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The Manchester Arena Inquiry has now concluded. The closure notice from the Inquiry Chairman is available here.

Volume 2 is divided into two sub-volumes: Volume 2-I and Volume 2-II. Volume 2-I is 695 pages long. Volume 2-I begins with a Preface and then continues with Parts 9 to 16. Volume 2-II is 189 pages long. It contains Parts 17 to 21 and the Appendices. A list of the names of the twenty-two who died is at page vii of Volume 2-I and at page iii of Volume 2-II.
A large format version combining Volume 2-I (ia, ib and ic) and Volume 2-II is also available.
Volume 2-I (standard format)
Volume 2-II (standard format)
Volume 2 (large format)

Part 14: Ambulance service response to the Attack

In Part 12, I set out North West Ambulance Service’s (NWAS’s) state of preparedness. NWAS had taken significant steps to be ready to respond to a terrorist attack in its area of operation. Despite this, there were substantial failures in its response to the Attack. In this Part, I will consider those failures, within the following structure.

First, I will start with NWAS Control. Broadly speaking, the initial mobilisation was timely. However, there were problems in specific areas.

Second, I will look at the contribution made by Advanced Paramedic Patrick Ennis. NWAS was fortunate to have Patrick Ennis on duty that night. He self‑mobilised at an early stage and played an important role.

Third, I will pause my narrative of events inside the Victoria Exchange Complex to set the role of Ambulance A344 in its proper place in the order of events. Ambulance A344 was flagged down by those assisting Saffie‑Rose Roussos at 23:00. It transported her from the scene to hospital.

Fourth, I will examine in detail the Operational Commander role until shortly before midnight. During this period, this responsibility was performed by Consultant Paramedic Daniel Smith. It was during this period that significant mistakes were made that had an adverse impact on the adequacy of the NWAS response.

Fifth, I will set out the response of the Hazardous Area Response Team (HART). The focus will be on the Greater Manchester HART (GM HART) crew as they were best placed to make the greatest contribution. I will also consider the position of the Cheshire and Merseyside HART (C&M HART) crew.

Sixth, I will review the tactical command of the incident. Annemarie Rooney was the Tactical Commander for NWAS. As I will explain, there were areas in which this role could have made a greater contribution.

Seventh and eighth, I will explore the roles of the two Tactical Advisor/National Interagency Liaison Officers (NILOs) who responded to the Attack. They were Jonathan Butler and Stephen Taylor.

Ninth, I will give brief consideration to the role of the Ambulance Intervention Team Commander. This role was expected to lead NWAS Operation Plato responders. On the night of the Attack, it was not allocated during the first half‑hour, despite efforts being made to identify a person qualified to undertake the role.

Tenth, I will examine strategic command of the incident. The Strategic Commander role was undertaken by Neil Barnes. As I shall explain, he did not have an impact in any meaningful way on the response.

Eleventh, and finally, I shall return to the Casualty Clearing Station, considering the period after midnight.