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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)

North West Ambulance Service preparedness

Key findings

  • On the night of the Attack, North West Ambulance Service (NWAS) had two Hazardous Area Response Team (HART) crews on duty: one based in Greater Manchester and one covering Cheshire and Merseyside. The HART crews were specialists at working in dangerous areas, including Operation Plato warm zones.
  • The NWAS Major Incident Response Plan anticipated that the Operational Commander would co‑locate at a Forward Command Post with the Operational/ Bronze Commanders of other emergency services.
  • Some NWAS personnel used the terms ‘hot zone’, ‘warm zone’ and ‘cold zone’ to apply to Major Incidents in which Operation Plato had not been declared. This had the potential to cause confusion.
  • NWAS did not have an action card for the HART Team Leader. It should have done.
  • NWAS did not have a site‑specific plan for the Victoria Exchange Complex. It should have done.
  • At the time of the Attack, NWAS had a draft plan outlining which hospitals in the Greater Manchester area patients should be sent to in the event of a mass casualty incident.
  • Commanders on 22nd May 2017 were competent to perform the roles they had.
  • The Joint Emergency Services Interoperability Principles (JESIP) were not sufficiently embedded in NWAS frontline personnel.
  • NWAS did not have a sufficiently well‑developed relationship with Emergency Training UK.


The North West Ambulance Service (NWAS) NHS Trust is the statutory ambulance service with responsibility for the provision of ambulance services in North West England, covering Greater Manchester, Cheshire, Lancashire, Merseyside and Cumbria.

In the response to a Major Incident, NWAS has responsibility for all NHS responders, the command and control of all health assets, and the pre‑hospital management of casualties including treatment, triage and distribution to an appropriate hospital.

NHS ambulance services in the UK are required to comply with a comprehensive range of standards and national policies in respect of emergency preparedness.

Having considered the wide range of emergency plans and procedures that NWAS had in place, the Ambulance Service Experts considered that NWAS was compliant with the national standards for emergency preparedness at the time of the Attack.507 Support for this view is found in the conclusion of the Emergency Preparedness, Response and Resilience annual assurance process and verified through an NHS England sponsored audit.508

While I accept that NWAS met those national standards, I have concluded that there were areas where NWAS’s planning for an emergency could and should have been improved.

In this section, I shall set out NWAS’s control function arrangement, introduce its specialist personnel, consider its plans, look at its training, address the issue of equipment and summarise its approach to exercising.

NWAS Control

NWAS divided its control functions into different areas of responsibility. The Emergency Operations Centre was responsible for resource allocation. There was an Emergency Operations Centre control room which covered the Greater Manchester area.509 Each Emergency Operations Centre control room had a Duty Manager. The Duty Manager was expected to provide support to the Strategic and Tactical Commanders during a Major Incident in his or her area.510

Major Incident response was supported by the Area Operational Co‑ordination Centres, which could be activated on an area basis. The Regional Operational Co‑ordinating Centres provided regional overview of capacity and resources across NWAS. Hospital monitoring was achieved through the Regional Health Control Desk. The Trauma Cell offered access to senior medical advice to assist in pre‑hospital clinical decision‑making.511

I shall refer to these collectively as NWAS Control.

NWAS specialist personnel

I recognise that all personnel working for NWAS were specialist in their particular roles. In my Report, I use the term ‘specialist’ in a particular way. When applied to NWAS staff it is a reference to the following resources.

HART operatives were, as their name suggests, specialists in working in hazardous areas. In 2017, NWAS had two HART crews: one based in Greater Manchester (the GM HART crew) and one covering Cheshire and Merseyside (the C&M HART crew). HART operatives were issued with a range of personal protective equipment, including ballistic protection. HART operatives were expected to operate in an Operation Plato warm zone.

HART is considered to be a national NHS capability. This means that any ambulance service can call on the HART capability of a neighbouring ambulance service when required.

The range of hazardous areas in which HART operatives are trained to operate is set out in Table 3.

Core Capability Tactical Options Commissioning
Hazardous Area Response Teams
Hazardous Materials
  • Working inside the inner cordon
  • Industrial accidents
  • High-risk infectious diseases
  • Complex transportation accidents
Reference costs are set out in the National Standards produced by NARU.
Then commissioned locally via the Ambulance Service baseline funding mechanism.
Chemical Biological Radiological Nuclear Explosives
  • Specialist, inner cordon response to CBRN(e)/also a component part of the CBRN(e) capability
Marauding Terrorist Firearms Attack
  • Specialist support to the wider MTFA response/component part of the MTFA capability
Safe Working at Height
  • Man-made structures
  • Natural environment
Confined Space
  • Substantially enclosed spaces
  • Building collapses
  • Compromised atmospheres
  • Entrapments
Unstable Terrain
  • Active rubble piles
  • Rural access/difficult terrain
Water Operations
  • Swift water rescue
  • Urban and rural flooding
  • Boat operations
Support to Security Operations
  • Support to security operations
  • Support to police operations
  • Illicit drug laboratories
  • VIP close protection support
Table 3Hazardous Area Response Team capabilities512

NWAS’s response to a Marauding Terrorist Firearms Attack was via the Ambulance Intervention Team. This comprised members of HART, together with other personnel selected from NWAS’s wider operational staff.513

On the night of the Attack, NWAS had two HART crews on duty: the GM HART crew and the C&M HART crew. Each crew comprised a Team Leader and five HART operatives.

On the night of the Attack, HART was mobilised as part of NWAS’s response. Other elements of the Ambulance Intervention Team were not. I shall return to the issue of the Ambulance Intervention Team in Part 14.

Major Incident Response Plan

The document at the heart of NWAS’s preparation for an event such as the Attack was the Major Incident Response Plan. This comprised a 70‑page document, accompanied by 29 action cards.514 The front page of the Major Incident Response Plan stated: “The ACTION CARD section of this plan MUST be used during the response phase of a Major Incident.515

At the time of the Attack, version 5.0 of the Major Incident Response Plan was in force. This had been in effect since 18th October 2016.

The first two objectives of the Major Incident Response Plan were stated to be: “Ensure an effective and co-ordinated response to the incident”, and “Follow the Joint Emergency Services Interoperability Principles (JESIP) ideal of working together, saving lives, reducing harm.”516

The introduction continued: “The Plan may be exercised alongside site specific plans (e.g. stadia)…”.517 NWAS did not have a site‑specific plan for the Victoria Exchange Complex or the Arena.

Section 2 of the Major Incident Response Plan was entitled “Joint Emergency Services Interoperability Principles (JESIP)”.518 It set out a summary of the five principles for joint working.

Section 3 of the Major Incident Response Plan was entitled “Major Incident Plan Activation”. It defined a Major Incident. It set out four potential Major Incident messages. The first of these was: “Major Incident – Standby”.519 This alerts the NHS that a Major Incident may need to be declared. Advanced Paramedic Patrick Ennis used this message on the night of the Attack as he entered the Victoria Exchange Complex. The second Major Incident message was: “Major Incident – Declared”.520 Seconds after Patrick Ennis’s message, NWAS Control declared a Major Incident for NWAS.

It is of note that the Major Incident Response Plan had a section addressing a scenario in which NWAS was informed that another agency had declared a Major Incident.521 However, there was no corresponding section under the Major Incident heading stressing the importance of NWAS communicating its Major Incident declaration to other agencies. While this requirement did appear elsewhere, its absence at this point is a shortcoming in the Major Incident Response Plan which was mirrored by NWAS’s failure to inform other agencies of its Major Incident declaration following the Attack. NWAS did share its Major Incident declaration with all hospitals within the Greater Manchester network.522


CSCATTT stands for ‘Command and Control; Safety; Communication; Assessment; Triage; Treatment; Transport’. The Major Incident Response Plan explained:
“The CSCATTT model is the mainstay of the NHS Ambulance response to Major Incident Management and provides a structured approach to ensure NWAS and the NHS maintain an effective coordinated response. JESIP Principles for Joint Working must be reinforced throughout Command and Control process.”523

An illustration of the model and its relationship with JESIP was included in the Major Incident Response Plan and is reproduced in Figure 29.Figure 29: CSCATTT model and the JESIP five principles for joint working from the Joint Doctrine524


In relation to command, the Major Incident Response Plan used the terms Strategic, Tactical and Operational Commander. It stated that the Tactical Commander may also be known as the “Ambulance Incident Commander”.525

The Major Incident Response Plan made clear that each role carries the authority and that takes precedence over the rank of any individual. It also stated: “The individual must have completed NWAS Major Incident Command Training particular to the role allocated to them.526 I will return to this at paragraphs 12.471 to 12.474 when I consider the Operational Commander role on the night of the Attack.

The first paragraph for each explanation of the commander role stated that they “must” use their relevant action card during the management of the incident.527 This requirement was not observed by all NWAS commanders during their period of command. It should have been.

Under the heading “Operational Commander”, the Major Incident Response Plan stated:
“The Operational Commander works at an operational level, and has responsibility for the activities undertaken at the scene. As such, they will be located at the incident scene, ideally alongside the Operational Commanders of the other responding agencies at a Forward Command Post (FCP). Where this is not possible, the Operational Commander must ensure regular multi-agency face to face briefings take place.”528

The Major Incident Response Plan is not the only place that guidance is given about where Operational Commanders should locate themselves. NWAS’s ‘Incident Deployment Guidance Including On Call’ stated: “The Operational Commander will co-locate with all other agencies’ Operational Commanders to facilitate a safe and efficient multi-agency incident response.”529

Safety at a Major Incident was a subject in its own right within the Major Incident Response Plan. It stated: “The Operational Commander must appoint an appropriate person who ideally has the necessary training, experience and knowledge as the Ambulance Safety Officer early in the Command and Control set up to ensure that health, safety and welfare of all medical personnel are observed.”530 This important role was overlooked by the NWAS Operational Commander on the night of the Attack. I shall consider the potential impact of this failure in Part 14.

The Major Incident Response Plan stated: “Identification of an appropriate interoperability talk-group should be an early consideration for commanders at the scene of an incident.”531 The NWAS Operational Commander did not do this. No Operational/Bronze Commander from any of the emergency services did. As a result of this and the lack of physical co‑location, the Operational/Bronze Commanders did not speak to each other during the critical period of the response.


The Major Incident Response Plan explained that there are two types of triage: “triage sieve” and “triage sort”. These processes were sometimes referred to as “primary triage” and “secondary triage”.532 In my view, these latter terms make it clearer and I will use them unless I am quoting from documents in use at the time.

The process of primary triage was described in the Major Incident Response Plan. It is reproduced in Figure 30. The Major Incident Response Plan stated: “All casualties should be clearly labelled with a SMART Triage Tag including the deceased. Any casualty that is found without a label should be triaged immediately in order to ensure and confirm that a clinical assessment has taken place.533 Primary triage identified categories of casualty by reference to their level of injury.
Figure 30: Primary triage (also known as the “triage sieve”)534

Patrick Ennis, who carried out primary triage initially on 22nd May 2017, did not have his SMART Triage Tags with him when he entered the City Room.535 This had consequences for the casualties in the City Room, which I will set out in Part 14.

The categories of patients by injury level set out in primary triage were described by NARU as follows. P1 casualties require immediate life‑saving interventions. P2 casualties require surgical or other interventions within two to four hours. Treatment for P3 casualties can safely be delayed beyond four hours.536

There was a P4 category of “Expectant”. This relates to anyone who is expected to die. This categorisation was not used on the night of the Attack. It is reserved for occasions of limited medical resources. The Major Incident Response Plan stated that only the Forward Doctor could categorise people as P4.537

In relation to any person who has died, the Major Incident Response Plan provided the following guidance. First, it expected that a deceased person should be labelled as such with a SMART Triage Tag. Second, confirmation of death may only be carried out by a medical doctor. Third, the deceased person should not be moved during the triage process. Fourth, the deceased person should in general be left uncovered. However, where the deceased person is in public view, consideration should be given to covering the body in order to maintain patient dignity.538

The process of secondary triage (triage sort) is expected to take place in an area known as a Casualty Clearing Station. I shall explain what this is in paragraph 12.410. A scoring process made by reference to breathing, blood pressure and level of consciousness is undertaken at this stage. As much clinical information as possible should be recorded for each casualty.539

In Part 20 in Volume 2‑II, I will consider a proposal to replace the existing approach to triage with a new structure. As I make plain at that stage, the new structure seems to have significant advantages over the existing approach.

Structure at a scene

There may need to be a number of stages of casualty triage and treatment during a Major Incident. The stages, as depicted in the Major Incident Response Plan, are shown in Figure 31.
Figure 31Structure of a Major Incident540

The Casualty Clearing Station aims to provide a treatment place to stabilise a casualty with a view to getting them to a definitive point of care “as soon as possible”.541 Once it has been established, “all casualties must be directed/ transferred from the site or CCP [Casualty Collection Point] to the facility for further triage…”.542 On the night of the Attack, several casualties remained in the Casualty Clearing Station for over two hours.

The Major Incident Response Plan stated that “safety considerations such as the integrity of buildings or land, vehicular accessibility” 543 should be taken into account when selecting the location of a Casualty Clearing Station.

A Casualty Collection Point is not required at every Major Incident. The Major Incident Response Plan suggested that its use is “commonplace for any multi-casualty incident”.544 The Casualty Collection Point is “designed to provide basic care for life threatening injuries prior to a casualty being moved to the CCS [Casualty Clearing Station] or direct to hospitalEquipment to establish the CCP [Casualty Collection Point] is carried by the Hazardous Area Response Team.”545 It is of note that the Casualty Collection Point, when established, precedes the Casualty Clearing Station as a place for a patient to receive care.

One of the issues explored during the Inquiry was whether there should have been a Casualty Collection Point established between the City Room and the station concourse. This could only have been on the raised walkway. I am not persuaded this would have been the right choice. Given the width of the raised walkway, there would have been a risk that a bottleneck was created. In light of my findings about non‑specialist paramedics and the City Room, it was not necessary to establish a Casualty Collection Point on the raised walkway.

Zoning an incident

Inner and outer cordons

The Major Incident Response Plan identified one area of a scene as “the inner cordon”. It did not provide a definition of this area. It did display it pictorially, as reproduced in Figure 32.
Figure 32: Incident diagram546

The Major Incident Response Plan stated: “Within the inner cordon, treatment is aimed at preventing further deterioration of life-threatening injuries.”547 It went on to state:
“The purpose of a HART response is to provide life-saving medical care within the inner cordon at a range of emergency incidents … Responding within the inner cordon of a scene, particularly at a major, hazardous incident, requires different working practices, equipment and systems of work to a conventional ambulance response. HART personnel have a range of PPE [personal protective equipment] and clinical equipment suitable for use in these conditions, and the skills and knowledge necessary to operate safely within these environments.”548

It is clear that the Major Incident Response Plan envisaged HART operatives working within the inner cordon. The Major Incident Response Plan did not state that non‑specialist paramedics were prohibited from working in that area.

On the night of the Attack, the City Room was within the inner cordon.

Operational discretion and the inner cordon

An issue arose as to whether NWAS commanders had a discretion to deploy non‑specialist paramedics into the inner cordon. Daniel Smith, who was the Operational Commander on the night of the Attack, stated:
“Certainly part of the decision-making is we do not deploy into, whether you term it warm zone or inner cordon, we do not deploy non-HART operatives into that area.”549

Daniel Smith was asked if there was a discretion. He stated:
“[M]y view, my training at the time is that there was no discretion, that the policies and procedures were clear on that fact, that we do not deploy, we should not, we must not deploy into warm zones.” 550

The question referred to “inner cordons”. Daniel Smith’s answer referred to “warm zones”. I shall deal with the relationship between these terms in paragraphs 12.429 to 12.432.

Patrick Ennis was an Advanced Paramedic. He was the only non‑specialist paramedic to go into the City Room. In evidence, he stated: “I don’t believe it [is] an absolute rule. A risk assessment would need to be carried out and then a decision.”551 He stated it was a decision for the Operational Commander.552 He described the risk assessment as needing to be “quite … robust.553

Derek Poland was one of two on‑call Operational Commanders contacted on 22nd May 2017. He stated in evidence that it was necessary to be “careful who we deployed within” the inner cordon.554 Later in his evidence, he was asked about what the policy said about commander discretion in these circumstances. He replied:
“It doesn’t say he can and it doesn’t say he can’t … But what we are taught on our commander training is if you do go outside of policy, you’ve got to have a rationale for that, and also you need to have a robust plan to get yourself back into policy.”555

Lea Vaughan was one of the two HART operatives who entered the City Room during the critical period of the response. She stated in evidence: “I do believe there is discretion in the NWAS protocols.556

Stephen Hynes was Deputy Director of Operations for NWAS. He took over from Daniel Smith as Operational Commander on the night of the Attack. He was asked if there was discretion in relation to sending non‑specialist paramedics into an Operation Plato warm zone. He replied:
“I think this is where it’s critical for commanders to have that JESIP discussion around about risk and shared situational awareness. It’s a very dynamic – moving incident that we’re dealing with here. And that could lead to discretion, yes. But that needs to be done through a JESIP process.”557

I understood Stephen Hynes’ evidence to be that, through a JESIP‑based risk assessment, there was a discretion to send non‑specialist paramedics into both the inner cordon and an Operation Plato warm zone.

Neil Barnes was the Strategic Commander on the night of the Attack. His evidence was that there was a discretion to deploy non‑specialists into the inner cordon. He stated that there was an expectation that commanders would make decisions “based on the outcome of [the risk] assessment and the needs at the time”.558 His evidence was that the same approach applied to an Operation Plato warm zone.559

The Ambulance Service Experts’ evidence was that an Operational Commander has a discretion to send non‑specialist paramedics to work in the inner cordon following a risk assessment.560 In light of all the evidence I heard, I accept the Ambulance Service Experts’ evidence on this point: Daniel Smith did have a discretion to send non‑specialist paramedics to work in the City Room on the night of the Attack. In Part 14, I will look at his decision‑making around this issue.

I am not able to say whether Daniel Smith’s belief that there was no discretion was a misunderstanding by him of his training or a failure in the training with which he was provided.

Major Incident hot, warm and cold zones

The Major Incident Response Plan did not refer to the terms “hot zone”“warm zone” or “cold zone”. As I set out in Part 11, these were terms which were used in JOPs 3 in connection with a Marauding Terrorist Firearms Attack and Operation Plato. However, some NWAS staff were familiar with hot, warm and cold zones being used in connection with Major Incidents that did not involve terrorism or an Operation Plato declaration. The Ambulance Service Experts stated that it was “commonplace” for hot, warm and cold zones to be used during a non‑Operation Plato Major Incident.561

For convenience, I will refer to non‑Operation Plato zones as ‘Major Incident hot zone’, ‘Major Incident warm zone’ and ‘Major Incident cold zone’. This is intended to distinguish them from Operation Plato zoning. This should not be taken to imply that an Operation Plato declaration means that a Major Incident is not taking place.

Major Incident hot and warm zones equated to the inner cordon; a cold zone equated to the outer cordon.562 There was no equivalent to an Operation Plato hot zone under Major Incident zoning, as paramedics were never permitted to enter the Operation Plato hot zone.

The NARU NHS Service Specification 2016/17: Hazardous Area Response Teams (HART) described HART operatives providing “care within the inner cordon or ‘hot zone’ of incidents”.563 Hot zone in this context was a reference to a Major Incident hot zone.

Risk of misunderstanding in relation to hot and warm zones terminology

There was a risk of misunderstanding. Under no circumstances was any paramedic permitted to go into the Operation Plato hot zone.564 However, paramedics could operate within a Major Incident hot zone. If a paramedic were told that an area was a hot zone, but did not know that Operation Plato had been declared, that person might operate in an area in which it was extremely dangerous for them to work.

An Operation Plato warm zone was governed by JOPs 3. This was focused on the threat from firearms. It rightly drew attention to the need for ballistic protection.565 A Major Incident warm zone, like a Major Incident hot zone, was broader in terms of the risks it contemplated.

Operational discretion and Operation Plato warm zones

As I said above, Stephen Hynes and Neil Barnes both considered that non‑ specialist paramedics could, in certain circumstances, be permitted to work in an Operation Plato warm zone. The Ambulance Service Experts agreed.566

However, NWAS’s position in its closing submissions to me was that “there was no discretion for non-specialist paramedics to enter a [an Operation Plato] warm zone” under paragraph 4.16 of JOPs 3.567  In my view, paragraph 4.16 of JOPs 3 could have been better phrased for the reasons I gave in Part 11. However, I have concluded that there was discretion for NWAS commanders to deploy non‑specialist paramedics into an Operation Plato warm zone. The text of the part in bold in paragraph 4.16 refers to “[e]mergency personnel”568 not just police officers. In any event, JOPs 3 stated it was “guidance” and “not prescriptive”.569

The fact that the application of JOPs 3 permitted the deployment of non‑specialist paramedics into the Operation Plato warm zone is not the end of the matter. A close reading of the document is one thing; how it was being taught to commanders may be another.

As I set out above, Daniel Smith did not believe there was a discretion that permitted non‑specialists to be deployed into an Operation Plato warm zone. Derek Poland stated that only HART and the Ambulance Intervention Team could operate in an Operation Plato warm zone. He stated that all other resources were confined to the cold zone.570 In its closing submission to me, NWAS said that this was the correct interpretation of JOPs 3.571

I have looked beyond NWAS to see how JOPs 3 was viewed by GMFRS. Some GMFRS officers thought that only the Technical Response Unit and Specialist Response Team were permitted in an Operation Plato warm zone. These included Specialist Response Team operative and Watch Manager, Andrew Simister, and Station Manager Neil Gaskell.572 Station Manager Andrew Berry appeared to allow for the possibility of non‑specialist firefighters being deployed to an Operation Plato warm zone but described JOPs 3 as “quite rigid”.573 Group Manager Ben Levy, Group Manager John Fletcher and Assistant Chief Fire Officer David Keelan all stated that there may be circumstances in which operational discretion permitted an Incident Commander to deploy non‑specialist firefighters into an Operation Plato warm zone.574

GMFRS’s closing statement characterised its position in this way:
“Although said not to be prescriptive, their rigid creation of zones and the categorisation of who could be deployed in them the JOPs strongly discouraged the use of discretion.”575

Bearing in mind that GMFRS specialists trained with NWAS specialists, GMFRS’s view is relevant to consideration of NWAS’s understanding of the Operation Plato warm zone.

I am satisfied that, while the terms of JOPs 3 did not prohibit the deployment of non‑specialist paramedics into an Operation Plato warm zone, the way it was taught to NWAS personnel meant that there was a belief by some that it did. The consequence for some of those who held that belief was that they thought there was no discretion for an Operation Plato warm zone, but there was a discretion for a Major Incident warm zone. Daniel Smith was not in this category as his belief was there was no discretion in either case.

Zoning conclusions

All of this serves to underline why it is unsatisfactory to have in use the same words which mean different things depending on whether the person hearing them knows that Operation Plato has been declared. In the course of the response on 22nd May 2017, there was an occasion when this problem occurred. I shall deal with this in Parts 14 and 15.

Under the title of “Communication”, the Joint Doctrine had a section headed “Common terminology”. Within that section, it stated: “Using terminology that … means different things to different people … is a potential barrier to interoperability … Agreeing and using common terminology is a building block for interoperability.”576 I agree. It is important that steps are taken to address this situation, to ensure that definitions are agreed and the words mean only one thing.


The Major Incident Response Plan envisaged the possibility of an incident being divided into sectors. It stated:
“For complex incidents (e.g. rail crash) or multi-sited incidents (e.g. terrorist attack) the incident may be divided into sectors. This will require a separate Commander for each sector. These Commanders, e.g. Sector Commander 1, 2, etc would be subordinate to the Operational Commander managing the incident scene. Ultimately the Tactical Commander will determine the operational management structure dependent upon the scale or nature of the incident.”577

In relation to the role of Primary Triage Officer and the use of sectors, the Major Incident Response Plan stated:
“Dependent upon the nature of the incident and the area the incident covers, there may be the requirement to have multiple Primary Triage Officers, for example when an incident scene is ‘sectorised’.”578

The Ambulance Service Experts considered that the HART Team Leader should have been assigned the role of Sector Commander for the inner cordon. The inner cordon was the City Room.579 The Ambulance Service Experts also considered it would have been “preferable” if a Sector Commander had been provided for the P3 casualties on Station Approach around to Hunts Bank.580

Pre-determined attendance

There was no specific pre‑determined attendance for a Major Incident, such as the Attack, suggested in the Major Incident Response Plan. This would have been helpful and should be a consideration for future planning.581

It is not clear to me whether a pre‑determined attendance would have assisted in relation to non‑specialist paramedics on the night of the Attack. But a pre‑determined attendance on 22nd May 2017 for the specialist crews may have accelerated the mobilisation process of these assets, which are of critical importance in a Major Incident.582

Major Incident Response Plan action cards

The key roles at a Major Incident were introduced in the Major Incident Response Plan and cross‑referred to the action card for each key role.583 The Major Incident Response Plan described the action cards as “an integral part” of the plan.584

For its Major Incident Response Plan, NWAS had adopted the action cards drafted by NARU. They were consistent with the national standard and requirements at the time. They were fit for purpose.585

Action cards provided an important aide‑memoire, which ensured that key principles and actions were not forgotten in the stress of a mass casualty incident.586 The main issue with the action cards is that they were not used effectively on 22nd May 2017. As a result, not all necessary actions were undertaken. In Part 14, I will consider this in further detail.

There was one notable exception to the adopting of NARU action cards. NWAS had not adopted NARU’s action card for HART Team Leader.587 Simon Beswick, who took the role of Team Leader for the GM HART crew, had not received any specific training in this action card.588 When undertaking an exercise in 2016 as HART Team Leader, Simon Beswick did not refer to this action card.589

This was not Simon Beswick’s fault. NWAS had not adopted this action card by 22nd May 2017.590 There is no good reason for this. I will return to this action card and Simon Beswick’s activity in Part 14.

Site-specific plan

There was no site‑specific plan for the Victoria Exchange Complex or the Arena.591 There was only a “site information sheet” dated October 2011 for the Arena.592 Site‑specific plans can provide detailed information, including maps and building plans, which would have assisted command and control planning for establishing an FCP, locating exits, and considering appropriate locations for a Casualty Collection Point and a Casualty Clearing Station.593

Although not required by NHS England, site‑specific plans were not uncommon and NWAS itself had some. NWAS had not chosen to produce or share with another responder agency a plan for the Victoria Exchange Complex. It should have done. The Ambulance Service Experts informed me that site‑specific plans for high‑risk locations were “commonplace” in 2017. They considered that NWAS should have had such a plan for the Arena.594

A particular advantage for NWAS of a site‑specific plan would have been dialogue between NWAS and Emergency Training UK (ETUK) and discussion of how they would interact if there were an emergency at the Arena. The lack of interaction between NWAS and ETUK, particularly at command level, was a significant failure on the night of the Attack. I will consider the relationship between ETUK and NWAS further in paragraphs 12.502 to 12.505, and in Part 16.

NWAS should ensure there is an up‑to‑date site‑specific plan for all large, complex or high‑risk locations within its area. These plans should include a floorplan layout so that entrances and exits are marked. It should include relevant contact details for those in charge of the location.595

While it is open to any single agency to produce its own site‑specific plan, good practice would have been to ensure that there was a single multi‑agency plan specific to the Victoria Exchange Complex. Fault for the failure to produce or share in such a plan for the Arena does not lie exclusively with NWAS. This was a failure of all of the Category 1 responders in the Greater Manchester area. There was a failure to collaborate through GMRF. All site‑specific plans should be multi‑agency with contributions from all categories of responders.

Mass casualty plans

The ‘Greater Manchester Mass Casualty Plan’ (the GMRF mass casualty plan) was approved on 9th September 2013. It was a GMRF document.596 Responsibility for activating the GMRF mass casualty plan lay with the NWAS incident commander in conjunction with the on‑scene medical adviser.597 Once activated, the GMRF mass casualty plan set in train a multi‑agency response focused on saving and protecting life.598

The GMRF mass casualty plan was scheduled for review on 1st October 2015.599 This review had commenced, but had not concluded, by the time of the Attack.600 The GMRF mass casualty plan was not formally activated during the critical period of the emergency response.

Complementing the GMRF mass casualty plan was the ‘GM Framework for Patient Dispersal in a Mass Casualty Event’ and the ‘GM Casualty Capability Chart in a Mass Casualty Event’.601 These were in draft at the time of the Attack. The draft was dated 9th February 2017.

These documents set out the pre‑determined capability of hospitals across the Greater Manchester area and beyond in relation to P1 and P2 patients. A flow diagram was included which was designed to help in the allocation of P1 and P2 patients to hospital.602

Annemarie Rooney, the NWAS Tactical Commander on the night of the Attack, provided Daniel Smith with the numbers in the GM Casualty Capability Chart in a Mass Casualty Event at 23:41.603


The Major Incident Response Plan required all frontline ambulance personnel to undertake generic Major Incident training. Specific training is required at each level of command: strategic, tactical and operational.604

It was a legislative requirement and a mandatory element of NHS England’s 2015 Emergency Preparedness, Resilience and Response Framework that personnel receive regular training and exercising. There is specific training for specialist teams and commanders. Control staff must also undertake mandatory training in the operation of the medical priority dispatch system, which includes call handling, control procedures and incident response initiation.605

Commander training

NWAS commanders attended a variety of multi‑agency, single‑agency and health service focused development courses specific to their role.606 The Ambulance Service Experts found: “Based on the national standards and guidance in place at the time, the training programme provided to NWAS Commanders was adequate.”607

The Ambulance Service Experts noted: “At least two [NWAS] individuals took on Command roles outside of what would be considered normal for incidents of this type and magnitude.”608 This was a reference to the two people who undertook the Operational Commander role: Daniel Smith and Stephen Hynes. The Ambulance Service Experts developed this further when giving evidence. They stated that the NWAS command structure did not function appropriately on the night of the Attack. They stated this was illustrative of a broader problem with command in the ambulance service at that time.609

I consider further the decisions taken and the actions of each of the NWAS commanders in Part 14. At this stage, I shall deal with what command level they were trained for and the roles they played on the night of the Attack.

Each of the commanders on the night had received sufficient instruction in JESIP and Operation Plato based on national standards at the time.610 Those commanders were Daniel Smith, Annemarie Rooney, Neil Barnes and Stephen Hynes. The difficulty on the night of the Attack was putting that JESIP training into practice.

Daniel Smith was a qualified Tactical Commander. On the night of the Attack, he took on the role of Operational Commander for approximately an hour from 23:01. He undertook NWAS commander training in 2013 and 2014. The latter of these was titled “JESIP multi agency (Bronze Commander) training course”.611 He did annual commander refresher training with NWAS in August 2015 and February 2016. In May 2016, he completed the NARU Tactical Command course. He undertook the role of Operational Commander at four pre‑planned events in 2015 and 2016: two events in August 2015, one in February 2015 and one in August 2016.612

NWAS’s position was that, in May 2017, Daniel Smith was competent in the role of Operational Commander.613 The Ambulance Service Experts’ opinion was:
“… we deemed Mr Smith overall to have been competent. He was a qualified and experienced Tactical Commander, but it’s our experience that in practice, a Tactical Commander often retains sufficient knowledge and experience to also function at the operational command level.”614

Overall, I have concluded that Daniel Smith had been adequately trained to perform the Operational Commander role.615 Nevertheless, Daniel Smith made a number of errors on the night. There were deficiencies in his early decision‑ making in relation to risk assessment and deployment of paramedics to the City Room. He failed to appoint a Safety Officer or an Equipment Officer. He did not call up the mass casualty vehicle. He did not create an adequate plan in relation to the removal of casualties from the City Room.616

Daniel Smith was a Consultant Paramedic.617 This meant he had a very high level of clinical skills that he could contribute to the incident. Considering all the various factors, it may have been better for Derek Poland to act as the Operational Commander and for Daniel Smith to have been deployed in a clinical role. Daniel Smith could have been deployed forward into the City Room at an early stage or remained in the Casualty Clearing Station. Alternatively, he could have been designated as the Sector Commander of the City Room. These might have been a better use of his skills.

Annemarie Rooney was a qualified Tactical Commander. She took on the role of Tactical Commander on the night of the Attack. She had sufficient training and was competent to function at the tactical command level.618

Neil Barnes was a qualified Strategic Commander. He took on the role of Strategic Commander on the night of the Attack. He had sufficient annual training and was competent to function at the strategic command level.619

Stephen Hynes was a qualified Strategic Commander. When he arrived at the scene on the night of the Attack, Stephen Hynes took on the role of Operational Commander, taking over from Daniel Smith. The Ambulance Service Experts stated: “[I]t remains unclear whether Mr Hynes had sufficient up-to-date training and operational level knowledge, particularly of specialist capabilities, to operate at the Operational Commander level.” 620

Stephen Hynes believed that he had maintained sufficient operational‑level experience and competence to function in the operational command role.621 It was not clear to me why Stephen Hynes took over at this late stage of the operation. Equally, I do not think that his lack of qualification as an Operational Commander had a detrimental effect on the rescue attempt.

Stephen Hynes did not have an NWAS issue commander bag, without which he may not have been suitably equipped to take on the role.622

There will be circumstances in which it is appropriate for the Operational Commander to remain in place throughout an incident. There will also be circumstances in which it will be appropriate for an Operational Commander to be relieved. This needs to be set out in a policy. If it is not, then a policy should be drawn up. All commanders should be clear on when and how this will occur according to the policy. The handover should follow an established procedure. Training of commanders should include practising handing over and taking over command.

Frontline ambulance personnel training

The Ambulance Service Experts found that frontline NWAS ambulance personnel were adequately trained to the requisite standard at the time.623 I accept this evidence.

All frontline staff, specialist and non‑specialist, had to comply with annual mandatory training, which included Major Incident training. The Ambulance Service Experts found that the mandatory training was “sufficient to provide the basic preparations to carry out a range of functional roles at a major incident”.624 That does not mean that there were not areas where additional training would have been of benefit. The Ambulance Service Experts further noted that national standards have changed since the Attack. They require ambulance services to provide more comprehensive training.625

On 29th August 2017, a JESIP assurance visit stated that NWAS had “acceptable standards of preparedness”.626 I accept that there was official approval for the belief that JESIP was properly understood and being implemented by NWAS. However, what happened on 22nd May 2017 reveals that JESIP requirements had not been sufficiently embedded in NWAS personnel.


Significant supplies of NWAS medical equipment were ready and available for emergency mobilisation to support a mass casualty emergency at the time of the Attack.627 The equipment was available both in vehicles at the scene and held elsewhere ready for deployment.628 This equipment was not all deployed effectively, and there seems no good reason why it was not.629 I will address this further in Part 14.

NHS dressings packs, designed for use by first aiders, were held at Manchester Victoria Railway Station, and they were used on the night.630

Each of the ambulances at the scene carried a “‘scoop’ orthopaedic stretcher, advanced and basic life support equipment”.631 The evidence of the Ambulance Service Experts and NWAS was that ‘scoop’ stretchers were only suitable to be used by persons trained to use them. GMFRS personnel received training in a variety of forms of casualty extrication.632

In my view, in a situation where there were insufficient trained personnel in the City Room, the risk presented of untrained personnel using a ‘scoop’ stretcher needed to be balanced against the alternative use of improvised stretchers. Although I am not critical of those who used such stretchers as they were doing their best, these did not provide a safe way of transporting people down a flight of stairs. Supervision of the use of ‘scoop’ stretchers could have been provided by NWAS personnel in the City Room.

The HART vehicles also carried stretchers. These were also available for use but were not used on the night of the Attack.633

Bulk equipment was available on the National Capability Mass Casualty Equipment Vehicle. This vehicle was described in the Major Incident Response Plan as having enough equipment to provide emergency treatment to 100 casualties, either P1 or P2, and up to 250 P3 casualties. It carried mass oxygen delivery systems and a range of specialised drugs and equipment to be used by doctors if required.634 No consideration was given to deploying this vehicle on the night.635 It should have been.

There was also bulk equipment on the HART and other specialist vehicles. The Ambulance Service Experts described the “pre-distribution of equipment across the NWAS area” as significant and demonstrating a “high level of preparedness”.636

Each NWAS paramedic or responding clinician had access to advanced clinical equipment such as clinical response bags, defibrillator/monitors, and clinical ‘consumables’ on each attending ambulance and in the HART response bags.637

Analgesia and controlled drugs were available and could be accessed via the locked vehicle safes.638 Equipment was also available in “Commander Bags”.639


Specific requirements for training and exercising were contained in the 2015 NHS Emergency Preparedness, Resilience and Response Framework640 and NARU documents.

NWAS staff trained as a single agency and with other agencies on their response to a possible attack. This was done via participation in a wide range of exercises to validate and test plans. Between 31st March 2016 and 16th May 2017, NWAS participated in around 30 exercises. Of these, 23 involved Marauding Terrorist Firearms Attack scenarios.641

The Ambulance Service Experts commended NWAS’s “active participation in a number of large-scale multi-agency exercises in the two years prior to the Arena incident”.642

I accept that NWAS had put in place extensive single‑agency and multi‑agency training and exercising. The exception to this is that there had not been multi‑agency JESIP training for some time prior to the Attack. The events on the night demonstrated that it was needed. To take just one example at this stage, Patrick Ennis, who played a central role in the response, had not taken part in any multi‑agency exercising despite having worked for NWAS for over 11 years and, at the time of the Attack, being one of only three Advanced Paramedics in Greater Manchester.

The training and exercising generated the opportunity to learn lessons, but there was a significant failure to implement changes in accordance with those lessons.643 The failure to implement change in areas identified as needing improvement is not confined only to NWAS.

The Ambulance Service Experts stated: “A number of issues identified during exercises were not sufficiently addressed and subsequently reoccurred during the multi-agency response to the incident on the 22nd May 2017.”644 An example of this was a failure to appoint a Safety Officer in an exercise which occurred prior to May 2017, as was the case on the night of the Attack.

There had been a failure to learn and embed key lessons from exercises. This was most relevant in the areas of shared situational awareness, joint understanding of risk and co‑location.645

One further issue that emerged from the evidence was the limited extent to which non‑specialists were involved in multi‑agency exercises. This is something which I am told NWAS is considering how to improve.646 I encourage NWAS to address this area for improvement as soon as possible. It is essential that the way specialist and non‑specialist ambulance personnel work together and with the other agencies in a Major Incident is tested in multi‑agency exercises.

I will consider the question of multi‑agency exercising in further detail in a section at the conclusion of this Part, at paragraphs 12.733 to 12.899.

Relationship with Emergency Training UK and the Arena

NWAS attended multi‑agency group meetings at the invitation of SMG. These meetings were about forthcoming events.647 There does not appear to have been a well‑developed relationship between ETUK and NWAS about what healthcare provision could be provided and how liaison would take place in the event of a Major Incident.

While it was open to ETUK to initiate contact, had there been a multi‑agency plan of the premises, it is likely that some enquiry would have been made into the amount of healthcare provision that there was on the premises and where it was located. Some liaison could and should have taken place.

I deal with ETUK in greater detail in Part 16.

In Part 20 in Volume 2‑II, I will consider the proposal for the deployment of Ambulance Liaison Officers at some events.