Greater Manchester Police response

Introduction

In Part 12, I identified failures by GMP in planning, including in planning for the consequences of a declaration of Operation Plato. On the night of the Attack, those failures had consequences.

Force Duty Officer

First reports

Within a minute of the detonation of the bomb in the City Room, GMP was informed that there had been an explosion at the Arena. At 22:31:52, a member of the public named Ronald Blake made a 999 call.²⁰⁵ The very first thing he said was: “There’s been an explosion at Manchester Arena.” ²⁰⁶ He went on to clarify that this had happened in “the foyer where the entrance is … near where MacDonald’s [sic] used to be.” ²⁰⁷ He explained that there were “loads injured … 30 or 40 injured”.²⁰⁸

When he made this call, Ronald Blake was with John Atkinson. He stayed with John Atkinson for nearly an hour, applying a makeshift tourniquet to his right leg and reassuring him, before then helping to carry John Atkinson down to the Casualty Clearing Station. Ronald Blake did all of this while himself injured.²⁰⁹ In the course of the evidence, John Atkinson’s family praised Ronald Blake for his humanity.²¹⁰ I agree. Also, his 999 call was clear, prompt and helped the emergency response overall.

While Ronald Blake was still on the line, GMP began to receive many other 999 calls. Overwhelmingly, those calls reported an explosion. Often the callers accurately stated that a bomb had detonated. There were also, however, a small number of references in the calls to shooting or gunshots, including in the second 999 call that was received by GMP. That second call commenced at 22:32:40,²¹¹ and the caller said: “I’m at the MEN²¹² Arena in Manchester. There’s been gunshots and explosion … There’s loads of people bleeding. There’s been gunshots and explosion.” ²¹³

Inspector Dale Sexton was the FDO for GMP on the night of the Attack. He was based in GMP Control along with the Force Duty Supervisor and other members of control room staff. The Force Duty Supervisor was Ian Randall, an experienced civilian employee with the title Police Support Staff Supervisor. His job was to support the FDO, supervising the rest of the staff in GMP Control and providing a link between the FDO and the rest of GMP and outside agencies.

Inspector Sexton came on duty at 21:00 on 22^nd May 2017.²¹⁴ As the FDO, it was his role to oversee and manage the response of GMP to incidents as they occurred across the service. To that end, he had authority to activate, deploy and command the different resources available to GMP. That included deploying GMP’s armed policing capability in his role as the Initial Tactical Firearms Commander.

As I explained in Part 12, Inspector Sexton had received the conventional FDO training in 2014 along with regular refresher training for his role as an Initial Tactical Firearms Commander. In the period between 2014 and 2017, he worked regularly as the FDO.²¹⁵ I accept that by the night of the Attack, Inspector Sexton was experienced and competent in that role, although as I have already set out, FDOs require greater and more specific training in the response to an Operation Plato situation.

In the early stages after the detonation on 22^nd May 2017, each of the many 999 calls received by GMP was recorded on its own incident log. Each log was given a unique number known as a ‘Force Wide Incident Number’. At 22:34:00, a master incident log was created, and information was transferred to that from the individual incident logs.²¹⁶ That was a sensible step that enabled all relevant information to be seen in one place.

The master incident log records that, at 22:34:09, just over three minutes after the explosion, the call was “switched to FDO FDS [Force Duty Supervisor]”.²¹⁷ Inspector Sexton explained that this means the call handler has sent the information via a ’switch system’ to the FDO’s screen. This was the point at which the FDO and the Force Duty Supervisor became aware of what had happened at the Arena.²¹⁸ This was also the point at which Inspector Sexton took command of the incident,²¹⁹ including command of the initial firearms response in his role as the Initial Tactical Firearms Commander.²²⁰ All this happened just three minutes after the explosion.

Inspector Sexton began to deploy firearms officers to the Arena immediately.²²¹ He did so by radio. His instruction directed these officers to travel to the Arena, but the deployment itself did not permit the firearms officers to utilise their firearms. Firearms officers may only use their firearms when granted Firearms Authority by a firearms commander or where they judge there to be an imminent threat to life.²²²

Inspector Sexton did not immediately grant Firearms Authority. He was ensuring that firearms officers were in position if needed, while giving himself time to assess the situation. This was a sensible approach. It meant that firearms officers arrived at the Arena very quickly and in numbers. Inspector Sexton’s approach ensured that, if there were a credible firearms threat at the Arena, there were officers there ready to engage with and neutralise the threat.

PC Edward Richardson was one of the firearms officers who heard the FDO’s instruction for all Armed Response Vehicles to go to the Arena. On hearing the instruction, PC Richardson travelled immediately to that location. He was to become the Operational Firearms Commander. I will consider his actions in the Operational Firearms Commander role in due course.

By 22:39, eight minutes after the explosion, PC Richardson had arrived on Trinity Way.²²³ He had spoken to members of the public who reported that fireworks had gone off. He gained the impression that what was being reported was a false alarm.²²⁴ At 22:39:30, PC Richardson communicated that impression over the radio to the FDO.²²⁵ News of a ’false alarm’ was a relief for Inspector Sexton,²²⁶ but only momentarily so.

At 22:41, one of the other firearms officers who had arrived at the scene, PC Lee Moore, transmitted the following message to the FDO: “Boss. It’s become a different story now … they’ve got major casualties.” ²²⁷ PC Moore also mentioned Operation Plato. From that information, Inspector Sexton understood that PC Moore thought officers at the scene were dealing with a Marauding Terrorist Firearms Attack.²²⁸

As he transmitted this message, PC Moore was still outside the railway station. While there, having just arrived and seeking situational awareness, PC Moore spoke to PC Roach, a BTP officer. PC Roach had already been into the City Room before leaving in order to obtain medical supplies.²²⁹ PC Roach had firsthand knowledge of the position there. The information that PC Moore provided to Inspector Sexton was based on what he had been told by PC Roach, who, at the time, had situational awareness.

At 22:42:44, CCTV captured the first two GMP officers present within the Arena. They were two firearms officers, PC Troy Tyldesley and PC James Dalton. They had entered via the lower Trinity Way doors.²³⁰

By this stage, Inspector Sexton had authorised an Emergency Search.²³¹ A number of witnesses explained that an Emergency Search is a high‑level, dynamic tactic. It would be inappropriate to explain that tactic in detail here. In simple terms, however, it involves firearms officers locating, confronting and neutralising a threat, typically a firearms threat. To that end, Inspector Sexton had also granted Firearms Authority two minutes earlier.²³² These were the right decisions by Inspector Sexton and were made at the right time.

At 22:42:52, eight seconds after PC Tyldesley and PC Dalton were seen inside the Arena, PC Moore and his colleague PC James Simpkin entered Manchester Victoria Railway Station through the War Memorial entrance. They ran alongside PC Roach.²³³ The three ran up the steps leading to the raised walkway. At 22:43:05, as they did so, PC Moore passed a message to the FDO over the radio, stating: “[T]hey’ve got major casualties in the MEN and they believe it’s a ball bearing device … Boss, I can confirm there’s definitely casualties … Operation Plato, Operation Plato.” ²³⁴

PC Moore performed his duties with distinction that night. In evidence, he was asked why he had referred to Operation Plato in the radio messages he transmitted to the FDO. He confirmed that he had received information that shootings had taken place. PC Moore considered that the situation was one in which Operation Plato ought to be declared. This was what he sought to pass on to the FDO.²³⁵ He was successful in that aim because that is what Inspector Sexton understood PC Moore to be communicating.²³⁶

At 22:44, the Force Duty Supervisor, Ian Randall, made contact with Temporary CI Rachel Buckle, the duty cadre Tactical Firearms Commander. He told her that the FDO, whom he described as “mad busy”,²³⁷ had asked him to contact her. Temporary CI Buckle said that she would make her way “in”.²³⁸ I will consider her role in due course.

Firearms officers continued to arrive at the Victoria Exchange Complex in numbers throughout this period. That is what Inspector Sexton wanted to achieve. This was a part of the emergency response that worked well. Had there been an armed terrorist present at the Victoria Exchange Complex, I have little doubt that person would have been swiftly located and neutralised.

At 22:44, GMP Inspector Michael Smith arrived in a patrol vehicle on Station Approach.²³⁹ He was to become the Operational/Bronze Commander in respect of the unarmed officers in the City Room. A striking feature of the events that night was that Inspector Sexton did not speak to Inspector Smith at any point.²⁴⁰ That the FDO never spoke to the Operational/Bronze Commander is a clear indication that not only did multi‑agency communication fail on the night of the Attack, but communication within GMP was also inadequate.

As I set out in Part 12, the refreshed CTPHQ Operation Plato guidance of March 2017 acknowledged that the dynamic and demanding nature of an Operation Plato incident would make it difficult to keep a written command log. It was recommended that police services therefore consider the introduction of audio‑recording devices for commanders, particularly the Initial Tactical Firearms Commander, in the police control room.²⁴¹ This was a sensible recommendation that I will consider further in Part 19 in Volume 2‑II.

There were Dictaphone recordings available to the Inquiry from two GMP commanders that night: Inspector Sexton and CI Dexter. Those recordings made a significant contribution to the Inquiry’s understanding of the emergency response to the Attack. In a Major Incident, emergency service commanders should use audio‑recording, or where appropriate video‑recording, devices to record their decisions and their rationales. On the face of it, this should be universal at any Major Incident. I recommend the Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College take steps to achieve this.

About four weeks before the Attack, no doubt in response to the CTPHQ advice, GMP had provided a Dictaphone for use by its FDOs. At 22:46, Inspector Sexton switched on that device.²⁴²

I have listened to the whole of the recording from Inspector Sexton’s Dictaphone. It lasts for just under 2 hours and 50 minutes in total. During Inspector Sexton’s evidence, the first 1 hour and 32 minutes of the recording was played. This covered the period from the declaration of Operation Plato up until Superintendent Craig Thompson took over from Inspector Sexton as Tactical Firearms Commander.²⁴³

In the recording, Inspector Sexton gave the time at which he was relieved of the Initial Tactical Firearms Commander role as 00:15 on 23^rd May 2017, when in fact this occurred at 00:18.²⁴⁴ By then, Inspector Sexton had been Initial Tactical Firearms Commander for a period of 1 hour and 44 minutes: 22:34 to 00:18. I consider that to have been far too long. This is an issue to which I will return in paragraph 13.239.

Declaration of Operation Plato

Inspector Sexton declared Operation Plato at 22:47. This was almost the first thing that was recorded on the Dictaphone:
“Yeah in view of that obviously er my first call was for OP Plato, that’s what we’ve got declaring OP Plato in relation to a report that we now have confirmation of a male who would appear to have strapped a device to his er body and er detonated it inside the arena causing multiple victims and injuries. Erm update when you’re (background noise) when you’re able to get inside to give me any er fatalities etc. Err but obviously we’re not we err expect that there’s anyone else involved. At this moment in time I can’t negate that it erm that it was a lone actor on this one.” ²⁴⁵

Operation Plato has been the agreed national identifier for the multi‑agency response to a Marauding Terrorist Firearms Attack since 2012. The original Association of Chief Police Officers (Terrorism and Allied Matters) (ACPO (TAM)) guidance and the CTPHQ March 2017 refreshed guidance made clear that the focus of Operation Plato was on a firearms attack.²⁴⁶

It is now well known that the Attack did not involve the use of firearms. In fact, the FDO was not confronted with a Mumbai‑style attack, but he was not to know that at the time of his declaration. I have explained what a Mumbai‑style attack is in Part 12.

I am not critical of Inspector Sexton for his declaration of Operation Plato or for the timing of that declaration.

Many FDOs in May 2017 would have been concerned that the detonation in the City Room might mark the start of a multi‑site, multi‑method terrorist attack. For several years, the strong focus within counter‑terrorism policing had been on countering a Mumbai‑style attack. Furthermore, the attack in Paris in November 2015 inevitably reinforced that focus. Inspector Sexton said in evidence that, when he declared Operation Plato, he had in mind the Paris attacks.²⁴⁷

In the Paris attacks, there had been explosions outside the Stade de France followed by gun attacks in busy restaurant and café areas and then a mass shooting at the Bataclan Theatre.²⁴⁸ I accept that Inspector Sexton had these events in mind when he declared Operation Plato and that it was sensible for him to do so.

In the period after the explosion in the City Room, some reports of gunshots and shooting were received by GMP. I referred to the 999 calls at paragraphs 13.139 to 13.141. At 22:43, the incident log records that there was a person with a “gunshot wound to the leg” at the entrance to the railway station.²⁴⁹ Inspector Sexton understood that this report had been made by an experienced firearms officer and it therefore carried weight with him.²⁵⁰

While these references to gunshots and shooting were not frequent in the reports that were being made, it is understandable that they provided support for the FDO’s view that a Mumbai‑style attack might be under way.

I am supported in my view that the decision to declare Operation Plato at 22:47 was a reasonable one by the opinion of the Policing Experts. They consider the declaration was appropriate in the circumstances that then existed.²⁵¹

Other experienced and knowledgeable witnesses held the same view. In particular, CI Richard Thomas, the Head of Specialist and Counter‑Terrorism Armed Policing at CTPHQ, made clear that the approach of CTPHQ was that if there was any doubt about whether a Marauding Terrorist Firearms Attack was under way, Operation Plato should be declared.²⁵² In my view, that is a sensible approach. It is clear, however, that any declaration must be kept under close review.

As for the timing of the declaration of Operation Plato by Inspector Sexton, it is possible to argue that the declaration could have been given earlier in view of the stage at which gunshots were first mentioned in a 999 call. It is also possible to argue that the declaration could have been delayed until firearms officers had provided a detailed situation report.

Both arguments were explored in the course of the evidence, and both arguments are credible. However, in my view, Inspector Sexton took an appropriate amount of time to assess the situation, having deployed firearms officers to the scene immediately. The timing of his declaration was reasonable in the circumstances, even if some FDOs might have declared it earlier and some later, and perhaps some not at all.

Declaration of a Major Incident

GMP’s Major Incident Plan had been in place for several years and had been updated in March 2017.²⁵³ It defined a Major Incident as “[a]n event or situation, with a range of serious consequences, which requires special arrangements to be implemented by one or more emergency responder agencies.” ²⁵⁴

At no stage that night did Inspector Sexton declare a Major Incident. In evidence, he said that he did not consider it necessary to do so because he thought, “[I]t was obvious what people were dealing with.” ²⁵⁵ In reality, I consider it likely that Inspector Sexton, in the highly pressured situation in which he found himself, simply overlooked the need to declare a Major Incident. I will consider the issue of the burden on the FDO in greater detail at paragraphs 13.236 to 13.255.

Whatever the reason for Inspector Sexton’s failure to declare a Major Incident, I regard it as a serious omission.

There is no doubt that the Attack constituted a Major Incident as defined by the GMP Major Incident Plan. Inspector Sexton even referred to it as a Major Incident in a call he made to a Derbyshire Police officer at 23:04. He stated: “Yeah we have got a major incident. It’s been confirmed it’s a terrorist attack.” ²⁵⁶

The Policing Experts explained that a Major Incident should have been declared as soon as the scale of the casualties was known and therefore before the declaration of Operation Plato.²⁵⁷ It is clear that other senior officers who came into the command structure at a later stage share that view.

Superintendent Thompson, who became the Tactical Firearms Commander, said that the delay in the declaration of a Major Incident was a mistake.²⁵⁸ Temporary Superintendent Christopher Hill, to whom silver command was transferred from Temporary Superintendent Arif Nawaz shortly after 00:00 on 23^rd May 2017, agreed. Shortly before 01:00, Temporary Superintendent Hill realised that a Major Incident had not been declared: “I just literally thought crikey no one’s declared a Major Incident yet, so I’m going to declare a Major Incident.” ²⁵⁹ It was clear from the evidence that both of these senior officers considered that a Major Incident should have been declared very much earlier.

I have no doubt that Inspector Sexton should have declared a Major Incident within a few minutes at most of first becoming aware of the events at the Arena at 22:34.

I disagree with Inspector Sexton’s expressed view that such a declaration at an early stage would not have been meaningful.²⁶⁰ I consider that an early declaration should have resulted in the implementation of the GMP Major Incident Plan. The Policing Experts note that this would have brought an automatic FCP and RVP structure into effect; it would have mobilised specialist assets and equipment. As the Policing Experts explained: “[I]t would have mobilised the force around consequence management rather than focussing exclusively on the believed continued threat.” ²⁶¹ Both Temporary Superintendent Hill²⁶² and Superintendent Thompson²⁶³ considered that an early declaration of a Major Incident by GMP would have made a real difference.

An early declaration of a Major Incident and the implementation of the GMP Major Incident Plan would have encouraged and enhanced a JESIP approach. Such an approach was lacking on the night. It would also have given greater clarity in relation to roles within the command structure. It would therefore have had real value.

It was not until 00:57, nearly two and a half hours after the explosion, that GMP declared a Major Incident.²⁶⁴ As I have explained, that declaration was made by Temporary Superintendent Hill. He did the right thing and took action as soon as he was aware that a declaration had not already been made. However, by then, the opportunity for that declaration to make a difference to the emergency response was long gone.

While the failure to declare a Major Incident was principally Inspector Sexton’s, others also bear some responsibility. In particular, neither Temporary Superintendent Nawaz in his role as Tactical/Silver Commander nor ACC Ford in her role as Strategic/Gold Commander declared a Major Incident. Each of them should have done so.

Communication of Operation Plato declaration

As I have explained, in May 2017, Operation Plato was the national identifier for the multi‑agency response to a Marauding Terrorist Firearms Attack. The term ‘Operation Plato’ had been adopted not only by the police, but also the ambulance service, the fire and rescue service, the military whose assets might be deployed in support of the response, the NHS, and local and central government departments.²⁶⁵ The expectation was that these bodies would all work together to achieve the best response possible in the event of a Marauding Terrorist Firearms Attack. This is at the heart of JESIP.

For Operation Plato to work, it is vital that all emergency services are informed promptly that an Operation Plato declaration has been made. Otherwise, no joint approach is possible, and JESIP will be compromised and may fail altogether. The imperative for sharing information is reflected in the national guidance.

The ACPO (TAM) guidance stated: “It is important that the FCR Inspector ensures that the other emergency response agencies are informed immediately once a declaration has been made, as this will also trigger a pre-defined response by those organisations.” ²⁶⁶ Within GMP, the “FCR” (Force Control Room) Inspector was the FDO.

The CTPHQ guidance of March 2017 stated:
“The declaration of an Operation PLATO incident triggers a multi-agency response designed to rapidly inform, mobilise and operationally deploy the most appropriate resources in order to identify, locate, confront and neutralise the threat and save life. In order to support an effective response, it is important that the relevant partner agencies and specialist national assets are informed as a priority.” ²⁶⁷

This guidance made clear that the responsibility for sharing this critical information rested with the FDO in their role as Initial Tactical Firearms Commander:
“When the Initial TFC identifies and declares an Operation PLATO incident they will be responsible for notifying their local Ambulance and FRS [fire and rescue service] control rooms as soon as possible. This will assist with the activation of contingency plans and also assist in minimising the risk to emergency service responders who may not be aware that an MTFA [Marauding Terrorist Firearms Attack] is occurring in their area.”²⁶⁸

I recognise that the 2017 guidance was introduced only shortly before the Attack, and training had not been given on it within GMP by 22^nd May 2017. This makes no difference, however, to the point under consideration, as no matter which national guidance was applied, it remained the job of the FDO to notify emergency service partners of the Operation Plato declaration. Under each plan, only the police could declare Operation Plato, so only they could communicate its declaration.

As for the GMP Operation Plato plans, there was confusion about which policy was applicable on 22^nd May 2017. That is a situation I criticised in Part 12. That confusion should not have happened and should never be allowed to happen again. The various policies were, however, consistent about the need for the FDO to alert emergency service colleagues to a declaration of Operation Plato.

Standard Operating Procedure (SOP) 47 v.5 provided that the duties of the FDO included to “inform emergency service partners once ‘Operation PLATO’ has been declared to enable Emergency Service contingency plans to be put into effect”.²⁶⁹

As I explained in Part 12, the Whittle Plan stated that the duties of the FDO included contacting the control rooms of GMFRS and NWAS and declaring Operation Plato, then establishing three‑way communications and providing a METHANE message.²⁷⁰

Whether the national plan or the GMP plan was applied, the burden remained with the FDO to notify NWAS and GMFRS of the declaration of Operation Plato and to do so promptly. This was a fundamental responsibility of the FDO.

Inspector Sexton described a situation in which 1,500 GMP policies and plans were applicable, or potentially applicable, to the work of the FDO. It was impossible, he explained, for an FDO to gain ready access to any particular plan at short notice. That included the Operation Plato plan.²⁷¹ I dealt with this and set out my criticisms of GMP’s approach to planning in the years leading up to the Attack in Part 12.

Recognising this proliferation of plans and the particular demands that a declaration of Operation Plato would place upon the FDO, Inspector Sexton had prepared what he described as an “aide-memoire” ²⁷² for a Marauding Terrorist Firearms Attack.²⁷³ He had first prepared this in January 2016.²⁷⁴ On 6^th June 2016, Inspector Sexton updated his aide‑memoire in light of learning from Exercise Winchester Accord and circulated it to his FDO colleagues.²⁷⁵

Inspector Sexton’s aide‑memoire recognised the need to ensure that the emergency service partners of GMP were informed in the event that Operation Plato was declared.²⁷⁶

In evidence, Inspector Sexton acknowledged that his aide‑memoire included early communication, by the FDO, of the Operation Plato declaration, followed by co‑location of the emergency service commanders at an FCP, to enable effective co‑ordination of the multi‑agency response in accordance with JESIP.²⁷⁷

Inspector Sexton was undoubtedly under a duty that night to notify the ambulance service and the fire and rescue service that he had declared Operation Plato, and he was under a duty to do so promptly. Both the national and GMP materials made that clear. Inspector Sexton’s aide‑memoire document also acknowledged that. Prior to the Attack, he was well aware of what his responsibility was. An indication of the pressure he was under that night is that it did not come to his mind during the response.

Shortly after 22:47, when he had declared Operation Plato, Inspector Sexton should have informed NWAS and GMFRS that he had done so.

On 22^nd May 2017, Inspector Sexton did not communicate his declaration of Operation Plato to NWAS or GMFRS either promptly or at all. That was a significant failure by him that had major consequences to which I shall turn.

This failure by Inspector Sexton gives rise to the question of why he failed to do something so fundamental to the response to a perceived Marauding Terrorist Firearms Attack and which was required by the national and regional Operation Plato plans and recognised in his own aide‑memoire document.

Inspector Sexton’s failure to communicate the Operation Plato declaration

Inspector Sexton gave evidence for two and a half days.²⁷⁸ From start to finish, he maintained that he had made a decision, on the night of the Attack, not to communicate his declaration of Operation Plato to the ambulance service and the fire and rescue service. He explained that he regarded the City Room as a ‘hot zone’ and he feared that, if he communicated the declaration, those who were in that location and tending to the injured would be withdrawn.²⁷⁹

In his first witness statement dated 6^th December 2019, provided before he gave evidence, Inspector Sexton said:
“I knew I had a number of armed officers at the scene. I believed they would be in a position to afford a level of protection against any possible firearms attack, therefore, I took a calculated risk to leave vulnerable unarmed people at the scene to treat and evacuate the casualties.”²⁸⁰

In evidence to me, Inspector Sexton confirmed that this represented his reasoning at the time.²⁸¹ He maintained that he had a recollection of having these thoughts as the situation unfolded on the night. He was asked on a number of occasions by Counsel to the Inquiry and various other advocates to consider whether the burden of the role and/or the burden of the occasion meant that, in fact, he had simply overlooked the need to communicate his declaration of Operation Plato. He insisted this was not so and that, instead, he had made a positive decision to conceal the declaration from GMP’s emergency service partners.²⁸²

In my view, a series of factors point away from the conclusion that Inspector Sexton made a deliberate decision to conceal his declaration of Operation Plato in this way.

First, many people within GMP knew that Inspector Sexton had declared Operation Plato. He did not tell anyone to keep that information to themselves.²⁸³ So, any one of them might, for all he knew, have disclosed the declaration to a representative of the ambulance service or the fire and rescue service.

Inspector Sexton broadcast a message on the firearms radio channel at 22:47 making clear that he had declared Operation Plato. It follows that all firearms officers will have known this had been done. Many of those firearms officers were at the Arena and could have told the paramedics there that Operation Plato had been declared.

Some of those working within GMP Control heard Inspector Sexton’s broadcast over the firearms channel. Certainly, the Force Duty Supervisor knew that Operation Plato had been declared. At 22:49, Inspector Sexton’s Dictaphone recording captures Ian Randall on the telephone referring to Operation Plato.²⁸⁴ In fact, this call was to the GMP Force Press Officer, Ben Ashworth.²⁸⁵ David Myerscough, who was in due course given the responsibility of answering the FDO telephone, also knew. He was also captured on the Dictaphone recording making reference to Operation Plato.²⁸⁶

The fact that Operation Plato had been declared was also recorded on the GMP master incident log at 22:47. That meant that anyone within GMP Control, or GMP more widely, who accessed the log would have known that Operation Plato had been declared, even if they did not hear the radio message.²⁸⁷ For all Inspector Sexton knew, the Force Duty Supervisor or any GMP Control Room Operator could have disclosed the declaration of Operation Plato to anyone from the ambulance service, the fire and rescue service or NWFC.

At 22:51, Inspector Sexton informed Temporary Superintendent Nawaz, the Night Silver, of the declaration of Operation Plato.²⁸⁸ At about 23:08, Inspector Sexton spoke to Inspector Darren Meeks of the North West Counter Terrorist Unit about the declaration, after leaving him a voicemail message to the same effect a few moments earlier.²⁸⁹ The Dictaphone recording shows that Inspector Sexton also told others within GMP that he had declared Operation Plato and did not ask or direct them not to disclose it further.²⁹⁰ Any of these people could have passed this information on to a colleague within the other emergency services.

If Inspector Sexton really intended to keep the fact of the declaration of Operation Plato a secret, it is incomprehensible that he did not, at any stage, even hint to those whom he had told that they should keep the declaration to themselves. That he did not do so points away from Inspector Sexton having made a positive decision at the time to conceal his declaration of Operation Plato from emergency service partners.

Second, the word “Plato” is heard 23 times in the Dictaphone recording. On 17 of those occasions, the speaker is Inspector Sexton.²⁹¹ There is not the slightest hint in any of those references that Inspector Sexton wished, at the time, to conceal the Operation Plato declaration from the wider emergency service community.

Third, Inspector Sexton knew that the purpose of the Dictaphone was to record his decision‑making.²⁹² He did not record on the Dictaphone or anywhere else at the time that he had made a decision to conceal the fact that he had declared Operation Plato.²⁹³

Fourth, the job of the Force Duty Supervisor is to provide support to the FDO. Inspector Sexton explained of the Force Duty Supervisor: “They are a very good source of support and they’re very knowledgeable about the mechanics of the room.” ²⁹⁴ He said that he had worked with Ian Randall many times and regarded him as “very capable”.²⁹⁵

I am satisfied, having heard from both Inspector Sexton and Ian Randall, that if Inspector Sexton had really been considering concealing his Operation Plato declaration, he would have discussed that with the Force Duty Supervisor. He did not do so. It is striking that at no stage that night did Inspector Sexton discuss or even mention to anyone the crucially important decision he claims to have made. That is a feature that speaks powerfully against his account to the Inquiry.

Fifth, the Dictaphone recording captures a short conversation between Inspector Sexton and Ian Randall at about 23:09. Inspector Sexton asked the Force Duty Supervisor “who have we spoken to now, everyone pretty much?”²⁹⁶ The recording indicates that this is the genuine query of an FDO who wishes to make sure he has alerted those who need to be aware of what is going on. As I have made clear, the Force Duty Supervisor had not been told that the declaration of Operation Plato was a secret. Asking him whether anyone else needed to be contacted carried the obvious risk that he would refer to the need to communicate the declaration of Operation Plato to emergency service partners. That Inspector Sexton asked the question provides an indication that he was not seeking to conceal the declaration from NWAS or GMFRS. In fact, the Force Duty Supervisor did not refer to the need to communicate on the declaration. That was pure chance and does not undermine this reasoning.

Sixth, subsequent to 22^nd May 2017, Inspector Sexton gave accounts of the events that night that are inconsistent with his account to the Inquiry.

On 26^th July 2017, Inspector Sexton took part in a structured debrief on behalf of GMP.²⁹⁷ He was Participant 6.²⁹⁸ He recorded:
“There was an inordinate amount of work for the Force Duty Officer to complete including a large number of people to contact. This proved almost impossible to do while completing all other tasks around the incident … It was difficult to speak to other Emergency Services due to the multi Airwave channel not working.”²⁹⁹

During the debrief process, Inspector Sexton did not suggest that he had made a deliberate decision to conceal the fact of the declaration of Operation Plato. On the contrary, he sought to justify the failure to communicate the declaration to GMP’s emergency service partners by reference to other factors, including the burden upon him as FDO.³⁰⁰

Operation Manteline was the Counter Terrorism Policing investigation into the Attack. In common with other officers and police staff, Inspector Sexton completed a questionnaire on 27^th July 2017, as part of that investigation.³⁰¹ In that questionnaire, he stated:
“I declared Op Plato some 20 mins from being made aware of the incident. However, due to demand on the FDO role and limited experienced Comms Operators I was unable to make contact with North West Ambulance and Greater Manchester Fire and Rescue Service.”³⁰²

Inspector Sexton did not state that he had made a deliberate decision to conceal the declaration of Operation Plato. On the contrary, once more, he sought to justify the failure to communicate the declaration to GMP’s emergency service partners by reference to other factors, including the burden upon him as FDO.

Inspector Sexton was interviewed on 10^th January 2018 as part of Lord Kerslake’s independent review of the preparedness for and emergency response to the Attack.³⁰³ Inspector Sexton explained what he had done on becoming aware of the Attack. He went on to say:
“I was satisfied that because I knew what services were at the scene, that certainly the key ones for NWAS, being the medical side, they knew exactly what was going on. I was satisfied with that. They knew it was an Op Plato. They were still happy to leave their staff in that zone. The police on the ground knew exactly what was going on. The fire service will have known from their communication, because obviously our divisional staff kept on making contact with the fire service, certainly in the early stages to let them know what was developing. And then, if I’m honest, as things developed, I totally forgot about the other services. I knew that actually Silver would put a foot on the ball and start, you know, really giving that clear picture, and certainly the forward command post, once [CI] Mark Dexter was on the ground, would have been able to do that. So, I wasn’t really that concerned about it, while I’m still dealing with this ongoing threat.” ³⁰⁴

Accordingly, Inspector Sexton was saying that NWAS knew that Operation Plato had been declared. That is incorrect. He was also saying that he had forgotten about the other emergency services. There is not the slightest suggestion that he had made a deliberate decision to conceal the declaration. Indeed, he was saying something quite different in the Kerslake process from what he said when he gave evidence to the Inquiry.

When pressed in evidence, Inspector Sexton had no convincing explanation for why he had given these accounts if in truth he had made a deliberate decision at the time to conceal the declaration, as opposed to simply overlooking the duty upon him to communicate.³⁰⁵

In all of these circumstances, I am satisfied that Inspector Sexton did not make a decision on the night to conceal the fact that he had declared Operation Plato from GMP’s emergency service partners.

That conclusion gives rise to two questions: first, what is the true explanation for the failure of Inspector Sexton to communicate the declaration to GMP’s emergency service partners; and second, how has Inspector Sexton come to give seriously inaccurate evidence to the Inquiry on an issue of the utmost importance?

As for the first of these questions, I consider that Inspector Sexton was overburdened on the night. He simply had too much to do. He overlooked the requirement to contact NWAS and GMFRS, just as he overlooked the need to declare a Major Incident. No one reminded him that he should do so. No one else within GMP Control had the responsibility allocated to them for making the necessary communication or for reminding the FDO to do so. Inspector Sexton was the single point of failure and, under severe individual pressure, he failed that night.

As for the second of these questions, towards the very end of his evidence, Inspector Sexton said:
“… it would have been easier for me to come here and say the demands and pressures that were placed on me by GMP and the role meant that, yes, I forgot about it. And my evidence, I’m sure, would have been a lot shorter if that was the case, but that’s not how it happened.” ³⁰⁶

There is some force in Inspector Sexton’s claim that it would have been easier for him to blame the burden he was undoubtedly under for his failure to communicate on the Operation Plato declaration. In one sense, therefore, the position he adopted with the Inquiry was contrary to his interests.

Inspector Sexton gave evidence over the course of about 17 hours. Ultimately, I was left with the impression of a man who believed what he was saying. I consider it a realistic possibility that over time he has persuaded himself that he cannot have overlooked something as fundamental as communicating on his declaration of Operation Plato, but must instead have made a decision to conceal that fact.

I do not consider that I can safely conclude that Inspector Sexton set out to lie to the Inquiry. However, as I have made plain, I am satisfied that his evidence about the reason for his failure to communicate the declaration of Operation Plato to GMP’s emergency service partners was incorrect.

Burden on Force Duty Officer

The Policing Experts expressed the following view, with which I agree:
“The activation of a regional Operation Plato response required the immediate completion of multiple different actions; the FDO completed many of them personally. He was quickly overwhelmed by the volume of Operation Plato related operational notifications, which was in addition to his command of the terrorist attack, of the Operation Plato armed response and to his remaining responsibilities as the force’s FDO. His role became untenable. To be clear this was not, in our view, a case of an inexperienced or incapable officer being faced with a situation beyond his capability. Insp Sexton was very capable, experienced, well trained and knowledgeable.”³⁰⁷

I will not attempt to describe every aspect of the burden that was placed upon Inspector Sexton that night, but it is relevant to note the following six factors.

First, firearms officers from GMP, and a number of officers from other police services, deployed into Greater Manchester on the night of the Attack. Many went to the Arena, but others went to different locations, such as Manchester Piccadilly Railway Station and the Royal Oldham Hospital.³⁰⁸ The firearms operation was a substantial one.

Inspector Sexton became responsible for that operation as Initial Tactical Firearms Commander at 22:34. He retained that responsibility until relieved by Superintendent Thompson at 00:18.³⁰⁹ Later in this Part, at paragraphs 13.518 to 13.519, I will consider the decision‑making that led to that situation. The result was that Inspector Sexton had the responsibility for tactical firearms command for far too long. In my view, this played a material part in the unacceptable burden that was imposed upon him that night.

Second, the role of the Force Duty Supervisor is vital in an Operation Plato situation. Inspector Sexton had an expert and experienced Force Duty Supervisor in Ian Randall. Inspector Sexton made a decision that Ian Randall should leave GMP Control at about 23:20 to travel to GMP HQ to set up the Silver Control Room.³¹⁰ That was a mistake.

The officer who replaced Ian Randall, Sergeant Andrew Core, lacked Ian Randall’s experience.³¹¹ Inspector Sexton should have recognised that Ian Randall was better deployed in GMP Control. His departure significantly depleted the experience available to the FDO and added to the already substantial demands on Inspector Sexton. There should have been someone else who was capable of setting up the Silver Control Room and available to do it.

Third, answering the FDO telephone line quickly became a drain on resources. At 22:57, Inspector Sexton demanded support from within the control room he was in. He asked for someone to step up and answer the FDO telephone on his behalf.³¹² David Myerscough, who had been a GMP radio operator since 2014,³¹³ assumed that responsibility.³¹⁴

I am not critical of David Myerscough. He did all that could reasonably have been expected of him and more. He sought to step up and that is to his credit. However, he was placed into a position that he was not trained for and for which he lacked experience. He was out of his depth. In evidence, he said:
“I’d never had the right sort of training for that role, I’m not familiar with the workings of the FDO, I have never been an FDS [Force Duty Supervisor] or a supervisor, so it’s not something I have been involved in a lot. I have a brief understanding of what they do but not an in-depth knowledge, so I didn’t feel prepared or qualified or experienced enough … I felt totally overwhelmed and completely stressed out by the task of answering the FDO line but I just wanted to help and assist as best I could.”³¹⁵

Inspector Sexton’s Dictaphone records several occasions when David Myerscough lacked the knowledge and understanding necessary to perform the role he had been given. He regularly had to seek clarification from the FDO, which distracted Inspector Sexton from his other work of directing the emergency response.³¹⁶

Fourth, it is striking how often the FDO telephone line became engaged by calls from the media. The Dictaphone recording shows that Inspector Sexton found this frustrating in the extreme. The following exchange between Inspector Sexton and David Myerscough at 23:02 illustrates that:
“[David Myerscough] Boss, do you want media enquiries cancelling or do you want me to answer them?
[Inspector Sexton] No, I don’t want you to speak to them at all I want you to tell them that we’re too busy, they’re going to have to wait. We have just turned out the media officer who should be able to start fielding those questions.”³¹⁷

The enquiries from the media nonetheless kept coming, including calls from the international media.³¹⁸

Inspector Sexton explained that the media enquiries had two effects on the FDO line. Time was taken up with answering calls from the media, and other calls received an engaged tone and were unable to get through.³¹⁹ This had real consequences.

In drawing attention to this issue, I am not criticising the media. The media were calling the FDO number because that was the number they had. There was an obvious public interest in accurate early reporting of what had happened at the Arena, and the media needed information to that end. The media also had an important role in encouraging members of the public not to enter the centre of Manchester and needed information for that purpose also.

However, the media enquiries on the FDO telephone line meant that time and resources were taken away from the work of the emergency response. It is clear to me from listening to the Dictaphone recording that the constant media enquiries added to the pressure that Inspector Sexton was experiencing. This should never happen again.

Steps need to be taken by all police services to ensure that, in the event of a Major Incident: the burden of dealing with media enquiries does not fall to the FDO; and the FDO telephone line does not become bogged down with such enquiries. Some separate provision needs to be made to ensure that the media gets the information it needs, while not interfering with the FDO response to the incident. This is an issue that the College of Policing should address.

Fifth, I have made clear the importance of action cards within GMP Control and the serious failure of GMP to introduce such prompts. David Myerscough stated that he had never seen CI Michael Booth’s action cards, and that no action cards were in use in GMP Control on the night of the Attack.³²⁰ Inspector Sexton said the same.³²¹

It would have helped to a significant degree on the night if action cards had been available in the control room and if the control room staff had been properly trained in their use. Particular tasks would have been automatically delegated from the FDO to others within GMP Control. That would have included, for example, the notification of emergency service partners that Operation Plato had been declared and the notification to other emergency services of the channel to be used for multi‑agency control room communication. This would have reduced the burden on the FDO and improved the emergency response.

David Myerscough confirmed that action cards are now available within GMP Control but said that he had received no training in them. He considered that if another event such as the Attack were to occur, he would not be able to cope.³²² That evidence was concerning. I do not know whether that state of affairs exists elsewhere in the country. I recommend the College of Policing and His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) urgently take steps to ensure that all police control rooms have action cards in place, and that all control room staff have been properly trained in their use. The importance of action cards to an effective emergency response cannot be underestimated across the emergency services. I will return to this topic in the recommendations in Part 21 in Volume 2‑II.

Sixth, Inspector Sexton was given no material assistance in directing the emergency response by either the Strategic/Gold or Tactical/Silver Commander during the period that he needed it.³²³ I will consider their roles later in this Part, at paragraphs 13.478 and 13.444.

In that regard, I acknowledge that when CI Dexter assumed the role of Ground Assigned Tactical Firearms Commander, he did relieve some of the burden upon Inspector Sexton,³²⁴ but he did not arrive at the scene until 23:23.³²⁵

Consequences of the Force Duty Officer’s failures

Inspector Sexton’s principal failures were his failing to communicate the declaration of Operation Plato to the ambulance service and the fire and rescue service and his failure to declare a Major Incident.

Other failures flowed from those omissions.

First, Inspector Sexton’s aide‑memoire identified that it was his job to ensure, in line with JESIP, that multi‑agency communications were put in place. As his own document acknowledged, that required Inspector Sexton to nominate one of the operational multi‑agency talk groups.³²⁶ He failed to do so.³²⁷

Multi‑agency communication is vital to an effective joint response. On the night of the Attack, multi‑agency communication between the three emergency services was non‑existent. That failure played a major part in what went wrong. While I recognise that other means for multi‑agency communication were a possibility, Inspector Sexton’s failure in this regard made a significant contribution to the overall failure of JESIP on 22^nd May 2017.

Second, as Inspector Sexton recognised in evidence,³²⁸ establishing an FCP is critical to the emergency response.³²⁹ This should be the location at which, in accordance with JESIP, the commanders from each emergency service co‑locate so as to enable them to communicate, co‑ordinate, jointly understand the risk and share situational awareness.³³⁰ Inspector Sexton failed to ensure there was an FCP.³³¹ Nor did he do anything to manage the confusion that developed in relation to a nominated RVP. These failures represent an important part of the explanation for why joint working never happened, but instead the three emergency services ended up operating largely in silos.

Third, the Policing Experts confirmed that the concept of zoning is critical to Operation Plato.³³² At the time of the Attack, the third edition of the Joint Operating Principles (JOPs 3) was applicable and defined Operation Plato zones as cold, warm and hot.³³³ I will address the meaning of these terms in further detail in paragraphs 13.336 to 13.355.

No emergency responder was ordinarily expected to operate in an Operation Plato hot zone save for police firearms officers. No emergency responder was ordinarily expected to operate in an Operation Plato warm zone except for specialist assets, such as: the Hazardous Area Response Team (HART); the Ambulance Intervention Team; and the Specialist Response Team of the fire and rescue service.

Having declared Operation Plato, it was vital that Inspector Sexton should have decided how areas were to be zoned as soon as he had the information to enable him to do so. It was also vital that he should then have communicated that decision to the police officers involved in the response along with the emergency service partners of the police. That is for the obvious reason that such decisions have, as JOPs 3 made clear, a major impact on the deployment forward of unarmed and/or non‑specialist emergency responders. In turn, that is likely to determine how quickly casualties receive the treatment they require and/or are evacuated.

Inspector Sexton repeatedly said in evidence that he considered the City Room, and indeed a larger area, to have been an Operation Plato hot zone for a prolonged period.³³⁴ I conclude that he made no such decision and that, on the contrary, he gave no thought to zoning that night. Support for that conclusion is provided by the fact that, as the Dictaphone recording reveals, Inspector Sexton did not use the words ‘zone’ or ‘zoning’ or ‘hot’, ‘warm’ or ‘cold’ at any stage during the period that he was Initial Tactical Firearms Commander, or indeed at any stage.³³⁵ That Inspector Sexton gave evidence that was factually inaccurate about his thinking at the time is a further example of the situation I described in paragraphs 13.227 and 13.228.

Not only did Inspector Sexton not use these terms, no one else did in discussion with him. As Inspector Sexton accepted in evidence, at no stage did any firearms officer, or indeed any officer at the scene or elsewhere, ask him how he had zoned the Arena and surrounding area.³³⁶ That the failure to engage with this vital issue was so widespread indicates strongly that there was a lack of understanding generally within GMP of the importance of zoning. That lack of understanding may well be present elsewhere in the country. It must be addressed. That is a job for CTPHQ.

I am satisfied that, had he engaged in a careful and informed assessment of risk, Inspector Sexton should have concluded by no later than 22:50 that the City Room was an Operation Plato cold zone. I consider that such a clear decision at that stage would have made a difference on the night.

What in fact happened was that different emergency responders and their commanders made their own decisions about zoning and/or risk. This had consequences. For example, it led the NWAS Operational Commander, Daniel Smith, to make unduly cautious decisions about deployment as I will explain in Part 14. If Inspector Sexton had made and communicated the right decision as to Operation Plato zoning, that should have given Daniel Smith the confidence to commit additional specialist and non‑specialist resources forward.

Fourth, the fact that Inspector Sexton failed to give any thought to zoning meant that, not only did he make no decision in that regard, he was not in a position to reconsider that decision.³³⁷ Such reviews of zoning decisions are critical, given their impact on deployment. JOPs 3 made that clear,³³⁸ although in my view it was a matter of common sense. There were a number of points in time at which Inspector Sexton should have reviewed his position on zoning.

Overall, the failures of Inspector Sexton were serious and far‑reaching in effect.

A number of senior GMP witnesses expressed the view that the things Inspector Sexton failed to do were straightforward.³³⁹ That was also the position of GMP in its closing statement to me.³⁴⁰ I regard that as an over‑simplification, and unfair to Inspector Sexton. In a situation where someone becomes overburdened, they may be just as likely to overlook something straightforward as something complicated.

I am satisfied that the burden placed on Inspector Sexton on the night of the Attack was too great. It overwhelmed Inspector Sexton. While this does not excuse Inspector Sexton’s failures, it does mitigate his culpability.

As I set out in Part 12, GMP had known, for several years, of the risk that the FDO would be overwhelmed in an Operation Plato situation. GMP should have put in place proper mechanisms of support for the FDO, such as ensuring that action cards were implemented, were well understood and utilised to achieve systems of delegation. GMP failed to do so. I regard that failure as very serious.

Looking as a whole at what went wrong in GMP Control on 22^nd May 2017, GMP’s culpability is substantial.

Firearms officers and Operation Plato zoning

Containing the scene

In the UK, police officers do not generally carry firearms. Instead, substantial investment has been made by policing in a network of Authorised Firearms Officers. They provide the primary armed response to no‑notice incidents such as terrorist attacks. They operate in Armed Response Vehicles. I will refer to Authorised Firearms Officers as ‘firearms officers’.

At 22:41:27, the first GMP Armed Response Vehicle arrived in the area of the Victoria Exchange Complex. The vehicle drove along Station Approach before travelling down Hunts Bank and onto Victoria Street. Less than half a minute later, a second Armed Response Vehicle arrived.³⁴¹

By 22:42:44, PC Tyldesley and PC Dalton, both firearms officers, had entered the Arena via the Trinity Roller entrance,³⁴² having arrived on Trinity Way in a further Armed Response Vehicle. They then proceeded up the internal staircase and towards the City Room.³⁴³

Seconds later, at 22:42:52, two more firearms officers, PC Moore and PC Simpkin, ran into Manchester Victoria Railway Station from Station Approach. They ran straight up the staircase leading to the raised walkway and on towards the City Room. They were accompanied by PC Roach of BTP, who had already been into the City Room.³⁴⁴ PC Moore had visited the Arena before the night of the Attack, so was familiar with its layout.³⁴⁵

In broad terms, PC Tyldesley and PC Dalton were approaching the scene of the bombing from the north and PC Moore and PC Simpkin were approaching from the south. This was an obviously sensible tactic in seeking to locate and neutralise any terrorist armed with a firearm.

By 22:43:21, two more firearms officers were within the Victoria Exchange Complex. Those officers were PC Richardson and PC Lewis Adams. Like PC Tyldesley and PC Dalton, they had entered the building via the Trinity Roller entrance. They, too, began to make their way towards the City Room.³⁴⁶

By 22:43:35, PC Moore and PC Simpkin had almost reached the doors to the City Room.³⁴⁷ Seconds later, they entered. They emerged at 22:44:37,³⁴⁸ having spent almost exactly a minute at the seat of the explosion. When he gave evidence, PC Moore explained what he and PC Simpkin spent that minute doing. I will reach that important part of his account in paragraphs 13.289 to 13.292.

PC Moore had joined GMP in 2004, following service in the British Army. His previous career meant that he had some familiarity with explosives. He had been a firearms officer for six years and qualified as an Operational Firearms Commander in late 2016. By 22^nd May 2017, PC Moore was an experienced firearms officer.³⁴⁹

On the night of the Attack, PC Moore and PC Simpkin were monitoring the GMP firearms radio channel when, shortly after 22:30, they heard reports of an explosion and possible gunshots at the Arena. They immediately made their way, in an Armed Response Vehicle, to the scene. On the way there, they learned that PC Richardson had been made the Operational Firearms Commander and that the FDO had granted Firearms Authority.³⁵⁰

PC Moore and PC Simpkin parked on Station Approach. In his evidence, PC Moore described seeing injured people. It was immediately obvious to him that something significant had happened.³⁵¹ Recognising the urgency involved in the situation, PC Moore and PC Simpkin deployed to the scene straight away, without putting on their extra personal protective equipment (PPE).³⁵² They put the protection of the public above their own personal safety.

As I explained earlier in this Part at paragraph 13.152, at about the time he entered the station, PC Moore spoke to PC Roach of BTP. PC Roach had already been into the City Room and told PC Moore that there were many casualties in that location. That enabled PC Moore to pass a clear message to the FDO. At 22:43:05, as he ran up the stairs leading to the raised walkway, PC Moore broadcast a message to the FDO making clear that a bomb had detonated, causing major casualties.³⁵³ He added, “… Operation Plato, Operation Plato”.³⁵⁴  In evidence, PC Moore explained that on the basis that there existed the material possibility of an active shooter, he considered that he and his colleagues were dealing with an Operation Plato situation. In such circumstances, as PC Moore observed: “[E]very second counts.” ³⁵⁵ Therefore, he sought to communicate his message to the FDO quickly by using the shorthand operational name for a Marauding Terrorist Firearms Attack.³⁵⁶

PC Moore’s thinking was clear and appropriate. He communicated his assessment to the FDO promptly and effectively.

‘Raw check’ of the City Room

PC Moore and PC Simpkin ran into the City Room. They were the first firearms officers to enter.³⁵⁷ While I recognise that this is what they were trained to do, their actions were undoubtedly brave.

In evidence, PC Moore described what confronted the two of them. It was immediately apparent to PC Moore that there were many dead and injured in the room. He also saw BTP officers, Arena staff and members of the public. Nothing, he explained, could have prepared him for what he saw and had to deal with. He wanted to stop and help the casualties, but believed that his sole responsibility was to locate and eliminate any threat.³⁵⁸

This highlights a shortcoming in the training of firearms officers. As I shall explain in Part 20 in Volume 2‑II, the evidence reveals that this shortcoming applies beyond GMP. Firearms officers should have been trained to understand that, while their primary responsibility in an Operation Plato situation is to locate and eliminate the terrorist threat, they may also have a role in providing emergency treatment to the injured. The opportunity to provide urgent treatment, even while seeking out any armed terrorist, may arise. I heard evidence that, in active combat, it is sometimes possible for soldiers to stop for seconds to treat a wounded colleague.³⁵⁹ Furthermore, once the firearms officers have secured the area concerned, such treatment should generally be provided. I emphasise that, in making this observation, I am not raising a criticism of any officer on the night. They did precisely what they understood their training required of them.

With a view to locating and eliminating any threat, PC Moore and PC Simpkin carried out what PC Moore described as a “raw check” of the City Room.³⁶⁰ The CCTV footage shows that this took almost one minute.³⁶¹ The raw check involved the officers carrying out a sweep to establish whether there was a gunman or secondary device in the area. PC Moore explained that excluding the possibility of a gunman was more straightforward than excluding the possibility of a secondary device.³⁶²

At the conclusion of the raw check, PC Moore was satisfied that there was no “imminent threat of an active shooter”.³⁶³ As for secondary devices, there was a rucksack on the concourse between the City Room and the Arena bowl which seemed to PC Moore to be out of place,³⁶⁴ but nothing of concern within the City Room itself.³⁶⁵

PC Moore considered that it was the FDO’s responsibility to zone the City Room and surrounding area on the advice from the Operational Firearms Commander on the ground who would be expected to have situational awareness.³⁶⁶ That seems to me to be correct as a matter of hierarchy, but it did not stop PC Moore forming his own view. Given his experience, it would have been desirable for him to have communicated his view to the FDO or Operational Firearms Commander. PC Moore did not do so.³⁶⁷ I regard this as a training issue rather than as a criticism of PC Moore.

PC Moore considered that on arrival, prior to the raw check, the City Room was an Operation Plato hot zone. After he and PC Simpkin had “cleared through”,³⁶⁸ PC Moore regarded that area as an Operation Plato warm zone. He explained that he was accustomed as a firearms officer to carrying out dynamic risk assessments³⁶⁹ and said: “[M]y dynamic risk assessment of the foyer of that area [the City Room] at that time was it was a warm zone and we’d be able to bring in medics.” ³⁷⁰

The radio messages show that PC Moore’s assessment that “medics” should enter was not an after‑the‑event rationalisation, but instead represents what he thought at the time. At 22:45, the following exchange took place over the firearms channel:
“[PC Moore] Boss, we’ve got multiple casualties top of the Victoria Train Station Entrance. I can confirm it looks like the scene of the explosion is above the train station. All available assets to that area please, medics, trauma kits etc.
[Inspector Sexton] To the Victoria entrance to the Arena?
[PC Moore]That’s correct boss. We’re talking upwards of 30 or 40 casualties.
[PC Deponeo] Angelo to the team at Victoria Station. Just by the front stairs. Got a couple of casualties. We need to go inside. Is anybody with me?
[PC Moore] Can we have all available trauma kit to the top of Victoria Station?”³⁷¹

I will return to these events concerning PC Moore, which all occurred within the first 15 minutes following the detonation, when I consider the issue of zoning in further detail.

PC Angelo Deponeo was another firearms officer.³⁷² It is clear from what he said in this exchange that he was not far from the City Room at the time. That reflects the fact that, throughout this period, other firearms officers were arriving at the railway station.³⁷³ Very quickly, firearms officers were present at and around the Victoria Exchange Complex in numbers. That included the prompt attendance of a number of Counter Terrorist Specialist Firearms Officers (CTSFOs). They arrived at the Victoria Exchange Complex at 22:54. CCTV captured those officers in the building at 22:57.³⁷⁴ I will consider the role of such officers in further detail in Part 20 in Volume 2‑II.

While PC Moore and PC Simpkin were carrying out their raw check in the City Room, PC Richardson and PC Adams,³⁷⁵ and PC Tyldesley and PC Dalton,³⁷⁶ were making their way to that location. By 22:46:30, they had arrived at the doors leading from the station concourse to the City Room.³⁷⁷ PC Richardson approached PC Moore. PC Moore informed him that he had carried out a “quick raw check” but that a secondary search would be necessary.³⁷⁸

Operational Firearms Commander

PC Richardson became a police officer with Merseyside Police in 2003, following eight years in the British Army. He qualified as a firearms officer in 2007 and became an Operational Firearms Commander in 2008.³⁷⁹ In November 2016, he transferred to GMP for career development reasons.³⁸⁰ At the time of the Attack, PC Richardson was an experienced firearms officer.

I have concerns about PC Richardson’s knowledge of the police response to a declaration of Operation Plato. His understanding in 2017 was that Operation Plato was the response to a terrorist attack, as opposed to being the response to a specific type of terrorist attack, namely a Marauding Terrorist Firearms Attack.³⁸¹ His understanding of zoning did not fit precisely with the definition in JOPs 3. He said that his idea of zoning was a “general” one.³⁸² He was not fully aware of the Marauding Terrorist Firearms Attack response capability of GMFRS.³⁸³

PC Richardson was the Operational Firearms Commander that night.³⁸⁴ It is important that an officer performing that role should have accurate and detailed knowledge of each of these things. PC Richardson did not. This does not represent a criticism of PC Richardson personally. It represents a criticism of the training he received. That PC Richardson’s training and experience spanned both Merseyside Police and GMP³⁸⁵ generates a concern that the training of firearms officers had not sufficiently embedded these important principles not only in GMP, but more widely. As I explained in Part 12, this is an issue that CTPHQ and the College of Policing should address.

On the night of the Attack, PC Richardson was partnered with PC Adams. They were on patrol when they became aware of the incident at the Arena. They responded immediately to the FDO’s instruction to attend. On the way, PC Richardson declared himself the Operational Firearms Commander.³⁸⁶ Given his experience and the expectation that he would arrive at the scene at an early stage, this was an appropriate decision.

PC Richardson and PC Adams parked on Trinity Way. On arrival at the railway station, PC Richardson spoke to people there. As a result of those discussions, he initially thought he was dealing with a false alarm, so he passed a message to the FDO at 22:39 to that effect.³⁸⁷ PC Moore had arrived at the scene a little earlier on the opposite side of the complex. He had gained situational awareness from PC Roach and put the FDO right.³⁸⁸

PC Richardson and PC Adams then headed straight to the City Room, with PC Tyldesley and PC Dalton.³⁸⁹ As they made their way there, the sights and smells they encountered made clear to PC Richardson that they were dealing with something very significant. PC Richardson gave an instruction to the officers he was with to enter “advance mode”, in other words to speed up towards the scene of the Attack.³⁹⁰ Shortly after PC Moore and PC Simpkin had concluded their raw check, at 22:46:30, the four officers arrived at the doors dividing the concourse from the City Room.³⁹¹

Having been briefed by PC Moore on the concourse, PC Richardson entered the City Room, with his partner PC Adams. As he did so, he gave instructions to the other firearms officers.³⁹² He positioned firearms officers on the concourse in a position to neutralise any potential armed threat coming from the Arena bowl. PC Richardson and PC Adams then performed a second sweep of the City Room. Like PC Moore and PC Simpkin, they were clear that there was no armed terrorist and no obvious secondary device within the City Room, but there could be no certainty about the absence of the latter.³⁹³

Briefing the Force Duty Officer

There is no doubt that, on leaving the City Room at about 22:48, PC Richardson made contact with the FDO.³⁹⁴ The content of the exchange is, however, the subject of some controversy.

In a witness statement provided to the Inquiry dated 1^st February 2020,³⁹⁵ PC Richardson explained that in making contact he was seeking to respond to a request by the FDO for an update on casualties. Inspector Sexton had made that request in the course of declaring Operation Plato at 22:47.³⁹⁶

PC Richardson’s recollection, as set out in his witness statement, was that in responding at 22:48, he informed the FDO that although he regarded the City Room as a “hot zone”, he considered it should be treated as a “warm zone” so that casualties could be treated and evacuated by emergency responders.³⁹⁷

In evidence, PC Richardson confirmed that this was an accurate reflection of his recollection.³⁹⁸ By the date of his evidence, PC Richardson had plainly become aware that the recording of the radio messages does not support his recollection of what he said.³⁹⁹ He advanced a number of potential explanations for this. First, that he had not in fact said what he recalled having said but had experienced what he described as “perceptual distortion”.⁴⁰⁰ Second, that he had not pressed the talk button on the radio when he sought to transmit the message. Third, that his message was blocked by someone else transmitting on the radio at the same time.⁴⁰¹

In my view, explanations two and three can be discounted. That is because the message that PC Richardson did transmit following his sweep, and in which he believes he made mention of the issue of zoning, was captured both on the radio recording and on the recording from Inspector Sexton’s Dictaphone. The exchange of messages started at 22:48:05:
“[PC Richardson] OFC [Operational Firearms Commander] to FDO.”
“[Inspector Sexton]Go ahead.”
“[PC Richardson] At the moment we we’ve got a large number of casualties inside the entrance to the arena some are not in a good way, we’ve got er paramedics and people administering First Aid, we’ve got to consider also a secondary device err we’ve got no one else coming forward in relation to anyone else that who’s been involved with this, but we need to start getting the public out the way from the front. We’ve got 3 ARV’s [Armed Response Vehicles] inside at the moment two are armed contingency and we got a number Paramedics who are administering First Aid.”
“[Inspector Sexton]Yeah received er we’ll get the er people moved from outside the location erm to clear er a sterile area as soon as we can, and try to get more erm resources down there to clear.”
“[PC Richardson] Any Whiskey patrols who have err explosive dogs on board please.”⁴⁰²

PC Richardson’s reference to paramedics was incorrect. The people he thought were paramedics were staff of Emergency Training UK.⁴⁰³

This exchange reveals that PC Richardson asked to speak to the FDO and the FDO expressly and immediately acknowledged that request. PC Richardson then spoke uninterrupted for almost 40 seconds, providing much information about his sweep but saying nothing about zoning. There is no hint of anyone else cutting in. The FDO then acknowledged what PC Richardson had said. PC Richardson is then heard, almost immediately, broadcasting a more general request for the attendance of explosives detection dogs. He had moved on from providing a situation report. I have listened to this exchange many times. I am satisfied that this is the exchange in which PC Richardson believes he referred to zoning. He did not do so or attempt to do so.

In my view, PC Richardson was an honest but mistaken witness. He made his first statement on 31^st January 2019.⁴⁰⁴ In it, he made no mention of this exchange with Inspector Sexton. The first reference to the exchange came in his witness statement of 1^st February 2020,⁴⁰⁵ 31 months after the events at the Arena. The likely explanation for PC Richardson’s error is that the delay in providing his detailed account has affected his memory of events that were over quickly and obviously fraught. That delay is unfortunate for reasons that are obvious and which I will address in Part 19 in Volume 2‑II.

It has been necessary for me to spend time addressing the inconsistency between PC Richardson’s recollection and the objective evidence only because it enables me to find that he made no reference to zoning over the radio that night. He has that in common with the other firearms officers and others, an issue to which I shall turn.

Recording events

Before I return to the chronology of events, I will deal with a related topic.

Several of the unarmed GMP officers who attended the City Room were wearing body‑worn video cameras. The footage from those cameras, much of which I have watched, was harrowing, but it did provide important evidence on a number of issues. Rightly, no one suggested at any stage of the oral evidence hearings that any of that footage should be played publicly.

PC Richardson explained that the firearms officers within GMP were not, at that time, equipped with body‑worn video cameras.⁴⁰⁶ PC Richardson considered that it would “definitely” be beneficial for all firearms officers to be deployed with body‑worn video cameras in future.⁴⁰⁷ It is easy to see the advantages in that. In this Inquiry, it would have removed any debate about whether PC Richardson ever made a reference to zoning. It would have revealed what passed between the firearms officers at the crucial stages. It would have enabled me to see what they saw as they carried out their sweeps of the City Room. Such advantages are likely to accrue in any serious incident in which firearms officers are deployed.

I did not hear detailed evidence on this topic, and it may be that there are reasons why firearms officers should not wear body‑worn video cameras. Nevertheless, I consider it appropriate that CTPHQ and the College of Policing consider whether all firearms officers should be so equipped.

City Room secured

To return to the chronology, CCTV footage shows that, having spoken to Inspector Sexton at 22:48, PC Richardson then returned to the City Room.⁴⁰⁸ He remained there until he left with CI Dexter at 23:30.⁴⁰⁹ CI Dexter had arrived and assumed the role of Ground Assigned Tactical Firearms Commander seven minutes earlier.⁴¹⁰ I will consider his role in due course, at paragraph 13.529.

On the evidence overall, it was clear to me that the City Room was entirely contained by firearms officers throughout the period from 22:48. PC Richardson described it as a “spiky bubble”.⁴¹¹

The firearms officers arrived at the Arena promptly and in substantial numbers. They bravely entered the City Room, quickly establishing that there was no active shooter and did what they could to establish that there was no secondary device in that location. They then locked down the City Room, creating an armed cordon to protect those within that area. Had a terrorist armed with a firearm sought to gain access, that person would have been killed almost immediately. While the firearms officers should have been trained to understand the need for them to provide ‘Care Under Fire’, a term I will explain in Part 20 in Volume 2‑II, they were entirely successful in discharging their primary responsibility under Operation Plato.

Role of the Operational Firearms Commander

Prior to the Attack, the College of Policing had issued a document addressing the roles and responsibilities of firearms command.⁴¹² This was a document of general application and not specific to Operation Plato situations.

The document described the Operational Firearms Commander as responsible for the command of “a group of officers carrying out functional or territorial responsibilities related to a tactical plan”.⁴¹³ This emphasised the importance to the Operational Firearms Commander of a tactical plan. In the context of a firearms operation, the Tactical Firearms Commander will be responsible for the provision of the tactical plan. Between 22:34 and 00:18, Inspector Sexton was the Tactical Firearms Commander.⁴¹⁴

The College of Policing document set out the role of the Operational Firearms Commander under a number of bullet points.⁴¹⁵ The document emphasised the importance of the tactical plan, and the role of the Operational Firearms Commander in ensuring “the implementation of the tactical firearms commander’s tactical plan within their territorial or functional area of responsibility”.⁴¹⁶

An Operational Firearms Commander can only implement the tactical plan if given one. On the night of the Attack, Inspector Sexton provided no tactical plan to PC Richardson. He should have done.⁴¹⁷ This represents a further respect in which the FDO failed that night. Throughout the critical period of the response, the FDO was too reactive. He did not take the necessary step back in order to assess, in a structured and proactive way, what was needed to ensure that the firearms response, the broader police response and the emergency response worked. I am satisfied, for the reasons I have given, that the burden imposed upon Inspector Sexton largely explains this failure.

Operational Firearms Commander’s situation reports

A further requirement of the Operational Firearms Commander role, as described within the College of Policing document, was to “update the Tactical Firearms Commander, as appropriate, on current developments”.⁴¹⁸

During the time he spent in the City Room prior to 23:30, PC Richardson discharged this responsibility by passing a number of situation reports to the FDO over the firearms channel. I am satisfied that he provided relevant and up‑to‑date information. I am also satisfied that PC Richardson gave clear indications of what was needed to enable the emergency response to make progress. In particular, PC Richardson made clear that more NWAS staff were needed in the City Room.

In a radio transmission at 22:53, PC Richardson stated: “[W]e just need more ambo staff, paramedics, anyone that they can get hold of please.” ⁴¹⁹ In evidence, he clarified that he was referring to a need for medically trained staff in the City Room.⁴²⁰ Inspector Sexton replied: “Yes, I’ve obviously declared Operation Plato and I’m trying to get as many NWAS down there as possible.” ⁴²¹

This exchange took place after PC Richardson had been into the City Room and seen the devastation there. It was obvious to him that emergency responders, able to provide treatment and evacuate casualties, were needed urgently and in numbers.⁴²² In evidence, PC Richardson confirmed that the FDO’s response at 22:53 reassured him that steps were under way to get additional paramedics into the City Room.⁴²³

A short time earlier, PC Richardson’s partner, PC Adams, transmitted a message to the FDO in similar terms. That exchange took place at 22:50:
“[PC Adams]Yeah boss so far I probably estimated we’ve got about 10 fatalities and probably 50-60 wounded and being worked on erm we do need a lot more trauma kits and staff etc.”
“[Inspector Sexton] … obviously I’ll feed this back to er NWAS to try and get as many resources they have got as we can, erm obviously you’re getting 3 ARV’s [Armed Response Vehicles] from the Airport to come and assist and we are trying to clear the personnel from outside in case there is a secondary device or a er another offender.” ⁴²⁴

PC Adams had been in the City Room with PC Richardson.⁴²⁵ It is obvious that, like PC Richardson, he would have been reassured by what he was told by the FDO that real attempts were being made to get paramedics to the City Room.

Inspector Sexton took no steps to secure that outcome.⁴²⁶

In evidence, Inspector Sexton did not accept that it was ‘unfortunate’ that he told the firearms officers that he was going to seek the attendance of NWAS resources and then did nothing about it.⁴²⁷ He said that he assumed that NWAS would be arranging their own resources. Inspector Sexton recognised that JESIP was designed to avoid the making of such assumptions, which might or might not be correct.⁴²⁸

Inspector Sexton’s failures were, as I have explained, one of the main reasons why JESIP failed.

I cannot say what would have happened if PC Richardson had not been misled into believing that the FDO was working hard to get paramedics into the City Room. I recognise that unarmed officers were asking for that to happen in any event and that this made no material difference to the response of NWAS.

However, if the Operational Firearms Commander had known that the FDO was not doing anything to secure the attendance of paramedics in numbers, there is a realistic possibility that PC Richardson would have done more himself. There are a number of obvious steps he might have taken: chasing the FDO; seeking the guidance of Inspector Smith, the Operational/Bronze Commander who was in the City Room; trying to communicate with the NWAS Operational Commander; and directing firearms officers to provide initial trauma care.

Inspector Sexton’s failure to act on the requests of the Operational Firearms Commander and PC Adams, for paramedics to attend, was a serious failure.⁴²⁹

Operation Plato zoning

The concept of zoning is critical to Operation Plato.⁴³⁰ That is because the designation given to a particular area determines, subject to operational discretion, which emergency responders are able to enter that area.

In the aftermath of the Attack, the most seriously injured casualties were in the City Room. Immediately after the declaration of Operation Plato, it was essential that consideration was given to the appropriate zoning of that area. That consideration did not happen.⁴³¹

At 22:45, immediately before the declaration, Inspector Sexton spoke to PC Moore over the firearms channel. By this time, PC Moore had been into the City Room. From that exchange, Inspector Sexton discovered that there were upwards of 30 or 40 casualties, and as many medics and as much medical equipment as possible were needed.⁴³²

At 22:48,⁴³³ immediately after the declaration, Inspector Sexton spoke to PC Richardson over the firearms radio channel. In that exchange, it was emphasised by PC Richardson that there were many badly injured casualties, that they were being treated by unarmed responders who were present and providing treatment, and that no one was suggesting that anyone other than the bomber was involved, but consideration needed to be given to the possible presence of a secondary device.⁴³⁴ PC Richardson had been into the City Room at the time of this exchange, as was apparent from what he said.⁴³⁵

Accordingly, by 22:50, Inspector Sexton was well aware that there were multiple casualties in the City Room. He knew that some unarmed responders were present and providing treatment. He also knew that many more emergency service responders were required in order to care for and/or evacuate the casualties. It was his responsibility as the FDO to take reasonable steps to ensure that treatment and evacuation could be achieved.⁴³⁶ Making the right Operation Plato zoning decision in relation to the City Room was critical to that aim.

Had Inspector Sexton discharged his duties adequately, he would have ascertained from PC Richardson at 22:48 that the City Room had been swept on two separate occasions by two separate teams of experienced firearms officers. He would have ascertained that the firearms officers were confident that there was no active shooter in the City Room. Inspector Sexton would have ascertained that the area was contained and that no armed terrorist could gain access to the City Room. Inspector Sexton would have ascertained that, while the firearms officers could not exclude the possibility of a secondary device in the City Room, they had seen nothing to indicate that such a device was present.⁴³⁷

In fact, Inspector Sexton ascertained none of that information at that time, or even soon afterwards, beyond his understanding that a secondary device was a possibility.

Had Inspector Sexton discharged his duties adequately, by 22:50, he would have been in a position to make an informed decision about the Operation Plato zoning of the City Room.

At the time of the Attack, JOPs 3 defined the Operation Plato zones as follows:
Cold zone: An area where it has been assessed that there is no immediate threat to life.
Warm zone: An area where the attackers are believed to have passed through but could enter/re‑enter imminently. These areas cannot be guaranteed as safe.
Hot zone: An area where the attackers are present and/or there is an immediate threat to life.⁴³⁸

In May 2017, unlike now, Operation Plato focused solely on a Marauding Terrorist Firearms Attack.⁴³⁹ That gives rise to the question of whether the immediate threat to life raised in the definitions of Operation Plato cold zone and hot zone must be a threat from a firearms attack or may arise from a different threat, such as a secondary explosive device. Similarly, the question of safety arises in the definition of an Operation Plato warm zone: does safety mean safe from a firearms attack or safe from all forms of attack, including by a secondary explosive device?

The Operation Plato definitions could have been clearer, particularly in the definition of a cold zone. However, in my view, the definitions, including the references to immediate threat to life and safety, should have been read as referring solely to a firearms threat.⁴⁴⁰ I have reached that conclusion for the following three reasons.

First, in May 2017, a declaration of Operation Plato was one that should only have been made if there was a proper basis for believing that a firearms threat existed. If there was no such basis, Operation Plato would not be an appropriate declaration.⁴⁴¹ Absent a declaration of Operation Plato, no issue of JOPs 3 zoning arises.

Second, specialist responders from the ambulance service and fire and rescue service are able to operate in a warm zone because they have PPE providing ballistic protection.⁴⁴² In 2017, that PPE provided no reliable protection from an explosion.⁴⁴³ As a result, the issue of safety in the definition of a warm zone must be understood by reference to a firearms threat: responders and those present in the zone were not safe from the threat of an explosion. It would be surprising if the Operation Plato warm zone had that narrow focus of only firearms and the other two zones a broader focus of firearms and explosions.

Third, my interpretation accords with that of CTPHQ. That was the effect of the evidence of CI Thomas, to whom I have referred earlier, at paragraph 13.174.⁴⁴⁴ The relevant exchange with Counsel to the Inquiry during his evidence on 7^th September 2021 was as follows:
“Q. If a point is reached at which there is no armed attacker within a particular area and where the police, by which I mean armed police, have control of the area, so they have armed officers within the area covering all points of potential entry by armed terrorists, does it follow that that area cannot be a hot zone in accordance with JOPs 3 and the refreshed guidance?
A. In line with the guidance, yes.
Q. Does it follow, moreover, if the police have control of that scene, in circumstances in which there might be an IED [Improvised Explosive Device] somewhere but there is no obvious sign of one, that that area is also not a warm zone?
A. So if there is control of the area – so to go back to the definitions of the zones, so if the attackers are believed to have passed through that area but they can’t re-enter by whatever control measures have been put in place, and you’ve secured that area, then by definition I would suggest that that then becomes a cold zone because, by the control measures you’ve placed around that area, you are making that area safe, you’re preventing the attackers coming back in there, and you don’t believe the attackers are already within it, so you are therefore creating a safe environment to deploy your responders.”⁴⁴⁵

Given that the Operation Plato risk assessment related only to the threat from firearms, it would have been better if JOPs 3 had made clear that a second risk assessment was also required. This second risk assessment would cover not only the potential threat from a secondary device, but also from risks that should routinely be assessed during a Major Incident, such as structural collapse, gas leak and fire.

It follows, from my conclusion that the Operation Plato risk assessment related only to the threat from firearms, that in the circumstances of 22^nd May 2017 the decision that Inspector Sexton ought to have made at 22:50, had he adequately informed himself, was that the City Room was an Operation Plato cold zone.

That decision, if communicated to GMP’s emergency service partners promptly after 22:50, along with or shortly after communication of the declaration of Operation Plato and a further assessment of the risks, should have resulted in both the specialist and non‑specialist resources of NWAS and GMFRS deploying into the City Room on arrival. That would have resulted in much swifter treatment and swifter and more appropriate evacuation of casualties. That should have saved John Atkinson’s life.

As I explained in paragraphs 13.264 to 13.268, on the night of the Attack, Inspector Sexton did not make that decision, or indeed any decision, about Operation Plato zoning. As with his other failures, he overlooked this vital aspect of his role.

As I observed when considering the role of the FDO in the emergency response, a striking feature of the evidence is that the FDO did not give any direction at any stage about Operation Plato zoning, and no officer on the ground asked the FDO about that issue or gave him any advice in that regard.⁴⁴⁶

The evidence indicates that it was only once CI Dexter arrived at 23:23 and assumed the role of Ground Assigned Tactical Firearms Commander that there was any discussion about the important issue of Operation Plato zoning,⁴⁴⁷ even though his approach involved a degree of expediency, as I shall set out. So widespread was the failure to consider zoning on the night, that it reveals this is an issue of training and education. This issue may exist elsewhere in the country. It should be addressed by CTPHQ.

Deployment of explosives detection dogs

Although I am clear that the City Room should have been zoned under Operation Plato as cold, I recognise that the possibility of a secondary device was one that could not be ignored. In that regard, the layout of the Arena created an issue that needed to be resolved.

The City Room leads to the Arena concourse. This, in turn, leads to the Arena bowl. The Arena bowl is a very large area. It is capable of accommodating 21,000 people, depending upon the configuration adopted.⁴⁴⁸ Furthermore, there were rooms off the concourse and elsewhere, some of which were locked on the night. The firearms officers were understandably concerned that there might be a secondary device in the City Room or elsewhere within the Arena. They were also ensuring that there were no terrorists hiding. Making sure the entire area was safe was a considerable task.⁴⁴⁹

PC Richardson made the right decision, at an early stage, when he dispatched a team of firearms officers and CTSFOs, including PC Moore, into the Arena bowl and surrounding area in order to carry out a search. However, it would have been contrary to common sense and contrary to their training for those officers to open any of the discarded bags that were present in order to check for bombs. That is why explosives detection dogs were required. Such dogs are trained to sniff and indicate whether explosives are present. Explosives detection dogs would, therefore, have been invaluable in the Arena on the night of the Attack.⁴⁵⁰

From an early stage, PC Richardson made requests for an explosives detection dog. He made such requests of the FDO at 22:53⁴⁵¹ and 23:01.⁴⁵² He made direct contact with a GMP dog handler, PC Mark Kay, at 23:04.⁴⁵³ Inspector Sexton took steps to attempt to secure the attendance of an explosives detection dog, but it was not until 23:47 that such a dog arrived.⁴⁵⁴

CCTV captured BTP dog handler PC Philip Healy on the raised walkway just outside the City Room with his explosives detection dog, Police Dog Mojo, at 23:47:01.⁴⁵⁵ By 23:47:24, the handler and dog were conducting a search in the City Room.⁴⁵⁶

Both the FDO and the firearms officers on the ground were frustrated by the length of time it took for an explosives detection dog to arrive at the scene. That is no criticism of PC Healy, who I accept responded as soon as he was able. However, it is striking that no explosives detection dog arrived at the scene until more than 75 minutes after the explosion and nearly 55 minutes after the first request was made. Even then, it was just a single dog. Although not entirely clear from the evidence, it seems that it was not until after 00:11 that the first GMP explosives detection dog arrived.⁴⁵⁷

The early attendance of explosives detection dogs would have enabled prompt confirmation that there was no secondary device in the City Room. Any sensible assessment at that stage would have recognised that: there was neither an active shooter nor a secondary device in the City Room; the location was encircled by firearms officers and any armed terrorist attempting to enter from outside was likely to be neutralised within seconds; and, therefore, the City Room was undoubtedly a cold zone, whatever the correct interpretation of the definitions of the zones in JOPs 3.

Given that the approach to Operation Plato zoning was wholly inadequate on the night, I cannot say with confidence that such prompt confirmation would have generated this line of reasoning. However, given the concern of those on the ground to secure the attendance of an explosives detection dog, it is a realistic possibility that it would have made a difference. That underlines the importance of GMP and all other police services having in place an effective system for the prompt deployment of explosives detection dogs.

In the circumstances, I recommend the Home Office, CTPHQ and the College of Policing consider issuing guidance for such deployments. On the face of it, this took too long to achieve on the night of the Attack.

GMP Operational/Bronze Commander

First notification

At 21:00 on 22^nd May 2017, Inspector Smith commenced a night shift. He was due to work until 07:00 the next morning. During that shift, Inspector Smith was one of two Inspectors with operational responsibility for the City of Manchester Division of GMP. His specific geographical responsibility included the city centre of Manchester. This covered the Arena. His team of officers was responsible for dealing with incidents requiring an immediate or priority policing response.⁴⁵⁸

By the date of the Attack, Inspector Smith was a highly experienced police officer. He had joined GMP in 1992. He was promoted to the rank of Sergeant in 1998 and to the rank of Inspector in 2008. Between those dates, he undertook a firearms training course and became qualified as a police search advisor. In 2012, as I explained in Part 12, he qualified as a public order Bronze Commander and subsequently performed the role of Operational/Bronze Commander on many occasions, although never in relation to an incident anything like as large or as serious as the Attack.⁴⁵⁹

In their report, the Policing Experts described Inspector Smith as “an officer with considerable experience, command ability and fortitude”.⁴⁶⁰ I agree with that description. On the night of the Attack, Inspector Smith went to the Victoria Exchange Complex and voluntarily assumed operational/bronze command for the unarmed officers within the City Room. In that role, he conducted himself with bravery, authority, resourcefulness and skill.

Shortly after 22:30, at an early stage of his shift, Inspector Smith walked into Central Park Police Station. He intended that location to be his base for the night. Central Park Police Station is just short of three miles from the Arena to the northeast.⁴⁶¹

At 22:34, almost as soon as he arrived at Central Park, Inspector Smith received a radio message from GMP Control, informing him that there had been an explosion “at the foyer McDonalds at the Manchester Arena. Upwards of 30 to 40 people injured.” ⁴⁶² The operator provided Inspector Smith with the Force Wide Incident Number. He replied to say that he would look at the incident log and then go to the Arena.⁴⁶³

Journey to the Arena

Inspector Smith read the master incident log and realised that something significant was occurring at the Arena. Within two minutes of being contacted by GMP Control, Inspector Smith was in a marked patrol car, speeding to the Arena on blue lights and a siren.⁴⁶⁴ He was with Sergeant James McGowan. Sergeant McGowan had been working the same shift as Inspector Smith as part of his team. He was present when Inspector Smith read the master incident log, and he volunteered to accompany him to the Arena.⁴⁶⁵

At 22:36, on his way to the Arena, Inspector Smith made contact with GMP Control, to seek an update.⁴⁶⁶ The operator asked him to nominate an RVP and Inspector Smith selected the “parking area outside the cathedral”.⁴⁶⁷ This was a few minutes’ walk from the Arena and was a sensible RVP on the basis of what Inspector Smith knew at that stage. This RVP was recorded on the incident log at 22:37:16 as “RVP CATHEDRAL CAR PARK AREA”.⁴⁶⁸

During this same conversation with the Control Room Operator, Inspector Smith asked the operator to do two things:⁴⁶⁹ first, to seek further information from a 999 caller who had provided information about casualties; and second, to contact the Night Silver, Temporary Superintendent Nawaz.⁴⁷⁰ No doubt Inspector Smith had in mind that it was important that a tactical plan should be in place by the time he arrived at the Victoria Exchange Complex. Temporary Superintendent Nawaz, who had been notified of the Attack by the Force Duty Supervisor at 22:39, was responsible for the preparation of that plan and should have prepared and provided that plan shortly after he assumed the role of Tactical/Silver Commander at 22:50.⁴⁷¹

Within two or three minutes of becoming aware of the events at the Arena, Inspector Smith had begun to travel to the scene of the Attack. He had nominated an RVP and taken steps to ensure that others within the command structure were aware of what he was doing. He had taken the initiative. This was good leadership.

At 22:40, four minutes away from the Victoria Exchange Complex, Inspector Smith made contact with GMP Control once more.⁴⁷² By now, he had received information that indicated that nothing of concern was occurring directly outside the railway station. He therefore reconsidered the RVP and decided that officers could and should travel directly to the scene.⁴⁷³ As a result, Inspector Smith instructed the operator to direct all officers directly to Manchester Victoria Railway Station.⁴⁷⁴ His intention was that this location should be recorded on the incident log as the new RVP. That should have happened. It did not, and this was to result in problems in due course.⁴⁷⁵

The 22:37 Cathedral car park RVP was communicated to NWFC but rejected by GMFRS when relayed on. I will deal with this in Part 15. NWFC was never told about what Inspector Smith said to GMP Control at 22:40.⁴⁷⁶ The fact that Inspector Smith had directed “officers”, which I would have expected to have been understood as non‑specialist emergency responders, to the scene was never communicated to NWFC or GMFRS. Whether knowing that non‑specialist police officers were being directed to the scene would have made a difference to GMFRS’s initial decision to stay away is, in my view, unlikely. Nonetheless, an opportunity for joint working was lost because of the failure to co‑locate at an agreed RVP.

This was not the fault of Inspector Smith, who had sought to establish a clear and appropriate RVP. The failures are, however, illustrative of the chaotic overall approach of the emergency services to the RVP. This was at the heart of what went wrong that night. An RVP was critical to effective joint working. The approach of the emergency services to this important issue reveals a fundamental failure across all emergency services to adhere to the vitally important principles of joint working. That is a criticism which features frequently across this Volume of my Report.

Before dealing with Inspector Smith’s arrival at the scene, it is important to record an omission on the part of Inspector Smith.⁴⁷⁷ Any police officer may declare a Major Incident on behalf of the police.⁴⁷⁸ The events in the City Room were indisputably a Major Incident within the parameters of the GMP Major Incident Plan.⁴⁷⁹

Having assumed the role of Operational/Bronze Commander, Inspector Smith should have taken steps to ensure that a Major Incident had been declared and, on establishing that it had not been, should have taken that step himself. Inspector Smith himself expressed the matter as follows:
“I think it was without a doubt a major incident, but I probably assumed that either the FDO or Silver Commander had already declared that. For completeness, I certainly should have declared it and that was an oversight by me.”⁴⁸⁰

While Inspector Smith was correct to acknowledge this omission, it seems to me to be largely a consequence of the FDO and the Night Silver’s lack of communication with him. The FDO never made contact with Inspector Smith.⁴⁸¹ The Night Silver only made contact once, and even then only for an update.⁴⁸² Inspector Smith performed to a high standard that night. The positive contribution he made to the emergency response far outweighs this single, limited omission.

Arrival at the Arena and initial entry into the City Room

CCTV footage shows the vehicle containing Inspector Smith and Sergeant McGowan arriving on Station Approach at 22:44:31.⁴⁸³ On leaving their patrol car, they stopped to check on casualties in the area,⁴⁸⁴ and Inspector Smith contacted GMP Control to direct closing off the surrounding roads.⁴⁸⁵

By 22:45:21, so within 15 minutes of the explosion, Inspector Smith had entered the Victoria Exchange Complex via the War Memorial entrance.⁴⁸⁶ As he did so, he passed a message to GMP Control to make clear that he had been told that there were major casualties inside and that he intended to go to where those casualties were.⁴⁸⁷

Following a brief discussion with firearms officers,⁴⁸⁸ Inspector Smith and Sergeant McGowan ran towards the City Room.⁴⁸⁹ On the raised walkway, Inspector Smith spoke to a BTP officer in order to gain further situational awareness.⁴⁹⁰ By 22:47:51, he had entered the City Room.⁴⁹¹ This was within 17 minutes of the explosion and within 14 minutes of being informed by GMP Control that an incident had occurred. Inspector Smith had acted with speed.

By the time he entered the City Room, Inspector Smith had decided that he should perform the role of Operational/Bronze Commander.⁴⁹² This meant that it was his responsibility to implement the tactical plan on the ground.⁴⁹³ The development of the tactical plan was the responsibility of the Tactical/ Silver Commander.⁴⁹⁴ At 22:39, Temporary Superintendent Nawaz was notified of the Attack. He became Tactical/Silver Commander for the incident at 22:50 when he spoke to the FDO. He was replaced by Temporary Superintendent Hill at 00:00 on 23^rd May 2017.⁴⁹⁵ At no stage did Temporary Superintendent Nawaz provide Inspector Smith with a tactical plan or indeed with any tactical direction.⁴⁹⁶

The only contact Temporary Superintendent Nawaz made with Inspector Smith was at 23:38,⁴⁹⁷ when communication occurred by telephone. In evidence, Temporary Superintendent Nawaz explained that he had made contact with Inspector Smith because he knew he was “Bronze on the ground”.⁴⁹⁸ In this conversation, Temporary Superintendent Nawaz sought an update,⁴⁹⁹ which was an appropriate request given that Inspector Smith was at the scene. However, Temporary Superintendent Nawaz provided no tactical guidance, which represents a failure on his part. This contact by Temporary Superintendent Nawaz was also, as I shall make clear when considering the role of tactical/silver command in due course, far too late.

Omitting to provide a tactical plan to Inspector Smith represents a significant failure of the GMP command structure on the night. Temporary Superintendent Nawaz is principally at fault in that regard, but ACC Ford, the Strategic/Gold Commander, should have realised that tactical command had failed.⁵⁰⁰ She should have ensured that the failure was corrected.

In this respect, Inspector Smith’s experience resembles that of PC Richardson. In the City Room, PC Richardson was Operational Firearms Commander and therefore Operational/Bronze Commander for the firearms operation. Inspector Smith was Operational/Bronze Commander for the unarmed operation. Like Inspector Smith, PC Richardson was provided with no tactical plan. In his case, the failure was that of the Initial Tactical Firearms Commander, Inspector Sexton. The failure within the GMP command structure in relation to tactical planning was therefore wide‑ranging and not restricted to a single individual.

Inspector Smith’s plan

Inspector Smith was left to devise and implement his own plan. To his credit, he did so. That involved making decisions at a strategic, tactical and operational level.⁵⁰¹ Once he had arrived in the City Room, his plan had two stages.⁵⁰² First, there were many severely injured people in the City Room. Their lives needed to be saved, if possible. That meant expert treatment and evacuation. Second, in the longer term, once lives had been saved, steps needed to be taken to preserve the area as a crime scene.⁵⁰³

This was the correct plan. It gives rise to two questions.

The first question is: who was to provide the treatment that Inspector Smith identified as necessary?

In evidence, Inspector Smith was clear that the first aid training he had received prior to the Attack was: “really basic first aid; it was nothing like trauma training”.⁵⁰⁴ For example, he had never received training in the application of a tourniquet.⁵⁰⁵ This lack of training was not unique to Inspector Smith. The unarmed officers generally lacked the skills necessary to deal with catastrophic bleeding and other life‑threatening conditions, something they found frustrating in the extreme.⁵⁰⁶ This was not the fault of Inspector Smith or the other unarmed officers. It was a reflection of a training regime across the country that needed to be improved if unarmed officers were to meet the challenge they faced on 22^nd May 2017. This is an important issue to which I shall return in Part 20 in Volume 2‑II.

The upshot was that Inspector Smith and the unarmed officers were never going to be able to provide the life‑saving interventions that the severely injured casualties in the City Room required. It is clear from the evidence that Inspector Smith recognised that reality immediately. As the radio messages and the footage from the body‑worn video cameras of certain unarmed officers reveal, it was the clear view of Inspector Smith from the outset that paramedics in numbers were needed in the City Room.⁵⁰⁷ He repeatedly made that clear and did so robustly. I will deal with examples of that shortly.

The second question is: in view of the declaration of Operation Plato, how was Inspector Smith’s wish for the attendance of paramedics to be achieved? As I have made clear, a declaration of Operation Plato, as had occurred by that stage, ought to be accompanied by a designation of zones. Such zoning will affect which emergency responders are able to respond in which areas.

A striking feature of the evidence was the limited extent to which Inspector Smith was aware of the meaning and the consequences of an Operation Plato declaration.⁵⁰⁸ He had heard of Operation Plato and knew that it was the response to a terrorist attack but did not know that it related specifically to a Marauding Terrorist Firearms Attack. He had received no training in zoning, so if someone had mentioned a particular zone that night, he would have needed to ask questions in order to understand what was meant by that zone.⁵⁰⁹ In fact, no one mentioned zoning until after 23:30, following the arrival of CI Dexter.⁵¹⁰

Inspector Smith’s usual job was as response inspector in an extremely busy inner‑city area. It is obvious that, in the event of a declaration of Operation Plato in Manchester, he might have a role to play.⁵¹¹ It is unacceptable that he should have had such an inadequate knowledge of Operation Plato. This does not represent a failure by Inspector Smith. It represents a failure in his training.

Inspector Smith was not operating on the firearms channel that night, so did not hear the FDO’s 22:47 broadcast declaring Operation Plato.⁵¹² In evidence, Inspector Smith explained that he was unaware of the declaration until told of it by CI Dexter following the Ground Assigned Tactical Firearms Commander’s arrival in the City Room.⁵¹³ The first meeting between Inspector Smith and CI Dexter that night can be seen on CCTV at 23:25:56.⁵¹⁴ This was just before CI Dexter switched on his Dictaphone.⁵¹⁵

The two men spoke again after switching on the Dictaphone, and those discussions were captured in the recording. Operation Plato was not mentioned on those occasions.⁵¹⁶ I am satisfied, however, that CI Dexter informed Inspector Smith of the declaration of Operation Plato in the unrecorded 23:25 conversation.

Accordingly, even if Inspector Smith had had a detailed and accurate understanding of Operation Plato, that would have been irrelevant to the work that he undertook during his first 38 minutes in the City Room, during which period he was unaware of the declaration having been made. This serves further to illustrate the extent of Inspector Sexton’s failure. Not only were NWAS and GMFRS unaware of the declaration of Operation Plato, but a significant figure within GMP command on the ground that night was similarly unaware of the declaration and discovered it only by chance.

While he was in the City Room and desperate for paramedics to arrive, Inspector Smith was not making his decisions by reference to zones. Instead, he made his assessment on the basis that it was “safe enough” for unarmed GMP officers, BTP officers, Arena staff and members of the public to enter and remain in the City Room.⁵¹⁷ The City Room was under the control of firearms officers. There was no sign of any armed terrorist. While Inspector Smith could not exclude the presence of a secondary device, he considered that unlikely.⁵¹⁸ Hence, it was his judgement that the area was safe enough for his staff, for the staff of the other emergency services and for the public who were helping the injured.

It is regrettable that no attempt was made by GMP strategic/gold or tactical/ silver command to obtain the views of Inspector Smith about the issue of safety in the City Room. Inspector Smith was a highly experienced and accomplished officer who was on the ground and had situational awareness. He had some experience of firearms and a background in police searching. He had an invaluable insight that was simply never sought. His view of the issue of safety in the City Room would have been the best‑informed view. It should have been obtained.

It follows from this analysis that Inspector Smith’s wish for the attendance of paramedics was not facilitated, as it ought to have been, by a careful, systematic designation of Operation Plato zones.

Implementation of the plan in the City Room

At 22:48:39, 48 seconds after he had entered the City Room, Inspector Smith made contact with GMP Control.⁵¹⁹ He said: “It looks to me like a bomb’s gone off here. I would say there’s about 30 casualties. Could you have every available ambulance to me please.”⁵²⁰ In evidence, Inspector Smith made clear that his expectation was that this request would result in paramedics coming to the City Room in large numbers.⁵²¹ Inspector Smith confirmed that he would not have asked for paramedics to come to the City Room unless he had thought it was safe enough for them to carry out their work there.⁵²²

Fewer than 90 seconds later, at 22:50:03, Inspector Smith passed a very similar message to GMP Control. He said:
“I need the station sealing off, please. We’ve got some ARV [Armed Response Vehicle] officers here. It looks as though what I said before was right. The booking hall is the seat of the explosion. It’s not the arena itself. There’s some walking wounded outside the arena but we’ve got a lot of casualties in here. Some of them look life threatening. I need every NWAS facility that we’ve got in here, please. Directly in here.”⁵²³

At 22:51:19, in a further conversation by radio with GMP Control, Inspector Smith emphasised that he wanted the entrances to the railway station sealed off and added: “Sent one of the PCs outside to tell any NWAS staff they need to get in here as soon as.” ⁵²⁴

Advanced Paramedic Patrick Ennis was the first NWAS resource at the scene.⁵²⁵ At 22:50:32, just after he had entered the station through the War Memorial entrance, Patrick Ennis spoke to GMP PC Grace Barker. It is clear that Inspector Smith’s message had reached her. The following exchange took place:
“[PC Barker] Every NWAS. They want every NWAS there.” “[Patrick Ennis] Where?”
“[PC Barker] At the booking office which is just … [upstairs].”⁵²⁶

Patrick Ennis made his way to the City Room, entering at 22:53.⁵²⁷ Almost straight away, he was approached by Inspector Smith, and the two men spoke.⁵²⁸ By the time they gave evidence, neither could recall what was discussed.⁵²⁹ However, given Inspector Smith’s strong determination that paramedics come to the City Room and given that Patrick Ennis was readily identifiable as a paramedic, it is overwhelmingly likely Inspector Smith raised this issue with him at that stage. When he gave evidence, Patrick Ennis agreed that in this conversation it was likely that Inspector Smith was communicating not only the seriousness of the situation, but also the need for paramedic resources to attend the City Room.⁵³⁰

At the end of this conversation, Inspector Smith made contact with GMP Control. He said that Patrick Ennis, whom he incorrectly but understandably identified as “Paramedic Bronze”, had arrived. Inspector Smith added: “He’s just having a look round to assess but still, if we get any more NWAS resources, send them in as soon as, please.” ⁵³¹

Inspector Smith showed determination and resourcefulness in seeking to get paramedics to the City Room in numbers. In his communications with GMP Control, he repeatedly made the need for paramedics clear. He ensured that an officer on Station Approach communicated that need for paramedics to Patrick Ennis. He told Patrick Ennis this himself. Inspector Smith could not realistically have done more than he did in this regard, given the other work that he was undertaking in the City Room.

At 22:49:14, shortly before Inspector Smith spoke to Patrick Ennis, a group of eight GMP officers ran into the railway station via the Todd Street entrance.⁵³² They were all members of a Tactical Aid Unit. The role of such a unit is to deal with, for example, high‑profile public gatherings, public order situations and large‑scale disturbances. Such units operate at the sharp end of policing.⁵³³

This particular Tactical Aid Unit had become aware of the events at the Arena at 22:35 and had travelled from their base immediately. Commanding the team was Sergeant Kam Hare.⁵³⁴ His leadership that night was exemplary, as was the performance of his team.

Having arrived and liaised with officers at the scene, Sergeant Hare’s team made their way to the City Room, with Sergeant Hare in the lead.⁵³⁵ By that stage, Sergeant Hare had switched on his body‑worn video camera.⁵³⁶ As the team walked along the raised walkway, Sergeant Hare’s body‑worn video camera records him telling the officers to stay together and remain calm. The team entered the City Room at 22:55.⁵³⁷ Inspector Smith saw them arrive. He understood the role of a Tactical Aid Unit and the capabilities of such a team. He described them as a “can-do team” and was pleased to see their arrival.⁵³⁸

Sergeant Hare had been told by GMP Control that Inspector Smith was in charge in the City Room.⁵³⁹ He made straight for Inspector Smith, who directed him and his team to check the casualties. Sergeant Hare shouted to his team: “Guys, first aid, first aid, first aid.” ⁵⁴⁰ He then instructed his officers to work in pairs. One of the team asked about the arrival of ambulances, and Sergeant Hare replied: “They’re coming mate. They’re co-ordinating.” ⁵⁴¹ In evidence, Sergeant Hare explained that he said this on the basis that the number of injured people made the attendance of paramedics necessary, and he therefore thought this would happen.⁵⁴²

In the period that followed, Sergeant Hare spoke to the injured, reassuring them that expert assistance was on its way; he encouraged his officers to help the casualties and exhorted his team to support each other. He and his team had received basic first aid training, but no more than that.⁵⁴³ As I have made clear, Inspector Smith was in exactly the same position: he had never received anything but basic training.⁵⁴⁴

It was obvious to Sergeant Hare that many of the casualties were seriously injured and required treatment by personnel who were better skilled and equipped than his team.⁵⁴⁵ As time passed and it became apparent to him that paramedics were not entering the City Room, he became concerned.⁵⁴⁶ At 23:00, a second Tactical Aid Unit team led by Sergeant John Goodwin entered the City Room.⁵⁴⁷ Sergeant Hare spoke to Sergeant Goodwin, saying: “We need the fucking medics John.” ⁵⁴⁸ He was referring to paramedics.⁵⁴⁹

Sergeant Hare continued to experience significant frustration at the fact that paramedics did not enter the City Room in numbers. At one stage, at 23:04, he shouted: “Come on paramedics.” ⁵⁵⁰ At 23:13, another officer shouted out to him, “Kam, are the paramedics coming?” to which he replied: “Paramedics mate, they need to be coming in in droves.” ⁵⁵¹

A highly unsatisfactory situation had developed. If NWAS and GMFRS were not going to enter the City Room promptly in sufficient numbers to preserve life and safely evacuate casualties, Inspector Smith needed early notice so that he could arrange an evacuation plan urgently. Ultimately, the fact that help was not coming in numbers dawned gradually on Inspector Smith, Sergeant Hare and others in the City Room.

In the absence of any significant NWAS deployment, Sergeant Hare, his team and indeed others in the City Room did what they could to provide support and treatment for casualties. They also became heavily involved in the evacuation of casualties.⁵⁵²

Involvement with those who died

GMP officers also sought to give help to those who were dying or had died.

PC Anthony Sivori covered Alison Howe.⁵⁵³

PC Owen Whittell,⁵⁵⁴ Sergeant Hare,⁵⁵⁵ PC Lauren Moore,⁵⁵⁶ PC David Lawrenson,⁵⁵⁷ Sergeant Stephen Wood,⁵⁵⁸ PC Gareth Wray,⁵⁵⁹ PC Nicholas White,⁵⁶⁰ Officer F2⁵⁶¹ and Sergeant Peter Anwyl⁵⁶² assisted Georgina Callander.

PC Whittell,⁵⁶³ Sergeant Anwyl⁵⁶⁴ and PC Thomas Ho‑McKenna⁵⁶⁵ gave CPR to Jane Tweddle. GMP officers PC Whittell⁵⁶⁶ and Sergeant Anwyl,⁵⁶⁷ and BTP PC Corke,⁵⁶⁸ covered Jane Tweddle when attempts at resuscitation were unsuccessful.

PC Ho‑McKenna and PC Chelsea Meaney both checked on John Atkinson while he was in the City Room.⁵⁶⁹ When the improvised stretcher on which John Atkinson was being carried failed, PC Leon McLaughlin went to seek help from NWAS together with Special Constable Michael Dalton.⁵⁷⁰ GMP Sergeant Darren Prince was involved in John Atkinson’s evacuation.⁵⁷¹

Sergeant Hare⁵⁷² sought to assist Kelly Brewster with a defibrillator. However, he found that, when he unpacked it, there were no defibrillator pads.⁵⁷³ PC Michael Williams assisted with evacuating Kelly Brewster from the City Room.⁵⁷⁴

PC Sivori⁵⁷⁵ and Sergeant Anwyl⁵⁷⁶ assisted Megan Hurley. Sergeant Hare assisted Megan Hurley, her father and brother.⁵⁷⁷ PC Whittell gave CPR to Megan Hurley and, with others, used a defibrillator in an attempt to resuscitate her.⁵⁷⁸ Officer F2 provided CPR to Megan Hurley.⁵⁷⁹ Officer F2 covered Megan Hurley when the attempts at CPR were unsuccessful.⁵⁸⁰ PC Gareth Dennison checked Megan Hurley for signs of life.⁵⁸¹

PC Sivori checked on Nell Jones. He believed that she had died when he saw her.⁵⁸² PC McLaughlin also checked Nell Jones for a pulse.⁵⁸³

Special Constable Dalton was involved in finding a makeshift stretcher for Saffie‑Rose Roussos.⁵⁸⁴ PC McLaughlin helped carry Saffie‑Rose Roussos from the City Room to Trinity Way.⁵⁸⁵

Sergeant Hare⁵⁸⁶ assisted Sorrell Leczkowski. PC McLaughlin gave CPR to Sorrell Leczkowski.⁵⁸⁷ Sergeant Anwyl and PC Hill also gave CPR to Sorrell Leczkowski.⁵⁸⁸ PC Hill was assisted by PC Michael Ball.⁵⁸⁹ PC Whittell used a defibrillator in an attempt to resuscitate Sorrell Leczkowski.⁵⁹⁰

PC McLaughlin checked on Wendy Fawell.⁵⁹¹

Evacuation of the casualties

Just before 23:00, NWAS Consultant Paramedic Daniel Smith arrived at Manchester Victoria Railway Station.⁵⁹² Shortly afterwards, he designated himself the NWAS Operational Commander.⁵⁹³ Patrick Ennis left the City Room⁵⁹⁴ and went to the station concourse, where he spoke to Daniel Smith and others from NWAS.⁵⁹⁵ He then returned to the City Room at 23:05.⁵⁹⁶ I will consider these events in further detail below.

By that stage, the work of evacuating the casualties had just started. Inspector Smith was heavily involved in that work and in directing it.⁵⁹⁷ In evidence, Inspector Smith explained that, absent expert assistance and equipment: “[M]y view was … we need to get them out as quickly as possible and we’ll use whatever we can to do that.” ⁵⁹⁸ This was the correct decision. Inspector Smith understood by this time, shortly after 23:00, that resources able to evacuate casualties in a conventional way were not going to arrive imminently. He rightly took a ‘needs must’ approach.⁵⁹⁹

At 23:12, having returned to the City Room, Patrick Ennis spoke to Inspector Smith.⁶⁰⁰ From that discussion, Inspector Smith learned that the Casualty Clearing Station was being set up on the station concourse.⁶⁰¹ The evidence reveals that, from that point, the work of evacuating casualties from the City Room increased in pace. Between 23:12 and 23:42, when the last casualty arrived in the Casualty Clearing Station, 33 casualties were evacuated from the City Room. All but eight of them were evacuated on makeshift stretchers.⁶⁰²

These casualties and their families were entitled to expect that evacuation would have occurred more promptly and in a way that was more appropriate and comfortable. That this did not occur was not the fault of Inspector Smith or any of the officers under his direction. They were doing the best that they could in extremely difficult circumstances.

At this stage, GMFRS had no presence in the City Room or indeed in the Victoria Exchange Complex. It is striking that neither Inspector Smith nor any of the others working to evacuate casualties were aware of their absence.⁶⁰³ On the evidence I heard, GMFRS possessed significant expertise in the extrication of casualties and considerable capacity in that regard.⁶⁰⁴ I would have expected their absence to have been obvious. That it was not, highlights a lack of education across the police in the capability of GMFRS. This reveals, too, that joint training had failed. The evidence revealed this to be an issue within NWAS too. I was left with a concern that there was a lack of adequate awareness on the part of each emergency service about the specialist capabilities of each other emergency service. Moreover, I am concerned that this problem may exist beyond Greater Manchester. This is an issue that needs to be addressed urgently by the Home Office, HMICFRS, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and all local resilience forums.

By 23:42, the last casualty had been evacuated from the City Room.⁶⁰⁵ Inspector Smith remained at the scene for many hours thereafter, eventually leaving after 04:00.⁶⁰⁶ While the system by which the casualties were treated and evacuated was entirely inadequate for the reasons I have set out and will develop further later in this Part, Inspector Smith had done all that he could in circumstances that were extremely trying. He provided real leadership to the rescuers and compassion to the injured. His decision‑making was prompt and effective.

GMP Tactical/Silver Commander (Night Silver)

Role of Night Silver

In dealing with the actions of Inspector Smith in the policing response to the Attack, I referred to his contact with Temporary Superintendent Nawaz, the Night Silver. I will turn next to address the role of Temporary Superintendent Nawaz in further detail.

First, it is relevant to recall where Night Silver fits in to the GMP command structure. As I have explained, the command structure for the response to any Major Incident will have three levels: gold command, also known as strategic command; silver command, also known as tactical command; and bronze command, also known as operational command.⁶⁰⁷

There will generally be a single Strategic/Gold Commander. That person’s role is to set the strategic plan. The purpose of that plan is to manage and resolve the incident.⁶⁰⁸ On the night of the Attack, ACC Ford was Strategic/ Gold Commander.⁶⁰⁹ I will turn to her role specifically in due course. It will, however, be necessary for me to address some aspects of her decision‑making in considering the actions of the Night Silver.

There will often be more than one Tactical/Silver Commander.⁶¹⁰ That will enable separate Tactical/Silver Commanders to set the tactical plan for different functional areas.⁶¹¹ For example, where a policing response involves the deployment of both armed and unarmed assets, it may be appropriate for the armed assets to be under the command of one Tactical/Silver Commander and the unarmed assets to be under the command of a second Tactical/Silver Commander.

On the night of the Attack, a number of officers held tactical/silver command for different functional areas. Inspector Sexton held tactical command for the overall firearms operation as Initial Tactical Firearms Commander until he was later relieved of that role by Superintendent Thompson.⁶¹² CI Dexter took the role of Ground Assigned Tactical Firearms Commander on his arrival at the scene at 23:23.⁶¹³ Temporary Superintendent Nawaz was Night Silver and, in that capacity, became Tactical/Silver Commander for the scene up until he was replaced, at around 00:00 on 23^rd May 2017, by Temporary Superintendent Hill.⁶¹⁴

There will usually be several Operational/Bronze Commanders.⁶¹⁵ Their role will be to organise separate resources to carry out the tactical plan.⁶¹⁶ On the night of the Attack, PC Richardson held operational command for the firearms officers at the Arena,⁶¹⁷ and Inspector Smith held operational command for the unarmed officers in the City Room.⁶¹⁸ As I have explained, neither was provided with a tactical plan by their respective Tactical/Silver Commanders and that represents a significant failure of GMP command on the night.

As I explained in Part 12, GMP produced guidance entitled ‘Silver Commanders Guide’ for those undertaking the role of Tactical/Silver Commander. The evidence indicates that the version in force at the time of the Attack was Version 1.4. This had been introduced in 2010.⁶¹⁹

The Silver Commanders Guide dealt with the role of Night Silver. Night Silver is the most senior GMP officer on duty at night. It is an important role so will commonly be undertaken by a Superintendent. The Silver Commanders Guide provided that:
“The night silver superintendent provides an active role within the force and attends any serious, major or unusual events; ensuring incidents are effectively managed and properly resourced. You will need to implement appropriate command and control structures, recognise the potential for an event becoming or escalating into a critical incident and protect the interests / reputation of the force.”⁶²⁰

Scott Wilson, one of the Policing Experts, described the role as being Chief Constable of the police service during the night.⁶²¹

The Silver Commanders Guide made clear that a Tactical/Silver Commander, whether Night Silver or otherwise, commands and co‑ordinates the overall tactical response pursuant to the Strategic/Gold Commander’s strategy. As part of that role, the Tactical/Silver Commander has the following responsibilities, among others: developing and co‑ordinating the tactical plan; being suitably located in order to maintain effective tactical command of the incident or operation; providing the pivotal link in the command chain between Operational/Bronze Commanders and the Strategic/Gold Commander; ensuring that the tactics employed by Operational/Bronze Commanders meet the strategic intention and tactical plan; managing and co‑ordinating, where required, multi‑agency resources and activities during the response to an incident or operation; and ensuring that Operational/Bronze Commanders understand the strategic intentions, the key points of the wider tactical plan, and tactical objectives that relate specifically to their area of responsibility.⁶²²

Temporary Superintendent Nawaz

Temporary Superintendent Nawaz joined GMP in 2000. In 2004, he was promoted to the rank of Sergeant. He was promoted to the rank of Inspector and, in March 2012, to the rank of Chief Inspector.⁶²³ In 2013, he was accredited as a public order Bronze Commander and thereafter performed that role at a number of pre‑planned events, such as football games.⁶²⁴ Spontaneous events such as the Attack will present greater challenges than pre‑planned incidents. In 2015, this officer was appointed as Temporary Superintendent, undertaking the role of Divisional Superintendent for Manchester City Centre. In 2016, he was accredited as a Silver Commander for public order and public safety events and thereafter performed that role at a number of pre‑planned events.⁶²⁵

On his appointment as a Temporary Superintendent in 2015, he was placed onto the Night Silver rota. Temporary Superintendent Nawaz estimated that in the two years prior to the Attack, he had performed that role on no more than ten occasions, probably fewer.⁶²⁶

I accept that Temporary Superintendent Nawaz has sound qualities in areas of policing. However, he was not competent to perform the role of Night Silver on the night of the Attack if for no other reason than he had not had the requisite training.

There were a number of glaring omissions in the training, knowledge and experience of Temporary Superintendent Nawaz as of 22^nd May 2017. First, he had received no training in what his role as a Superintendent would be in the event of a terrorist attack and had no recollection of ever having been involved in a training exercise involving terrorism.⁶²⁷

Second, he had never heard of Operation Plato. He had no idea that this represented the response to any form of terrorist attack, let alone the response to a Marauding Terrorist Firearms Attack.⁶²⁸

Third, as I have explained, at an early stage, Inspector Sexton authorised an emergency search. Temporary Superintendent Nawaz had no idea what this was. Indeed, he had no experience of firearms command at all.⁶²⁹

Fourth, Temporary Superintendent Nawaz’s experience of tactical/silver command of any type was limited and was restricted to pre‑planned public order and public safety events. A spontaneous event, particularly one on the scale of the Attack, was always going to be significantly more challenging than anything Temporary Superintendent Nawaz had experienced previously.⁶³⁰

In drawing attention to these inadequacies of Temporary Superintendent Nawaz, I have not overlooked the fact that in an Operation Plato situation, tactical firearms command will sit with the Initial Tactical Firearms Commander, and later Tactical Firearms Commander, not with the Night Silver.⁶³¹ However, the Night Silver has a critical role in an Operation Plato response by providing tactical command for those at the scene (or scenes). The Night Silver will need to work with the firearms commanders and so will need to understand their operation.⁶³² It is not possible for the Night Silver to perform that role with the level of training, knowledge and experience that Temporary Superintendent Nawaz had. The reality is that Temporary Superintendent Nawaz had little idea what was going on during the period that he held tactical command. That is unacceptable.

Temporary Superintendent Nawaz himself recognised in evidence that his training and experience did not equip him to deal with a terrorist incident.⁶³³

This was also the view of ACC Ford, who was Strategic/Gold Commander on the night. She gave the following straightforward evidence:
“[Counsel to the Inquiry] [Is the upshot that Temporary Superintendent Nawaz] was not competent to perform the role that he was initially put into?
[ACC Ford] I think that’s a fair assessment because he hadn’t been given training and knowledge that he should have had in order to fulfil that role that night.
[Counsel to the Inquiry] That does or may reveal a systemic problem that you had someone in that critically important role that was not qualified for it.
[ACC Ford] Absolutely. And finding out in the midst of an incident, an attack, that someone doesn’t know what Plato is – and I have seen the broader evidence, sir, from the force duty officer’s team – the lack of awareness of Plato was something that organisationally GMP needs to or should have considered beforehand, which it certainly needs to consider now.”⁶³⁴

In May 2017, as I have emphasised many times, the Joint Terrorism Analysis Centre Terrorism Threat Level was at ‘severe’. This meant that an attack was highly likely. On the night of 22^nd to 23^rd May 2017, the Night Silver on duty was not competent to perform that role in the event that such an attack occurred. GMP should have identified that fact given that it had been responsible for Temporary Superintendent Nawaz’s training and career development since 2000. Temporary Superintendent Nawaz should never have been in the position he was in. That he was represents a significant failure on the part of GMP.

Actions of Temporary Superintendent Nawaz

In the early evening of 22^nd May 2017, Temporary Superintendent Nawaz located himself at Central Park Police Station in order to perform his Night Silver duties. He was with an officer who was shadowing him for career development purposes. There could be no criticism of that officer.

At 22:39, Temporary Superintendent Nawaz received a telephone call from the Force Duty Supervisor, Ian Randall. Ian Randall informed him of the explosion at the Arena.⁶³⁵ Temporary Superintendent Nawaz then took steps to locate and print out a contingency plan for the Arena.⁶³⁶ This may have been a sensible step to take, but it took time and is something he should have delegated to the officer who was shadowing him. In fact, the plan was outdated, and Temporary Superintendent Nawaz made no real use of it. What he had done was a waste of his time. Even if the plan had proved relevant, there were more pressing things for him to have done. He should have set off for the scene immediately.

At 22:50, Inspector Sexton telephoned Temporary Superintendent Nawaz.⁶³⁷ He informed the Night Silver that there were confirmed deaths as a result of a suicide bombing. The following exchange then took place:
“[Inspector Sexton] … So, I’ve declared an Op Plato, which is a terrorist attack.
[Temporary Superintendent Nawaz] Op What?
[Inspector Sexton] Op Plato, which is a terrorist attack.
[Temporary Superintendent Nawaz] Yeah.”⁶³⁸

I am critical of GMP for putting Temporary Superintendent Nawaz into a role that he was not competent to perform. However, in this conversation, Temporary Superintendent Nawaz effectively kept his lack of knowledge from the FDO. At no stage in that conversation or in any other conversation, including in his conversations with the Strategic/Gold Commander, did Temporary Superintendent Nawaz reveal his ignorance of Operation Plato. He allowed others within the command structure to believe that he understood what was happening, when he did not. Temporary Superintendent Nawaz should have explained that he did not understand what Operation Plato was and that he did not know what his role was within it.

If Temporary Superintendent Nawaz had done that, it is likely he would have been replaced at an earlier stage. As it was, Temporary Superintendent Nawaz retained tactical/silver command for nearly 70 minutes longer.⁶³⁹ During that time, he made no contribution of substance to the emergency response. A more experienced and knowledgeable Tactical/Silver Commander would have made a positive contribution.

At 22:52, Temporary Superintendent Nawaz telephoned ACC Ford.⁶⁴⁰ There is no recording of that conversation, which lasted just short of three minutes. The result of the call was that Temporary Superintendent Nawaz, who had initially intended to travel to the scene and could have been there by 23:00, instead went to GMP HQ to set up the Silver Control Room.⁶⁴¹

Throughout much of the evidence in relation to the emergency response, there was a debate between witnesses about whether the Tactical/Silver Commander should go to the scene or to GMP HQ.⁶⁴² I will consider this issue when I deal with the involvement on the night of CI Dexter, the Ground Assigned Tactical Firearms Commander. My view is there will undoubtedly be situations in which a Tactical/Silver Commander must be at GMP HQ. That does not mean that a Tactical/Silver Commander cannot be at the scene. In most complex incidents, it is likely to be necessary to have separate Tactical/Silver Commanders at GMP HQ and the scene or scenes.

At 23:00, Temporary Superintendent Nawaz telephoned the Force Duty Supervisor.⁶⁴³ In evidence, he explained that at this stage he had not reached GMP HQ. He was either still at Central Park or on his way to GMP HQ with the officer who was shadowing him.⁶⁴⁴ In the call, Temporary Superintendent Nawaz explained that he considered a number of people ought to be contacted. With the possible of exception of the North West Counter Terrorist Unit, the Force Duty Supervisor had already contacted them all.⁶⁴⁵ This is not a criticism of Temporary Superintendent Nawaz. It was sensible for Temporary Superintendent Nawaz to make those checks.

Temporary Superintendent Nawaz and the officer who was shadowing him arrived at GMP HQ at about 23:10 and entered the Silver Control Room. They were the first to arrive, but within a short time many others joined them.⁶⁴⁶

At 23:34, Temporary Superintendent Nawaz made a radio call to ascertain “who’s the commander at scene?” He was told that it was “6694, Inspector Smith”.⁶⁴⁷ Temporary Superintendent Nawaz was the Tactical/Silver Commander for the scene. I have listened to the recording of this call a number of times. That left me in no doubt that, at 23:34, Temporary Superintendent Nawaz was unaware of the critical role Inspector Smith was performing at the scene.⁶⁴⁸ It is difficult to understand how he lacked that knowledge. Inspector Smith had been in the City Room for 47 minutes by this time.⁶⁴⁹ His collar number had appeared on the incident log 40 times during that period. His voice had been heard repeatedly on the radio, seeking the attendance of paramedics.

That Temporary Superintendent Nawaz did not know what Inspector Smith was doing at the scene, and did not know what Inspector Smith desperately wanted for the City Room in terms of help and resources, is inexplicable and inexcusable.

At 23:38, Temporary Superintendent Nawaz telephoned Inspector Smith, and they communicated for just over three minutes.⁶⁵⁰ As I explained when dealing with Inspector Smith’s role at paragraph 13.384, in this call, Temporary Superintendent Nawaz sought an update but provided no tactical plan or tactical guidance.

In evidence, Temporary Superintendent Nawaz was pressed on what appeared to be a failure to discharge one of his core responsibilities, namely to provide a tactical plan for implementation by the Operational/Bronze Commander.⁶⁵¹ He accepted that he had not handed over what he described as “a documented plan”.⁶⁵² However, he maintained that he had developed a 20‑point tactical plan, albeit one that he had not committed to writing.⁶⁵³

By the time he gave evidence, Temporary Superintendent Nawaz had set out those points in writing. I am not clear at what point he did so, save that it was plainly after the night of the Attack. He provided the list to the Inquiry Legal Team following the completion of his evidence.⁶⁵⁴ It contains 19 items. It is not an impressive document. Most of the listed items are descriptions of activities rather than tactical decisions or directions. For example: “review the FWIN [Force Wide Incident Number]” and “locate Arena plan”.⁶⁵⁵

Many others on the list are things that had already been done before any active involvement by Temporary Superintendent Nawaz, as any review of the master incident log would have revealed to him, such as: “BTP to be made aware and attend”; “ARVs [Armed Response Vehicles] to scene”; and “unarmed Bronze Commander to the scene”.⁶⁵⁶ Where the list described sensible tactical decisions, Temporary Superintendent Nawaz had done nothing to implement them himself or to communicate to the Operational/Bronze Commander the need to do so. “GMFRS to be notified and attend” and “Collocate, coordinate and communicate with partners” are examples of these.⁶⁵⁷

If this document represents Temporary Superintendent Nawaz’s cotemporaneous but undocumented tactical plan, it serves only to emphasise how ill‑equipped he was in the role of Tactical/Silver Commander that night.

Among the things that the tactical plan should have addressed were the following: ensuring that a Major Incident declaration was made and communicated within GMP and to emergency service partners; directing that a METHANE message be obtained and communicated within GMP and to emergency service partners; directing the implementation of the Major Incident Plan; setting tactical objectives, including the treatment and evacuation of casualties; joint working with emergency service partners; appointing Operational/Bronze Commanders; liaising with the FDO; establishing multi‑agency tactical communications; directing the setting up of the FCP; and ensuring adequate tactical command at the scene.

None of that was addressed by Temporary Superintendent Nawaz, nor did he make any substantial attempt to address any of these important actions. He also failed to discharge all or almost all of the responsibilities of a Tactical/Silver Commander listed in the Silver Commanders Guide, perhaps because he had not read it.⁶⁵⁸ His failures are mitigated but not excused by the fact that GMP had not trained him adequately for the role.

Replacement of Temporary Superintendent Nawaz

As ACC Ford made her way to GMP HQ, she spoke to Temporary Superintendent Nawaz on two further occasions: at 23:10 for 13 seconds⁶⁵⁹ and at 23:12 for just short of two minutes.⁶⁶⁰ As a result of those conversations, ACC Ford developed “a growing unease”.⁶⁶¹ She explained:
“I felt that in terms of tactical command and updates and command being applied to the situation that little had moved on or progressed since the original conversation. So, while I hadn’t – I don’t believe I’d consciously decided at that point that Arif [Temporary Superintendent Nawaz] didn’t really understand or didn’t know what Plato was, but the fact that Chris [Temporary Superintendent Hill] had offered and I had previous experience of him as an experienced commander, that gave me reassurance that he would be able to come in and apply the command and control needed.”⁶⁶²

She agreed that even as she drove towards GMP HQ she was developing a sense that Temporary Superintendent Nawaz was “not the right man for the job in these circumstances”.⁶⁶³

The “Chris” to whom ACC Ford referred was Temporary Superintendent Hill, an officer who had experience in operational/bronze, tactical/silver and strategic/ gold command roles and who was also an experienced firearms commander.⁶⁶⁴ He had become aware of the Attack and offered to help. He spoke to ACC Ford, and she instructed him to attend GMP HQ and take up the role of Tactical/ Silver Commander.⁶⁶⁵ I find that ACC Ford acted promptly to replace Temporary Superintendent Nawaz once she became aware of the extent of the problem.

Temporary Superintendent Hill relieved Temporary Superintendent Nawaz at about 00:00 on 23^rd May 2017, 90 minutes after the explosion.⁶⁶⁶ By that stage, all casualties had been removed from the City Room.⁶⁶⁷ Despite his experience and preparedness to help, by that stage there was nothing of substance Temporary Superintendent Hill could do to make a difference to the emergency response at the Victoria Exchange Complex.

ACC Ford was asked whether for a prolonged period that night she lacked a Tactical/Silver Commander who was qualified and equipped to the extent that she was entitled to expect. She agreed that was so.⁶⁶⁸ She was right to acknowledge that fact. The role of Night Silver failed that night to an extent that was fundamental and major.

GMP Strategic/Gold Commander

Assistant Chief Constable Ford

In 2017, as now, GMP operated a rota that ensured a Strategic/Gold Commander was available when an incident required strategic command.⁶⁶⁹ That person, known as ‘duty Gold’, was always a qualified Strategic Firearms Commander so that if a firearms deployment was needed, duty Gold could provide strategic oversight for this deployment as well as for the response more generally.⁶⁷⁰

On the night of the Attack, ACC Ford was rostered as duty Gold and duty Strategic Firearms Commander. She was a highly trained and experienced senior officer.⁶⁷¹

ACC Ford became accredited as a Gold Commander in early 2015, while an officer in Northumbria Police. The focus of this training was on public order.⁶⁷² Having become accredited, ACC Ford performed the role of Strategic/Gold Commander on many occasions at major events in the North East. Each of those events was pre‑planned, such as the Great North Run and football derby games. Spontaneous events are likely to present greater challenges than pre‑planned incidents, as ACC Ford identified and emphasised when she reflected on the Attack.⁶⁷³

ACC Ford had significant experience of firearms command. She became a Tactical Firearms Commander in 2010 and passed the Strategic Firearms Commander course in 2015. Between 7^th and 12^th May 2017, only days before the Attack, she attended a specialist firearms commander course.⁶⁷⁴ The aim of that course was to prepare senior firearms commanders for the additional demands of the policing response to the most demanding operations, including counter‑terrorism operations.⁶⁷⁵

ACC Ford stated in evidence that, although her training as a firearms commander provided a good foundation for responding to the Attack, she thought more could have been done to prepare her for the specific demands of an Operation Plato situation.⁶⁷⁶ She explained that a way needed to be found to prepare commanders for the exceptional pressures involved in responding to a spontaneous incident such as a terrorist attack.⁶⁷⁷

After completing her evidence, at my request, ACC Ford set out her views about this and other areas for change and improvement in a witness statement dated 28^th May 2021.⁶⁷⁸ I am grateful for her views, which are informed and instructive. She summarised her position in relation to training in Operation Plato in this way:
“In my opinion, a more stringent approach is needed to testing and exercising. We need to create the stress, pressure and pace of a no notice attack to test decision making in an intense, dynamic atmosphere.”⁶⁷⁹

ACC Ford may well be describing a concept about which Pre‑Hospital Care Expert Lieutenant Colonel Dr Claire Park gave evidence when the Inquiry considered the Care Gap, namely high‑fidelity training.⁶⁸⁰ I will consider this in Part 20 in Volume 2‑II. In any event, having performed the role of Strategic/Gold Commander on the night of the Attack, ACC Ford’s insight in this regard is one that CTPHQ and the College of Policing should take on board.

Notwithstanding that ACC Ford considered that she would have benefited from additional training, she was well aware of what Operation Plato was and what its declaration would require of her and others.⁶⁸¹ She expressed a serious concern in evidence that not all of those involved in the emergency response were as well informed as her or, in some cases, informed at all. She explained that, as the events of the night of the Attack unfolded, it became apparent to her that many members of staff who were directly involved in the response lacked knowledge of Operation Plato, including the Night Silver and her own staff officer.⁶⁸² This was plainly a surprising and disturbing revelation for ACC Ford.

I share ACC Ford’s concern. As I have explained, all officers, whether armed or unarmed, should be educated in what Operation Plato involves and what will be expected of them in the event of such a declaration. That should be so across the country.

ACC Ford had received specific training in JESIP, both on the introduction of those principles and subsequently. When she attended the College of Policing strategic command course in early 2016, part of the training involved an exercise that was focused on the importance of joint working for Strategic/Gold Commanders.⁶⁸³ ACC Ford also had substantial practical experience of working in collaboration with the emergency service partners of the police and other bodies. For example, when an officer of Northumbria Police, ACC Ford had been a member of the local resilience forum.⁶⁸⁴

In evidence, ACC Ford gave a clear account of the training she received over the course of her career. However, her recollection was not fully reflected in her training records.⁶⁸⁵ I am satisfied that ACC Ford’s recollection is to be preferred to the records. Her police training records were not the only ones that I heard about in evidence which were incomplete or inaccurate. The records relating to Temporary CI Buckle were also incomplete, and the thrust of the evidence was that this was a more generalised problem.⁶⁸⁶ As ACC Ford agreed, that is an unsatisfactory state of affairs.⁶⁸⁷ For obvious reasons, it should be possible to identify what training an officer has undertaken. This problem is not restricted to GMP, because ACC Ford’s Northumbria records were also incomplete.⁶⁸⁸

This is a problem that needs to be resolved. In her witness statement of 28^th May 2021, ACC Ford said:
“I think that each officer and staff member should have an electronic training record held by their force, which is transferable with the individual if they change forces and that is consistent in the type of training recorded. The individual should be able to view their record, review its accuracy and agree it on an annual basis. This would enable identification of training or exercising gaps which would need to be addressed. This could include all courses, including the nationally accredited courses held by the College of Policing and for example, table tops, testing and exercising, and national exercises within Counter Terrorism policing.”⁶⁸⁹

I agree and recommend the College of Policing consider the introduction of a national scheme that achieves this.

Notification of Assistant Chief Constable Ford

Ariana Grande is a major US performing artist. Her concert at the Arena was a sell‑out. It brought approximately 14,500 people, many of them children, into the centre of Manchester from all around the country. ACC Ford was unaware that any event was taking place at the Arena that night, let alone one of that size or with that profile.⁶⁹⁰ It is unacceptable that duty Gold did not know that such a major event was taking place in Manchester. That is so for a number of reasons, including the fact that the event presented a potential target for terrorists and, in the event of an attack, GMP would be required to respond. In future, all police services should ensure that mechanisms are in place to ensure that the duty command structure is aware of any major event taking place within the force area.

Each duty Gold shift is lengthy. Accordingly, where the demands of the role allow, the duty Gold is permitted to rest.⁶⁹¹ On the night of the Attack, ACC Ford was at home and asleep in bed when she was woken by a telephone call from Temporary Superintendent Nawaz at 22:52.⁶⁹² He informed her that an attack had taken place at the Arena and that many were dead and injured. He also told her that Operation Plato had been declared. As I have explained, Temporary Superintendent Nawaz did not inform ACC Ford that he was unaware what Operation Plato was. ACC Ford did not check on his knowledge, but I am not critical of her in that regard.⁶⁹³ She was entitled to expect that the Night Silver would have known what the declaration of Operation Plato meant and, if not, to have informed her of that gap in his knowledge, something he did not do.

Given the declaration of Operation Plato, ACC Ford would have expected to have been contacted by the FDO, but that had not happened. At the end of the call, which lasted for nearly three minutes, ACC Ford asked Temporary Superintendent Nawaz to open up the Gold and Silver Control Rooms at GMP HQ. ACC Ford explained to me that she did this because she was keen to get command and control established as quickly as possible. Accordingly, it was her expectation that Temporary Superintendent Nawaz would go to GMP HQ, not to the scene.⁶⁹⁴

This takes me back to the debate over whether the Tactical/Silver Commander should go to the scene of an incident.

I am not critical of ACC Ford for sending Temporary Superintendent Nawaz to GMP HQ. I accept that it was reasonable to direct someone senior to establish the hub of command operations. I accept also that ACC Ford recognised the possibility that the Attack might be the start of a series of attacks at multiple sites, as had occurred in Mumbai in November 2008 and in Paris in November 2015.⁶⁹⁵ If that had occurred, having a Tactical/Silver Commander at GMP HQ as opposed to at just one of a number of scenes would have been beneficial in terms of ensuring an overall tactical plan was in place and was implemented.

Equally, however, from the first notification to ACC Ford of the Attack, it was obvious that many officers would be needed at the Arena, both armed and unarmed. ACC Ford should have given consideration at that early stage to the question of which officer would provide tactical command for the unarmed officers at the scene and should have ensured that such command was achieved. She did not do so.

Instead, whether the unarmed assets would come under effective command was left to chance. Inspector Smith stepped up to command those officers in the City Room, and CI Dexter, following his arrival at 23:23, stepped up to command the unarmed assets at and around the Victoria Exchange Complex.⁶⁹⁶ CI Dexter did so notwithstanding that his principal focus was on the armed assets in his role as Ground Assigned Tactical Firearms Commander.⁶⁹⁷ The emergency response to the Attack benefited from the presence of two such experienced and committed officers at the scene. They made it work, within the limits of their control. However, there can be no guarantee that would happen in the aftermath of a terrorist attack. In future, those responsible for the response to a terrorist attack must ensure that an experienced officer arrives at the scene or scenes promptly with the sole or principal task of providing tactical command to the unarmed assets. This is an issue upon which CTPHQ and/or the College of Policing should issue clear guidance.

While still at home, ACC Ford took steps to ascertain the nature of the concert at the Arena, and the demographic of the audience.⁶⁹⁸ Those steps would have been unnecessary if the system I recommend above had been in place. She then called the Chief Constable, Ian Hopkins,⁶⁹⁹ and the Head of the North West Counter Terrorist Unit, Chief Superintendent Russell Jackson, to let them know what was happening.⁷⁰⁰ Next, she called her staff officer⁷⁰¹ and Chief Superintendent John O’Hare,⁷⁰² a highly experienced firearms commander. Those were sensible steps for ACC Ford to take in her role as Strategic/Gold Commander. They show that she was thinking in a clear and structured way about the response to the Attack.

Throughout this period at home, ACC Ford also made attempts to contact the FDO. This, too, was sensible. She was unable to get through despite a number of attempts.⁷⁰³ This is illustrative of the problem to which I referred when considering the role of the FDO that night. The FDO line had become overloaded. The upshot was that one significant figure within the command structure was unable to make contact with another significant figure within that structure. That the Strategic/Gold Commander, who was also Strategic Firearms Commander, was unable to get through to the FDO, who was also Initial Tactical Firearms Commander, was unacceptable.

There is an obvious degree of speculation involved in seeking to ascertain what ACC Ford would have learned if contact had been made with the FDO at this stage, namely around 23:00. She may simply have assumed that Inspector Sexton had done all that he ought to have done, as she did in respect of others. However, given her keenness to speak to the FDO and to do so at an early stage, there exists the reasonable possibility that she would have learned that the declaration of Operation Plato had not been communicated to NWAS, NWFC or GMFRS. If so, she may have discovered that the issue of Operation Plato zoning had not been addressed.⁷⁰⁴ At the very least, the difficulties in communication deprived the Strategic/Gold Commander of the opportunity to discover that things were going wrong.

After 22^nd May 2017, ACC Ford took part in a debrief.⁷⁰⁵ One of the recommendations that emerged was for the creation of a dedicated hotline by which senior staff within the command structure could contact the FDO.⁷⁰⁶ Unsurprisingly given her experience on the night, ACC Ford wholeheartedly supports that recommendation.⁷⁰⁷ So do I, not only within GMP but across the country. This should be a hotline that those within the command structure of all three emergency services are able to use. I recommend CTPHQ and the College of Policing take this forward.

By 23:05, ACC Ford was on the road, driving to GMP HQ. The journey was just under five miles. During the course of it, she made and received calls. She made contact with Temporary Superintendent Nawaz on two occasions.⁷⁰⁸ In those calls, ACC Ford gained no additional information from the Night Silver.⁷⁰⁹ As I explained earlier, she therefore began to develop a concern about the competence of Temporary Superintendent Nawaz.⁷¹⁰ Later this was to cause her to replace him.

At 23:13, while still travelling to GMP HQ, ACC Ford was telephoned by CI Dexter.⁷¹¹ He was travelling towards the Arena and had not yet switched on his Dictaphone. CI Dexter could not get through and left a voicemail.⁷¹²

Force Command Module

ACC Ford arrived at GMP HQ at about 23:15 and entered the Force Command Module at about 23:20.⁷¹³ In Part 12, I explained that Force Command Module housed both the Gold and Silver Control Rooms. ACC Ford agreed that, usually, and certainly for pre‑planned operations, the Gold and Silver Control Rooms would be separate from each other.⁷¹⁴ That has the advantage of ensuring that there is delineation between strategic and tactical decision‑making. On the night, ACC Ford considered that combining the two was the better approach:
“It felt entirely appropriate on the night given the fact that there was so much information, so many views, so much on the log, that to separate that out, it would have drawn me away from the ability to have that communication in the room and understand if there were issues from other agencies, issues for my own staff in terms of the tactical command of the firearms operation, the tactical command room and [CI] Mark Dexter at that scene. To separate them out would have left me isolated from all the information that was coming into that location.”⁷¹⁵

ACC Ford’s explanation made sense to me. However, as I shall explain, there were things missed by her that night. I formed the impression that there may have been too much going on in the combined command room, too many people present and too much information being passed to enable ACC Ford to maintain focus on her strategic role. Ultimately, the evidence did not provide a clear answer to the question of whether a combined command room is a good or bad idea, or whether it depends on the nature of the incident. I recommend CTPHQ and the College of Policing consider this issue with a view to issuing guidance.

Once inside the Force Command Module, ACC Ford called the Chief Constable again,⁷¹⁶ updating him. At 23:41, she telephoned CI Dexter in response to his earlier voicemail message.⁷¹⁷ By that stage, CI Dexter had been at the scene for 18 minutes⁷¹⁸ and had spent time in the City Room.⁷¹⁹ He had good situational awareness. The call between ACC Ford and CI Dexter lasted for just over four minutes.⁷²⁰ Shortly after he arrived at the scene, CI Dexter activated his Dictaphone. I have been able to listen to his side of the conversation. It is clear that the call enabled ACC Ford to gain some situational awareness, but she does not appear to have provided any strategic or other direction to CI Dexter.⁷²¹ I acknowledge that she had a lot to think about and do at the time, but she should not have overlooked this.

Shortly after coming off the telephone from CI Dexter, ACC Ford set out her working strategy in writing in her Gold Duty Book. It read:
“* Protect the public from harm
Minimise the risk to the public
Maximise safety of officers/staff/first responders
Provide information to victims and families that is accurate and up to date”⁷²²

In evidence, ACC Ford accepted that this was somewhat general, but maintained that she considered the strategy was adequate.⁷²³ The Policing Experts were not critical of ACC Ford’s strategy.⁷²⁴ On the evidence, however, she did not communicate her plan, at least not adequately, to the Tactical/Silver Commanders. This is a further example of an issue that arose across the night and across the command structure because, as I have pointed out, no tactical plan was formulated or, if formulated, was not adequately communicated to the Operational/Bronze Commanders. Most of the GMP commanders tackled what was in front of them. That is not unreasonable given the enormity of what they each faced. However, planning at the three levels of command is of obvious importance as is the communication of those plans.

I recommend the College of Policing consider whether the current requirements are too onerous or unwieldy and whether some simpler approach may be achievable. It may be that there is a view that the strategic plan in this type of incident is so obvious that it doesn’t need specifically to be set out to Tactical/Silver Commanders but, if so, that needs to be understood by all in the command structure and needs to be communicated in the plans.

ACC Ford is a highly professional officer with strong qualities. The Force Command Module was an extremely busy and stressful place. Many decisions were made as part of what ACC Ford described as “the consequence management” of the Attack.⁷²⁵ By this, she meant, for example, ensuring that the families of casualties and the dead should receive information and support, that Manchester should get back up and running as soon as possible, and that the investigation into what had happened and who was responsible should be progressed.⁷²⁶ All of that, I acknowledge, was important, and ACC Ford and her team in the Force Command Module worked hard to achieve those aims. The Policing Experts considered that, in the circumstances of great stress and pressure, ACC Ford got much right.⁷²⁷ I agree, but if lessons are to be learned and change implemented, what did not go right needs also to be acknowledged.

It is important to ask what difference the Force Command Module and those within it made to the emergency response as distinct from the aftermath of that response. ACC Ford gave the following candid evidence on that issue:
“[Counsel to the Inquiry] In terms of what actually happened on the ground and in particular in the period … to one hour after the declaration of Plato, so we are at 11.47, did anything happen, either in the Gold Command Suite or in the Silver Command Suite that made any difference to what happened on the ground?
[ACC Ford] In the actual response to as opposed to things that happened after?
[Counsel to the Inquiry] Yes.
[ACC Ford] Probably not, no.”⁷²⁸

In my view, ACC Ford and those she commanded within the Force Command Module were capable of making a difference to the emergency response and should have done so. As Strategic/Gold Commander, ACC Ford could and should have done the following things in the period after her arrival at GMP HQ.

First, by the time of ACC Ford’s arrival into the Force Command Module, GMP had not declared a Major Incident.⁷²⁹ As I have explained, the events at the Arena were, without doubt, a Major Incident within the meaning of the GMP Major Incident Plan. ACC Ford was entitled to expect that someone would have addressed this issue in the period before her arrival, indeed even before she was alerted to the events at the Arena at 22:52. However, this step was sufficiently important that she should have checked that it had been done. She did not do so.⁷³⁰ Had she made that check, she would have realised that this important step had not been taken and would have dealt with it herself. ACC Ford accepted this in evidence.⁷³¹ For the reasons I identified earlier, the declaration of a Major Incident would have made a difference to the emergency response.

Second, ACC Ford knew that Operation Plato had been declared.⁷³² She knew that zoning was critical to such a declaration. She knew that this would influence which emergency responders could deploy into which areas.⁷³³ As ACC Ford correctly acknowledged, she had an obligation to review the declaration.⁷³⁴ That necessarily involved a review of zoning. Annemarie Rooney, the NWAS Tactical Commander, was present within the Force Command Module. ACC Ford did not discuss with her or with anyone else in the Force Command Module whether the declaration of Operation Plato should continue and, if it should, what the zoning within the Arena and surrounding area should be.⁷³⁵

ACC Ford proceeded on the basis that others knew that Operation Plato had been declared and were addressing that issue.⁷³⁶ She was right to expect that others were engaged in this important matter. However, she was in ultimate control and should have taken a grip of this issue or at least shown an active interest. She did not do so. That was an omission. However, it was not ACC Ford’s omission alone. There was simply no discussion about zoning within the Force Command Module at all until 00:22, when the issue was first discussed between ACC Ford and CI Dexter.⁷³⁷ That is unacceptable.

Third, by the time of ACC Ford’s arrival in the Force Command Module, Inspector Smith had been making clear for some time that paramedics in numbers were needed in the City Room.⁷³⁸ ACC Ford was unaware of this, and no one seems to have drawn it to her attention.⁷³⁹ Equally, no member of GMFRS had arrived at the Victoria Exchange Complex, let alone entered the City Room by that stage. In the call at 23:41, CI Dexter informed ACC Ford: “We’ve got no fire.” ⁷⁴⁰ She accepted in evidence that this was significant information but explained that she had not registered it given everything that was going on.⁷⁴¹ She should have done. Had ACC Ford registered what she had been told, she would have taken steps to investigate why GMFRS was not at the scene.⁷⁴²

GMFRS had significant value to add to the emergency response at the Arena. GMFRS had the ability to provide some treatment and, importantly, had expertise in the extrication of casualties.⁷⁴³ Had GMFRS attended during the critical period of the response at the Victoria Exchange Complex, it would have made a difference. ACC Ford assumed that all of this was in hand.⁷⁴⁴ It was understandable that she considered that others in the command structure were addressing this obvious and important issue. Nonetheless, I consider that she should have taken steps herself to ascertain what the situation was in the City Room.

Fourth, in common with all senior officers, ACC Ford was aware that, in the event that Operation Plato was declared, there was a significant risk that the FDO would become overwhelmed.⁷⁴⁵ Indeed, as I explained in Part 12, ACC Ford was aware of the conversation between Associate Inspector Andrew Buchan of HMICFRS and Temporary ACC Catherine Hankinson in November 2016 about this very issue because she had received the email of 3^rd November 2016.⁷⁴⁶ One of the things ACC Ford could have done to support the FDO was to ensure he was relieved of the Initial Tactical Firearms Commander role. Temporary CI Buckle was cadre Tactical Firearms Commander on the night of the Attack and the person who would naturally be expected to have relieved the Initial Tactical Firearms Commander.⁷⁴⁷ She arrived at GMP HQ at about the same time as ACC Ford. She was in a position to relieve Inspector Sexton by 23:20 or shortly afterwards.⁷⁴⁸

In a 51‑second call at 23:10, Superintendent Thompson informed Temporary CI Buckle that he intended to take the role of Tactical Firearms Commander following his arrival at GMP HQ.⁷⁴⁹ I acknowledge that Superintendent Thompson was more experienced as a Tactical Firearms Commander than Temporary CI Buckle and that he had additional qualifications that she did not have.⁷⁵⁰ However, what neither Temporary CI Buckle nor ACC Ford ascertained was how much longer it was likely to take Superintendent Thompson to arrive at GMP HQ than Temporary CI Buckle.⁷⁵¹ They should both have ascertained this. The upshot was that Superintendent Thompson arrived at GMP HQ at 23:45 and did not relieve Inspector Sexton until 00:18, much later than Temporary CI Buckle could have done so.⁷⁵² ACC Ford should have informed herself about likely timescales. Had she done so, she would have appointed Temporary CI Buckle as Tactical Firearms Commander, at least until Superintendent Thompson was in a position to receive a handover from her, a role that she was entirely competent to perform. That would have relieved Inspector Sexton of a significant part of his burden at a much earlier stage.

Fifth, by the time ACC Ford arrived at GMP HQ, no common RVP had been established, nor had an FCP been identified.⁷⁵³ These steps are vital to joint working. ACC Ford failed to establish that these steps had not been taken.⁷⁵⁴ She should have done, and others within the Force Command Module should have established this and alerted her to the problem. These failures played an important part in why JESIP failed that night.

Sixth, one of the reasons why effective co‑ordination between the three emergency services did not happen was because of a delay in the Force Command Module in organising a meeting of the Strategic Co‑ordinating Group, a concept I explained in Part 12.⁷⁵⁵ ACC Ford explained the purpose of such a meeting:
“Its purpose is to bring the strategic commanders together from all the organisations who are involved in the response. Again, that’s beyond the initial response, to draw together where we’re at, to agree the strategy and to agree priority actions and activities that need to be undertaken to further progress the response to the incident.” ⁷⁵⁶

Had such a meeting taken place at an early stage, it would have had an impact on the emergency response, as ACC Ford candidly acknowledged.⁷⁵⁷ It is likely that the issues with the non‑attendance of GMFRS and the JESIP failures more generally would have been identified. Ultimately, the first meeting of the Strategic Co‑ordinating Group did not take place until 04:15 on 23^rd May 2017. By this time, the ability of the group to have any impact on the immediate emergency response had long gone.⁷⁵⁸

ACC Ford explained that, in the first hours following her attendance in the Force Command Module, her focus was upon managing what was, or might be, coming and on “recovery planning”.⁷⁵⁹ This thwarted her attempts to organise the meeting earlier. I entirely accept that much important work was undertaken by ACC Ford during this period. I also accept that she was seeking to address less formally what a Strategic Co‑ordinating Group would be expected to address.⁷⁶⁰ That was, however, no substitute for a Strategic Co‑ordinating Group. An early meeting of the Strategic Co‑ordinating Group should have been prioritised by ACC Ford. The fact that it was not represents a missed opportunity on the part of the Strategic/Gold Commander to identify that things were going wrong.

In evidence, ACC Ford acknowledged that many things went wrong in the Force Command Module. She explained that a substantial part of the explanation for this was that she expected that others would have been attending to these important issues. She said:
“[ACC Ford] … In my head, the response to the arena in the initial stages was very much a bottom-up approach, it was happening at the scene and it was evolving from the scene, so the people with the best decision making capability and the most relevant information as to whether they’d applied zones or otherwise, but what was happening at the scene that would allow people to get into the actual area to deal with the casualties was there. I could have applied my limited understanding and made assumptions that I thought I was not in a position to make because I would then have applied something to a situation that I couldn’t assess.
[Chairman] So, in the command suite what you’re actually all saying is: on the ground, they know what’s going on, they’ve got – we just have to leave it to them?
[ACC Ford] Leave it to them whilst you start to understand what’s going on and also that broader kind of understanding of what else needs to be done. But the there-and- then situation needs to be addressed by those who are physically present at the scene and they understand what should be done, and then seek resources, seek an understanding, and then, when we’re able to, step back from it.”⁷⁶¹

Later in evidence, ACC Ford stated:
“If however you are responding to an incident where a plan has been initiated, I have a lot of responsibilities in terms of the response, but is it the role of the strategic commander to be checking what should have already been done in the plan? Because that is going to take an inordinate amount of my time to do. And you would have to, bearing in mind this is a spontaneous response, presume that people are initiating the plan that we have all been trained to work to.”⁷⁶²

I accept that ACC Ford was entitled to expect that others in the command structure beneath her would understand their roles and perform them. I acknowledge, too, that for a lengthy period, she lacked the support of a competent Tactical/Silver Commander. However, as ACC Ford accepted in evidence, the buck stopped with her that night in terms of command.⁷⁶³ It was, as she put it, “my responsibility to make sure that the response is as good as it can be”.⁷⁶⁴ While a Strategic/Gold Commander must be entitled to expect that others within the command structure will perform their roles, ACC Ford placed too much confidence in that approach. The reality is that the emergency response was failing on multiple levels, and JESIP was not working. She should have established that fact and intervened.

ACC Ford is, in my view, a good and committed senior police officer. When she was telephoned by Temporary Superintendent Nawaz at 22:52 on the night of 22^nd May 2017, it was the end of what had already been a long day for her.⁷⁶⁵ In the period that followed, she demonstrated clarity of thinking and decisiveness in many respects. She made a significant difference to what followed after the emergency response. However, as Strategic/Gold Commander, she should have made a difference to the emergency response itself. She did not do so. In substantial part, she was let down by systemic failures of education and by the inadequacies and failures of individuals. She was also let down by those from the other emergency services who should have known what was going wrong but did not draw it to her attention. However, for the reasons I have outlined, ACC Ford does bear some responsibility herself for the failures in the emergency response.

ACC Ford gave evidence with candour and insight. She recognised that there are important lessons for the emergency services to learn from that night. Her evidence has assisted the Inquiry to learn from her experience and will, I hope, be part of the drive for improvement.

Ground Assigned Tactical Firearms Commander

Role of Ground Assigned Tactical Firearms Commander

On the night of the Attack, the role of Ground Assigned Tactical Firearms Commander was performed by CI Dexter.⁷⁶⁶

First, it is necessary to identify where the Ground Assigned Tactical Firearms Commander fits into the GMP command structure. This was a controversial issue during the Inquiry.

The term Ground Assigned Tactical Firearms Commander appears to have been introduced by the CTPHQ refreshed Operation Plato guidance.⁷⁶⁷ I considered this guidance in Part 12. It was issued by CTPHQ in March 2016 and provided:
“7.1 Forces should review their Operation PLATO plans in relation to command locations and should consider their structures in relation to deploying dedicated (Cadre) TFCs [Tactical Firearms Commanders] as part of the response.
In particular Forces should review their Operation PLATO plans in relation to their ability to deploy a TFC(s) to undertake the role of on-scene commander (or ground assigned TFC) in a timely manner. A ground-assigned tactical command function is essential in order to develop command situational awareness, the overall ability to resolve the incident and to meet the requirements of the multi-agency approach to an Operation PLATO incident.
As part of this assessment, Forces may wish to take into account that the initial command structure will already have a suitably trained and competent commander within the police control room (Initial TFC) and that the immediate identifiable need will be a Cadre TFC in the role of on-scene/ground assigned commander.|
As subsequent Cadre TFCs become available, consideration should then be given to the transition from an Initial TFC to a Cadre TFC within the police control room or similar police operations room.” ⁷⁶⁸

The term ‘on‑scene commander’, used in the refreshed guidance, is one that was also used in JOPs 3. It was defined there as:
“An appropriate police, FRS [fire and rescue service] or ambulance commander at the scene who is responsible for undertaking an ongoing joint assessment of risk and for decision-making on the deployment of their organisation’s assets at that location. On-scene commanders will therefore ensure the emergency services’ response is effectively co-ordinated at scene.”⁷⁶⁹

These sources of guidance have generated two competing arguments about the role and responsibilities of the Ground Assigned Tactical Firearms Commander. The rudiments of those arguments can be summarised in the following way.

First, officers such as ACC Ford have contended that, since the refreshed guidance used the terms on‑scene commander and Ground Assigned Tactical Firearms Commander interchangeably, the roles are one and the same.⁷⁷⁰ Because JOPs 3 made an on‑scene commander responsible for decision‑making on the deployment of police assets at the scene, without distinguishing between armed and unarmed assets, the on‑scene commander is responsible for the tactical command of all police officers at the scene of an Operation Plato incident.⁷⁷¹ Because the on‑scene commander is the Ground Assigned Tactical Firearms Commander, the Ground Assigned Tactical Firearms Commander therefore has that broad responsibility for all officers. Hence, it is not necessary for an additional Tactical/Silver Commander to go to the scene in order to command the unarmed assets only. Such a person would merely duplicate the role of the Ground Assigned Tactical Firearms Commander.⁷⁷²

Second, officers such as CI Dexter have contended that the Ground Assigned Tactical Firearms Commander is responsible, as ‘Firearms’ in the title suggests, for the tactical command of the armed assets at the scene of an Operation Plato incident.⁷⁷³ The Ground Assigned Tactical Firearms Commander is responsible for the deployment of unarmed assets only to the extent that such officers are required for the purposes of the firearms operation. Thus, the Ground Assigned Tactical Firearms Commander is responsible for the forward‑facing officers,⁷⁷⁴ whether armed or unarmed. The unarmed officers more generally are under the tactical command of a Tactical/Silver Commander dedicated to that role. The term ‘on‑scene commander’ was used in a different and broader way in JOPs 3 to denote the Tactical/Silver Commander with the JESIP role. That commander would commonly be expected to be present at the FCP. Hence, it is necessary for an additional Tactical/Silver Commander to go to the scene/FCP in order to command the unarmed assets who are carrying out roles for which the Ground Assigned Tactical Firearms Commander is not responsible.⁷⁷⁵

Both arguments make sense and represent reasonable interpretations of the guidance available. Both arguments were advanced by senior and experienced officers driven by a desire to ensure that the policing response to an Operation Plato incident is as effective as possible. Both sides of the debate recognise that those on the other side have a reasoned argument.

As I made clear in the course of the evidence, I do not consider it important to rule on this dispute, as the clarity of the documents left something to be desired. I do, however, regard it as my role to identify what approach to the command structure is likely to work best in the response to an Operation Plato situation.

On the night of the Attack, CI Dexter took tactical command of unarmed police officers beyond those necessary for the purposes of the firearms operation.⁷⁷⁶ In other words, he assumed command of unarmed officers in addition to those who were forward‑facing. He explained that he did so because there would otherwise have been a command vacuum.⁷⁷⁷ CI Dexter also explained that he had been able to manage because, as it turned out, the events of 22^nd May 2017 did not involve further attacks at the Arena or multi‑site attacks elsewhere. Had events developed along the lines of a Mumbai‑ or Paris‑type attack, CI Dexter said, things might have been very different: “That’s why I have taken this position because I have been there and I’ve done it and I know that to do both roles is not achievable.” ⁷⁷⁸ He explained this further:
“I adopted the role of the Plato on-scene commander and took on additional responsibilities that should have been taken up by a tactical commander at the scene regardless of who that should have been. And the reason I raised this … is that it was broadly manageable on the night. But had it developed into an MTFA [Marauding Terrorist Firearms Attack]
… it definitely would not have been manageable under one commander. So, I accept the point, and in fairness to you, on the night by the time I arrived it didn’t make a massive difference to me, but it could in the future and that’s what’s really important, I think, to learn.”⁷⁷⁹

In my view, CI Dexter is correct. To expect the Ground Assigned Tactical Firearms Commander to take on the principal role for liaising with the Tactical/Silver Commanders of the other emergency services in the FCP, and to command unarmed officers in relation to tasks such as the creation of cordons, gives rise to the real risk that the Ground Assigned Tactical Firearms Commander’s ability to perform their core firearms role will be compromised. How, for example, is the Ground Assigned Tactical Firearms Commander to perform those tasks if actively involved in commanding firearms officers in the search for and neutralisation of an armed terrorist?

The events in Manchester demonstrate that the policing response to any Major Incident is likely to be enhanced by the deployment of Tactical/Silver Commanders to the scene or scenes. In the event that the Major Incident is one in which Operation Plato is declared, or indeed in which there is any involvement of firearms officers in numbers, it is likely to be desirable for that deployment to involve the mobilisation to the scene of a Ground Assigned Tactical Commander for the armed response, the Ground Assigned Tactical Firearms Commander, and a Ground Assigned Tactical Commander for the unarmed response, the Ground Tactical/Silver.

I recommend this issue be the subject of review by CTPHQ, the Home Office and the College of Policing. Clear guidance should then be issued. There should never again be a situation in which senior commanders, from the same organisation and who responded to the same Major Incident, are unable to agree on the responsibilities of someone performing a key role in the command structure for the response to a Major Incident.

Chief Inspector Dexter’s experience and training for the role of Ground Assigned Tactical Firearms Commander

CI Dexter was an experienced senior police officer.⁷⁸⁰ He joined GMP in 1999 and progressed through the ranks. During 2014 and 2015, he qualified as a Tactical/Silver Commander and as a Tactical Firearms Commander. Thereafter, he carried out each role. In particular, he regularly performed the role of Tactical Firearms Commander and did so in relation to a number of complex firearms operations, both planned and spontaneous. Just days before the Attack, CI Dexter attended the same specialist firearms commander course as ACC Ford.⁷⁸¹ By May 2017, CI Dexter was one of GMP’s most experienced firearms commanders.⁷⁸²

As a result of his training, CI Dexter was aware of Operation Plato and what such a declaration would mean in terms of the deployment of capabilities. Following his experiences on the night of the Attack, he reflected on whether this training had given him all the knowledge he needed about Operation Plato. CI Dexter concluded that his training had given him an insufficient understanding of how Operation Plato would be applied by the commanders of the other emergency services and how, on the ground, Operation Plato zoning should be applied.⁷⁸³ On the night, this gap in CI Dexter’s training had an impact on his management of the scene and on his communications with the other emergency services.

CI Dexter was a straightforward witness whose views had been formed on the basis of mature and intelligent reflection. In identifying this gap in his training, he was not seeking to excuse inadequacies in what happened on the night of the Attack. Instead, he was providing a considered account of respects in which he believed different and better training would have made him more prepared for what confronted him on 22^nd May 2017. The gap in knowledge described by CI Dexter was something I recognised across a number of witnesses. CI Dexter’s evidence reinforces my view that Operation Plato training needs to be better across the board.

Notification of Chief Inspector Dexter

At 22:45 on 22^nd May 2017, CI Dexter was telephoned by PC Kevin Winyard of GMP’s Specialist Operations Branch.⁷⁸⁴ In that call, PC Winyard explained that there had been an explosion at the Arena and that Operation Plato had been declared.⁷⁸⁵ This call was, in fact, before Inspector Sexton’s declaration of Operation Plato at 22:47. However, Operation Plato had been referred to over the GMP radio firearms channel by PC Lee Moore, a firearms officer, at 22:41.⁷⁸⁶ This explains what would otherwise be an odd feature of the evidence.

CI Dexter was not on duty on 22^nd May 2017 and was at home asleep when PC Winyard telephoned.⁷⁸⁷ CI Dexter explained that the Specialist Operations Branch, of which he was a senior member, is at the sharp end of policing.⁷⁸⁸ It includes the GMP armed policing units and other teams such as the Tactical Vehicle Intercept Unit. Members of these teams are regularly involved in acute incidents across Greater Manchester. Senior line management might not be immediately available. Hence, CI Dexter had an arrangement that he would be called, even when off duty or on leave, in the event of any significant incident within Greater Manchester. PC Winyard was putting this arrangement into effect on the night of 22^nd May 2017.⁷⁸⁹

CI Dexter responded to PC Winyard’s call by deploying to the Arena.⁷⁹⁰ He took steps to inform the command structure of what he was doing.⁷⁹¹ So, to describe his actions as self‑deployment would not fully or accurately reflect what he did. Nonetheless, it was a notable feature of the evidence that a number of those who deployed on the night of the Attack into significant positions in the command structure were not rostered to do so. Instead, they volunteered. That included Superintendent Thompson, who replaced Inspector Sexton as Tactical Firearms Commander.⁷⁹² These two officers made a significant contribution on the night, and I am not critical of them. On the contrary, each stepped up.

I was, however, left with a lingering concern about the informality with which important roles were filled on the night. That was a concern shared by the Policing Experts.⁷⁹³ Even though I am satisfied it did not cause problems on 22^nd May 2017, such an approach is capable of causing difficulties during the response to an emergency. CI Dexter acknowledged that this was so.⁷⁹⁴ I recommend every police service take steps to ensure they have in place a system that ensures appropriately qualified and experienced personnel are rostered 24 hours each day so that, in the event of a terrorist attack, or any Major Incident, a prepared and effective command structure can be geared up swiftly.

Chief Inspector Dexter’s journey to the Arena

Having received PC Winyard’s call, CI Dexter immediately dressed, got into his car and drove towards the Arena.⁷⁹⁵ At 22:51, he made contact with the FDO by radio asking whether a Ground Assigned Tactical Firearms Commander had been assigned.⁷⁹⁶ CI Dexter had it in mind that this would be the appropriate role for him to fulfil, and he was sensibly checking to see whether anyone else had already been allocated to this job. They had not.

In a radio communication at 22:52, CI Dexter was made aware that Temporary CI Buckle was “making her way in”.⁷⁹⁷ By implication, this was to GMP HQ. He indicated that she should continue to do so and that he would perform the role of Ground Assigned Tactical Firearms Commander, at least initially.⁷⁹⁸ At 22:54, CI Dexter telephoned Temporary CI Buckle. They spoke for just over a minute and agreed that these were the appropriate deployments, that is to say CI Dexter to the scene and Temporary CI Buckle to GMP HQ.⁷⁹⁹

At an early stage, I was concerned that CI Dexter was ‘pulling rank’ in what was decided about Temporary CI Buckle’s deployment. However, I have been able to hear parts of subsequent conversations between the two in the recording from CI Dexter’s Dictaphone. I also heard evidence from each of them as witnesses. CI Dexter said of the discussion at 22:54: “It was a very adult, professional conversation … I would never pull rank on Rachel.” ⁸⁰⁰ I am satisfied on the evidence that this is correct. It is clear that the two had respect for each other. They made a mutual decision about what was the best deployment in the circumstances. Given CI Dexter’s greater experience and his recent attendance on the specialist firearms commander course, the decision that he should deploy to the scene was an appropriate one. My initial concerns were dispelled.

At 22:56, CI Dexter made a short call to Superintendent Thompson, and at 23:02 and at 23:09 the two spoke for slightly longer periods.⁸⁰¹ At this stage, CI Dexter was still travelling. Superintendent Thompson was CI Dexter’s line manager. He was also a Specialist Tactical Firearms Commander.⁸⁰² At some stage that night, a Counter Terrorism Police Operations Room⁸⁰³ would need to be opened, and a Specialist Tactical Firearms Commander would be required for that purpose. CI Dexter suggested to Superintendent Thompson that he head in to GMP HQ for that purpose.⁸⁰⁴ This made good sense, as the Policing Experts agreed, but is an example of the informality with which some important roles in the command structure were filled that night.

While travelling in his car, CI Dexter was involved in further radio communication relevant to the Attack.⁸⁰⁵ He also took steps to liaise with military assets.⁸⁰⁶ At 23:13, he telephoned ACC Ford, the Strategic/Gold Commander and the Strategic Firearms Commander.⁸⁰⁷ He was unable to get through and left her a voicemail message.⁸⁰⁸ She called him back at 23:41.⁸⁰⁹

CI Dexter stopped off at a police station on the way to the Arena. He did so to obtain necessary equipment, including body armour, and to make logistical arrangements for certain specialist capabilities.⁸¹⁰ These were appropriate actions. He arrived at the Arena at 23:23.

CI Dexter had travelled to the Arena as quickly as he could following notification of the Attack by PC Winyard. On the way there, he made sure that his deployment as Ground Assigned Tactical Firearms Commander was the appropriate one and took steps to establish that others would be in place within the structure of firearms command. Although there was a degree of informality involved in some of his actions, CI Dexter was doing what he could to make the emergency response work. What he did represented good leadership.

Events between 23:23 and 23:30: Arrival and gaining situational awareness

The arrival of CI Dexter at the Victoria Exchange Complex at 23:23 was captured by the CCTV system.⁸¹¹ On reaching Station Approach, he wanted to find the Operational Firearms Commander and therefore headed straight inside the railway station.⁸¹² He went to the City Room, entering at 23:25.⁸¹³ He then spoke to Inspector Smith.⁸¹⁴ On his first visit to the City Room, CI Dexter remained for five minutes, leaving at 23:30.⁸¹⁵

While still in the City Room, at 23:26, CI Dexter made radio contact with the FDO, dealing with the need to deploy firearms resources to Manchester Piccadilly Railway Station given the risk of a further attack.⁸¹⁶ This demonstrates that he was, as he told me, concerned about a multi‑site attack.

CI Dexter owned a Dictaphone because of a previous role as a crisis negotiator.⁸¹⁷ He had sensibly brought it to the scene. At 23:27, while still in the City Room, CI Dexter activated this device.⁸¹⁸ The recording lasts, unbroken, for 4 hours and 12 minutes.

As I recommended when considering the role of the FDO, the practice of emergency service commanders using audio‑recording devices to record their decisions and rationale should be universal at any Major Incident. CI Dexter did not always record the rationale for his decisions that night. He said, in evidence, that this was because of the pace of the events he was dealing with and also because to have done so would have felt “unnatural”.⁸¹⁹

This represents a useful insight from someone who has been involved in the response to a Major Incident. It suggests that, if my recommendation as to the use of recording devices is to be implemented, it will need to be accompanied by training designed to enable commanders to overcome what might otherwise be regarded as the difficult and artificial approach of speaking their rationale out loud during the course of stressful events.

In Part 19 in Volume 2‑II, I will say more about the way in which decision‑making might be recorded.

Notwithstanding that CI Dexter did not always record the rationale for his decisions, the recording from his Dictaphone provides an invaluable insight into his decisions and what he did. It gives a sense of what confronted him and the other emergency responders in the hours after 23:25. In the course of the hearings, only short sections of the recording were played. To have played it in public in its entirety, or even just the most important first 90 minutes, would have been inappropriate because of the distressing nature of some of what is captured on the recording. I have, however, listened to the whole of the recording. I agree with Counsel to the Inquiry’s assessment, explained in the course of the hearings, that it reveals commitment, hard work and active decision‑making by CI Dexter throughout that night.⁸²⁰

The first conversation that is recorded is a discussion between CI Dexter and Sergeant Cawley of BTP. That took place at 23:27 while they were both in the City Room.⁸²¹ Sergeant Cawley informed CI Dexter of what was known of the number of fatalities. CI Dexter asked about cordons and established that the City Room was secure with firearms officers at each entrance. He then spoke to the Operational Firearms Commander, PC Richardson, and established that a search of the Arena bowl was under way. He also took steps to arrange the extraction of any members of the public who remained within the bowl.⁸²²

In evidence, CI Dexter explained that, on this first visit to the City Room, he considered that there was no immediate firearms threat and did think that there was a risk of secondary devices.⁸²³ His recollection was that he considered the City Room to be warm in terms of Operation Plato zoning.⁸²⁴ I have already explained, in dealing with the role played by the firearms officers, that the correct application of JOPs 3 would have resulted in the City Room being designated as an Operation Plato cold zone from 22:50 or shortly afterwards. PC Lee Moore and PC Simpkin had carried out a raw check by 22:45 and had established that there was no firearms threat in the City Room, that being the relevant factor so far as Operation Plato zoning was concerned, and the City Room was contained with firearms officers at all entrances.⁸²⁵ There existed what PC Richardson described as a “spiky bubble”.⁸²⁶ If anything, by 23:25, there was even less reason than there had been at 22:50, to designate the City Room as anything other than an Operation Plato cold zone.

There were no specialist assets, beyond the firearms officers and two HART operatives, in the City Room while CI Dexter was there between 23:25 and 23:30, but there were unarmed GMP and BTP officers, Arena staff and members of the public present.⁸²⁷ JOPs 3 dictated that non‑specialist assets and members of the public should not ordinarily be present in an Operation Plato warm zone. However, CI Dexter did not direct that they should leave. In evidence, he explained that he balanced the risk of a secondary attack against the risk to those who were present and decided that they should remain.⁸²⁸ He made the right decision, but his reasoning was flawed because he had wrongly concluded that the City Room was an Operation Plato warm zone. He should have made the decision to leave non‑specialist assets and the public in this area on the basis that it was an Operation Plato cold zone and that there was no other compelling reason to remove them. I consider that had CI Dexter received better and more specific training in Operation Plato, as should have been the position, he would have reached his decision by the correct route.

While in the City Room, it was obvious to CI Dexter that a Major Incident had occurred.⁸²⁹ In evidence, he agreed that GMP should have declared it as a Major Incident and explained, as others have done, that an early declaration would have enhanced co‑ordination between the emergency services.⁸³⁰ As I have explained already, the failure of GMP to declare a Major Incident was a significant omission.

Principal responsibility for that failure rests with Inspector Sexton, who should have made the declaration shortly after becoming aware of the explosion at 22:34. However, others also bear some responsibility. Many GMP officers simply assumed that the declaration had been made, making that assumption because it was so obvious that it should have occurred. As he acknowledged, CI Dexter fell into that category.⁸³¹ He arrived in the City Room 54 minutes after the explosion and assumed that this basic step would have been taken by someone involved at an earlier stage.

That so many officers, including senior officers, did not check that a Major Incident had been declared reveals a systemic issue within GMP and possibly beyond. GMP needs to ensure that all officers understand the need to declare a Major Incident along with the need to ensure that such a declaration is widely communicated. GMP needs also to ensure that all officers, particularly senior officers, understand the need, once they become involved, to check that a declaration has been made if they have not received confirmation that this has occurred. The College of Policing should consider ensuring that this message is understood more generally within policing.

Events between 23:30 and 23:40: Operation Plato zoning

Having gained situational awareness in the City Room, CI Dexter walked out onto the raised walkway with PC Richardson.⁸³² He then walked down the stairs leading to the station concourse.⁸³³ As the CCTV footage shows, CI Dexter was on the telephone as he did so. He was speaking to Temporary CI Buckle who was at GMP HQ.⁸³⁴ She had called him. In that call, CI Dexter made clear that the City Room was contained and that he had deployed firearms officers to Manchester Piccadilly Railway Station.⁸³⁵

As the call ended, CI Dexter reached the station concourse. That is the place that NWAS had established the Casualty Clearing Station. CI Dexter was still with PC Richardson, to whom he turned and said: “Are we declaring this warm?” ⁸³⁶ It was now 23:32. PC Richardson replied: “Yes.” ⁸³⁷ In evidence, CI Dexter explained that in this short conversation he was referring to the area of the Casualty Clearing Station.⁸³⁸ It follows that by this stage, at 23:32, CI Dexter regarded both the City Room and the Casualty Clearing Station/concourse as an Operation Plato warm zone. That assessment was wrong within the context of Operation Plato zoning for the reasons I gave in paragraphs 13.336 to 13.344. Each was, in fact, an Operation Plato cold zone. That was the view of the Policing Experts⁸³⁹ and also of CI Thomas of CTPHQ.⁸⁴⁰ CI Dexter’s error was the consequence of the inadequacies in his training. However, at least he was giving the issue of zoning under Operation Plato some thought.

In evidence, CI Dexter agreed that he had not communicated his Operation Plato zoning assessment in relation to the City Room and Casualty Clearing Station/concourse to the other emergency services directly or to the FDO to enable him to communicate it on.⁸⁴¹ He explained that he did not consider his assessment would affect deployments within the City Room and that the issue of Operation Plato zoning was therefore not “massively relevant or critical at the time”.⁸⁴² Furthermore, he assumed that the declaration of Operation Plato and associated zoning assessments must already have been communicated given that it was by now just over 60 minutes post‑explosion.⁸⁴³

Each of those explanations requires examination.

First, on balance, I am satisfied that prompt communication by CI Dexter of his Operation Plato zoning assessment would not have made a material difference to the emergency response in the City Room for the reasons outlined in the following paragraphs.

By 23:32, when CI Dexter had his conversation with PC Richardson, all but 10 of the 38 patients who ultimately received treatment in the Casualty Clearing Station were already there,⁸⁴⁴ and Saffie‑Rose Roussos, who by‑passed the Casualty Clearing Station, had arrived at hospital nine minutes earlier.⁸⁴⁵ Of the remaining ten, all had arrived in the Casualty Clearing Station by 23:42.⁸⁴⁶ Of those ten, two were already being moved on makeshift stretchers at 23:32, and all but one were being evacuated by 23:37. ⁸⁴⁷

Everyone acknowledges that firefighters would have made a real contribution to the evacuation of casualties from the City Room had they been present at a relevant time.⁸⁴⁸ However, notification to GMFRS of CI Dexter’s Operation Plato zoning assessment shortly after 23:32 could not have made any difference to the casualties in the City Room. There was no prospect of any asset of GMFRS arriving before the casualties all reached the Casualty Clearing Station in any event.

There were, of course, NWAS assets present at the Victoria Exchange Complex, both specialist and non‑specialist. There were two HART operatives and one non‑specialist paramedic in the City Room. There were HART operatives at the Casualty Collection Point on Station Approach and non‑specialist resources at the Casualty Clearing Station on the station concourse. Two questions arise. First, had CI Dexter informed the NWAS Operational Commander, Daniel Smith, of his Operation Plato zoning decision at or shortly after 23:32, would Daniel Smith have committed additional NWAS resources forward? Second, if Daniel Smith had committed additional NWAS resources forward at that stage, was that capable of making any difference to the casualties who were still in the City Room in that period? The evidence provides a clear answer to both questions.

Had CI Dexter communicated his zoning decision to Daniel Smith, he would have been telling the NWAS Operational Commander that he considered the City Room an Operation Plato warm zone. As I explained in Part 12, Daniel Smith believed he did not have a discretion to deploy non‑specialist paramedics into an Operation Plato warm zone. As I shall explain in Part 14, Daniel Smith’s approach to the deployment forward of NWAS resources that night was unduly cautious. In the circumstances, I am sure that knowledge of CI Dexter’s Operation Plato zoning decision would not have caused Daniel Smith to commit further NWAS resources, whether specialist or non‑specialist, into the City Room. Whether Daniel Smith should have adopted a different approach is a separate question.

Had CI Dexter communicated his decision to Daniel Smith, it would have taken him at least some time to do so. There would then inevitably have been a discussion between the two. If Daniel Smith had been persuaded by that discussion to deploy additional NWAS resources into the City Room, that too would have taken some time. The HART operatives would have had to have been deployed from the Casualty Collection Point and the non‑specialist assets from the Casualty Clearing Station.

Once deployed, the resources would have had to have made their way to the City Room. It is probable they would not have arrived in the City Room before 23:36. By 23:36, the final living casualties were about to be moved to the City Room. They had been triaged. This included an assessment of whether any immediate life‑saving intervention was required. The casualties were in a ratio of fewer than three to one paramedic. There were members of the public and a large number of police officers who helped with the evacuation. The final living casualty was removed from the City Room at 23:39.

In those circumstances, I consider it most unlikely that any additional NWAS resources could in any event have reached the City Room in time to make a material difference either to the treatment of casualties or their evacuation, save in one potential respect. Even at that late stage, taking stretchers up to the City Room to transport those who could not move themselves would have improved the safety, comfort and dignity of those who had yet to be evacuated.

The real failure of communication in relation to Operation Plato zoning was not CI Dexter’s. It was Inspector Sexton’s. Having declared Operation Plato, he did not make any or any appropriate Operation Plato zoning assessment and did not communicate such an assessment to the other emergency services, or even the fact that he had declared Operation Plato. As I have explained already, I am satisfied that if Inspector Sexton had engaged in a careful and systematic assessment of risk, having consulted the firearms officers at the scene for their views, he would have concluded, by no later than 22:50, that the City Room was an Operation Plato cold zone. A clear decision communicated at that stage should have given Daniel Smith the confidence to commit both additional specialist and non‑specialist resources forward shortly after that time. Whether it would have done so is less likely, as Daniel Smith’s main concern was that there may be secondary devices in the City Room. Properly understood, a declaration that the City Room was an Operation Plato cold zone would not have given him any reassurance as to that.

Had Daniel Smith been reassured at 22:50 or shortly afterwards by the declaration of an Operation Plato cold zone and sent in more paramedics, that would have made a meaningful difference to the 38 casualties who ultimately received treatment in the Casualty Clearing Station. Those 38 were all still in the City Room at 22:50.⁸⁴⁹ Indeed, the first evacuation of any of the 38 did not commence until 23:02,⁸⁵⁰ and that person did not arrive in the Casualty Clearing Station until 23:07.⁸⁵¹

For a number of reasons, effective treatment was delayed for many if not all of the 38. One of those was John Atkinson, who arrived in the Casualty Clearing Station at 23:24.⁸⁵² The delay probably cost him his life. As I have observed, Saffie‑Rose Roussos did not go to the Casualty Clearing Station. Instead, she was taken to Trinity Way, arriving there at 22:58.⁸⁵³ She transferred into an ambulance at 23:06⁸⁵⁴ before travelling on to hospital.⁸⁵⁵ Any delay in treatment in her case, along with the nature of the treatment, may have made a difference to survival. However, it almost certainly did not do so for the reasons I have explained. I will deal with this in further detail in Part 18 in Volume 2‑II.

The second reason CI Dexter gave for not having communicated his Operation Plato zoning assessment was that he presumed that this would have been dealt with before his arrival. I consider it was reasonable for CI Dexter to assume that the FDO had made prompt and accurate decisions about Operation Plato zoning and communicated these to NWAS, NWFC and GMFRS. However, on making his own assessment at the scene, CI Dexter should have made contact with the FDO to inform him of that assessment and to ensure it was communicated to the other emergency services.

I consider that CI Dexter’s failure to communicate with the FDO on this issue was the consequence of a number of factors: the inadequacies in his training; the failure in common with other GMP commanders to appreciate the importance of Operation Plato zoning, which flows from an inadequacy of training; his assumption that the issue must already have been addressed; his correct belief that communication of his assessment would make no difference to deployments into the City Room; and the pressure that he was otherwise under. These factors make his omission understandable. They serve to emphasise that, in future, Operation Plato training must instil in commanders an understanding of the need to review regularly a declaration of Operation Plato and the consequent zoning decisions and ensure that there is proper communication about those matters both within the police and to the emergency service partners of the police.

To return to the chronology, as he spoke to the Operational Firearms Commander about Operation Plato zoning, CI Dexter walked through the Casualty Clearing Station, the station concourse and out onto Station Approach.⁸⁵⁶ He remained there between 23:32 and 23:40.⁸⁵⁷ While there, he was involved in deploying firearms officers, including sending CTSFOs to the Cathedral to deal with reports of a suspicious male.⁸⁵⁸

Events between 23:40 and 00:00

By 23:40, CI Dexter had deployed firearms assets to Manchester Piccadilly Railway Station and the Cathedral.⁸⁵⁹ Later, he deployed firearms officers to a hospital in Oldham.⁸⁶⁰ In evidence, CI Dexter accepted that in making these deployments he was to some extent stepping outside the role of Ground Assigned Tactical Firearms Commander and into the role of Tactical Firearms Commander.⁸⁶¹ This is what Inspector Sexton described later during the response as “crossing over”.⁸⁶² CI Dexter accepted, in evidence, that this might cause problems in some situations, although he was clear, and I accept, it had not done so that night.⁸⁶³

My impression was that, in making these deployments, CI Dexter was seeking to assist the FDO because he knew of the pressure that he was under. However, CI Dexter also had responsibilities that were too wide‑ranging. By this stage, he was commanding both the armed and unarmed police assets at the scene. This cross‑over serves to illustrate that these two roles, the FDO and the Ground Assigned Tactical Firearms Commander, simply came under too much pressure that night. In future, in the ways in which I have recommended, that burden must be reduced.

During the period prior to 23:40, CI Dexter had also checked on the cordons and ensured that a safe location had been established for those who had been evacuated from the Victoria Exchange Complex with no or limited injuries.⁸⁶⁴ He addressed the potential role of military assets, and had a discussion with James Allen, the Arena General Manager for SMG, about SMG’s staff and SMG’s assessment of risk.⁸⁶⁵ He then gave further instructions in relation to the broader search.⁸⁶⁶ In addition, CI Dexter spoke to Superintendent Leor Giladi, alerting him to the fact that Superintendent Giladi was likely to be needed for duties the following day.⁸⁶⁷

Throughout the period from his arrival until 23:40, CI Dexter had dealt with matters that were for the commander of firearms officers to deal with. He had also dealt with matters that were for the commander of unarmed officers to deal with. I have already explained my view that the latter responsibilities ought to have been discharged by a Tactical/Silver Commander at the scene, not the Ground Assigned Tactical Firearms Commander. CI Dexter’s view, in evidence, was that, on the night, he coped with this combined responsibility.⁸⁶⁸ I agree in the sense that he dealt with whatever was put in front of him and was also proactive in certain important respects. He showed a strong commitment to both roles.

However, if a Tactical/Silver Commander had been at the scene with responsibility for the unarmed officers only, there are things that the Tactical/ Silver Commander would probably have done that CI Dexter simply did not have time to do. In particular, such a commander would have been able to focus to a much greater extent on JESIP. That, I am satisfied, would probably have resulted in the establishment of an FCP and earlier co‑ordination between the emergency services. Ultimately, such co‑ordination was, of course, sorely lacking on the night.

At 23:41, CI Dexter took the call from ACC Ford to which I have already referred.⁸⁶⁹ In their discussion, CI Dexter provided her with an update. It was in this conversation that he said: “We’ve got no fire.” ⁸⁷⁰ CI Dexter confirmed, in evidence, that he was referring to the fact that GMFRS was not at the scene.⁸⁷¹ In the Dictaphone recording, after CI Dexter said this, there is a short pause, following which CI Dexter said: “[Y]ou might as well.” ⁸⁷² In evidence, his understanding of this was that, in the pause, ACC Ford indicated that she would put right the absence of GMFRS.⁸⁷³ ACC Ford explained, conversely, that she simply had not registered the reference to fire and so did not accept this interpretation.⁸⁷⁴

Each witness was trying to help in relation to a conversation that took place in circumstances of great pressure, several years earlier. I do not regard the resolution of the difference between their accounts as having value. The real significance of this conversation is it reveals that, at the time, CI Dexter registered the absence of firefighters. However, as he explained, by the time of his call this was of little real significance to him because he knew that the final casualties were being removed from the City Room. The skills of firefighters in providing trauma treatment and evacuating casualties were therefore no longer of use.⁸⁷⁵

CI Dexter was right. As he was on the telephone to ACC Ford, the final casualty arrived in the Casualty Clearing Station from the City Room.⁸⁷⁶ That brought to an end the opportunity for GMFRS to contribute to the evacuation of casualties from the City Room that night.

As the call with ACC Ford came to an end, CI Dexter was still on Station Approach.⁸⁷⁷ At 23:45, he spoke again to the Operational Firearms Commander and was introduced to PC Healy, the BTP dog handler who had arrived with Police Dog Mojo.⁸⁷⁸ He established that PC Healy was content to go into the City Room and Arena bowl and then left it to the Operational Firearms Commander to direct him.⁸⁷⁹ CI Dexter then left Station Approach⁸⁸⁰ to return to the City Room, arriving there at 23:47.⁸⁸¹ He remained in that location until 00:15.⁸⁸²

Once in the City Room, CI Dexter liaised with Inspector Smith and others.⁸⁸³ They ascertained that no living casualty remained in the City Room.⁸⁸⁴ He ensured that the City Room remained secure and that the cordon was in place around Manchester Victoria Railway Station.⁸⁸⁵ He again became involved in the deployment of firearms officers to Manchester Piccadilly Railway Station.⁸⁸⁶

At 23:52, Inspector Sexton made a telephone call to CI Dexter.⁸⁸⁷ The conversation is captured on the Dictaphone recording of each,⁸⁸⁸ and it is therefore possible to understand the whole of it. It was in this conversation that Inspector Sexton said: “I am very much aware we’re erm crossing over each other on command and control.” ⁸⁸⁹ It was agreed that CI Dexter would “take command at Victoria and the MEN” ⁸⁹⁰ and Inspector Sexton would speak to Temporary CI Buckle about command at Manchester Piccadilly Railway Station.⁸⁹¹ It is correct to say that there had been cross‑over of responsibility for firearms command. Even at this stage, however, it was not resolved and the Ground Assigned Tactical Firearms Commander continued to exercise control for deployments well beyond the Victoria Exchange Complex. This demonstrates that the firearms structure was not working as it ought to have done, even at a late stage.

Subsequently, in the period between the end of this conversation and 00:00 on 23^rd May 2017, CI Dexter was again involved in the arrangements for the search of the wider premises. As part of that, he spoke again to ACC Ford at 23:54, seeking access to additional dogs through the process of mutual aid.⁸⁹² Mutual aid refers to seeking assistance from other police services. I have already drawn attention to the apparent delay in securing the attendance of explosives detection dogs and have made a recommendation in that regard.

Events between 00:00 and 00:23

The period between 00:00 and 00:23 takes events up to the point one hour after the arrival of CI Dexter. Between 00:00 and 00:15, he remained in the City Room, where he liaised with a number of people both directly and by telephone or radio.⁸⁹³ That included speaking to ACC Ford in order to disclose the outcome of certain enquiries he had directed be undertaken in relation to the Arena CCTV system⁸⁹⁴ and to the FDO in relation to the deployment of sensitive assets.⁸⁹⁵ At 00:06, CI Dexter spoke to Superintendent Thompson, who was shortly to take over as Tactical Firearms Commander from the Initial Tactical Firearms Commander, Inspector Sexton. CI Dexter provided Superintendent Thompson with a briefing.⁸⁹⁶

While still in the City Room, CI Dexter continued to be involved in a variety of tasks, including speaking by telephone to the FDO line in order to seek the deployment of a further unarmed Operational/Bronze Commander to command the unarmed assets on what he described as “the outer perimeter”.⁸⁹⁷ This conversation, along with others that night, indicates that CI Dexter regarded himself as responsible for the armed assets and wanted support in relation to the unarmed assets.

CI Dexter continued to progress the broader search. He met James Allen in person to ensure that he understood the layout of the Arena and the search that Arena staff had carried out.⁸⁹⁸

At 00:15, CI Dexter left the City Room.⁸⁹⁹ The recording from his Dictaphone indicates why. At 00:13:53, he appears to be speaking to the Operational Firearms Commander, when he said:
“Right let us just go and just have a round. I just want to understand the Forward Command Point, I want to see what’s at Forward Command Point and in terms of Armed Resources and I want to see what the cordons, if any is on …”⁹⁰⁰

In his evidence, CI Dexter explained that he had developed an understanding that the FCP was on Station Approach.⁹⁰¹ In a sense, that is what Station Approach was to become because that is where commanders met, although it was never a nominated and agreed FCP for the three emergency services. I have already made clear that the failure to identify an FCP was a major failure that had occurred long before CI Dexter’s involvement.

When CI Dexter went towards Station Approach at 00:15, that was his first attempt to co‑locate with other emergency service commanders. I do not criticise CI Dexter for that. He had been extremely busy. However, this is precisely what a Tactical/Silver Commander with responsibility for the unarmed assets and with a greater focus on JESIP would have been expected to do much earlier, if at the scene.

At 00:16, while in the Casualty Clearing Station on his way to Station Approach, CI Dexter asked NWAS Operations Manager Derek Poland: “Who is the NWAS Incident Commander?” ⁹⁰² Derek Poland directed him outside, where NWAS Deputy Director of Operations Stephen Hynes who had taken over as NWAS Operational Commander from Daniel Smith, was situated.⁹⁰³

Outside, CI Dexter was asked by Stephen Hynes if he was in charge, and he answered: “I am from the firearms point of view.” ⁹⁰⁴ This reinforces yet further the view that CI Dexter consistently expressed that he considered that his role was to command the firearms officers.

Stephen Hynes asked CI Dexter if it was safe.⁹⁰⁵ CI Dexter understood him to be referring to the Casualty Clearing Station, as I accept he was. In response, CI Dexter said: “I’d say warm. That you’re okay anywhere in there, fine. I’ll border on cold but I will stick with warm.” ⁹⁰⁶ Stephen Hynes pressed him and CI Dexter then said: “I would declare this cold for now.” ⁹⁰⁷

In evidence, CI Dexter acknowledged that this represented, on his part, “a rather vague or non-technical approach to zoning”.⁹⁰⁸ It was plain to me that he was adopting a pragmatic approach. He did not want to discourage emergency responders from working in an area that he regarded as safe. CI Dexter effectively accepted that this was his approach, in evidence.⁹⁰⁹

I consider that CI Dexter’s aim was laudable, but the problem would have been avoided if his training had equipped him to carry out an accurate Operation Plato zoning assessment. If it had, he would have had no hesitation in informing Stephen Hynes that the Casualty Clearing Station was an Operation Plato cold zone, as was the City Room.

In the subsequent minutes leading up to 00:23, CI Dexter spoke to PC Lee Moore and again to ACC Ford.⁹¹⁰ In his discussions with them, CI Dexter’s references to Operation Plato zoning were also vague.⁹¹¹

Events after 00:23

At 00:24, a radio broadcast on the firearms radio channel reported shots fired at a hospital in Oldham.⁹¹² In evidence, CI Dexter described how this report hit him hard. He explained the fear it generated that a Paris‑style attack was under way.⁹¹³ Coincidentally, a CTSFO team from outside Greater Manchester contacted him at 00:25, and CI Dexter was therefore able to deploy them to Oldham.⁹¹⁴ The report was later discovered to be false.

In the ten minutes that followed this report, CI Dexter was heavily involved in managing the events at Oldham. Then, at 00:37, he was spoken to again by Stephen Hynes.⁹¹⁵ Stephen Hynes continued to be concerned about the issue of safety. CI Dexter explained that the Casualty Clearing Station was “getting near to cold”. ⁹¹⁶ In fact, there is no doubt that the Casualty Clearing Station was an Operation Plato cold zone and had been for a long time. If CI Dexter had been adequately trained, he would have understood that.

In evidence, CI Dexter again accepted that this was not the language of JOPs 3 but explained that he was seeking to communicate the quantum of risk to Stephen Hynes in language he thought would be understood.⁹¹⁷ My views about this conversation are identical to the views I expressed about the earlier conversation between CI Dexter and Stephen Hynes.

CI Dexter then returned to the City Room and liaised with Inspector Smith about the progress of the search.⁹¹⁸ He then briefed a group of firearms officers on the Arena concourse⁹¹⁹ before returning to the City Room⁹²⁰ and then going again to Station Approach, where he spoke to Superintendent Thompson, Temporary Superintendent Hill and Temporary CI Buckle by telephone and radio.⁹²¹

At 00:54, CI Dexter spoke again to Stephen Hynes on Station Approach.⁹²² The NWAS Operational Commander asked for a briefing.⁹²³ The GMFRS NILO, Station Manager Berry, had now arrived. Station Manager Berry explained that he had the Chief Fire Officer on the telephone, who even at this late stage required reassurance before committing the assets of GMFRS into the Victoria Exchange Complex.⁹²⁴

CI Dexter said, “It’s warm going cold”, and then spoke directly to Chief Fire Officer Peter O’Reilly by telephone, using the term “Plato standby”.⁹²⁵ This was not a term used in JOPs 3 or in the CTPHQ refreshed guidance. It was, as CI Dexter accepted in evidence, an attempt to find a pragmatic solution to a situation in which, 2 hours and 25 minutes after the explosion, the Chief Fire Officer of GMFRS was still not prepared to sanction his staff entering the Victoria Exchange Complex.⁹²⁶ Again, I applaud CI Dexter’s purpose and his imagination, but once more I observe that this confusion of language would have been avoided if his training had given him the ability and the confidence accurately to zone the station concourse and the City Room under Operation Plato as cold and then communicate that assessment.

CI Dexter did not leave the Victoria Exchange Complex until 03:30.⁹²⁷ Before leaving, he updated NWAS and GMFRS and handed over scene security to an unarmed Operational/Bronze Commander supported by an Operational Firearms Commander. He had spoken to the Senior Investigating Officer and undertaken a whole series of additional tasks, including assisting in the identification of the murderer.⁹²⁸

I have not detailed everything CI Dexter did in the period of more than four hours that he was at the Victoria Exchange Complex. As for any person responding in circumstances of great pressure, it is possible to identify things that he could, and sometimes should, have done differently on the night. In particular, his approach to Operation Plato and zoning was deficient. Overall, however, the emergency response benefited greatly from CI Dexter’s presence at the scene. He commanded those on the ground with intelligence, authority and resourcefulness. I agree with Counsel for the families that his dedication and efforts that night should be recognised.⁹²⁹

Conclusion

The GMP firearms officers discharged their primary responsibility with skill and efficiency. Individual officers of GMP who entered the City Room acted with courage and resourcefulness. Inspector Smith and CI Dexter made significant contributions to the response.

However, others within the GMP command structure did not make the contribution that the public was entitled to expect they would make in the event of a terrorist attack in the heart of Manchester. Although there were individual failures, the principal responsibility for that rests with GMP at a corporate level.

GMP’s failures are very significant, but are not the only explanation for why joint working between the emergency services broke down on the night of the Attack.