officer Group.398

Chief Constable Hopkins explained that the next meeting of the Chief Officer Group took place on 27th April 2017.399 He agreed that there was no mention in the minutes of that meeting of the Operation Plato plan. It had been overlooked. That, he acknowledged, was not good enough.400 I agree. This was an issue of the utmost importance, which should have been high up on the agenda. The fact that it fell off the agenda is likely, in my view, to have contributed to the delay that occurred.

In any event, even if the issue of the Operation Plato plan had been scheduled for discussion at that meeting, there would have been nothing for the Chief Officers to look at. That is because nothing effective appears to have been done in response to the Chief Constable’s instruction for over a month.

Although not revealed by the email chain, Inspector Lear confirmed that, on 6th April 2017, he had received an email from Superintendent Giladi directing him to ask Sergeant Whittle to update the Operation Plato plan.401 The evidence did not reveal what was done in the three weeks that followed, although Inspector Lear said he had spoken to Sergeant Whittle.402

At 12:05 on 29th April 2017, ACC Potts chased Superintendent Giladi by email indicating that the plan was needed for the May meeting of the Chief Officer Group. In evidence, Superintendent Giladi made clear that he would not have ignored an instruction from a Chief Officer but could not recall why nothing appeared to have been done to progress work on the plan before then. He agreed that it looked like a month had been lost.403

At 10:27 on 2nd May 2017, three days later, Superintendent Giladi raised with Inspector Lear the preparation of the plan.404 Inspector Lear replied six minutes later. Subsequent exchanges between the two of them on the same day indicate that Inspector Lear felt under time pressure to produce the new plan.405 That is hardly surprising.

The subject line of the email had originally read “Questions for MTFA [Marauding Terrorist Firearms Attack]”. On forwarding the chain to Inspector Lear, Superintendent Giladi added to this so that it read “Questions for MTFA PLATO REVIEW URGENT !!!!!!”.406 Inspector Lear explained in evidence that he understood the plan was required by 5th May 2017, three days later.407

Substantial time was lost between the email of Chief Constable Hopkins on 28th March 2017 and the events of 2nd May 2017. The chronology did not explain what happened during this period, and so I am not in a position to criticise any officer. However, it is a fact that the three days from 2nd May 2017 plainly did not provide a sufficient period to prepare an adequate updated Operation Plato plan.

In early May 2017, Inspector Lear still had the benefit of Sergeant Whittle’s support in the Policy Compliance Unit. Inspector Lear delegated the task of complying with the Chief Constable’s instruction to Sergeant Whittle, although precisely when he did so is not entirely clear. By 4th May 2017, two days after Superintendent Giladi’s email, Sergeant Whittle had produced what the Inquiry termed “the Whittle Plan” during the course of the evidence.408 For reasons that I will explain, it was badged “North West Armed Policing Collaboration” and was entitled “Operation Plato – Initial Response to a Marauding Terrorist Firearms Attack (MTFA) by North West Region”.409

Just as there are a number of troubling aspects with the circumstances in which SOP 47 v.5 was created, so there are a number of troubling aspects with the circumstances in which the Whittle Plan was created.

First, not for the first time, a piece of work that was of a high degree of importance was being prepared in a rush. In his evidence, Inspector Lear explained that he could not understand why there was this rush. He was satisfied that, had he been tasked to arrange an updated Operation Plato plan shortly after the hot debrief on 3rd November 2016 or indeed at any point that allowed time for proper research and reflection, the product would have been better.

For example, Inspector Lear recognised that the Whittle Plan placed obligations not only on the firearms officers and unarmed officers who might deploy to the scene but also on the staff in GMP Control. Inspector Lear explained that more time would have enabled liaison to have taken place with colleagues in GMP Control in relation to the support they needed, for example the important issue of action cards.410 In the end, Sergeant Whittle was given just a few days to finalise the plan. What was required was impossible to achieve in that timescale.

Second, as I have explained, HMICFRS identified what I regard as significant inadequacies with the approach to Operation Plato reflected in SOP 47 v.5, namely whether the FDO would be able to cope in the event of an Operation Plato event and the absence of training of unarmed staff in Operation Plato. These two issues were communicated to GMP in the hot debrief of 3rd November 2016. Inspector Lear and Sergeant Whittle plainly needed to be informed that HMICFRS had identified these issues if they were to produce an adequate Operation Plato plan.

Inspector Lear confirmed that no one told him about the issues identified by HMICFRS.411 He was therefore unable to tell Sergeant Whittle. Sergeant Whittle understandably observed in evidence that it would have been better if he had known these facts.412 GMP should have ensured that these officers knew what had been identified by HMICFRS.

Third, a degree of confusion seems to me to have crept into what was expected of Inspector Lear and then Sergeant Whittle. At this time, there existed a hierarchy of provisions beneath the CTPHQ guidance.413 An organisation called the North West Armed Policing Collaboration was brought into existence in 2012. It represented a number of police services in the North West, including GMP.

The North West Armed Policing Collaboration created a series of plans. The top layer of those plans involved a plan that addressed cross‑border armed support. Beneath that was a regional policy that dealt with how the North West as a region would respond to a Marauding Terrorist Firearms Attack. This was known as Appendix C, and Version 10 was in force at the time I am considering.414

Inspector Lear understood that he had been instructed to create a plan that would replace Appendix C and SOP 47 v.5 and that would therefore be a plan for the whole of the North West.415 Sergeant Whittle understood that he had been instructed to create a plan that would replace Appendix C but that SOP 47 v.5 would continue to run beneath it as a plan for GMP only, at least initially.416

Either way, the reason why Sergeant Whittle marked his plan v.2 was because it was a development on Appendix C v.10. What he appears to have been asked for was simply a replacement for the GMP plan, namely SOP 47 v.5, but that was not made clear to him.417

Ultimately, the North West Armed Policing Collaboration declined to accept the Whittle Plan as the regional policy.418

The confusion about what Inspector Lear and Sergeant Whittle were actually required to produce serves to underline that GMP was approaching an important task in a way that was inadequate. It lacked structure. Those actually doing the job lacked information, and the work was required to be completed in too short a timescale.

Unsurprisingly, given the circumstances in which it was created, the Whittle Plan was flawed.

SOP 47 v.5 contained a section dealing with FDO actions. It provided: “[T]he FDO will need strong support from the OCB [Operational Communications Branch] team. Some of the actions are likely to be delegated to OCB supervision.419 So, this plan at least acknowledged that the FDO would be incapable of personally discharging all of the responsibilities listed, although it said nothing about when or how support would be provided.

The Whittle Plan then removed any reference to delegation, creating the impression that all listed tasks were ones for the FDO.420 It added substantially to the responsibilities on the FDO in the event of an Operation Plato declaration.421 The Whittle Plan made worse the risk of the FDO being overburdened in such a situation. I do not blame Sergeant Whittle or Inspector Lear for that. They were acting without the information they required and under an unacceptable pressure of time. The fault was that of GMP itself.

In the period prior to the Attack, GMP’s approach to its Operation Plato policy was inadequate.

On 12th May 2017, Inspector Lear circulated the Whittle Plan and other documents to a variety of recipients, including all FDOs and some Chief Officers.422 The email related to command training for the year 2017/18. This email was sent at a time of significant pressure for the Policy Compliance Unit and Inspector Lear in particular.

Nonetheless, as Inspector Lear acknowledged, there were problems with this communication. The email made no reference to the relationship between Appendix C v.10, SOP 47 v.5 and the Whittle Plan.423 The version of the Whittle Plan that was attached was marked with the word “Draft”. Inspector Lear said this may have been a clerical error.424 The email did not indicate to the recipients which plan they ought to follow in the event of the declaration of Operation Plato, and the training that was proposed was months in the future.425 This was a highly undesirable and confusing situation which had been allowed to develop.

Three plans

By 22nd May 2017, there were three Operation Plato plans which were capable of applying to GMP: the regional plan Appendix C v.10, and the GMP plans SOP 47 v.5 and the Whittle Plan. They were not consistent. The problem this created was real, not imagined. The evidence revealed that different officers, including those who performed vital roles, had different views about which plan was the one that ought to be followed on the night of the Attack.426

Furthermore, GMP appears to have allowed an ad hoc system to develop in which officers would digest the available policies and create their own “crib sheet”, as Sergeant Whittle described it.427

This was an unacceptable state of affairs. Something so important should have been organised by GMP and gone through a proper approval process.

I cannot be sure what effect this chaotic state of affairs had on the events of 22nd May 2017. I am sure that, had the planning for an Operation Plato declaration been approached competently by GMP, action cards would have been available within GMP Control on the night. That would have reduced the burden on the FDO. Whether that would have made a material difference to the outcome, I do not know, but it may have done.

The situation that GMP allowed to develop was dangerous. Even if it led to no loss of life on 22nd May 2017, it was capable of doing so. GMP’s approach to its Operation Plato plan deserves significant criticism.

This situation should never have happened and should never happen again, not just in Manchester but anywhere in the country.

All police services must recognise the importance of planning. Even if pressure on resources exists, no police services should allow a situation to develop in which planning for a Major Incident assumes the low level of priority that it assumed in GMP between at least 2013 and 2017.

I recommend that HMICFRS, the College of Policing, CTPHQ and the Home Office work together to put in place robust systems, policies and guidance to ensure all police services have sufficient resources dedicated to the operational plans, particularly for responding to Major Incidents, including terrorist attacks.


Force Duty Officer training

Inspector Sexton was the FDO for GMP on the night of the Attack. In evidence, he explained what that role involved.428 Along with managing day‑to‑day business across the service, he had responsibility for the initial command and control of major critical incidents.429 That included acting as Initial Tactical Firearms Commander in the event that a firearms response was required. It also included having authority to activate GMP’s emergency plans, such as the Operation Plato plan.430

As is obvious, Major Incidents can occur spontaneously. In the early stages of such an event, the command structure needed to address the incident is unlikely to be in place. The FDO is intended to fill what would otherwise be a void.431 During that period, the FDO will be making decisions at a strategic level, a tactical level and an operational level. It is a role that is both important and demanding.

By 2017, Inspector Sexton was an experienced police officer. He joined GMP in 1991 and by 2001 had reached the rank of Inspector. He had principally worked as a uniformed officer.432 Prior to 2014, he had no experience of firearms operations, save that while working as a uniformed response inspector he had on occasion performed the role of unarmed Operational/Bronze Commander for firearms incidents.433 In 2014, he applied to join the FDO cohort. He was successful in that application and was appointed as an FDO in June 2014. By that stage, he had 23 years’ experience as a police officer.434

Inspector Sexton carried out a period of FDO training prior to undertaking the role. This involved being mentored for a number of months. It also involved training as an Initial Tactical Firearms Commander. Inspector Sexton agreed that, by the night of the Attack, he was familiar with JESIP and with the importance of the emergency services co‑locating in the event of a Major Incident.435

One topic on which Inspector Sexton did not receive dedicated training prior to the Attack was Operation Plato. He explained that he did receive annual training in order to maintain his accreditation as a firearms commander. Inspector Sexton set out that this training included a component on Operation Plato. Subsequent to the Attack, Inspector Sexton attended a course that was dedicated exclusively to Operation Plato. While he did not consider attendance on that course revealed any gaps in his May 2017 knowledge, I consider that there was more that he needed to know prior to the night of the Attack. In particular, he had not received any specific training in zoning.436 That is a critical aspect of the declaration of Operation Plato. I recommend that in future all FDOs and Force Incident Managers attend a comprehensive course that is dedicated to Operation Plato before taking up their role.

That training should ensure that all FDOs understand the exceptional demands that will be placed upon them in the event of an Operation Plato declaration, even if proper support is available to them. It should also ensure that: they understand the need to carry out regular reviews of the declaration of Operation Plato; they understand the need to identify with clarity the zones into which different emergency responders may enter; they communicate those zones to all emergency services promptly; and they keep their zoning decisions and the declaration of Operation Plato more generally under review. The training should ensure that each emergency service understands the need to work jointly with partners and that there is a mutual appreciation of how commanders of other emergency services apply Operation Plato. The need to work jointly with emergency service partners must be ingrained. None of this was achieved on the night of the Attack. This recommendation is directed to all emergency services and their supervisory bodies.

Having been trained, Inspector Sexton regularly undertook the role of GMP FDO prior to May 2017. That included being Initial Tactical Firearms Commander for a large number of firearms incidents.437 He also performed the role of Initial Tactical Firearms Commander during training exercises in early 2016 and through that had gained some experience of zoning.438 That was no substitute for thorough training on that important issue. By the date of the Attack, Inspector Sexton regarded himself as highly experienced in the role of FDO. He was confident in his training and experience.439 Of course, he did not know what he did not know. Nor, in my view, was he prepared by his training and experience for what confronted him on the night of the Attack.

I accept that in general terms Inspector Sexton was a professional and committed police officer. He was undoubtedly competent to deal with the overwhelming majority of incidents that confronted the GMP FDO. However, as I will come on to explain in Part 13, on the night of the Attack he failed in a number of important respects. Those failures, in turn, played a major part in the total failure of joint working that night.

I consider Inspector Sexton’s failures to be the consequence of two connected things.

First, notwithstanding his training and experience, the importance of joint working, namely JESIP, had not become sufficiently ingrained in Inspector Sexton. Nor had he developed the skills to deal with the situation with which he was confronted. This is why I have made a recommendation in relation to FDO training.

Second, the sheer scale of the task that confronted Inspector Sexton that night was capable of overwhelming any FDO. As I have explained, GMP well knew that in an Operation Plato situation there was a real risk that the FDO would be overburdened. In Part 13, I will explain that I consider that is exactly what happened on the night of 22nd May 2017. I will also explain why that was not only predictable but also avoidable.

Unarmed commander training

In order to attain Sergeant and Inspector ranks, police officers have to pass examinations. For ranks above Inspector, there is training specific to role and rank. To be promoted to Chief Officer rank, there is a rigorous selection process, followed by a three‑month command course which must be passed.440 There is an expectation within GMP that officers can carry out command roles commensurate with their rank and experience.441

The College of Policing accredited public order commander training courses. Once passed, officers were then subject to a period of workplace shadowing and mentoring. Once signed off, officers must complete annual refresher training to retain their accreditation.442 The two key specialisms were firearms and public order.443 There was substantial overlap between the training provided on a public order commander training course and the Major Incident command roles.444 The public order course is focused on the Tactical/Silver Commander role for pre‑planned, as opposed to spontaneous, events.445

Inspector Smith qualified as a public order Bronze Commander in 2012. He carried out the necessary refresher training to maintain this.446 He had undertaken Authorised Firearms Officer training. He had never operated in this role.447 He had not undertaken any firearms commander training. He undertook the role of Operational/Bronze Commander on the night of the Attack. He had sufficient training and was competent to operate as an Operational/Bronze Commander. He was an experienced Operational/Bronze Commander.448

Temporary Superintendent Nawaz qualified as a public order Silver Commander in 2016.449 He had not undertaken any firearms commander training. It was not a requirement of his role as GMP Night Silver or his rank of Temporary Superintendent for him to have done so. He undertook the role of Tactical/ Silver Commander on the night of the Attack. He had not had sufficient training and, as a result, was not competent to operate as a Tactical/Silver Commander during an Operation Plato incident.450

Temporary Superintendent Christopher Hill qualified as a public order Silver Commander in 2010. He was also qualified as a Tactical Firearms Commander and Gold Commander.451 He replaced Temporary Superintendent Nawaz as Tactical/Silver Commander at 00:00 on 23rd May 2017. He had sufficient training and was competent to operate as a Tactical/Silver Commander.452

ACC Ford qualified as a public order Gold Commander in 2015. This qualification included multi‑agency commander of Major Incidents.453 She undertook the role of Strategic/Gold Commander on the night of the Attack. She had sufficient training and was competent to operate as a Strategic/Gold Commander.454 ACC Ford also acted as the Strategic Firearms Commander. I will deal with her firearms training at paragraph 12.332.

Firearms commander training

Following training in late 2006, PC Edward Richardson accepted his first position as an Authorised Firearms Officer in 2007. In 2008, he qualified as an Operational Firearms Commander.455 On the night of the Attack, he undertook the role of Operational Firearms Commander.456 He had sufficient training and was competent to operate as an Operational Firearms Commander.457

Temporary CI Rachel Buckle qualified as a public order Silver Commander in 2010. In 2014, she qualified as a Tactical Firearms Commander.458 She was the on‑call Tactical Firearms Commander on the night of the Attack.459 She did not take up the role of Tactical Firearms Commander or Ground Assigned Tactical Firearms Commander. She had sufficient training and was competent to function in either role. I shall return to the decisions around Temporary CI Buckle’s role on the night of the Attack in Part 13.

CI Mark Dexter qualified as a public order Silver Commander in 2015.460 The same year, he qualified as a Tactical Firearms Commander. Between 7th and 12th May 2017, he attended a specialist firearms commander course. This course built on the Tactical Firearms Commander course, addressing more complex firearms incidents, and included a counter‑terrorism element.461 He undertook the role of Ground Assigned Tactical Firearms Commander on the night of the Attack. He had sufficient training and was competent to operate as a Ground Assigned Tactical Firearms Commander.462 By reason of the recent specialist firearms commander course he had attended, CI Dexter was better qualified to act as Ground Assigned Tactical Firearms Commander than Temporary CI Buckle.463

By May 2017, Superintendent Craig Thompson had many years of experience as a Tactical Firearms Commander. In June 2016, he undertook the Tactical Firearms Commander course.464 Superintendent Thompson relieved Inspector Sexton of tactical firearms command at 00:18 on 23rd May 2017 and undertook the role of Tactical Firearms Commander from that point.465 He had sufficient training and was competent to operate as a Tactical Firearms Commander. By reason of his specialist firearms commander qualification, Superintendent Thompson was better qualified to act as Tactical Firearms Commander than Temporary CI Buckle.466

ACC Ford qualified as a Strategic Firearms Commander in 2015.467 She attended the same specialist firearms commander training as CI Dexter.468 She undertook the role of Strategic Firearms Commander on the night of the Attack. She had sufficient training and was competent to operate as Strategic Firearms Commander.469

JESIP training

The commanders had all received JESIP training, which had been delivered to them in 2014 by reason of their rank.470 JESIP was also included as an element of the public order commander training courses from the end of 2016.471 All GMP officers had undertaken e‑learning training in JESIP in 2015.472

The events of 22nd May 2017 demonstrated that the JESIP training which GMP officers had received was insufficient to ensure that important elements of the response were not overlooked. The failure by all those involved at an early stage to declare a Major Incident in a timely way or to provide or seek a METHANE message applies across all levels of seniority. The failure by the commanders to identify an FCP where co‑location at the scene could occur was significant. The lack of attempts to conduct a joint risk assessment with other agencies was a substantial failing.

While I have identified elsewhere in Volume 2 that some individual officers bear personal responsibility for these failings, I am satisfied there was a failure by GMP as an organisation to embed JESIP in its officers and staff. It may well be a result of the national standards at the time and the general approach to training across all police services.

Operation Plato training of unarmed officers

Knowledge within GMP of what an Operation Plato declaration signified was confined to specialists, particularly from the firearms environment.473 This meant that none of the unarmed frontline officers who deployed into the City Room had been trained in what an Operation Plato declaration would mean. This is in contrast to BTP, which had provided many of its officers, down to PCSO level, with training on what Operation Plato was.474

As a result of the way GMP chose to approach Operation Plato, neither Inspector Smith475 nor Temporary Superintendent Nawaz476 knew that it was the response to marauding terrorists with firearms. PC Richardson, the Operational Firearms Commander, thought that it related to a terrorist attack, whatever form such an attack took.477 This was an unacceptable and dangerous state of affairs. It had the potential to place lives at risk.

In Temporary Superintendent Nawaz’s case, the responsibility for his lack of knowledge was shared between him and GMP. In Inspector Smith’s case, it was entirely GMP’s fault that he did not know.

GMP Control staff, other than the FDO, were in the same position as the unarmed commanders. Police Support Staff Supervisor, Ian Randall, who was the Force Duty Supervisor on the night,478 did not know what Operation Plato was, beyond that it related to terrorism in some way.479

This was not Ian Randall’s fault. It is particularly concerning given that he informed a number of people that Operation Plato had been declared. He would have been unable to answer any questions about it had he been asked.480 His lack of knowledge gave rise to a risk that he might make incorrect assumptions or interpret information incorrectly.

During the HMICFRS inspection in late 2016, staff in the control room were questioned about their knowledge of GMP’s planned response to a Marauding Terrorist Firearms Attack.481 Their knowledge was found to be not good or reassuring.482 The HMICFRS Inspector concluded: “GMP control room staff have not received specific training regarding the force response to an MTFA … This may mean that control room staff do not know immediately what to do in the event of an MTFA.483

A similar discovery was made as part of the same HMICFRS inspection following a group discussion with patrol officers. The HMICFRS Inspector found that none of the officers was aware of GMP’s plans to respond to a terrorist attack. They did not know the details of Operation Plato and zoning.484

As I have explained, these findings were communicated to Temporary ACC Hankinson by the HMICFRS lead Inspector, Andrew Buchan, during the hot debrief on 3rd November 2016.485 In the course of an email that same day, Temporary ACC Hankinson wrote to the GMP Chief Officer Group: “Our front line unarmed staff have had no specific training relating to MTFA.486

The HMICFRS report based on the November 2016 visit is dated August 2017.487 It rehearsed the findings about unarmed officers’ lack of knowledge of Operation Plato. Strikingly, the report records the account of a Tactical Firearms Commander who told the Inspectors: “[T]he unarmed first response is the untested area for the force, that’s where our vulnerability lies … Because of the possible ARV [Armed Response Vehicle] response times, it’s likely that the first officers to the scene will be unarmed, and they have had the least amount of MTFA training.”488 Although GMP received this report after the Attack, the Tactical Firearms Commander was stating facts which GMP should have realised for itself. This was readily available information to GMP in the event it had asked the obvious questions.

The shortcomings in the control room staff and patrol officers’ knowledge were readily established by HMICFRS. It was GMP’s responsibility to ensure all of its staff and officers were adequately trained. HMICFRS drew GMP’s attention to this shortcoming six months before the Attack. It was a significant failing on the part of GMP that so few of its officers who might be affected had any proper awareness of what an Operation Plato declaration would mean.

That should not have been the position. As HMICFRS acknowledged, unarmed officers will often form the initial response to a terrorist attack.489 If they are to work effectively as part of the response with the firearms officers, they need to understand what the plan involves and what it requires of them. That was not the position in GMP in 2017. It is clear from the evidence of Andrew Buchan that the issue also existed elsewhere.490

I recommend that CTPHQ and the College of Policing take steps to ensure that all firearms officers and frontline unarmed officers receive training in Operation Plato. Operation Plato now applies to all Marauding Terrorist Attacks and not just those involving firearms.

First aid training of unarmed officers

The events of 22nd May 2017 revealed that the first aid training of frontline unarmed GMP officers could and should be improved.

ACC Iain Raphael was Director for Operational Standards at the College of Policing.491 In evidence, he explained that all police officers serving within Home Office police services, including GMP, must complete the First Aid Learning Programme (FALP) training. This programme was generated by the College in accordance with the Police Service Quality Assurance scheme. It was endorsed by the National Police Chiefs’ Council and the Health and Safety Executive.492

The College sought to ensure that police services complied with the requirements of FALP by requiring each police service to carry out a self‑assessment against the guidance framework delivered by the College.493 I am concerned about the adequacy of this quality assurance process for a number of reasons.

First, a system based on self‑assessment is likely to be less robust than a system based on independent inspection, possibly substantially less so.

Second, at the time of the Attack, self‑assessments were required every 12 months. Now they are required only every 24 months.494 That seems to give rise to a much greater risk that a problem will go unaddressed for a lengthy period. It was clear to me that ACC Raphael saw the benefits in an annual process.495

Third, in the event that a police service is found to be in default of the requirements of FALP, the College of Policing has no ability to sanction, but instead is dependent upon achieving an outcome through persuasion.496

The training of frontline police officers in first aid is of the utmost importance. I recommend that the Home Office, together with the College of Policing, introduce a more regular and more robust system for ensuring that all police services meet the needs of their officers in first aid training.

The evidence revealed that GMP did not meet all of the FALP requirements for a prolonged period covering 2014 to 2020.497 At one stage it seemed to me that this might be a matter of considerable significance. However, it proved to be the case that, with the support of its clinical governance group, GMP had structured its training differently from the FALP model.498 GMP had drawn this to the attention of the College of Policing in 2014/15 but the College had not required GMP to do anything differently until 2020. When the issue was raised in 2020, GMP regularised the situation promptly.499 In the circumstances, I am satisfied that GMP had shown a commitment to training its frontline officers in first aid and that the failure to comply with FALP was technical in nature.

In my view, it was not GMP’s failure to comply strictly with FALP that created a problem on the night. Instead, the problem was with the FALP training itself. It did not equip unarmed officers with the skills they needed to deal with the severity of injuries they encountered within the City Room. They had received no training in life‑saving interventions, such as stopping catastrophic bleeding or opening an airway.500 The unarmed officers who bravely entered the City Room and did everything they could for the casualties found their lack of skill in this regard extremely frustrating.

In Part 13, I will deal with the experiences of those unarmed officers in greater detail. In Part 20 in Volume 2‑II, I will deal with the steps that I have been assured are being taken to ensure that all officers will receive training in life‑ saving interventions. I will emphasise at that stage that I regard it as vital that this be achieved as soon as is reasonably practicable.

If all officers are to be trained in life‑saving interventions, they need to be provided with the equipment necessary to make those interventions effective. So, if officers are to be trained in the application of tourniquets, they need to be provided with the tourniquets themselves. On the night of the Attack, they did not have such equipment. The unarmed officers of GMP were no better equipped to provide first aid than the officers of BTP.

Firearms officer training

The Policing Experts considered the training for GMP’s firearms officers as part of their review of the evidence. They noted that this training complied with the national requirements. The experts concluded that the GMP firearms officers were qualified and competent.501

I agree that these officers were qualified and competent for their important role of locating and neutralising a threat. Furthermore, as I shall explain in Part 13, the speed and efficiency with which they deployed on the night of the Attack were commendable.

There are, however, three areas in which the evidence gives rise to concerns about the training of GMP’s firearms officers. I am confident that these concerns are not unique to GMP but instead arise more widely across the country.

First, the principles of joint working were not sufficiently embedded within the firearms officers.502 On the night, none of them recognised the absence of GMFRS and the disadvantage this created for the rescue effort. Nor were the principles of zoning that are integral to Operation Plato sufficiently embedded in their response. None of them ever asked the FDO what zoning he had applied or gave him any advice in that regard. I have other connected concerns that I will examine in Part 13. None of this is a criticism of the firearms officers. It does, however, highlight a training need that CTPHQ and the College of Policing should address.

Second, the firearms officers had enhanced first aid training.503 There was a lack of understanding on their part of the need for them to provide life‑saving interventions while deployed in their firearms capacity. The officers rightly recognised that their primary duty was to locate and neutralise any threat but did not understand that, even during the course of doing so, it was their role to provide first responder interventions where possible.

As a result, despite their strong instinct to do so,504 the firearms officers who initially attended the Arena provided no treatment to any casualty. This does not apply only to those firearms officers who went to contain the City Room but also to the other firearms officers who attended the Victoria Exchange Complex and might have provided medical assistance within the City Room. Again, this is not a criticism of the individual officers but a criticism of the training regime.

Third, I was concerned that the procedure adopted following the Attack did not produce the most complete and accurate accounts of the firearms officers.

I will address each of these concerns further in Part 13, and in Parts 19 and 20 in Volume 2‑II.


Later in this Part, at paragraphs 12.733 to 12.899, I will deal with multi‑agency exercising. At this stage, it is sufficient to say that GMP was involved in over 100 exercises in the two years prior to the Attack.505

I am satisfied that GMP dedicated an appropriate level of resource, time and commitment to exercising.506 GMP’s failure in relation to exercising was in capturing and acting upon the learning points which arose. I will address this in the final section of this Part, at paragraphs 12.751 to 12.759.