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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)

British Transport Police response

Key findings

  • British Transport Police (BTP) frontline officers responded immediately to the explosion and reports of the explosion.
  • BTP declared a Major Incident at 22:39. BTP failed to pass on the Major Incident declaration to Greater Manchester Police (GMP), North West Fire Control or Greater Manchester Fire and Rescue Service.
  • A METHANE message was passed from the Victoria Exchange Complex to BTP Control between 22:58 and 23:03. It should have been provided sooner than it was.
  • The person who was identified by the Silver Commander to take up the Bronze Commander role agreed to act in that capacity at 23:15. He did not arrive at the Victoria Exchange Complex until after 01:00 on 23rd May 2017. This left BTP without a Bronze Commander until that time.
  • The Chief Inspector who arrived at the Victoria Exchange Complex before 00:00 on 23rd May 2017 did not view herself as the Bronze Commander and did not undertake key Joint Emergency Services Interoperability Principles (JESIP) actions.
  • The Silver Commander did not create a written tactical plan. He should have.
  • The Gold Commander had not read or received any training on the BTP Major Incident Manual.
  • The issue of whether BTP or GMP were the lead agency was not formally resolved until 01:16 on 23rd May 2017. This should have been resolved sooner than it was.


In Part 7 in Volume 1, I set out BTP’s approach to policing at the Victoria Exchange Complex. As I explained, because of the Ariana Grande concert, a number of BTP officers were assigned to police the Victoria Exchange Complex on 22nd May 2017. They comprised an experienced Police Constable, a Police Constable in her probationary period and two Police Community Support Officers. A third Police Community Support Officer, who was undergoing tutoring, attended because his tutor was one of the other Police Community Support Officers.

The experienced Police Constable had not arrived at the Victoria Exchange Complex by the time the explosion occurred.

In addition to those who had been assigned to police the Victoria Exchange Complex, BTP had other officers on duty in the Greater Manchester area that night.

BTP did not have a firearms capability in Greater Manchester in 2017. It had one explosives detection dog in the Greater Manchester area.

Officers at Victoria Exchange Complex

Figure 37 depicts the layout of the Victoria Exchange Complex. When the bomb exploded at 22:31, four BTP officers were standing at the War Memorial entrance to the station concourse: Police Constable (PC) Jessica Bullough, Police Community Support Officer (PCSO) Mark Renshaw, PCSO Lewis Brown and PCSO Jon Paul Morrey.1 Within seconds of hearing the explosion, they began to move in the direction of the City Room.2

Figure 37: The Victoria Exchange Complex3

At 22:32, PCSO Renshaw broadcast a radio message on an open BTP channel,4 stating: “We need more people at Victoria, we just had a loud bang.” 5 Seconds later, he was following PC Bullough into the City Room via the Fifty Pence staircase. In the same group were two TravelSafe Officers, Philip Clegg and Niall Pentony. Also with them was probationary PCSO Brown.6

When the explosion occurred, Sergeant David Cawley was a short distance from the Victoria Exchange Complex at the Peninsula Building, together with Sergeant Peter Wilcock.7 Sergeant Cawley heard the explosion and began running towards the Arena.8 At 22:33, he responded to PCSO Renshaw’s message by saying: “To officers at Victoria, give me a sitrep as soon as you can … I heard the bang, try and establish what it is as soon as you can.” 9 Within a minute, BTP Control received two important messages from PC Bullough. PC Bullough broadcast from inside the City Room: “It’s definitely a bomb, people injured, at least twenty casualties.” 10 She followed this up with: “[W]e are going to need ambulances as well, we have a female bleeding – much blood.11

At 22:34, BTP Control responded: “[W]e’re already calling ambo to get multiple ambulances en route, we’re also calling GMP.” 12

At this point, fewer than four minutes had passed since the explosion. The response from BTP had been exemplary. Junior officers had, without any delay, made their way to the seat of the explosion. They had communicated clearly and accurately what had happened, and they had identified the immediate need for ambulances.

BTP Control had responded by immediately trying to contact North West Ambulance Service (NWAS) and GMP. At the same time, BTP officers had mobilised in numbers and had begun to make their way to the Victoria Exchange Complex with the first vehicle arriving at 22:34.13

Realising that first aid equipment was needed, PCSO Renshaw and PCSO Brown left the City Room14 and retrieved first aid kits from the patrol car parked on Station Approach.15 At 22:37, as they were re‑entering the City Room with first aid kits,16 PCSO Renshaw broadcast to BTP Control: “In the box office, we need as much first aid as you can bring.” 17

PCSO Renshaw’s broadcast was followed up by PC Bullough, who was in the City Room at the time: “Ambulances need to get to the main … the main entrance because there’s loads of casualties.” 18 This was a request from a BTP officer at the scene for ambulances to come straight to the Victoria Exchange Complex. The first request from BTP Control to NWAS Control for ambulances to go to Victoria Exchange Complex was nearly 20 minutes later.19

By 22:38, there were nine BTP officers in the City Room or on the raised walkway. They were PC Bullough, PCSO Renshaw, PCSO Brown, PC Jane Bridgewater, PC Dale Edwards, PC Stephen Corke, PC Simon Trow, PC Matthew Martin and PC Carl Roach.20 Some had brought first aid bags with them.

At 22:39, PC Trow made a request for the “orange bags out [of] the van, all the first aid kits”. He went on to say, “we’ve got about 60 casualties”, and confirmed the location as being “the ticket office in the Arena, near where the McDonald’s used to be”.21

One minute later, Sergeant Neil Wildridge, who was in Liverpool,22 raised the issue of a Rendezvous Point (RVP): “Obviously … there’s going to be a lot of emergency vehicles turning up at that location, can we start looking for an RV[P] please and closing down the actual station for an inner cordon and an outer cordon.” 23 This was a timely intervention from Sergeant Wildridge.

Sergeant Cawley, who was at the Victoria Exchange Complex at this point, replied: “Re last broadcast, at the moment that is not possible because there’s multiple that we’re all treating.24 Sergeant Cawley was one of two supervisors present at the scene at this time. The other was Sergeant Wilcock, who entered via the Trinity Roller entrance at 22:40, a couple of seconds before Sergeant Cawley’s response.25

Sergeant Cawley was in a very difficult position. Quite naturally, he wanted to help those he had encountered who were injured and in distress. He had come across a badly injured casualty in the NCP car park.26 He had then run down the Trinity Way link tunnel to wait for an ambulance on Trinity Way.27 However, there was also a need for someone to take a step back and ensure that the incoming emergency services personnel knew where to go. This is an important part of bringing order to chaos.

Sergeant Cawley should not have dismissed the request for an RVP. Had he been too occupied to suggest one himself, he should either have not replied to Sergeant Wildridge’s request or he should have encouraged other officers on the scene to provide one. His training should have ensured that, even in the terrible circumstances he was facing, he kept in mind the importance of establishing a co‑ordinated and ordered response.

At 22:41, BTP Control called NWAS Control. I will address the contents of this call in greater detail in Part 14. In this call, BTP Control did not pass on to NWAS Control PC Bullough’s request at 22:37, from the scene, for all ambulances to come to “the main entrance”, which was a request for ambulances to come directly to the station entrance of the Victoria Exchange Complex.28 BTP should have passed this on in this call.

First officer at scene

BTP’s Major Incident Manual provided for the initial actions of the first officer on the scene. It stated: “The first officer at the scene must not become personally involved in the rescue work. The priorities must be to assess, inform, establish a Rendezvous Point (RVP) and maintain effective contact with FCR(L)or (B) [Force Control Room, London or Birmingham].” 29

It also set out the responsibilities of the first officer on scene. There was an expectation that this person would provide a formal report to BTP Control. Because it had not been updated to incorporate the Joint Emergency Services Interoperability Principles (JESIP), BTP’s Major Incident Manual set out the predecessor form of report to METHANE. I set out the parts of the METHANE message in Figure 23 in Part 11. There was an expectation that this person would also: declare a Major Incident if appropriate; complete a dynamic risk assessment; assume interim command until relieved by an officer of more senior rank; and establish a Forward Command Post (FCP).30

PC Bullough was the first officer on scene in the City Room.31 She did provide a number of reports to BTP Control on the situation she was facing. Other colleagues who were with her or were elsewhere in the Victoria Exchange Complex also made reports of what they could see.

None of those present at the Victoria Exchange Complex volunteered a METHANE message. None of those present relayed the result of a dynamic risk assessment to BTP Control. No command structure was established at the scene for the first 20 minutes.

None of the above occurred because no BTP officer took a step back for that purpose. At 23:03, Sergeant Cawley was asked by Inspector Benjamin Dawson “to take a step back and be my eyes and ears there and give me updates”.32 By this time, over 30 minutes had passed.

Sergeant Cawley spoke in evidence about the overwhelming situation he was facing. When asked why he had not sought out the GMP Operational/Bronze Commander, Inspector Michael Smith, he said: “Within the areas I was, there were still lots and lots of people and families and people seeking people and people wishing to speak to police officers, lots of external inputs, so basically under the pressure and the different inputs I was getting at the time, I didn’t think to do that.” 33 I have no doubt that many others felt similarly given the magnitude of the situation. I do not criticise Sergeant Cawley for this.

This gives rise to whether or not the Major Incident Manual’s expectation of the first officer at the scene was unrealistic. I do not think that it was. What Sergeant Cawley’s evidence demonstrates is the need for practical training. As Sergeant Cawley stated: “[R]eferring back to the e-learning we do, it’s quite clean and clinical and sterile and posed situations that there are solutions to.” 34 Real life is different.35 In Part 20 in Volume 2‑II, I will consider high‑fidelity training, which aims to address this difference.

The fact that none of the BTP officers undertook the responsibilities of first officer on the scene until Inspector Dawson insisted, reveals a significant training deficit that BTP needs to address.

On-scene command

During the ten minutes following the detonation, there were a number of messages over the BTP open radio channel to the effect that the City Room was the seat of the explosion. A significant number of junior BTP officers converged on the City Room. Someone needed to take charge of them. The obvious two people for this role were the two supervisors on site: Sergeant Cawley and Sergeant Wilcock.

The BTP junior officers in the City Room had to wait a further seven minutes, until GMP’s Inspector Smith entered via the raised walkway at 22:47, for there to be a command presence.36 Despite not having anyone to direct them during the first 17 minutes, the junior BTP officers in and around the City Room showed commendable initiative: responding to the sound of the explosion or a call for support; recognising the need for first aid kits and collecting them from vehicles; and providing what assistance they could to the casualties they encountered.

Also showing initiative in that time, PC Roach, recognising that Sergeant Cawley did not feel in a position to provide an RVP, at 22:44 nominated the Fishdock car park.37 This was in response to a repeated request by Sergeant Wildridge.38 Having nominated the Fishdock car park, PC Roach asked “[i]f we can get that checked as well just for secondary devices.” 39 He did this as part of “the natural course of procedure. You don’t assume anything.” 40

At 22:45, Sergeant Wildridge asked: “Who’s at the RV point as incident commander at the moment to book us all in …?”41 He did not receive a direct response to this enquiry. PC Roach did go to the RVP to check on who was there at 23:20. He found no one had attended it.42 When I address the response of the firearms officers, at paragraphs 13.274 to 13.335, I will deal with the contribution that PC Roach made to their actions. He made a positive contribution at an early stage of the response.

BTP’s policy on command requires a person to hold the rank of Inspector or above in order to be approved as a Bronze Commander. During the critical period of the response, BTP did not have anyone of Inspector rank present at the scene. Because it is a national police service, understandably it had far fewer Inspectors in the region than GMP.

This is something to which BTP needs to give careful consideration. It should not be the case that during a Major Incident there is any substantial period where there is no commander on scene to co‑ordinate the efforts of BTP with the other emergency services. While a Tactical/Silver Commander may be able to operate away from a scene, there needs to be someone with situational awareness, derived from being present on the incident ground, who is directly co‑ordinating the junior officers in the overall response.

Shortly after GMP’s Inspector Smith arrived in the City Room, at 22:49, he was joined by BTP Sergeant Wilcock.43 This meant that the junior BTP officers in the City Room now had a supervisor present.

I shall return to the issue of on‑scene command when considering the appointment of the Bronze Commander from paragraph 13.77.

Involvement with casualties

The BTP officers in the City Room, on the raised walkway and in the area of the NCP car park did what they could for those who had been directly affected by the explosion. I heard evidence of officers using defibrillators, performing CPR, applying dressings and, in one case, improvising tourniquets.44 Junior BTP officers worked well with others and did their best.

BTP officers were involved in the removal of casualties from the City Room using improvised stretchers. They also offered reassurance and what comfort they could.

We should be grateful to all the BTP officers who participated in this way. As I explained in Part 12, their first aid training was inadequate for the situation with which they were presented. Despite this, they showed great compassion, resourcefulness and resilience. In doing so, I have no doubt they made a positive difference to the effectiveness of the response.

Involvement with those who died

A number of BTP officers sought to give help to those who were dying or had died.

PC Bridgewater gave CPR to Alison Howe.45

PC Bullough can be seen on video footage standing over Marcin Klis.46 Sergeant John Whitaker was shown on video footage appearing to check Marcin Klis for a pulse.47 PC Corke also checked Marcin Klis for a pulse.48

PC Bridgewater49 and PC Trow50 both gave CPR to Elaine McIver.

Medic PC Ben Davidson assisted Georgina Callander.51

PC Bullough assisted Jane Tweddle.52 PC Corke covered Jane Tweddle when attempts at resuscitation were unsuccessful.53

PC Bullough assisted John Atkinson.54 PC Thomas Campbell applied a bandage to John Atkinson,55 as did PSCO Morrey.56 Detective Sergeant (DS) Christopher Broad also assisted John Atkinson.57 PC Corke, PC Mark Emberton, PC Bridgewater, PC Bullough, PC Edwards and PC Michelle Johnson were among those who helped with John Atkinson’s evacuation.58

PC Danielle Ayers gave CPR to Kelly Brewster.59 PC Edwards,60 PC Richard Melling,61 PC Lee Owen62 and PC Johnson also assisted Kelly Brewster.63 Later, PC Johnson64 and PC Corke65 covered Kelly Brewster.

PC Bullough assisted Michelle Kiss.66 PC Corke covered Michelle Kiss.67 PC Bullough assisted Philip Tron.68 PC Bullough believed that it was likely she also covered Philip Tron.69

Sergeant Wilcock asked off‑duty nurse Bethany Crook to assist Saffie‑Rose Roussos.70 Temporary Detective Constable (DC) Mark Haviland was involved in finding a makeshift stretcher for Saffie‑Rose Roussos.71 PC Trow helped carry Saffie‑Rose Roussos from the City Room to Trinity Way.72

PC Johnson helped to give CPR to Sorrell Leczkowski and later covered her.73

Sergeant Wilcock checked on Wendy Fawell following the explosion.74

Force Incident Manager

As more and more people from the emergency services became involved, and more information began to come in, the need for a commander increased. While the police officers could trust in their generic training and discipline, what was required was that the incident be gripped by someone. At 22:35, the Force Incident Manager, Inspector Dawson, appointed himself as incident commander.75 This was in accordance with the expectation for his role. Under the Major Incident Manual, the Force Incident Manager took the role of initial Silver Commander.76 I was impressed with the evidence Inspector Dawson gave. Although there were things he could have done better, he acted calmly and professionally in the early stages of the response.

At 22:39, within minutes of becoming the initial Silver Commander, Inspector Dawson had declared a Major Incident.77 This declaration was recorded on the BTP incident log. It was passed on to NWAS in a call which began at 22:41.78

It was not passed on to GMP or Greater Manchester Fire and Rescue Service (GMFRS). It should have been.

The most significant effect of this oversight was on GMP. GMP did not declare a Major Incident until 00:57 on 23rd May 2017. Had GMP been told that BTP had declared a Major Incident, it may be that this would have acted as a prompt to anyone at GMP who was notified of this fact. I will consider GMP’s approach to Major Incident declaration in the next section.

METHANE message

At 22:50, having requested a METHANE message on a number of occasions, Inspector Dawson broadcast over the radio: “All units on scene … is there someone who can … I can speak to … to obtain a METHANE report at this time?” 79 Sergeant Cawley replied saying he was available. Following some difficulty connecting on a different radio channel because it was “too busy”,80 Inspector Dawson decided that Sergeant Cawley should use his mobile phone. This was unsuccessful.81

At 22:57, seven minutes after Sergeant Cawley agreed to provide the METHANE message, he and Inspector Dawson were able to speak properly via a separate radio channel.82 Inspector Dawson began by saying: “All I need is somebody just to take a step back, give me a sitrep of everything that’s going on down there, that means I can help … It will help me co-ordinate … the support you get down there.” 83 He then asked for a METHANE message.

Sergeant Cawley asked to be talked through the categories of required information. Over the following four minutes, he provided the information Inspector Dawson needed. At the conclusion of the METHANE message, Inspector Dawson said: “[A]t the moment we’re just going to get as many ambulances and fire and all that to you as we can.” 84 The METHANE message was entered into BTP’s incident log by Inspector Dawson three minutes later, at 23:04.85 It was not passed on to any other emergency service. There was no concerted effort from BTP to get GMFRS to the scene. This was a failure by BTP.

The ‘H’ in METHANE stands for ‘Hazards’.86 Sergeant Cawley’s report for this entry, as recorded by Inspector Dawson on the BTP incident log, was: “None seen other than bomb. Lights and water on.” 87 Sergeant Cawley provided this information 30 minutes after the bomb had detonated. He did so having been at the Victoria Exchange Complex for 20 minutes. He had heard the detonation himself and had had access to the BTP radio traffic since the explosion. He had heard the reports from a number of colleagues within the City Room. He had been into the NCP car park, through the Trinity Way link tunnel, onto the station concourse and had spoken to GMP officers there.88

Sergeant Cawley was well placed to provide a reliable report of the identifiable hazards. His report was to the point. It was accurate.

As Sergeant Cawley was providing this information to Inspector Dawson, GMFRS was mustering at Philips Park Fire Station. They were doing so for two related reasons. First, because when he was initially told of the incident, Station Manager Andrew Berry, the GMFRS duty National Interagency Liaison Officer (NILO), considered it prudent to mobilise the GMFRS assets to what he regarded as a safe distance away. Second, because Station Manager Berry had not then managed to speak to the Force Duty Officer (FDO), whom he hoped would provide him with further information. Station Manager Berry intended to use that further information to review his initial decision.

If BTP had passed on Sergeant Cawley’s METHANE message to NWFC, it could have been relayed to Station Manager Berry. It could also have been provided to the two other GMFRS NILOs who were mobilised only minutes after Sergeant Cawley concluded his message. It was not passed on. It should have been. It was to be another 70 minutes before GMFRS considered it sufficiently safe to deploy firefighters to the scene.89

Before leaving the topic of METHANE messages, there is one more matter that merits comment. The second ’E’ in METHANE stands for ‘Emergency Services’. The prompt in Joint Doctrine: The Interoperability Framework (the Joint Doctrine) next to this entry was: “Which, and how many, emergency responder assets and personnel are required or are already on-scene?” 90 This part of the message requires two pieces of information: which responders are required; and which responders are present already.

Inspector Dawson’s entry on the log was: “LAS/LFB – GMP firearms on scene assisting.” 91 ‘LAS’ stands for the ‘London Ambulance Service’ and was intended to indicate the ambulance service. ‘LFB’ is an initialism for the London Fire Brigade and was intended to indicate the fire and rescue service. The London‑ centric references are unfortunate, but were unlikely to cause significant confusion on their own.

When the incident log entry is laid alongside the conversation with Sergeant Cawley,92 it is clear that Inspector Dawson was intending to indicate that the ambulance service and fire and rescue service were required; whereas GMP firearms officers were already present. This was not sufficiently clear from the log entry alone. The entry also failed to record the obvious, namely that BTP was present. Nor did it record that GMP unarmed officers were present. Inspector Dawson should have recorded both of these in his entry.

I did not receive any evidence that any person at BTP was misled by the ‘E’ entry in Inspector Dawson’s record of the METHANE message. As a result of this METHANE message not being relayed to partner agencies, no one at GMP, NWAS, NWFC or GMFRS could have been misled by it. But it is important in the future that any METHANE message should clearly record which services are required and which services are already present. Otherwise, there is a risk that it will be read that a Category 1 responder is present, when they are not.

Senior Duty Officer

The Senior Duty Officer served an important purpose supporting the Force Incident Manager when acting as incident commander. Inevitably, the Force Incident Manager will have a lot to do when in that role. This support can include: providing advice when needed; checking that important actions have not been overlooked; and contacting more senior members of BTP to ensure that they are aware of what is going on.93 All this allows the Force Incident Manager to focus on acting in a command capacity, knowing she or he has immediate access to support. It is a sensible approach to take.

The Senior Duty Officer role was relatively new at BTP at the time of the Attack. It had been introduced in 2015.94 It had not been incorporated into the Major Incident Manual.

On the night of the Attack, the Senior Duty Officer was Chief Inspector (CI) Antony Lodge. He struck me as being a thoughtful witness, who was candid about where improvements could be made. In a number of important respects, CI Lodge did not provide the support to Inspector Dawson that was required. He failed to identify that the Major Incident declaration was not shared with all emergency service partners. He did not take steps to ensure it was. He failed to identify that the METHANE message was not shared. He did not take steps to ensure it was. He did not prompt Inspector Dawson to appoint a commander on scene. He did not prompt Inspector Dawson to seek to contact the GMFRS or NWAS commanders.

CI Lodge attributed the above to the fact that JESIP was not embedded sufficiently well. He also stated in evidence that following an action card would have assisted him.95 I accept his assessment.

Silver command

I have addressed the actions of the initial Silver Commander, Inspector Dawson, above. He was relieved of this role at 23:34 by Chief Superintendent Allan Gregory, who became the Silver Commander at that point.96

Chief Superintendent Gregory was the divisional commander for C Division, within which the Victoria Exchange Complex was located.97 He was on call that night.98 At 22:44, he was telephoned by CI Lodge.99 He was in his hotel room in Birmingham, having concluded an Office of Rail and Road stakeholders’ event at the same venue.100

In the telephone call, Chief Superintendent Gregory was told that there had been an explosion at the Arena, that there were four reported fatalities and about 100 casualties.101 He made his way to Force Control Room Birmingham, which was approximately ten minutes from his hotel.102 At 23:05, he received a telephone call from Assistant Chief Constable (ACC) Robin Smith, the on‑call Gold Commander. At that point, he was within Force Control Room Birmingham.103 Chief Superintendent Gregory informed ACC Smith that he would be taking up the Silver Commander position. He confirmed to ACC Smith he was best placed to perform that role.104

I am not critical of Chief Superintendent Gregory for his decision to travel to Force Control Room Birmingham rather than the scene. At Force Control Room Birmingham, he was able to use the facilities available to him to participate in the command of the incident effectively.105 The alternatives available to him were to appoint someone else to act as Silver Commander or travel to the scene. Neither of these were better than the decision he made.

Appointment of Bronze Commander

At 23:08, Chief Superintendent Gregory tried to contact Superintendent Edward Wylie in order to appoint him as the Bronze Commander.106 Superintendent Wylie was the subdivisional commander for the Pennine subdivision. The Arena fell into this subdivision. Superintendent Wylie lived about 25 miles from Manchester.107 Superintendent Wylie did not answer the call, and Chief Superintendent Gregory left a message.108

Having been unsuccessful in his attempt to contact Superintendent Wylie, at 23:12 Chief Superintendent Gregory called Superintendent Kyle Gordon, whom he understood was the next most proximate Superintendent to the Arena. Chief Superintendent Gregory’s intention was to appoint Superintendent Gordon as the Bronze Commander.109

Chief Superintendent Gregory recognised: “[T]here was a need to move quickly to establish a command structure.” 110 He agreed that, if the Silver Commander does not travel to the scene, it is essential that there is a Bronze Commander at the scene at the earliest opportunity.111 He accepted that the first appointment does not necessarily need to be the perfect person, as they can always be relieved when a more appropriately qualified person arrives.112 I agree with these statements.

Chief Superintendent Gregory knew that Superintendent Gordon was in Blackpool.113 Blackpool is approximately 50 miles from the centre of Manchester. This was not a location that would result in Superintendent Gordon being able to be on scene quickly.114 Chief Superintendent Gregory should have considered appointing someone more junior than a Superintendent as Bronze Commander.115 He could then have mobilised Superintendent Gordon who could relieve that person when he arrived.

At the time of Chief Superintendent Gregory’s call, over 35 minutes had passed since the detonation. Chief Superintendent Gregory expected Superintendent Gordon’s journey to take him about an hour.116 This would mean that he would not arrive before 00:15.117 This was far too long a period for the junior BTP officers to be left without a Bronze Commander. In the event, Superintendent Gordon did not arrive until much later. I will consider this further at paragraphs 13.95 to 13.110.

Taking up the Silver Commander role

Having spoken to Superintendent Gordon, Chief Superintendent Gregory again spoke to ACC Smith.118 He also spoke to the Force Incident Manager, Inspector Dawson.119 At 23:34, BTP’s incident log records that Chief Superintendent Gregory became the Silver Commander, relieving Inspector Dawson.120 This was at the very end of what I have described as the critical period of the response.

It took Chief Superintendent Gregory over 30 minutes from his arrival at Force Control Room Birmingham to relieve Inspector Dawson. There were a number of tasks he undertook during this period as set out above. He also reviewed the incident log so as to familiarise himself with what was recorded there.

Silver command actions

According to the Major Incident Manual, as Silver Commander, Chief Superintendent Gregory was responsible for developing “a tactical plan in order to achieve the strategic intentions of the Gold Commander, to deliver the plan, review and amend as appropriate to the circumstances.121 The Major Incident Manual also stated: “Bronze Commanders must have a clear understanding of the Silver Commander’s tactical plan.” 122

Chief Superintendent Gregory did not write a tactical plan down or develop one. He took the view that a tactical plan would be developed after “the initial hours”.123 I accept that a lengthy document was not appropriate in the circumstances. I also accept the presence of GMP, the issue of which police service was the lead agency and communication difficulties made it difficult for one to be developed.

These were not good‑enough reasons for a tactical plan not to be developed by Chief Superintendent Gregory. He should have done so.124 He had sufficient time to do so before he formally took up the Silver Commander role. As it was, with no Bronze Commander on scene to implement the tactical plan until after 01:00, the absence of a tactical plan did not affect the operational decision‑ making of the Bronze Commander. However, the act of creating a plan may have caused Chief Superintendent Gregory to recognise the absence of an on‑scene commander to communicate it to. This, in turn, may have caused one to be appointed pending the arrival of Superintendent Gordon.

JESIP expected that different agencies’ commanders would communicate with each other. The Major Incident Manual required that the Silver Commander contact the Tactical/Silver Commanders from the other emergency services.125

Chief Superintendent Gregory did not speak to the GMP Tactical/Silver Commander at any point during that evening. He asked a member of BTP Control staff shortly before 00:00 on 23rd May 2017 to establish who the GMP Tactical/Silver Commander was and inform GMP that he wished to speak to that person. This did not result in any contact between the two commanders.126

At no stage during the evening did Chief Superintendent Gregory become aware that GMP had declared Operation Plato. The Operation Plato declaration by the GMP FDO at 22:47 signified that it was suspected that a Marauding Terrorist Firearms Attack was under way at the Victoria Exchange Complex. Had Chief Superintendent Gregory spoken to the GMP Tactical/Silver Commander, he may have been told of the declaration. I say ‘may’ because there is considerable uncertainty about this given that the GMP Tactical/Silver Commander did not tell the NWAS Tactical Commander about the Operation Plato declaration when they spoke in person at around 23:15.

Chief Superintendent Gregory’s message that he wanted to speak to the GMP Tactical/Silver Commander was not relayed using the police hailing talk group. This was a method of communication of which Chief Superintendent Gregory was only vaguely aware at the time of the Attack. He stated that he relied upon others in BTP Control to advise him in relation to such matters.127

The fact that BTP did not use all available communication routes was a significant part of the cause of BTP’s communication failures on the night of the Attack.

It was not the only reason for BTP’s communication failures. Chief Superintendent Gregory did not make any attempt to contact his counterpart at GMFRS.128 His sole focus was on contacting GMP. This was an unacceptable omission.129 Had Chief Superintendent Gregory made direct contact with his equivalent within GMFRS, he would have been able to share situational awareness that was capable of bringing GMFRS resources to the scene much sooner than they in fact arrived.

Similarly, Chief Superintendent Gregory did not make any attempt to contact the NWAS Tactical Commander. This was also an important task that he should have carried out. Given the time at which Chief Superintendent Gregory took up the Silver Commander position, this failure was not capable of making any difference to the treatment of casualties in the City Room.

In due course, at 00:40 on 23rd May 2017, Chief Superintendent Gregory directed that CI Susan Peters should attend GMP Headquarters (GMP HQ) to act in a liaison capacity.130 CI Peters was recorded as arriving at GMP HQ and being “imbedded in” the Silver Control Room at GMP HQ at 01:53.131

Bronze command

Superintendent Gordon

In the course of the conversation between Chief Superintendent Gregory and Superintendent Gordon at 23:12, there was no discussion of how long it would take for Superintendent Gordon to be in a position to be an effective Bronze Commander. They did not discuss how Superintendent Gordon was going to travel to the Arena. They did not discuss how long Superintendent Gordon thought it would take him to get there. They did not discuss how Superintendent Gordon would gain situational awareness as he travelled.132

It took Superintendent Gordon over two hours from first being notified that he was Bronze Commander to his arrival at the Victoria Exchange Complex.133 This was over twice as long as Chief Superintendent Gregory assumed it would take when he appointed him.

The principal explanation for the additional delay was that Superintendent Gordon did not have access to a vehicle. He had been notified of the incident at the Arena about 20 minutes before he spoke to Chief Superintendent Gregory.134 He booked himself a taxi to take him to Manchester.135 Superintendent Gordon then called Superintendent Wylie and left a voicemail message when he did not answer.136

When Chief Superintendent Gregory called, Superintendent Gordon was waiting for the taxi to arrive. Chief Superintendent Gregory did not recall this being mentioned in their call.137 Superintendent Gordon thought he had mentioned it, but deferred to Chief Superintendent Gregory’s recollection.138

A Bronze Commander using a taxi to travel from Blackpool to a Major Incident in Manchester is sufficiently striking for it to be likely to have been remembered by Chief Superintendent Gregory. Chief Superintendent Gregory told me he regarded the use of a taxi as not being acceptable in the circumstances.139 I accept his evidence, and Superintendent Gordon’s deference to it,140 that a taxi was not mentioned.

It was a significant oversight by Superintendent Gordon, accepted by him during his evidence, not to mention he was reliant on a taxi.141 That information was capable of influencing an important command decision by Chief Superintendent Gregory.142 The obvious disadvantages of travelling by taxi included: the wait time; the fact it could not travel on blue lights; the fact it did not have a police radio;143 and the fact it would be delayed at every checkpoint.144

After the call with Chief Superintendent Gregory, Superintendent Gordon tried to arrange transportation in a police car. He was unsuccessful in this.145 He had to wait a further 15 minutes for the taxi to arrive.146

Superintendent Gordon did not provide any update to anyone at BTP Control about the travel difficulties he was facing.147 He should have notified the Force Incident Manager, the Senior Duty Officer or Chief Superintendent Gregory of the delay he was experiencing.

Superintendent Gordon did not have access to a radio in the course of the journey.148 Consequently, his situational awareness was derived from email and telephone calls. This was not a satisfactory way for a person who was to take up Bronze command at a Major Incident to prepare themselves. One of the things Superintendent Gordon was able to do in the course of the taxi journey was approve a press release. He was not in an appropriate position to do so, as he accepted.149

At no point in the journey to Manchester did Superintendent Gordon speak to Chief Superintendent Gregory.150 He received an email from Chief Superintendent Gregory at 00:10 on 23rd May 2017 instructing him to “[t]ake command on scene initially”. In the same email, he was told that Chief Superintendent Gregory would “call GMP around command arrangements”.151

At 00:19 on 23rd May 2017, Superintendent Gordon emailed in reply to ask if he could get a briefing from someone. He indicated he was in a taxi about 20 minutes from the scene, subject to any diversions, and he wanted to arrive as “briefed as possible”.152 In fact, it was to take him another hour to reach the Victoria Exchange Complex. Chief Superintendent Gregory could not recall when he first read that email, but he did not reply until over an hour later.153 His reply, at 01:23, was that Superintendent Gordon should speak to CI Andrea Graham.154

Superintendent Gordon spoke to CI Graham shortly after he sent his email at 00:19.155 He received “a very quick situational update” from her. At the conclusion of the conversation, Superintendent Gordon believed that CI Graham was acting as the Bronze Commander.156 As I shall set out at paragraphs 13.111 to 13.120, CI Graham did not think she was acting as Bronze Commander.

In the course of the journey, Superintendent Gordon’s BTP‑issue BlackBerry device ran out of power. This caused him to lose access to a number of telephone numbers he had saved on it.157 This further compromised his ability to gain situational awareness. He was still able to use his personal mobile phone.158

Superintendent Gordon rightly accepted the Policing Experts’ opinion that: “There is little evidence that [he] was able to influence BTP actions or operational decisions during [his] journey.” 159

The advantages of Superintendent Gordon’s undoubted experience and seniority were significantly outweighed by the practical difficulties that confronted him. These disadvantages should have been raised by him to help Chief Superintendent Gregory’s decision‑making.

Superintendent Gordon did not ever take up the role of Bronze Commander in any meaningful sense. He arrived at the outer cordon at approximately 01:06 on 23rd May 2017160 and at the Victoria Exchange Complex at approximately 01:20.161 CI Graham conducted a briefing shortly after he arrived.162 He considered that he assumed the role of Bronze Commander after this briefing.163 At 01:57, he supplied a briefing to Chief Superintendent Gregory, who informed him that his role was to co‑ordinate BTP assistance of GMP at the scene.

Chief Inspector Graham

In May 2017, CI Graham was in charge of the Manchester area for BTP. She was a qualified public order Bronze Commander.164 At the time the Attack took place, she was not on duty or on call.

CI Graham learned of the Attack shortly after 23:00, after her husband saw it on the news.165 At 23:08, she called BTP Control, who informed her that it was a Major Incident. CI Graham informed BTP Control she would “get [herself] in”.166 She got ready and drove to the Peninsula Building, arriving at 23:38.167 She collected some equipment and went from there to the Victoria Exchange Complex.168 At 23:56, she was captured on the CCTV on the raised walkway.169 Very shortly before that image was taken, CI Graham spoke to Sergeant Cawley, who gave her a situation report.170

CI Graham viewed herself as becoming on‑scene commander at the point at which she arrived at the Victoria Exchange Complex.171 She stated that she did not view herself as relieving anyone of incident command.172

Shortly after her arrival, CI Graham spoke to CI Malcolm McKinnon. CI McKinnon was not at the scene. He had been given the role of “bronze resources” by Chief Superintendent Gregory. The contemporaneous record in the BTP incident log by CI McKinnon states that he informed CI Graham of “her role as Bronze Scene”.173 CI Graham does not recall being informed that she was Bronze Commander.174

Having heard CI Graham’s evidence on the point, I am satisfied that she did not finish that call understanding that she was the BTP Bronze Commander for the Victoria Exchange Complex.175 I am not able to say who, between CI Graham and CI McKinnon, is responsible for that communication breakdown.

The lack of clarity around whether or not CI Graham was the Bronze Commander for BTP was made worse by a telephone conversation between her and Chief Superintendent Gregory at 00:13 on 23rd May 2017.176 Chief Superintendent Gregory asked her to be his “eyes and ears” on the ground. He accepted he did not make clear in the conversation that he had appointed her the Bronze Commander pending Superintendent Gordon’s arrival.177

In the time between her arrival and Superintendent Gordon’s arrival, CI Graham spoke with GMP Inspector Smith, discussed cordons, discussed obtaining CCTV and offered resources to GMP.178 At 00:20 on 23rd May 2017, she liaised with the bomb disposal technicians from the Army.179 At 01:00, she spoke to the Ground Assigned Tactical Firearms Commander, GMP CI Mark Dexter.180 As set out above, she had also spoken to Sergeant Cawley, CI McKinnon, Superintendent Gordon, Chief Superintendent Gregory and other BTP officers at the scene.

CI Graham stated that she never saw herself as “Bronze Commander” at the scene. As I understood her evidence, CI Graham took issue with the title of Bronze Commander applying to her role. She went on to say that if she had seen herself as Bronze Commander, it would have made “no difference” to her actions.181 She accepted that JESIP did not work without an FCP,182 that she should have set one up183 and that there were “learning points in relation to liaison with commanders”.184

Through no fault of her own, having chosen to self‑deploy from her home, CI Graham arrived after the critical period of the response. Her arrival mitigated Superintendent Gordon’s absence. While she worked well with her colleagues from GMP, she did not have JESIP at the forefront of her decision‑making. Had she done so, she would have been more concerned about ensuring there was an FCP and speaking to the NWAS Operational Commander.

CI Graham focused her activity on the police response rather than the multi‑agency response. A Bronze Commander at a Major Incident had communication obligations with all other responder agencies.185 She was an ideal candidate to act as Bronze Commander. She should have been clearly instructed to act in that role. It was for the Silver Commander, Chief Superintendent Gregory, to make this clear to her. He failed to ensure this occurred.

Gold command

ACC Smith was the on‑call Chief Officer on the night of 22nd May 2017.186 He had joined BTP in September 2016 and was a qualified Gold Commander.187 Prior to the Attack, he had not read or received any training on BTP’s Major Incident Manual.188 This was an oversight on the part of BTP and ACC Smith.

At 22:56, ACC Smith received a telephone call from CI Lodge. He was at home in the south of England.189 At this point, ACC Smith became Gold Commander for BTP.190

ACC Smith spent the next hour making telephone calls, including to the Chief Constable of BTP, Chief Superintendent Gregory and the Senior Duty Officer.191 At no stage did he ask whether a tactical plan had been developed.192 This was something ACC Smith should have done as it was his responsibility under the Major Incident Manual as Gold Commander to “[r]atify and review” it.193

ACC Smith stated in evidence that he had assumed a tactical plan had been developed.194 He also stated, in contrast to Chief Superintendent Gregory’s evidence, that he would have expected it to have been developed within the first hour.195 ACC Smith’s failure to ratify the tactical plan meant that he did not discover that Chief Superintendent Gregory intended to leave its development until much later in the response.

ACC Smith was also informed that Superintendent Gordon would be attending in a command role. He was not told that it would take at least an hour for Superintendent Gordon to get to the Arena. Had he been, he would have asked if there were any alternatives. ACC Smith stated he did not believe it was essential that a person as senior as a Superintendent take the role at an early stage of the incident.196 I agree with ACC Smith’s view.

In the course of speaking to the Chief Constable of BTP at 23:17, ACC Smith was instructed to go to Manchester to attend the Strategic Co‑ordinating Group.197 At 23:31, CI Lodge made a record of the command structure, which ACC Smith had ratified: “From SDO [Senior Duty Officer] – for GSB [Gold – Silver – Bronze] command structure – Superintendent Gordon is Bronze, Chief Superintendent Gregory Silver, and ACC Smith Gold.” 198

At 00:37 on 23rd May 2017, ACC Smith was in a police vehicle being driven under blue lights to Manchester.199

Between 01:16 and 01:22 on 23rd May 2017, ACC Smith spoke to the GMP Strategic/Gold Commander, ACC Deborah Ford. He was told that the station was a ‘warm zone’. He was not told that Operation Plato had been declared.200 In the course of the conversation, the two Strategic/Gold Commanders spoke about which agency was the lead agency. ACC Ford confirmed that GMP was taking the lead. ACC Smith agreed.201 Agreement at this stage was too late to make any meaningful difference to the response. The issue of which police service was the lead agency should have been resolved sooner than this.

ACC Smith arrived at GMP HQ shortly before 04:00 on 23rd May 2017. At 04:15, he attended the Strategic Co‑ordinating Group.202

At no stage did ACC Smith try to contact the Strategic/Gold Commanders of NWAS or GMFRS before he arrived in Manchester. This, as ACC Smith rightly accepted, meant that he did not put himself in a position where he could tell those other responder agencies that there were many BTP officers working in the City Room.203

ACC Smith’s lack of communication with NWAS and GMFRS mirrored that of Inspector Dawson, CI Lodge, Chief Superintendent Gregory and, once she was on scene, CI Graham. The only external agency any of them sought to deal with at a command level during the critical period of response was GMP. In CI Graham’s case, her involvement came after this period, but what had gone before was consistent with her approach.

The fact that this was a consistent approach across all levels of command leads me to conclude that there was a major failure by BTP to train its commanders in the importance of joint working with all emergency service partners. This was a systemic issue. I do not criticise the individuals involved. The consequence of this major failure by BTP was that NWAS and GMFRS were denied important situational awareness.

Finally, ACC Smith helpfully provided constructive remarks at the conclusion of his evidence. First, he suggested that contact details for on‑duty and on‑call commanders in an emergency responders’ app would speed up communication. This would require co‑operation at a national level. Nevertheless, it seemed to me to be an idea worth exploring.

I recommend the Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College consider together whether this may have value.

Second, as an officer who had come to BTP from a Home Office police service, he was initially “quizzical” of the Senior Duty Officer role. Having seen it in action, ACC Smith was strongly supportive of it.204 This accords with my view.


BTP officers made an important and positive contribution to the emergency response. The first officers to enter the City Room after the explosion showed particular courage. Better training would have enhanced the contribution the frontline officers could have made.

The BTP command structure should have been better than it was. Having a Bronze Commander on scene as early as possible and playing an active role in accordance with JESIP is the best way to ensure BTP makes the most effective contribution it can to a multi‑agency emergency response. It is important that BTP gives careful thought to how this can be improved in the future.