North West Ambulance Service response

NWAS Control

First 999 call (22:32)

At 22:32, a member of the public, having called 999, was connected to NWAS Control. The caller stated: “I’m at the MEN [Manchester Evening News] Arena in Manchester there’s a bomb just gone off in the foyer.”¹ The caller said that he had been in the “foyer” when the bomb had gone off. He confirmed that the address was Hunts Bank. He identified the location of the detonation as “in the main reception near the box office”.² He went on to say: “[T]here’s people everywhere, blood everywhere.”³ The call ended, after just over two and a half minutes, with the caller saying he needed to find his daughter.⁴

At 22:32, there were seven vehicles within the Greater Manchester area immediately available to NWAS for deployment: four ambulances, two Urgent Care Vehicles and an Intermediate Care Vehicle.⁵

Call to GMP Control (22:36)

At 22:36, NWAS Control telephoned Greater Manchester Police (GMP) Control. It took over two minutes for the call to be answered by GMP Control.⁶ If there had been a multi‑agency control room radio talk group which all control rooms were monitoring 24 hours a day, seven days per week, the delay in getting through to GMP Control, at this important early stage, would not have occurred.

Three minutes into the call, GMP Control said: “[W]e’ve got a lot of officers en-route … we’ve got officers on scene … Where are the ambulances?”⁷ NWAS Control replied: “[W]e’re 10 minutes away – we’ve got quite a lot of ambulances coming.”⁸ Five minutes into the call, GMP Control asked how many vehicles were en route. NWAS Control replied: “We’ve got five at least, but we’re shouting out for crews to clear if they can.” ⁹ As the call was concluding, GMP Control stated: “[W]e’ve got an officer on scene … they’re just updating literally every few minutes.”¹⁰

This call covered the period 22:38 to 22:44.¹¹ In the course of it, GMP Control repeatedly mentioned that there were GMP officers at the scene. It is significant that this information was passed to NWAS Control at this stage of the response. During the period of this call, NWAS Control was mobilising its personnel to a Rendezvous Point (RVP) at Manchester Central Fire Station.

Call to NWFC (22:37)

At 22:37, NWAS Control telephoned North West Fire Control (NWFC).¹² This was the correct thing for NWAS Control to do. However, as it turned out, NWFC had more information to give NWAS than NWAS had information to give NWFC. This was because NWFC had already received a substantial amount of information from GMP Control.

There were unsatisfactory elements to the telephone call between NWAS Control and NWFC. I shall deal with these in greater detail when I consider NWFC’s response to the Attack, in Part 15.

Initial mobilisations

Advanced Paramedic Patrick Ennis was on duty at Central Manchester Ambulance Station when he became aware of a number of 999 calls coming in to NWAS Control related to the Arena. At 22:36, he radioed NWAS Control and asked: “[W]hat’s going on in the city?”¹³ NWAS Control replied: “As at the minute we’re just taking all the call[s], we’ll get back to you in a second when we know what’s happening.”¹⁴

On 22^nd May 2017, Nicola Pratt was the duty Manager of the Emergency Operations Centre for Greater Manchester, which was part of NWAS Control. At 22:36, Nicola Pratt made a call to another part of NWAS Control, the Regional Health Control Desk. In that call, Nicola Pratt said that there were reports of a bomb going off at the Arena. She advised that the hospitals may need to be put on standby.¹⁵ It was important that this step was taken at an early stage. Nicola Pratt did well to do so at the point she did.

At 22:38, Patrick Ennis contacted NWAS Control again. He said: “I’m just on my way … I’m just going to follow the police.”¹⁶ He also requested: “[J]ust see if anybody in Manchester has spoken to … Silver.”¹⁷ “Silver” was a reference to the on‑call NWAS Tactical Commander.

As Patrick Ennis was confirming that he was on his way to the Arena, NWAS Control called Annemarie Rooney. Annemarie Rooney was the on‑call NWAS Tactical Commander. The call was made by Nicola Pratt. Nicola Pratt informed Annemarie Rooney: “[W]e are getting reports of a bomb gone off at the Manchester Arena.”¹⁸ Annemarie Rooney asked: “When did this come in?”¹⁹ She is one of the few commanders across the entire emergency response who asked this question. It was appropriate that she did so.²⁰

Nicola Pratt informed Annemarie Rooney that NWAS Control would contact the on‑call Operational Commanders: Derek Poland and Matthew Calderbank.²¹ Nicola Pratt can be heard asking for someone in NWAS Control to contact both of these men.²² It was identified that the on‑call NWAS Strategic Commander was Neil Barnes. Annemarie Rooney said that she would contact him.²³

Annemarie Rooney said: “[W]e need to get HART, we need to find out who’s the … AIT on duty.”²⁴ It was 22:39 when HART was first mentioned. ‘AIT’ stands for Ambulance Intervention Team.²⁵

While Annemarie Rooney was correct to identify that HART was required, in light of the clear report at 22:32 that “a bomb”²⁶ had detonated, it would have been better if the need for HART had been identified before 22:39 by NWAS. One of the issues with HART is the limited number of teams covering a large area. For this reason, it is essential that contact is made with the nearest HART crew as early as possible. It should be possible for the control room to do this as part of a standard response. NWAS should review its policies for mobilising the HART resource, to seek to ensure that it is available as soon as possible for any emergency where its specialist skills are required. This important issue is examined in further detail in Part 20 in Volume 2‑II.

While the telephone call between Annemarie Rooney and Nicola Pratt was ongoing, NWAS Control called the GM HART crew.²⁷

At 22:40, NWAS Control telephoned Derek Poland. He was mobilised to Manchester Central Fire Station. Two minutes later, Matthew Calderbank was also mobilised to Manchester Central Fire Station by NWAS Control.²⁸

At 22:41, Annemarie Rooney telephoned Consultant Paramedic Daniel Smith. In that call, they agreed that he would travel to the scene. This call was as a result of an existing informal agreement between Annemarie Rooney and Daniel Smith. It was not part of any formal or approved plan. Their agreement was to the effect that if either of them learned of an incident which they thought the other might want to mobilise to, they would let the other know. Although Daniel Smith would later take up the role of Operational Commander once he was at the scene, they did not discuss this in the call. Following the call, Daniel Smith got dressed, got in his car and drove towards the Arena.²⁹

I am not critical of Annemarie Rooney contacting Daniel Smith. As a Consultant Paramedic, Daniel Smith had a very high level of expertise he could contribute. However, contacting Daniel Smith when he was off duty gave rise to a risk to the pre‑determined command structure, which had been put in place for good reason.

Shortly after 22:40, Neil Barnes telephoned Annemarie Rooney. She had telephoned him at 22:40, but he had not answered that call. She informed him of the Attack. He asked her to call him back once she had received greater situational awareness through a METHANE message. Annemarie Rooney informed Neil Barnes that she was intending to travel to GMP Headquarters (GMP HQ). He was also made aware that two on‑call Operational Commanders, Derek Poland and Matthew Calderbank, were being mobilised to the incident.³⁰

Call from BTP Control (22:41)

At 22:41, British Transport Police (BTP) Control telephoned NWAS Control. The purpose of the call was “just to give you a bit of info from our officers on … scene”.³¹ BTP Control went on to provide a casualty update. There was a discussion about the information NWAS had about “an active shooter”. BTP Control said: “[We have had] it come through as a bomb threat or attack because of the use of ball bearings.”³²

BTP Control informed NWAS Control: “[I]t has been declared a major incident by [BTP] … we are working on getting more officers to the scene obviously.”³³ BTP Control told NWAS Control: “[F]ire have been made aware etc.”³⁴

The call continued, with NWAS Control saying: “[W]e [have] got about 30 odd jobs that have come through … from the MEN reception area and from the train station with injuries, so are you on scene at the train station[?]”³⁵ BTP Control replied: “Yeah … I’ve got I think two officers or maybe three on scene. It is hard to say really … I have got numerous going and Greater Manchester Police will likely be on scene as well.”³⁶ NWAS Control told BTP Control: “[A]t the moment we’ve got 1, 2, 3, 4 … it looks like 6 crews going and two officers at the minute. We have got an officer going to Thompson Street [Manchester Central Fire Station] as well.”³⁷

By 22:45, both GMP Control and BTP Control had informed NWAS Control that each organisation had officers on scene and more were on their way. It is unclear the extent to which this information had been adequately communicated and understood by NWAS as an organisation. This information was not passed on to Daniel Smith when he telephoned at 22:50.³⁸

Ambulance A344 (22:44)

Paramedic Gillian Yates and Emergency Medical Technician Gemma Littler were crewed together in Ambulance A344 for their shift on 22^nd May 2017.³⁹ They were in Withington dealing with a patient when they received notification of the Attack. At 22:44, they told NWAS Control they were nearly ready to deploy.⁴⁰

At 22:48, they contacted NWAS Control a second time. They were told: “There’s been an explosion at the MEN Arena, a nail bomb, 60 casualties so far. There’s an RV point at the fire station, I’ll pass you the details.”⁴¹ They confirmed they were on their way. The reference to “the fire station” was to Manchester Central Fire Station, sometimes referred to as ’Thompson Street Fire Station’.

In evidence, Gillian Yates stated: “I think the rendezvous point was Thomas Street Fire Station [sic], but I think the satnav was taking us to Hunts Bank.”⁴² She was asked who programmed the satnav and replied: “It’s done automatically from when they send the information to our computer in the ambulance, it automatically sends it to the satnav at the same time, so we don’t manually programme it in.”⁴³

At 23:00, Ambulance A344 drove along Trinity Way, where it was flagged down by those helping Saffie‑Rose Roussos. She had been carried out of the City Room and on to Trinity Way via the Trinity Way link tunnel.⁴⁴ I will return to Ambulance A344 at paragraphs 14.189 to 14.191.

Major Incident declaration (22:46)

At 22:45, a call within NWAS Control took place. The Regional Health Control Desk telephoned Greater Manchester Emergency Operations Centre. In the course of the call, the caller asked: “[J]ust a quick one is this a major incident standby or is it declared?”⁴⁵ Following a short discussion with Nicola Pratt, who was in the background of the call, the response came back: “[W]e will call it declared as from now 22:46.”⁴⁶

It was appropriate for this conversation to have taken place and for the decision to have been taken as it was. Even though those discussing the issue of a Major Incident declaration were remote from the scene, NWAS Control had adequate information at 22:46 to justify the declaration.

Following this call, the Regional Health Control Desk Major Incident action card was accessed. This led to a series of calls notifying local hospitals of the Major Incident declaration and giving approximate casualty numbers. NWAS records indicate that, by 23:00, six hospitals had been informed of the Major Incident declaration. More hospitals were notified in the minutes following 23:00.⁴⁷ NWAS did not notify GMP, BTP, NWFC or Greater Manchester Fire and Rescue Service (GMFRS) of its Major Incident declaration, as it should have done.

The fact that both NWAS Control and BTP Control were able to declare a Major Incident in a timely way contrasts with GMP, which did not declare a Major Incident until 00:57 on 23^rd May 2017.⁴⁸ GMFRS and NWFC should also have declared a Major Incident.

Notification of Tactical Advisors/NILOs (22:49)

At 22:49, NWAS Control contacted Jonathan Butler. Jonathan Butler was one of two on‑call Tactical Advisors/NILOs.⁴⁹ In accordance with the guidance provided by the National Ambulance Resilience Unit (NARU), NWAS operated a system in which the roles of Tactical Advisor and NILO were combined.⁵⁰

In the telephone call, NWAS Control gave Jonathan Butler a brief situation report. He said he would contact the other on‑call Tactical Advisor/NILO, Stephen Taylor.⁵¹ I shall return to the role the NWAS Tactical Advisors/NILOs played on the night of the Attack below, at paragraphs 14.523 to 14.574.

Rendezvous Point

At an early stage of NWAS’s response, it was decided that Manchester Central Fire Station would be used by NWAS as an RVP. NWAS Control informed BTP Control of this at 22:43.⁵² I am not critical of the selection of Manchester Central Fire Station as an RVP at an early stage. It was an appropriate site for an RVP. It was close to the scene. In the event that it transpired that the scene was unsafe, it was far enough away to provide ambulance crews with some protection. My criticism of its selection relates to the lack of multi‑agency discussion around its use.

Joint Emergency Services Interoperability Principles (JESIP) require co‑location. It was not sufficient for NWAS Control to inform BTP Control where NWAS resources were going. There should have been a concerted effort to agree on where co‑location should take place. Had there been such a conversation, it would have become apparent that BTP regarded the scene itself as sufficiently safe to deploy its unarmed responders there. By 22:43, BTP was the best placed of all the emergency services to make this judgement, having direct situational awareness from a significant number of officers within the Victoria Exchange Complex.

Having identified Manchester Central Fire Station as the RVP, it was important for NWAS Control to respond quickly to any new information emerging from the scene as to whether it was safe enough to deploy ambulances in numbers to the Victoria Exchange Complex.

Contact between NWAS Control and Patrick Ennis (22:46)

At 22:46, NWAS Control asked Patrick Ennis for a situation report. He replied from Hunts Bank to say: “We’ve had reports of a nail bomb, possibly with shooting.”⁵³ He said he could see six to eight casualties whom he described as walking wounded.⁵⁴ At 22:47, he asked for “at least four emergency ambulances” and suggested that the best access would be from Cross Street, “liaising at the [Victoria] Station”.⁵⁵ He was describing how to get to the Victoria Exchange Complex, not Manchester Central Fire Station. Four minutes later he entered the Victoria Exchange Complex through the War Memorial entrance.⁵⁶

Contact between NWAS Control and Patrick Ennis (22:50)

Patrick Ennis entered the Victoria Exchange Complex at 22:50.⁵⁷ Within seconds, at 22:50:22, he informed NWAS Control: “[W]e need NWAS to be at … Hunts Bank, by Victoria Station will be … the best access for the moment, we can change that … as and when Police confirm.”⁵⁸ This information should have resulted in the dispatch of all available ambulances to Hunts Bank. In the event, that did not occur.

Immediately upon sending this message, Patrick Ennis spoke to GMP Police Constable (PC) Grace Barker. I will deal with the conversation they had at paragraph 14.116.

Contact between NWAS Control and Daniel Smith (22:50)

Daniel Smith had been notified of the incident by Annemarie Rooney. At 22:50, while he was travelling to the Victoria Exchange Complex, he radioed to inform NWAS Control that he was on duty. At that time, Daniel Smith’s intention was to take whatever role he was “best suited for”.⁵⁹

Daniel Smith asked if there was an RVP. He was told: “Nothing down at the moment … the RVP was Thompson Street [Manchester Central Fire Station] but I’ve just had an update from the AP on scene, it’s Paddy. He has gone straight to scene … confirmed it is a nail bomb.”⁶⁰ Daniel Smith replied: “Just to confirm that someone on scene is saying the scene is safe to go in.”⁶¹ In response, NWAS Control said: “He’s gone in and he’s said that he’s on scene with patients … that’s all I have at the moment.”⁶² Daniel Smith then informed NWAS Control that he would go to the scene. He instructed NWAS Control “to maintain RVP for now in case it is an MTFA [Marauding Terrorist Firearms Attack] type incident”.⁶³

Daniel Smith’s instruction to maintain the RVP at Manchester Central Fire Station pending his arrival at the scene could have been significant. Daniel Smith was not part of the planned command structure.

Annemarie Rooney described this intervention by Daniel Smith in her second witness statement as follows: “The RVP was notified initially at Thompson Street [Manchester Central] Fire Station when a change to this was notified … then the Operational Commander intervened and confirmed that the RVP was to remain at Thompson Street [Manchester Central Fire Station].”⁶⁴ This is a mischaracterisation of what occurred. Daniel Smith was not the Operational Commander at the point at which he made this intervention.

With what I accept were good intentions, Daniel Smith inserted himself into the chain of command. He was no better placed than either of the two on‑call commanders at 22:50. He was not as well placed as Patrick Ennis to make the decision about whether or not Hunts Bank should be used. On the basis of what he had observed at the scene, Patrick Ennis had asked NWAS Control to send four ambulances to the Victoria Exchange Complex.

NWAS Control was unable to confirm to Daniel Smith that the scene was safe, because Patrick Ennis had not been asked that question directly. However, Patrick Ennis had not passed a message to say the scene was unsafe. Patrick Ennis was highly experienced. He could and should have been relied upon to inform NWAS Control if he had concerns about scene safety.

Daniel Smith did not ask NWAS Control what information had been received from any of the other emergency services. Given that Daniel Smith had decided that he would make command decisions at this early stage, he should have sought to inform himself better before making a decision that could lead to delay. He did not consult the Tactical Commander about this decision.

It is inevitable in the early stages of a Major Incident that an emergency services control room will receive simultaneous calls which will need to be reconciled. When he made his command decision to maintain the RVP at Manchester Central Fire Station, Daniel Smith did not know that Patrick Ennis, who was at the scene, had informed NWAS Control that ambulances should be sent to Hunts Bank.

By 22:50, there were two ambulances on the forecourt of Manchester Central Fire Station.⁶⁵ These were ambulances that could immediately have been dispatched to Hunts Bank in accordance with Patrick Ennis’s request. They could have been at Hunts Bank within three minutes. This did not occur.

Instead, those two ambulances waited at Manchester Central Fire Station. They were joined by a third ambulance at 22:53, a fourth at 22:56, a fifth at 22:59 and a sixth at 23:02. Those latter four ambulances could have arrived at Hunts Bank within seconds of their arrival time at Manchester Central Fire Station, had they been directed to go straight to the scene.⁶⁶

Contact between NWAS Control and GMP Control (22:51)

As Daniel Smith’s call with NWAS Control concluded, GMP Control informed NWAS Control: “Our Inspector is saying can we have all available ambulances … to … Hunts Bank.”⁶⁷ GMP Control went on to identify “the booking office … over the bridge to the main entrance” as being the exact location. GMP Control also stated: “[O]ur Inspector … is asking for all ambulances there.”⁶⁸ This call took place at 22:51.

NWAS Control should have acted immediately upon the information from GMP and directed all ambulances allocated to the incident to Hunts Bank. The information had come directly from a senior GMP officer at the scene. It was entirely consistent with the information that Patrick Ennis was providing at the same time.

NWAS Control did start to mobilise individual resources to Hunts Bank shortly after the call with GMP Control concluded.⁶⁹ However, it was not until 23:00 that the ambulances that were at Manchester Central Fire Station were instructed by NWAS Control to move forward to Hunts Bank.⁷⁰

Contact between NWAS Control and BTP Control (22:54)

BTP Control contacted NWAS Control at 22:54. The call lasted seven minutes. In the course of it, BTP Control informed NWAS Control: “[N]umerous officers are asking for ambo.” A little later, BTP Control said: “[W]e’ve got you updated that its Hunts Bank for the RVP.” Towards the end of the call, BTP Control stated: “[C]an I just pass on a bit more information … It’s just … to let you know … the cordon is in place at both ends of Hunts Bank where your RVP is.”⁷¹

Contact between NWAS Control and Patrick Ennis (22:54)

Patrick Ennis entered the City Room at 22:53.⁷² At 22:54, he sent another message to NWAS Control. He said: “[T]his is a confirmed major incident we’ve got at least … 40 casualties approximately 10 … appear to be deceased on scene. We’ve got at least a dozen priority 1 … ambulance [inaudible] still need to be er Hunts Bank … Victoria Station.” ⁷³ NWAS Control replied: “[E]veryone is now making their way to Hunts Bank.”⁷⁴

Patrick Ennis’s confirmation that ambulances should go to Hunts Bank prompted a response from NWAS Control that Hunts Bank was now being used by all NWAS responders. This may have been the intention. However, for a number of ambulances already sent to Manchester Central Fire Station, it was to be another 12 minutes before they set off from that location to the Arena. In the period immediately after a Major Incident, every minute is vital.

Contact between NWAS Control and the GM HART crew (22:54)

The GM HART crew, which by 22:54 were en route to Manchester City Centre, were notified that the new RVP was “Hunts Bank Bridge”.⁷⁵

Contact between NWAS Control and Daniel Smith (22:56)

Two minutes after the GM HART crew were notified that Hunts Bank was the RVP, NWAS Control contacted Daniel Smith. In that contact, NWAS Control informed Daniel Smith: “[T]he new RVP is Hunts Bank.”⁷⁶

By 22:56, NWAS Control’s approach was to deploy some of its resources to the scene, such as Daniel Smith and the GM HART crew, while ambulances at Manchester Central Fire Station were not instructed to move forward. In light of the information received from Patrick Ennis and GMP Control, there was no good reason not to send the ambulances at Manchester Central Fire Station to the scene as well. By 22:56, there were four ambulances at Manchester Central Fire Station, three minutes’ drive from Hunts Bank. These could have been at the Victoria Exchange Complex by 23:00 had they been deployed at this point.

Contact between NWAS Control and Annemarie Rooney (22:56)

As Daniel Smith was being contacted at 22:56 by NWAS Control, so too was Annemarie Rooney. She was informed by Nicola Pratt about the location of NWAS resources in the following terms:
“We’re all at Thompson Street [Manchester Central] Fire Station but it’s been changed by the police to the bridge over Hunts Bank … Dan Smith is going straight to scene, I can’t get hold of the force duty officer to see if it’s safe, so we are all staying at that RVP for now.”⁷⁷

Despite the information from GMP Control about Hunts Bank, the position at the start of the call appears to be that Manchester Central Fire Station would continue to be used until Daniel Smith reached the scene. This approach was consistent with the instruction given by Daniel Smith at 22:50.

Four minutes into the call, at 23:00, Nicola Pratt can be heard to say to someone within NWAS Control: “Stay at the RVP, until we can get confirmation … at the RVP, yeah … Hunts Bank is the new RVP, the new RVP’s Hunts Bank.”⁷⁸

Contact between NWAS Control and Derek Poland (22:57)

Shortly before he arrived at Manchester Central Fire Station, at 22:57, Derek Poland was contacted by NWAS Control and informed: “Paddy [Ennis] on scene, has been declared a major incident, there is at least 40 casualties … the new rendezvous point is Hunts Bank near to Victoria [Railway] Station.”⁷⁹

Contact between NWAS Control and responding crews (23:00)

At the same time that Nicola Pratt was informed that the “new” RVP was Hunts Bank, NWAS Control broadcast on an open radio channel: “[T]o all crews on the major incident. Can you make your way across to Hunts Bank at the railway station … back of the Arena.”⁸⁰ This should have resulted in the immediate departure of the five ambulances that, by then, were at Manchester Central Fire Station. It did not.

Contact between NWAS Control and Joanne Hedges (23:03)

At 23:03, Senior Paramedic Joanne Hedges contacted NWAS Control. Joanne Hedges had arrived at Manchester Central Fire Station at 22:59.⁸¹ Joanne Hedges said: “I’m … in charge here at the moment.”⁸² She asked if the scene was safe. In reply, NWAS Control informed her that Hunts Bank was the RVP, but that the scene had not been confirmed as safe. Joanne Hedges responded: “We’ll stay here at the fire station.”⁸³ NWAS Control informed Joanne Hedges: “[W]e’ve been advised by the police for everybody, go to Hunts Bank. That’s the new RV.”⁸⁴

Joanne Hedges’ evidence was that there “was no clear instruction … for us to leave immediately”.⁸⁵ I disagree. At 23:00, a clear instruction had been issued by NWAS Control to all crews. This should have led to an immediate departure by all the ambulances at Manchester Central Fire Station. What Joanne Hedges was told at 23:03 was also clear. While I recognise that an incident of this nature will create understandable concern about scene safety, Joanne Hedges should have followed the clear mobilising instruction by NWAS Control. The failure to do so led to further avoidable delay.

During the seven minutes she was at Manchester Central Fire Station, Joanne Hedges spent the time constructively. In evidence, which I accept, she described how she discussed the situation with colleagues, readied kit and made sure they had their Major Incident packs available.⁸⁶ However, once the instruction came through at 23:00, it should have been followed immediately. Any necessary tasks that remained could have been done on arrival at Hunts Bank.

Mobilisation from Manchester Central Fire Station (23:06)

At 23:06, the six ambulances at Manchester Central Fire Station set off in convoy for Hunts Bank. They began to arrive on Hunts Bank at 23:08. The journey time of the lead ambulance was 2 minutes and 20 seconds.⁸⁷

Operation Plato

In the call at 22:38 described at paragraph 14.22, Annemarie Rooney advised Nicola Pratt: “Go through your Plato card.”⁸⁸ This was a reference to the Operation Plato action cards for NWAS Control. This was reasonable advice for Annemarie Rooney to give in light of the fact that Nicola Pratt had said: “[W]e are getting … multiple calls … saying there may be somebody shooting as well.”⁸⁹

Annemarie Rooney also said: “[W]e need to find out who’s the AITC.”⁹⁰ AITC stands for ‘Ambulance Intervention Team Commander’. The Ambulance Intervention Team was NWAS’s specialist response team for Operation Plato. It comprised HART operatives and other employees drawn from NWAS’s wider operational staff.⁹¹

At 22:43, Nicola Pratt spoke to Kevin Mulcahy, an on‑call Tactical Commander. She asked him: “Do you want me to go through Plato?”⁹² He asked if the police had “declared it … a marauding terrorist incident”.⁹³ She replied: “I don’t know, I will speak to the Force Duty Officer now.”⁹⁴

At 22:56, Nicola Pratt spoke to Annemarie Rooney again. As set out at paragraph 14.70, towards the beginning of this call, Nicola Pratt stated: “I can’t get hold of the force duty officer.”⁹⁵ Later in the call, Nicola Pratt said: “We’re not treating it as a marauding terrorist as there are no reports of that and the police have said it’s not, so I’ve not gone down Plato, I’m just going down the major incident card, is that ok?”⁹⁶ Annemarie Rooney replied: “Right.”⁹⁷

Towards the end of the call, Annemarie Rooney asked: “[H]ave we identified an AITC?” Nicola Pratt replied: “AITC, other than the HART team leader?”⁹⁸ Annemarie Rooney replied: “[Y]es.” The two discussed who that might be. The call ended with NWAS Control saying: “I’ll find one.”⁹⁹

NWAS Control had been unable to contact the Force Duty Officer (FDO). This was in common with the experience of GMFRS’s NILO during the period between 22:43 and 22:56. In the absence of direct contact with the FDO, Annemarie Rooney’s decision to mobilise an Ambulance Intervention Team Commander was correct. Overall, in my view, NWAS’s approach to the issue of Operation Plato during the first half‑hour was appropriate. I shall return to the issue of the Ambulance Intervention Team Commander when I consider the Tactical Advisors/NILOs at paragraphs 14.523 to 14.574.

I am satisfied that NWAS Control was right to have in mind the possibility that it may be responding to a Marauding Terrorist Firearms Attack. The decision to approach the response on the basis of the Major Incident action card was appropriate given the information NWAS Control had at that time.

Position 30 minutes post-explosion

As set out at paragraph 14.49, the first paramedic on scene was Patrick Ennis. He entered the Victoria Exchange Complex at 22:50.¹⁰⁰ He headed straight for the City Room. He entered the City Room for the first time at 22:53.¹⁰¹ He then left the City Room at 22:59 to return to the station concourse.¹⁰²

At 22:58, the first ambulance arrived on Station Approach.¹⁰³ One minute later, Daniel Smith approached the War Memorial entrance with Dr Michael Daley. They entered the Victoria Exchange Complex seconds later.¹⁰⁴ Following almost immediately behind Daniel Smith and Dr Daley were two paramedics and a student paramedic: Martyn Nealon, Callum Gill and Leigh‑Sa Smith.¹⁰⁵ These five NWAS staff were joined by on‑call Operational Commander, Derek Poland.¹⁰⁶

By 23:01, Advanced Paramedic Patrick Ennis had entered the City Room, he had made his assessment and was making his way down to the station concourse. A dual‑crewed ambulance, Ambulance A344, was stationary on Trinity Way. Five ambulances were waiting on the forecourt of Manchester Central Fire Station just under one mile away. Another ambulance was just one minute away from Manchester Central Fire Station.¹⁰⁷ The GM HART crew and other non‑ambulance resources were on their way to Hunts Bank.¹⁰⁸

First paramedic on scene

Background, experience and training

At the time of the Attack, Patrick Ennis was a highly experienced paramedic.

He joined the ambulance service in October 2005 as a trainee ambulance technician, and in December 2008, he qualified as a paramedic. In 2012, having undertaken a higher education diploma in paramedic studies, he was promoted to the role of Senior Paramedic. In 2015, he completed a degree in paramedic practice and was promoted to the role of Advanced Paramedic.

In May 2017, Patrick Ennis was one of three Advanced Paramedics who covered Central Manchester and Salford.¹⁰⁹

In evidence, Patrick Ennis described the role of an Advanced Paramedic in this way:
“An Advanced Paramedic is a more senior clinician able to provide clinical support to ambulance clinicians, both on scene at incidents and also remotely via telephone or radio in order to assist ambulance clinicians in being able to provide a high level of care … Advanced Paramedics have additional training and are able to administer a wider variety of drugs and medicines and other procedures as well … with responsibility for the clinical management of a team of senior paramedics and also a large team of paramedics and emergency medical technicians.”¹¹⁰

In the course of his career prior to May 2017, Patrick Ennis had received extensive training.

He had been trained in each role he had undertaken. He had also received mandatory training each year and was clear in evidence that on each of those occasions he had received training in JESIP and Major Incident management.¹¹¹ He also had personal experience of the response to a Major Incident, having been on board the air ambulance during the emergency services’ response to the mass shooting in Cumbria on 2^nd June 2010.¹¹²

Patrick Ennis’s Major Incident training had, he explained, educated him in the declaration of a Major Incident, the passing of a METHANE message, the actions required of the first and subsequent ambulance resources on scene, the role of an Operational Commander, and the NWAS zoning of the area of an incident. Prior to the Attack, Patrick Ennis had also received training in how the ambulance service might respond to a Marauding Terrorist Firearms Attack, although it emerged in evidence that he had never heard of Operation Plato prior to 22^nd May 2017.¹¹³ I will say more about that later in this Part.

Asked in evidence whether his training had equipped him for what he was confronted with on the night of the Attack, Patrick Ennis explained that no training could ever provide adequate preparation for such an event. He felt, however, that he had been sufficiently trained for the role he performed that night.¹¹⁴

I accept that the formal training of Patrick Ennis was of a good standard. There was, however, an important respect in which his training was lacking. He had never taken part in any live exercising. That should not have happened. By May 2017, Patrick Ennis had held a supervisory paramedic role for five years, two of which as an Advanced Paramedic. In the event of a Major Incident in Central Manchester or Salford, there was every chance that he would form part of the response. He should have taken part in live exercises with emergency service partners in order to see how JESIP worked, or did not work, and in order to see and understand the capabilities of each service.¹¹⁵ Responsibility for this rests with NWAS, not Patrick Ennis.

In Part 20 in Volume 2‑II, I will address the issue of JESIP training further, including what has been described as ‘high‑fidelity training’.

Journey to the Victoria Exchange Complex

On 22^nd May 2017, Patrick Ennis came on duty at 19:00. He was the only Advanced Paramedic working across Greater Manchester that night.¹¹⁶

Patrick Ennis had no idea that a major event was taking place at the Arena that evening. There was, he explained, no system in place to ensure that NWAS was informed of major events, such as music concerts or sporting events, taking place in Manchester.¹¹⁷ I find that surprising, just as I found it surprising that there was no system in place to ensure that GMP’s duty command structure was informed of such events. Where an event brings people in large numbers into a particular area, it is obvious that the demand upon the emergency services may increase. A system in which they have advanced notice of major events in their area seems to me to be a good idea. Ambulance services and other Category 1 responders should ensure that they have this information. That would enable the emergency services to consider whether additional resources might be needed or other steps of preparation taken. In the first instance, in the case of ambulance services, this is an issue for the Department of Health and Social Care (DHSC) and NARU to reflect upon.

At 22:31, Patrick Ennis was at Central Manchester Ambulance Station in South Manchester. He was dealing with administration and keeping an eye on incidents on the Control screen. He became aware of a number of calls coming in about an incident at the Arena. Patrick Ennis gave evidence that the calls were all coded by the system as amber on a scale of purple (the highest priority), red, amber and green (the lowest priority).¹¹⁸ Each call was shown as involving “bomb or explosion”, so to prioritise them in the second lowest category would seem to be wrong.¹¹⁹

Patrick Ennis explained that the system used by NWAS is called the Advanced Medical Priority Dispatch System (AMPDS). He stated: “One of the very much understood things about the AMPDS … is that it vastly underemphasises the priority of traumatic calls.”¹²⁰ Patrick Ennis was clear that this had not delayed his departure for the scene that night, and I accept this. Nonetheless, as he acknowledged, this is capable of creating a misleading impression and is therefore capable of causing confusion and delay.¹²¹

My understanding is that AMPDS is applied generally around the country, so this issue is not restricted to NWAS. I did not conduct a detailed investigation into this system, but from all of the information I have received, I am concerned that it needs review. I recommend that DHSC and NARU consider whether AMPDS is fit for purpose and, if it is, whether it can be improved. Particular consideration should be given to how the AMPDS prioritises emergency calls.

As Patrick Ennis was learning of the events at the Arena from the Control screen, a pager that he carried also sounded to alert him to the incident.¹²² He realised that something significant was happening. He went straight to his response car and began to drive to the Arena, a location he knew. At 22:36, Patrick Ennis radioed the Emergency Operations Centre within NWAS Control to say he had seen a message on his pager. He asked: “[W]hat’s going on in the city?”¹²³ NWAS Control said that they would get back to him.¹²⁴ Patrick Ennis explained that he was already in the car at this time.¹²⁵ It follows that within five minutes of the explosion, Patrick Ennis was already on his way to the Arena. He responded swiftly.

Patrick Ennis drove on lights and sirens, following a police vehicle that he correctly assessed was going to the scene. At 22:38, while still on the way, he spoke to Advanced Paramedic Jackie Carney. It appears from the conversation that Patrick Ennis called her. Jackie Carney was based in the part of NWAS Control called the ‘Trauma Cell’ in the Emergency Operations Centre in Preston. The purpose of the Trauma Cell was to ensure that incidents involving trauma were rapidly identified, and the correct resources allocated to them.¹²⁶

I introduced the Trauma Cell in Part 12. In this call, Patrick Ennis made clear that Major Incident command needed to be established.¹²⁷ Patrick Ennis was taking appropriate steps to set up the NWAS response to what he knew was likely to be a significant incident. Patrick Ennis followed the police vehicle all the way to the Arena and parked his response car on Hunts Bank. He believed he arrived at the scene at 22:42. This timing is likely to be broadly correct given that Patrick Ennis is captured on the body‑worn video footage of a GMP officer outside the station at 22:45:46.¹²⁸

Equipment

Patrick Ennis’s response car had on board a Basic Life Support bag, an Advanced Life Support bag, a Commander Pack and a Medicines Bag. Patrick Ennis explained that the general approach, and his own approach, was for the first on the scene, as he rightly understood himself to be, to deploy initially with the Basic Life Support bag, collecting other equipment later if needed. On arriving on Hunts Bank, Patrick Ennis decided to deploy with the Basic Life Support bag and an extra pouch, which duplicated some of the equipment in the Basic Life Support bag, including dressings and an extra tourniquet.¹²⁹ I am not critical of Patrick Ennis for deploying with the Basic Life Support bag as opposed to the Advanced Life Support bag, but whether he should have deployed with the Commander Pack as well or later taken steps to obtain it requires careful consideration.

The Commander Pack contains, among other things, a pack of what Patrick Ennis described as “cruciform cards”.¹³⁰ These are referred to as ‘SMART Triage Tags’ in the NWAS Major Incident Response Plan.¹³¹ Such cards represent an invaluable tool as part of triage in a mass casualty situation. They are colour coded: P1 cards are red; P2 cards are yellow; P3 cards are green; and the dead cards are white. The cards are placed around a casualty’s wrist and provide what Patrick Ennis described as “a visual identifier of the triage category for that patient”.¹³²

When giving evidence in relation to the Care Gap, Lieutenant Colonel Claire Park, Pre‑Hospital Care Expert, explained that tagging avoids casualties being unnecessarily assessed, which is highly undesirable in a mass casualty situation, where an efficient process is critical.¹³³ The cards avoid those carrying out the triage being distracted from their work by being asked the status of casualties. They ensure that, once moved to the Casualty Collection Point and/or Casualty Clearing Station, the status of the casualty is understood and treatment prioritised accordingly. They save time and avoid confusion. They may save lives.

In evidence, Patrick Ennis acknowledged that his work within the City Room that night would have been made easier if he had had the SMART Triage Tags with him.¹³⁴

As he arrived at the Victoria Exchange Complex, Patrick Ennis knew that what had occurred was a bomb or explosion, and he must have known of the material risk of mass casualties. It would have been better if, along with the Basic Life Support bag and extra pouch, he had also taken the Commander Pack or at least the SMART Triage Tags. Alternatively, once he was in the City Room and saw the scale of what had happened, it would have been better if Patrick Ennis had instructed someone, probably a police officer, to retrieve the cards from his NWAS vehicle or had obtained them from elsewhere, for example from Daniel Smith once he arrived. He did not do so, and it was not until after the arrival of the HART members Christopher Hargreaves and Lea Vaughan at 23:15 that SMART Triage Tags were available for use within the City Room. In the meantime, Patrick Ennis was reduced to writing the number and type of casualties on his glove.¹³⁵

This observation about the delayed arrival in the City Room of SMART Triage Tags must be tempered by recognition of the decisive action by Patrick Ennis that enabled him to reach the scene quickly and by what he did thereafter. Furthermore, ambulance services should in any event, to the extent possible, accommodate circumstances in which a paramedic decides to deploy to a scene without such tags and then realises they are needed, or simply overlooks the issue in the heat of the moment. I can see no reason why the Basic Life Support and Advanced Life Support bags should not contain packs of SMART Triage Tags. I recommend that DHSC and NARU give this consideration.

Arrival at the Victoria Exchange Complex

On arriving on Hunts Bank, Patrick Ennis was immediately aware of a large police presence, of many members of the public moving away from the area and of people who appeared injured.¹³⁶ At 22:46, while still outside but having spoken to police officers and members of the public, Patrick Ennis made contact with NWAS Control via the radio. He did so in order to provide a situation report. This was the right thing to do. He said:
“Yeah, it’s a major incident … standby. We’ve had reports of a nail bomb, possibly with shooting, apparently between 6 and 8 casualties all appear to be walking wounded currently but I can’t confirm that number, I’ve got no major incident command post set up, but for the time being, I could do with at least 4 emergency ambulances …”.¹³⁷

In evidence, Patrick Ennis explained that in describing the situation as “a major incident … standby” he was not declaring a Major Incident but was alerting NWAS Control to the likelihood that this was what they were dealing with.¹³⁸ ‘Major Incident – Standby’ is, as I explained in Part 12, one of four potential Major Incident messages set out in the Major Incident Response Plan. The plan said of Major Incident – Standby:
“This alerts the NHS that a major incident may need to be declared. Major Incident Standby is likely to involve the participating NHS organisations in making preparatory arrangements appropriate to the incident … NWAS resources should be identified and held awaiting further information. EOC [the Emergency Operations Centre within NWAS Control] will effectively activate the Major Incident Plan and processes required to prepare the service for a Major Incident – Declared response. Resources can easily be cancelled later if not required.”¹³⁹

The information contained in the 22:46 situation report of Patrick Ennis was, as it turned out, not all accurate. The consequences of the explosion were far more terrible than Patrick Ennis understood, and many more than four ambulances were needed; furthermore, there had of course been no shooting. However, in the early stages after an incident such as the Attack, there will inevitably be confusion. That this was so in the period after 22:31 was not the fault of Patrick Ennis. In his message to NWAS Control, Patrick Ennis was conveying what he knew at that time. He made clear that this was likely to require a Major Incident response. What he did was appropriate, and the information he provided should have helped NWAS to start to prepare a response to the Attack.

At 22:49:43, Patrick Ennis was captured on the CCTV system walking from the direction of Hunts Bank towards the War Memorial entrance.¹⁴⁰ Just before he entered the station, at 22:50:02, he was approached by PC Barker.¹⁴¹ The officer’s body‑worn video¹⁴² records that the two had a short conversation just after Patrick Ennis had entered. The GMP Operational/Bronze Commander, Inspector Michael Smith, was already in the City Room at this stage. Inspector Smith had recognised that there was an urgent need for paramedics to attend in order to treat the injured. As I explained in the section dealing with GMP’s response, in Part 13, that message had reached PC Barker, and, as a result, the following exchange took place between her and Patrick Ennis:
“[PC Barker] Every NWAS. They want every NWAS there.”
“[Patrick Ennis]Where?”
“[PC Barker] At the booking office which is just … [upstairs].”¹⁴³

Immediately after this exchange, Patrick Ennis continued his journey within the Victoria Exchange Complex. In the CCTV footage, he can be seen carrying the Basic Life Support bag on his back.¹⁴⁴ He then made his way straight to the City Room, entering at 22:53.¹⁴⁵ He was asked in evidence what role he was performing when he did so. Patrick Ennis said:
“At that time, I still don’t feel I was performing any specific role. I was aware that I was likely first ambulance on scene, but I was still at the stage of gathering as much information and as much relevant information as possible in order to be able to, firstly, decide whether or not this was, as it seemed, a major incident, and also to be able to provide the remainder of the information that was required of me, i.e., a METHANE report to control.” ¹⁴⁶

Patrick Ennis confirmed in evidence that he recognised he was, so far as NWAS was concerned, the first resource on the scene. He acknowledged that he knew that the role of ‘First Resource on Scene’ is one with a particular meaning in the Major Incident Response Plan.¹⁴⁷ According to the Major Incident Response Plan, that person should: assume the role of Acting Operational Commander until relieved; provide a METHANE message; not become involved in treating patients but instead concentrate on establishing initial command and control of the incident; establish key functional roles; and, when possible, co‑locate with commanders from other responding organisations.¹⁴⁸

Patrick Ennis agreed that, even though he was the first NWAS resource to arrive on the scene, he had not assumed the role of Operational Commander. Early in the oral evidence hearings on the emergency response, I thought that this was likely to represent a failure on the part of Patrick Ennis. Having heard his evidence, I concluded that it did not. Patrick Ennis explained that, although he had received some information about the situation in the City Room, both while outside and just inside the railway station, he considered it crucial that he should assess the situation for himself. That would enable him to confirm whether a Major Incident had occurred, assess what would be needed in terms of resources, provide a detailed METHANE message and then assume the role of Operational Commander, unless in the meantime that role had been filled by someone else.¹⁴⁹

Inevitably, this meant that there was an absence of operational command for a short period. But I am satisfied that what Patrick Ennis did was the right thing in the circumstances. To have stayed at the War Memorial entrance and attempt to direct events remotely would not have been appropriate.

The Major Incident Response Plan should make clear that the attendant from the ‘First Resource on Scene’ should assume the role of Operational Commander only once they have achieved situational awareness. Situational awareness must be the priority because, until that person has such knowledge, he or she will not be able to discharge his or her other responsibilities properly.

First visit to the City Room

Patrick Ennis entered the City Room at 22:53.¹⁵⁰ Although he was an experienced paramedic, he had not received HART training¹⁵¹ and had none of the personal protective equipment (PPE) that such operatives have.¹⁵² What he did in going into a place that he knew might be unsafe was brave.

At or near the entrance doors to the City Room, Patrick Ennis was met by Inspector Smith, Operational/Bronze Commander for the GMP unarmed assets in that location. The two can be seen from the CCTV footage to have a conversation. While there is no recording of this conversation, the circumstances make plain what Inspector Smith was communicating to Patrick Ennis, as I shall now explain.

By 22:47:51, five minutes before his conversation with Patrick Ennis, Inspector Smith had entered the City Room.¹⁵³ At 22:48:39, 48 seconds later, he made contact with GMP Control. 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?”¹⁵⁴ Fewer than 90 seconds later, at 22:50:03, Inspector Smith passed a further, similar message to GMP Control, stating: “I need every NWAS facility that we’ve got in here, please. Directly in here.”¹⁵⁵ At 22:51:19, in a further conversation with GMP Control by radio, Inspector Smith said that he had “sent one of the PCs outside to tell any NWAS staff they need to get in here as soon as.” ¹⁵⁶

Inspector Smith’s conversation with Patrick Ennis occurred almost immediately after these various messages were passed. In these circumstances, as I touched upon in Part 13 dealing with GMP’s response, I find that Inspector Smith communicated to Patrick Ennis not only that the situation in the City Room was exceptionally serious, but also that there was an urgent need for paramedics in that location. Patrick Ennis could not recall the conversation, but realistically agreed it was likely that this is what Inspector Smith had conveyed.¹⁵⁷

In fact, Patrick Ennis did not need to be told what the situation demanded. He could see for himself the seriously injured, some of whom were shouting for help, and the dead.¹⁵⁸

At 22:54, just a minute after his arrival in the City Room, Patrick Ennis contacted NWAS Control to provide another situation report:
“[Patrick Ennis] [F]urther update this is a confirmed major incident we’ve got at least, we’ve got at least 40 casualties approximately 10 er appear to be deceased on scene we’ve got at least a dozen priority 1 erm ambulance [inaudible] still need to be er Hunts Bank er Victoria Station over.
[Emergency Operations Centre] [Inaudible] everyone is now making their way to Hunts Bank over.
[Patrick Ennis]Yeah affirmative.”¹⁵⁹

This provided useful information to NWAS Control and covered most but not all of the requirements of a METHANE message, as outlined below:
M: Patrick Ennis declared a Major Incident. This was the right thing to do, although, in fact, NWAS Control had taken the initiative and already made a declaration a short time earlier.
E: The exact location was already known.
T: The type of incident was already known and, in any event, in his 22:46 message, Patrick Ennis had made clear that there had been a bombing and potentially a shooting.
H: The message does not indicate the presence or suspicion of any hazards.
A: The message implied that the route was safe to use by requesting ambulances to Hunts Bank, where, of course, Patrick Ennis had himself parked and spoken to members of the public.
N: The message did indicate an approximate number, type and severity of casualties.
E: The message did not indicate which emergency services were present or those that were required. A striking feature of the evidence of Patrick Ennis, in common with the evidence of a number of others, is that it simply did not occur to him at the time that no firefighters were present in the City Room.¹⁶⁰ He recognised with hindsight, as did everyone, that GMFRS had real value to add to the emergency response, particularly in relation to the evacuation of casualties, which went badly on the night.¹⁶¹ It is of a high degree of importance that each emergency service should have a clear understanding of the capabilities of the others. This can only be achieved through realistic and effective joint training. This needs to improve, an issue to which I shall turn in Part 20 in Volume 2‑II.

At 22:57:13, a conversation was captured between Patrick Ennis and GMP PC Christopher Dawson on the body‑worn video:
“[Patrick Ennis]We’ve got Ambulances coming soon Hunts Bank we’ve got as many as we can get into Victoria Station. In a minute we need to start thinking about trying to get some casualties moved out.”
“[PC Dawson] What do you need from us now? What’s best that we can do for you now?”
“[Patrick Ennis]Basically, at the moment it’s going to be providing first aid at the moment to those that are bleeding heavily. I haven’t got enough equipment. It’s going to be basic … basic stuff until we can get some people here.”¹⁶²

This conversation is instructive.¹⁶³ It reveals that Patrick Ennis was anxious at this stage to achieve two things. First, he sought to enable the evacuation of casualties onto the station concourse. In fact, no casualty was treated in the Casualty Clearing Station set up on the station concourse until ten minutes after this conversation, and the final casualty did not reach there until 45 minutes after this conversation.¹⁶⁴ Second, he was anxious to get other paramedics to come “here”, namely to the City Room. In fact, only two more paramedics ever arrived, and they did not reach the City Room for a further 18 minutes.¹⁶⁵

Discussion with Daniel Smith

Patrick Ennis left the City Room shortly before 22:59:46.¹⁶⁶ He had been present there for nearly seven minutes. During that period, he gained situational awareness.

In those seven minutes, even though there were many people in the City Room in urgent need of treatment and even though he had the skills and equipment to provide some treatment, Patrick Ennis did not attend to any casualty.¹⁶⁷ This may be thought to represent a failure on his part. It does not. The responsibility of Patrick Ennis was to gain situational awareness to enable an effective command response to be established. It is an uncomfortable reality of mass casualty incidents that for someone in the position of Patrick Ennis to start to provide treatment will risk the overall response and likely cost lives, not save them. I am aware that Patrick Ennis was the subject of some public criticism in this regard. That criticism was ill‑founded and unfair. Patrick Ennis was doing his job as he had been trained to do it, and he was seeking to achieve the best outcome for the emergency response overall in what he did in those seven minutes.

As Patrick Ennis left the City Room, Daniel Smith was arriving on Station Approach with Dr Daley.¹⁶⁸ Daniel Smith was a Consultant Paramedic for Greater Manchester and was Patrick Ennis’s line manager. Dr Daley was a member of the Medical Emergency Response Incident Team.¹⁶⁹

Daniel Smith and Dr Daley entered the railway station at 22:59:53.¹⁷⁰ A little behind them was NWAS Operations Manager Derek Poland,¹⁷¹ who was the on‑call Operational Commander but was to be appointed the Parking Officer. Daniel Smith and Dr Daley remained just inside the War Memorial entrance.¹⁷² At 23:01:01, Patrick Ennis started his descent down the staircase leading to the concourse.¹⁷³ By 23:01:24, he had joined the others.¹⁷⁴ There was a conversation, but by 23:02:51, Daniel Smith had walked away and left the concourse via the War Memorial entrance.¹⁷⁵ The conversation between Patrick Ennis and Daniel Smith therefore lasted for 90 seconds, if that.

Patrick Ennis gave evidence about his conversation with Daniel Smith.¹⁷⁶ So did Daniel Smith.¹⁷⁷ Neither has a good recollection of the discussion, which is unsurprising given the stress of the situation. The two agree, however, that during the course of this conversation, Patrick Ennis made clear that there were fatalities in the City Room, and that there were people in that location in need of urgent medical treatment. They also agree that Daniel Smith made clear that he had assumed the role of NWAS Operational Commander.¹⁷⁸

The evidence indicates that a number of other issues were discussed. While he was with Daniel Smith and Derek Poland, or walking away from them on his return to the City Room, Patrick Ennis passed a message to NWAS Control informing them that he had been told that all communications were to be passed through Daniel Smith’s channel.¹⁷⁹ It is also clear from a conversation between Patrick Ennis and GMP PC Gareth Dennison at 23:05:29, just as Patrick Ennis re‑entered the City Room, that Daniel Smith had given an instruction that casualties were to be moved down into the railway station concourse.¹⁸⁰ That this instruction was given accords with the recollection of Daniel Smith.¹⁸¹ What is clear is that this instruction had been given in broad terms, with no information about how it was to be achieved.

There was an additional topic that demanded analysis between Daniel Smith and Patrick Ennis in their conversation between 23:01 and 23:02, namely how safe it was in the City Room and what the situation there meant for NWAS deployment into that location.

Both Patrick Ennis and Daniel Smith suggested that something about risk had, or may have, been said in their discussion. Patrick Ennis said that he had “probably” told Daniel Smith about the “perceived risks” in the City Room, by which he meant the possibility of a secondary device.¹⁸² Daniel Smith said: “[W]e did have … and, again, it’s seconds of a conversation, but we did have a conversation about his risk. I think his words to me were, ‘It’s as safe as it could be.’”¹⁸³

I have no doubt that each witness was doing his best to give accurate evidence. However, each was necessarily reconstructing a conversation of which he had little independent recollection. I consider it likely that, in doing so, each applied hindsight and was, at least to some extent, describing what he hoped or expected he would have said or asked, rather than what he in fact said or asked.

In my view, the reality of this 90‑second conversation is that there was no, or no sufficient, discussion between Patrick Ennis and Daniel Smith about the issue of safety in the City Room and the NWAS resources that were needed there. Indeed, I conclude that there was no, or no adequate, discussion between the two men at any stage about these important issues. I consider that Patrick Ennis gave the most accurate account of whether the issue of safety and deployment was discussed in the following exchange in evidence:
“[Chairman] [W]ere you ever asked by Dan Smith, ‘Is it safe enough for me to get paramedics, when we have got enough here to do it, to come up and help you?’
[Patrick Ennis] No, I wasn’t.
[Chairman] So, you never gave an assessment to Dan Smith about it?
[Patrick Ennis]I don’t believe that there was a conversation where I … where he asked that of me or whether I explained to him that I felt it was appropriate for more paramedics to come into that area, no.”¹⁸⁴

Before turning to what Patrick Ennis could have communicated to Daniel Smith about the issue of safety in the discussion at 23:01, it is important to recognise what he could not have communicated to him.

Patrick Ennis could not have informed Daniel Smith that Operation Plato had been declared. On the night of the Attack, Patrick Ennis was not told of Inspector Dale Sexton’s declaration.¹⁸⁵ Even if Patrick Ennis had been told, it would have meant nothing to him because he had never heard of Operation Plato.¹⁸⁶

I indicated that I would come back to this issue, which relates to the training of Patrick Ennis. It is surprising that one of a small cadre of Advanced Paramedics in Greater Manchester, likely to have an important role to play in the event of a terrorist attack, was unaware of this important response plan. At least in part, this is likely to be a consequence of the fact that Patrick Ennis had not taken part in any live exercising with the emergency service partners of NWAS.¹⁸⁷ It is imperative that all of those who may have a role to play in the response to a declaration of Operation Plato understand what Operation Plato is and what will be required of them in the event of such a declaration. NWAS ought to take steps to ensure that all of its employees have this basic knowledge. NARU should take steps to ensure that, if this lack of knowledge is an issue beyond NWAS, it is resolved.

I will now turn to the issue of what Patrick Ennis could have told Daniel Smith about the issue of safety in the City Room. Patrick Ennis had situational awareness. He knew that there were many unarmed officers of GMP and BTP, Arena staff and members of the public present in that location and seeking to help the many casualties who needed help. He also had his own firm and informed view on the issue of safety, as the following exchange in evidence reveals:
“[Chairman] Okay. If he’d [Daniel Smith had] asked you, ‘Is it safe, when we’ve got enough, can I send some paramedics in there?’ because you’re saying he must know they’re needed and you know they’re needed, what would you have said?
[Patrick Ennis] I believe I would have said that I couldn’t guarantee it was safe, the firearms police have said that there was a potential for secondary device, there are hazards in the area, such as the unstable roof, but that as far as I was concerned it appeared to be safe to work in there.”¹⁸⁸

Daniel Smith was the NWAS Operational Commander. It was his job to decide which assets of NWAS should be deployed forward into the City Room.¹⁸⁹ The view of the experienced Advanced Paramedic who had been into that location was that it appeared to be safe to work there. While I accept that this was not determinative of the issue, this information would have been of considerable value to Daniel Smith in making his deployment decision. I am satisfied on the evidence I heard that Daniel Smith never sought or obtained the assessment of Patrick Ennis. He should have done.

What difference it would have made to Daniel Smith is a separate matter. As I explained in Part 12, Daniel Smith in fact had an operational discretion to deploy at least some of the non‑specialist assets available to him into the City Room shortly after 23:00. He mistakenly considered that he had no such discretion. It is therefore a realistic possibility that, even with information from Patrick Ennis, he would have maintained his line of, as I find it to have been, excessive caution.

At the very least, however, had Daniel Smith obtained this information from Patrick Ennis, it should have provoked him to seek the views of the emergency service partners of NWAS about the risks involved in entering the City Room in order to treat casualties. Had he, in particular, sought out the GMP Operational/ Bronze Commander for the unarmed officers, he would have discovered that Inspector Michael Smith felt that it was safe enough for his officers to operate in the City Room and that he himself was in that location.¹⁹⁰ Such information, which was consistent with the view of Patrick Ennis, should have caused Daniel Smith to make a different assessment of the deployment of non‑specialist NWAS assets into the City Room. I consider it a realistic possibility that it would have done so, notwithstanding Daniel Smith’s caution.

Daniel Smith did not obtain any of this information. He permitted Patrick Ennis to return to the City Room. In doing so, the working assumption of Daniel Smith was that Patrick Ennis would be the only paramedic working there at that stage.¹⁹¹ Daniel Smith knew that there were multiple casualties in that location in urgent need of medical assistance. Patrick Ennis had made clear to PC Dawson that more paramedics were needed, and that much was obvious. The police officers in the City Room were literally shouting out for paramedics to attend. While I accept that Daniel Smith is a good, experienced paramedic and acknowledge the pressure he was working under, I am satisfied that the arrangements made by him were not sufficient to meet the needs of the casualties.

Daniel Smith did direct that the casualties should be evacuated from the City Room, but even that plan lacked any detail of how it was to be achieved.¹⁹² Ultimately, Patrick Ennis was left on his own for the next ten minutes, and only three paramedics, including Patrick Ennis, ever operated in the City Room during the critical period of the response. The evacuation of casualties occurred in a way that was unacceptable.

Return of Patrick Ennis to the City Room

Patrick Ennis arrived back in the City Room shortly before 23:05:30¹⁹³ and remained there until 00:39:23.¹⁹⁴ He spent almost 94 minutes in that location on this occasion. He provided no treatment to any casualty during that period.¹⁹⁵ Instead, he understood that it was his job to perform the role of Primary Triage Officer, even though he was never designated as such by the Operational Commander.¹⁹⁶

The description of the Primary Triage Officer given in the NWAS Major Incident Response Plan is as follows:
“The Ambulance Primary Triage Officer is responsible for the coordination of triage by all resources including the Hazardous Area Response Team (HART). They will ensure teams of suitably qualified staff will perform a triage sieve of all casualties at the scene of the incident. The Primary Triage Officer will report to the NWAS Operational Commander with the number and status of casualties so that appropriate arrangements can be implemented to enable their effective treatment. Dependent upon the nature of the incident and the area the incident covers, there may be the requirement to have multiple Primary Triage Officers, for example when an incident scene is ‘sectorised’. Where this is implemented, the call sign will have numerical suffixes (Primary Triage 1, Primary Triage 2 and so on).”¹⁹⁷

This description serves to illustrate the problem that existed in the City Room when Patrick Ennis returned to it. The Major Incident Response Plan anticipated that in the event of a mass casualty incident, best practice expected that there would be a number of pairs of paramedics carrying out triage, along with other paramedics providing treatment in a Casualty Clearing Station.¹⁹⁸ In the City Room, prior to 23:15, in the nearly 45 minutes after the explosion, there were no teams for Patrick Ennis to manage. It was just him.

I understand why some may feel frustrated that Patrick Ennis applied himself to triage rather than treatment. It is important to recognise that Patrick Ennis has dedicated his life to the treatment of casualties. My strong sense during his evidence was that he, too, felt frustrated by not providing care and treatment. However, he considered that his primary responsibility was to carry out triage.¹⁹⁹ He was right to take that view.

Arrival of HART

An illustration of the sense of feeling within the City Room at the time before the arrival of the members of HART is provided by a comment caught on the body‑worn video footage of one of the GMP officers in the City Room.²⁰⁰ At 23:13:32, GMP PC Matthew Hill shouted across to GMP Sergeant Kam Hare: “Kam, are the paramedics coming?” Sergeant Hare replied: “Paramedics mate, they need to be coming in droves.”²⁰¹

At 23:15:10, two members of HART, Lea Vaughan and Christopher Hargreaves, entered the City Room.²⁰² Patrick Ennis provided them with a briefing and then left them to get on with their work.²⁰³ Even with the addition of two HART members, there were too few paramedics in the City Room. Three was simply not enough. There are a number of reasons for that which I will address below at paragraphs 14.310 to 14.326.

I recognise that in the period both before and after the arrival of the two HART members, Patrick Ennis was operating in circumstances of enormous pressure. Nonetheless, he should have communicated to the Operational Commander in the clearest terms that more paramedics were needed.

In the period that followed Lea Vaughan and Christopher Hargreaves entering the City Room, Patrick Ennis was involved in making arrangements for the evacuation of casualties. At 23:40, when the last casualty had been moved, Patrick Ennis remained in the City Room. He understood that further casualties were coming from the Arena bowl, but none arrived. At 00:40, he was stood down.²⁰⁴

As I have explained, Patrick Ennis did not get everything right that night. However, his courage and commitment should be acknowledged. The family group that was principally involved with the examination of the NWAS response observed, in their closing statement, that while it was possible to find examples of things Patrick Ennis could have done better, overall he made “an enormously positive contribution to the emergency response on 22 May 2017”.²⁰⁵ In my view, that is a fair comment with which I agree.

Involvement of Patrick Ennis with those who died

At 22:54, Patrick Ennis leaned over Saffie‑Rose Roussos, who was being assisted at that time by two members of the public, Paul Reid and Bethany Crook.²⁰⁶

At 22:56, Patrick Ennis approached Sorrell Leczkowski. He did not conduct an assessment at this time. ²⁰⁷

At 22:56, Patrick Ennis assessed Alison Howe. This was the first time Alison Howe was assessed by a paramedic in the City Room. Patrick Ennis said to the police officers with Alison Howe that there was nothing that could be done for her.²⁰⁸ He returned to Alison Howe at 23:34 and lifted the covering which had been placed on her. At that stage, Patrick Ennis attached a label to Alison Howe identifying that she had died. He returned to Alison Howe a third time at 23:41 and lifted her arm.²⁰⁹

At 23:05, Sergeant Hare asked Patrick Ennis to assess Megan Hurley. Less than one minute later, Patrick Ennis spoke to the police officers who were treating Megan Hurley. Having been told Megan Hurley was not breathing and that both CPR and a defibrillator had been attempted, Patrick Ennis instructed the police officers to stop treatment on the basis that Megan Hurley was dead. He informed the police officers that there was nothing that could be done for Megan Hurley.²¹⁰

At 23:06, Sergeant Hare encouraged Patrick Ennis to assess Georgina Callander. Patrick Ennis assessed Georgina Callander and concluded that she was a P1 casualty. This was the first time that Georgina Callander was assessed by a paramedic. Patrick Ennis considered Georgina Callander to be the most serious P1 casualty he had assessed by that point.²¹¹

It was another 20 minutes before Georgina Callander was removed from the City Room.²¹²

At 23:07, Patrick Ennis leaned over Elaine McIver but conducted no physical check.²¹³ This was the first time Elaine McIver was assessed by a paramedic.

At 23:08, Patrick Ennis informed the police officers who were treating Sorrell Leczkowski that if she needed CPR there was nothing they could do for her due to the number of casualties.²¹⁴

At 23:08, Patrick Ennis discussed moving Georgina Callander. He described her condition as “critical” and said that Georgina Callander would “have to be moved in a minute, she’s one of the highest priorities”.²¹⁵ A minute later, he informed another police officer that Georgina Callander was “critically unwell”.²¹⁶ Patrick Ennis said she needed to be removed by any means possible.²¹⁷

At 23:10, Patrick Ennis assessed Kelly Brewster for just over ten seconds. He returned one minute later and leaned over Kelly Brewster as she was receiving treatment from police officers.²¹⁸

At 23:16, Patrick Ennis assessed Georgina Callander a second time.²¹⁹

At 23:38, Patrick Ennis lifted the covering which had been placed over Philip Tron. He attached a label to Philip Tron identifying that he was dead.²²⁰ This was the first time Philip Tron was assessed by a paramedic.

At 23:39, Patrick Ennis placed a label on Lisa Lees identifying that she was dead.²²¹ This was the first time Lisa Lees had been assessed by a paramedic.

At 23:39, Patrick Ennis attached a label to Angelika Klis identifying that she was dead. One minute later, he attached a label to Marcin Klis identifying that he was dead.²²² This was the first time either Angelika Klis or Marcin Klis were assessed by a paramedic.

At 23:44, Patrick Ennis attached a label to Wendy Fawell identifying that she was dead.²²³ This was the first time Wendy Fawell was assessed by a paramedic.

At 23:45, Patrick Ennis lifted the covering which had been placed over Kelly Brewster. He attached a label to Kelly Brewster identifying that she was dead.²²⁴

At 23:45, Patrick Ennis lifted the covering which had been placed on Olivia Campbell‑Hardy. He attached a label to Olivia Campbell‑Hardy identifying that she was dead.²²⁵ This was the first time Olivia Campbell‑Hardy was assessed by a paramedic.

At 23:47, Patrick Ennis lifted the covering which had been placed over Jane Tweddle. He attached a label identifying that Jane Tweddle was dead.²²⁶ This was the first time Jane Tweddle was assessed by a paramedic.

At 00:32, Patrick Ennis assessed Michelle Kiss.²²⁷ This was the first time Michelle Kiss was assessed by a paramedic.

At 00:36, Patrick Ennis checked the label he had earlier attached to Lisa Lees.²²⁸

Covering people

The NWAS Major Incident Response Plan advises NWAS personnel not to cover people who have died. The exception to this is if the person is in public view. In these circumstances, it is advised that consideration be given to covering the person in order to maintain patient dignity.²²⁹

On 22^nd May 2017, many of those who died were covered before they were verified as deceased by a person with the clinical qualification to do so, such as a paramedic. The process of verifying death is a process which is separate to the certification of death, which can only be done by a medical doctor.²³⁰

Members of the public, Emergency Training UK (ETUK) staff and police officers covered individuals whom they believed to be dead. On some occasions, this occurred after Patrick Ennis had indicated that no further help could be given. The items used to cover people included T‑shirts and posters.

Fifteen of those who died had been covered in some way by the time Patrick Ennis started triage at 23:05.²³¹ Once Patrick Ennis began to triage casualties, he was not able to attach a label marking anyone as dead. This was because, as explained above at paragraph 14.111, he did not have any SMART Triage Tags with him. During the period before the HART operatives entered the City Room at 23:15, four further people believed to have died were covered.²³²

In the case of each of them, this was after Patrick Ennis had said that no further help could be given to them.

This is a difficult and sensitive issue. I well understand the wish to preserve the dignity of the person who had died. There may also be thought to be a potential benefit to the response overall: any person who has been marked as being dead will not further occupy responders who are trying to save other lives.

The difficulty with this approach is demonstrated by the case of one of those who survived, Eve Hibbert. She was covered.²³³ She was not dead. It is possible that she might have received treatment sooner had she not been covered. The fact that she was covered gave rise to the risk that she would not be treated, when her life could still be saved. Fortunately, her life was saved due to the intervention of her father, Martin Hibbert.²³⁴

Covering people who have not been verified to be dead, by a qualified person, is capable of leading to the loss of saveable life.

DHSC and NARU should provide guidance for all emergency services on whether to cover someone they believe has died, before they have been assessed by a person with appropriate clinical expertise. Those subject to the Protect Duty should also receive training and information to this effect. This information should be included in the guidance and training received by event healthcare providers.

One important aspect of the guidance will be alerting all of the above to the fact that members of the public will instinctively want to cover people whom they believe to be dead. The guidance should extend to the general public but should also include training for emergency services staff and event staff in how to give clear instructions to the public as to what they should do.

Ambulance A344 on Trinity Way

Saffie‑Rose Roussos was evacuated from the City Room on a makeshift stretcher at 22:57. A member of the public and police officers carried her out onto Trinity Way via the Trinity Way link tunnel. Accompanying them was an off‑duty nurse. Saffie‑Rose Roussos arrived on Trinity Way at 22:58.²³⁵

At 23:00, Ambulance A344 pulled up on Trinity Way. At 23:02, NWAS Control was informed that Ambulance A344 had been flagged down and was dealing with an eight‑year‑old with multiple injuries.²³⁶

At 23:06, Saffie‑Rose Roussos was placed into the back of Ambulance A344. Ambulance A344 departed for the Royal Manchester Children’s Hospital 11 minutes later.²³⁷

Operational command

Journey to and arrival at Victoria Exchange Complex and initial command decisions

Daniel Smith held a senior position within NWAS. He was Lead Paramedic for Greater Manchester and a Consultant Paramedic.²³⁸ He was experienced and well trained.

Daniel Smith travelled to the Victoria Exchange Complex in an unmarked vehicle on blue lights and sirens. He did not live far away at the time, and, as a result, he entered the railway station via the War Memorial entrance just before 23:00.²³⁹ He was in uniform and carrying two clinical response bags along with a tabard on the back of which was written “Ambulance Commander”. On assuming the role of Operational Commander, following his arrival at the scene, Daniel Smith put on this tabard.²⁴⁰ This was good practice. He was the only emergency services commander at the scene who did this.²⁴¹ If all commanders had done so, it would have made it easier for them to identify each other.

Daniel Smith’s evidence was that, by the time he entered the Victoria Exchange Complex, his understanding was that a terrorist incident had occurred and that this had taken the form of a bomb attack, as opposed to a firearms attack or a bomb and firearms attack. A number of factors led to this understanding.

First, in his discussion with NWAS Control at 22:50, he had been told that Patrick Ennis had “confirmed it’s a nail bomb”.²⁴² Second, on his journey on foot from where he parked his vehicle to the railway station, Daniel Smith had seen members of the public whose clothing suggested to him that there had been an explosion as opposed to a firearms attack. Third, Daniel Smith asked a police officer whether there had been a shooting. He was told that there was believed to have been a suicide bombing.²⁴³

Assuming the role of Operational Commander

Within seconds of Daniel Smith’s arrival at the railway station, three NWAS staff arrived in that same area. They were paramedics Martyn Nealon and Callum Gill and student paramedic Leigh‑Sa Smith. At 23:00:50, they can all be seen in conversation by the War Memorial.²⁴⁴ By 23:01:24, that conversation was over. Martyn Nealon, Callum Gill and Leigh‑Sa Smith walked towards the War Memorial entrance. Daniel Smith had deployed them to Trinity Way in order to deal with a single patient, albeit one he believed to be seriously injured.²⁴⁵

At the time of this deployment, there were six members of NWAS staff available to Daniel Smith in the Victoria Exchange Complex. By deploying three of those six to Trinity Way, Daniel Smith significantly depleted the resources immediately available to him. This was the wrong decision. This was a second command decision that Daniel Smith made before he had assumed the role of Operational Commander. At paragraphs 14.51 to 14.60, I set out his first intervention, which occurred at 22:50. The decision to deploy resources to Trinity Way was made without clear situational awareness about the City Room and without consultation with anyone else.

Almost immediately after Martyn Nealon, Callum Gill and Leigh‑Sa Smith departed for Trinity Way, Patrick Ennis arrived at the War Memorial. He had walked there directly from the City Room. A discussion then took place between Patrick Ennis and Daniel Smith in the presence of Derek Poland and Dr Daley. Patrick Ennis’s involvement in the conversation lasted for no more than 90 seconds.²⁴⁶

Daniel Smith explained in evidence that it was in this conversation that he assumed the role of Operational Commander. He had only a general recollection of the conversation. He was unable to remember the detail but was able to confirm that by its conclusion he was aware that the City Room was the seat of the explosion and that there were a number of dead. He also knew that there were other casualties in that location in need of urgent medical treatment. Daniel Smith acknowledged that it was his responsibility as Operational Commander to make sure that those people received treatment as soon as possible.²⁴⁷

It was a significant conversation. It was Daniel Smith’s first opportunity to obtain situational awareness and to seek the views and advice of the paramedic on the ground about how the casualties should receive the treatment they urgently needed. The conversation was over very quickly. This was not because of efficiency of expression and understanding, but because important matters that should have been discussed were not discussed, or at least not adequately discussed.

In considering the actions of Patrick Ennis earlier in this Part at paragraphs 14.131 to 14.149, I identified the inadequacies in this conversation. I will not repeat all of my findings but will summarise them.

First, Daniel Smith failed to ascertain from Patrick Ennis, a highly experienced paramedic with a senior role, that in his view the City Room was a safe place to work.²⁴⁸

Second, when Patrick Ennis returned to the City Room following the discussion, the working assumption of Daniel Smith was that Patrick Ennis would be the only paramedic in the City Room. Daniel Smith must have known that a single paramedic would be inadequate to carry out effective triage in the City Room, let alone carry out life‑saving interventions. However, beyond a briefly discussed suggestion that the casualties would need to be moved, Daniel Smith did not discuss with Patrick Ennis how this situation was to be resolved.²⁴⁹

Daniel Smith bears principal responsibility for failing to ensure that the conversation with Patrick Ennis provided him with the information he needed to make important decisions. By this stage, he was the Operational Commander. In that role, he had the main responsibility for achieving effective treatment for the casualties in the City Room.

Daniel Smith’s approach to zoning of the City Room

Daniel Smith’s understanding from an early stage that a bomb attack, not a firearms incident, had occurred was important. It was highly relevant to how the seat of the explosion should be zoned under Operation Plato and the Major Incident Response Plan. That, in turn, was capable of affecting decisions around deployment of non‑specialists into the City Room. In Part 12, I considered the issue of NWAS commander discretion in relation to Operation Plato and Major Incident zoning.

The overall effect of the evidence of Daniel Smith was that he seemed to treat the City Room as an Operation Plato warm zone. In evidence, he stated:
“I think my view on scene around the armed police is that they were very present very quickly in numbers and that the potential for danger from … again, at the time, a lot of training around marauding terrorists with firearms. I felt relatively quickly comfortable around the threat of firearms, but not around the threat of further devices and not around the … risk of detonation having occurred in the room and the subsequent damage that will have caused …
I think … I knew the terrorist had been in that room and detonated a device in that room, my view is that the policies aren’t ambiguous on that and that is a warm zone … I didn’t know which way the terrorist had been in, so by very definition I could have said downstairs was cold because I didn’t know which way he walked in. But for me, it was a warmish zone downstairs, but I’d have to call it warm upstairs, I’m sorry.”²⁵⁰

Later in his evidence, Daniel Smith stated: “[T]he zoning would be from the JOPs [Joint Operating Principles].”²⁵¹ He had a rigid view of what this meant as a matter of procedure, namely that it meant that only specialist resources could enter the City Room.²⁵²

Daniel Smith was supported in his position by NWAS. In its closing statement, NWAS submitted that I should find that Daniel Smith “properly concluded that it [the City Room] was a warm zone”.²⁵³ In that closing statement, NWAS also invited me to note that: “[T]here was no discretion for non-specialist paramedics to enter a warm zone.”²⁵⁴

I will set out below what I consider to have been Daniel Smith’s failure to take steps to establish whether his zoning decision was correct. I will also consider whether, on the basis of his zoning decision, Daniel Smith’s view of the options available to him was correct.

One of the striking aspects of Daniel Smith’s evidence was that he felt he had no discretion to commit non‑specialist assets into the City Room.²⁵⁵ Indeed, as he walked away from the railway station at 05:30 on 23^rd May 2017, what Daniel Smith thought he would be criticised for was not that he failed to get paramedics in numbers into the City Room, but that he allowed Patrick Ennis to stay in that location.²⁵⁶ This explains why Daniel Smith did not speak to Patrick Ennis about the deployment of further non‑specialist assets forward. He thought that the applicable procedures simply did not allow that to occur, so there was no point talking about it.

If GMP had given proper thought to the Operation Plato zones, the City Room should have been declared a cold zone by the time Daniel Smith was in a position to deploy paramedics. Even if it was an Operation Plato warm zone, Daniel Smith still had a discretion, although this was not understood by him at the time. Either way, the risks that Daniel Smith was rightly focused on were not Operation Plato risks. As I set out in Part 11, properly understood, JOPs 3, in full Responding to a Marauding Terrorist Firearms Attack and Terrorist Siege: Joint Operating Principles for the Emergency Services, was concerned with the threat from a marauding gunman. Daniel Smith had correctly assessed the risk of this to be low. The risks Daniel Smith was concerned about were from a secondary device or structural collapse.²⁵⁷ These should have been considered under a robust risk assessment and zoning applied in accordance with the NWAS Major Incident Response Plan.

Even in an Operation Plato situation, a risk assessment of threats to safety outside of Operation Plato was required. The fact that an area is an Operation Plato cold zone does not automatically mean it is safe for everyone to operate in. There may be a gas leak; there may be a risk of fire. What this demonstrates is the importance of Daniel Smith gaining as much information as he could about the potential hazards in the City Room. He should then have shared that with the GMP Operational/Bronze Commander and jointly assessed risk.

In any event, Daniel Smith did not know Operation Plato had been declared.²⁵⁸ His decision‑making falls to be judged by the system he thought he was operating under. I judge his decision‑making by reference to the City Room being an inner cordon in accordance with NWAS’s Major Incident Response Plan. I accept that he was acting to protect NWAS personnel. However, he was too cautious. This was the result of inadequate information and inadequate efforts to obtain information.

As I set out in Part 12, NWAS Operational Commanders had a discretion, following a robust risk assessment, to send non‑specialist paramedics into the inner cordon. It is important that commanders should understand that exercising such a discretion may save lives and that they should feel supported if they choose to do so. NWAS should review its training to ensure that commanders are not left with a false impression.

When he walked away from Patrick Ennis at 23:02, Daniel Smith knew that Patrick Ennis was returning to the City Room and knew that he would be the only paramedic in there. Daniel Smith would have known that the paramedic numbers in that location were inadequate.²⁵⁹

Daniel Smith was just two minutes’ walk from the City Room throughout this period. He should have visited the City Room. That would have enabled him to make his own assessment of the number and nature of casualties, the number and skills of those assisting the paramedics, the difficulty of the route for extraction and the equipment available for carrying out those extractions. Daniel Smith did not at any stage visit the City Room.²⁶⁰ Because there was no City Room Sector Commander, that was a mistake. It deprived him of an important opportunity, namely jointly to assess the risk with Inspector Michael Smith of operating in the City Room.

A proper assessment of the risk in light of the need to provide life‑saving care would have led to the conclusion that it was safe enough to deploy non‑specialists into the City Room.²⁶¹ When they were deployed would have depended on the availability of resources.

If Daniel Smith had not deployed Martyn Nealon and Callum Gill at 23:01 to treat a patient on Trinity Way, they would have been available to help Patrick Ennis triage in the City Room. The delay in mobilising ambulances at Manchester Central Fire Station resulted in Daniel Smith having fewer resources available to him than ought to have been the case, at the point at which he should have been considering sending non‑specialist paramedics into the City Room.

Allocation of the Operational Commander role

Derek Poland was present when Daniel Smith and Patrick Ennis had their discussion and confirmed that, at the end of it, he understood that there were many people requiring urgent medical treatment.²⁶²

Derek Poland had more than 20 years’ experience as a paramedic. He was Special Operations Response Team (SORT) and Ambulance Intervention Team trained. He was also a trained Operational Commander, having held that position for five years at the date of the Attack.²⁶³ He had a balanced and well‑informed understanding of the approach that ought to be adopted to the deployment of NWAS assets into different zones. He was also one of the two NWAS on‑call Operational Commanders that night.²⁶⁴ He would have been a more obvious choice for the role of Operational Commander than Daniel Smith, whose training in operational command was years out of date.²⁶⁵

Daniel Smith’s position in evidence was that he assumed the role of Operational Commander because he arrived a short time before Derek Poland²⁶⁶ and that, in the briefest of subsequent discussions, Derek Poland communicated that he was content that Daniel Smith assumed that role.²⁶⁷ The time of arrival does not seem to me to be relevant to the issue, given that Daniel Smith was clear that he only assumed the role once Derek Poland was present at the scene.

Derek Poland’s recollection was different from that of Daniel Smith. His memory is that Daniel Smith, while holding the tabard, said that he would take the Operational Commander role unless Derek Poland wanted it, and, knowing Daniel Smith’s “background and experience”, Derek Poland declined.²⁶⁸ Derek Poland stated that he had no issue with Daniel Smith taking the Operational Commander role and that Daniel Smith was a very competent commander.²⁶⁹

What had happened was that a senior figure within the NWAS hierarchy attended the scene because of an informal arrangement with another senior figure. Once there, he assumed the position of Operational Commander notwithstanding that the on‑call Operational Commander, who had more recent training in that role, was present. That is not how command roles should be allocated in the response to an emergency.

There needed to be a good reason why Derek Poland did not assume the role of Operational Commander. There was none. I have no doubt that Daniel Smith’s actions were well intentioned, however, and that he believed he was well‑equipped through ability and experience to perform the role of Operational Commander.

Derek Poland volunteered to go to the City Room in order to support Patrick Ennis. In evidence, he stated that one paramedic “wouldn’t be able to cope” on their own.²⁷⁰ This would have been a good use of Derek Poland at this stage. Before becoming an Operations Manager in 2011, he was a Senior Paramedic.²⁷¹ He had maintained his clinical skills. He was a trained Operational Commander, a member of the Ambulance Intervention Team and a member of SORT.²⁷² He was prepared to work in the City Room.

Derek Poland could have been deployed forward as either the City Room Sector Commander or in a clinical capacity. Instead, Daniel Smith instructed that he should remain downstairs to help set up the command and control structures there.²⁷³ In due course, Derek Poland was allocated the role of Parking Officer, which was an important functional role.²⁷⁴

Events after Daniel Smith became Operational Commander

By 23:03:54, Daniel Smith was on Station Approach wearing the Ambulance Commander’s tabard.²⁷⁵ He remained on Station Approach or in the area of the War Memorial until 23:57, when he handed over the Ambulance Commander’s tabard to Stephen Hynes.²⁷⁶

During that 54‑minute period, Daniel Smith worked hard to deal with what was happening in the area that became the Casualty Clearing Station. He showed compassion and resourcefulness in those efforts. However, I consider that Daniel Smith became focused on that area to the detriment of what was happening in the City Room. Because patients were arriving regularly in the Casualty Clearing Station, he assumed that systems were in place and working properly. In fact, the paramedics, police and others in the City Room were under intolerable pressure, and the way in which casualties were being transported to the Casualty Clearing Station was unsatisfactory.²⁷⁷ Daniel Smith did not realise this.²⁷⁸

Daniel Smith made other significant errors in the discharge of his role as Operational Commander.²⁷⁹

First, while Daniel Smith correctly sanctioned the deployment of HART paramedics Lea Vaughan and Christopher Hargreaves forward into the City Room, he did not ensure that the remaining members of the GM HART crew were deployed into the City Room. Instead, they were tasked with setting up what they considered to be a Casualty Collection Point.²⁸⁰ I will consider this issue in further detail below at paragraphs 14.384 to 14.401, but in summary it is my view that Daniel Smith played a significant part in the confusion that developed around this issue, which in turn prevented additional, much‑needed HART members deploying to the City Room.

Second, contrary to the requirements of the Major Incident Response Plan,²⁸¹ Daniel Smith failed to take steps to establish the location of a Forward Command Post (FCP). GMP had primary responsibility for establishing an FCP, but it was for Daniel Smith to find out where it was.²⁸²

Daniel Smith did not liaise with either of the two GMP Operational/Bronze Commanders nor with anyone in a command role from BTP. He was not even aware that Inspector Michael Smith, the GMP unarmed Operational/ Bronze Commander, was present in the City Room throughout the period when Daniel Smith was Operational Commander.²⁸³ In evidence, Daniel Smith acknowledged that liaison with Inspector Michael Smith would have brought a number of benefits, in particular an understanding of his desire that more paramedics came to the City Room. All Daniel Smith needed to do to understand that was walk to the City Room and speak to Inspector Michael Smith or take other steps to arrange to speak to him.²⁸⁴ He should have done so.

Third, it was Daniel Smith’s responsibility as Operational Commander to appoint a number of people to roles within the command structure.²⁸⁵ While he did fill some roles, others he did not. Most notably, he did not appoint a Safety Officer. The role of the Safety Officer includes ensuring that the environment and working practices of all ambulance and medical personnel involved with the incident do not pose an undue risk.²⁸⁶ In my view, such a person would have been likely to have ascertained the true situation in the City Room and communicated that to Daniel Smith. Daniel Smith candidly acknowledged that there was a role for a Safety Officer at the scene and that he had made a mistake in not appointing one.²⁸⁷ He did not appoint an Equipment Officer or Forward Doctor either.²⁸⁸ I will discuss the failure to appoint an Equipment Officer further at paragraphs 14.248 and 14.487.

Fourth, while dealing with the period in which Daniel Smith made decisions about arrangement of the scene, it is relevant to note that at 23:22:53, Daniel Smith transmitted a METHANE message to Control.²⁸⁹ This was a sensible step to take. He followed the METHANE acronym precisely and in clear terms.

The final ‘E’ stands for “[E]mergency services present and those required.”²⁹⁰ What Daniel Smith said of this was: “Currently we’ve got a large number of emergency services on scene.”²⁹¹ He did not refer to the fact that no member of GMFRS was present. That is because he had not noticed that was the case.²⁹² He was unaware of their absence until Stephen Hynes arrived at the scene and pointed it out to him.²⁹³

I do not regard this to be a personal failure by Daniel Smith. Others who were present in important roles were similarly oblivious, including Inspector Michael Smith and Patrick Ennis. This seems to me to demonstrate a lack of realisation of the value the fire and rescue services bring to a mass casualty incident. As I have previously observed, it is very important that each emergency service has a clear understanding of the capabilities of each of the others.

Finally and significantly, Daniel Smith failed to come up with an adequate plan to evacuate the City Room. I will address that as a topic on its own.

Evacuation plan

The Casualty Clearing Station was based on the station concourse. A total of 38 people were treated in the Casualty Clearing Station. Of those, 30 people were moved there. A wheelchair was used for three. Two people were carried on a purpose‑made stretcher. The other 25 people were moved on makeshift stretchers.²⁹⁴

Daniel Smith’s plan involved deploying only some of the GM HART crew beyond the bottom of the staircase. In the event, only two members of HART went beyond this point. All the other available paramedics were deployed to the area at the bottom of the staircase and out onto Station Approach.²⁹⁵ The only exception to this was Patrick Ennis, who volunteered to go back into the City Room.²⁹⁶

Patrick Ennis’s and the HART operatives’ joint role was to carry out triage in the City Room. It was not to transport patients down to the Casualty Clearing Station. Their role included providing life‑saving treatment when required. This gave rise to the obvious issue of how the triaged patients would travel from the City Room, along the raised walkway, down the staircase and onto the station concourse to the Casualty Clearing Station.

In his conversation with Daniel Smith at approximately 23:01, Patrick Ennis informed Daniel Smith that there were seriously injured people in the City Room.²⁹⁷ It should have occurred to Daniel Smith that many of those people required safe transportation to the Casualty Clearing Station. The first patient was carried into the Casualty Clearing Station on a makeshift stretcher at 23:07.²⁹⁸

Between 23:01 and 23:07 Daniel Smith did not know what was already available by way of items in the City Room and the Arena that might be used to transport immobilised casualties. He should have identified the need for the stretchers carried by the ambulances to be made available for use in the City Room.²⁹⁹

During this period, there was only one ambulance available to Daniel Smith at the scene: the vehicle in which Martyn Nealon arrived. Having dispatched Martyn Nealon and his colleagues to Trinity Way, I accept that Daniel Smith may not have thought he had any stretchers immediately available.³⁰⁰ This does not mean that Daniel Smith could not have issued the instruction that all arriving paramedics should bring their stretchers with them. He should have given this instruction.

In the event, had Daniel Smith considered that non‑specialist paramedics were not able, or not available, to move those stretchers to the point of need, he could have asked for the assistance of the police in this. This is exactly the sort of conversation that should have taken place at a co‑location of Operational/ Bronze Commanders.

At 23:07, Daniel Smith was able to see for himself that there were insufficient stretchers readily available to those in the City Room. In fact, at that time there was only one. This should have prompted him to realise that the stretchers on the ambulances ought to be used. Daniel Smith’s evidence on this point was as follows:
“So the process of moving patients on makeshift stretchers started … as the first … ambulances started to arrive with me … I didn’t see the struggles of people happening … It seemed to me on the night that things were working, they were working efficiently, they were working well, and patients were being moved quickly to where we wanted them to be. The use of scoops stretchers from the ambulances, again, being totally open, I did not consider on the night, and I didn’t consider because I just did not notice the problems that people were having.”³⁰¹

I am grateful to Daniel Smith for the candid way in which he answered this question. I accept his explanation. It does not follow that I regard his approach to stretchers as an acceptable state of affairs. On the contrary, it is clear that the failure to make stretchers available for the City Room delayed the evacuation.

Daniel Smith could have no idea of the extent to which makeshift materials would continue to be available for evacuating people because this was never information he was given. Nor could he be satisfied that whatever makeshift materials people were using provided a safe way of moving critically injured people down a substantial staircase. Both of these should have been obvious to him as more and more people were carried into the Casualty Clearing Station by improvised means.

On the issue of stretchers, Daniel Smith’s failure to appoint an Equipment Officer becomes more significant. Having a person whose role it was to consider the NWAS response by reference to what equipment was required may have resulted in a more satisfactory approach to evacuation being identified and addressed. The Equipment Officer could also have organised a more efficient distribution of blankets. Blankets are an important part of the management of severely injured casualties, as blood loss greatly increases the risk of hypothermia.

Two examples of the consequences of the lack of stretchers in the City Room arise from the evidence relating to two of those who died: John Atkinson and Georgina Callander.

John Atkinson’s evacuation from the City Room

At 23:16, police officers retrieved an advertising board to use as a makeshift stretcher for John Atkinson. A few seconds later, they carried the advertising board from the merchandise stall to where John Atkinson was. The advertising board was slid under him. At 23:17, John Atkinson was dragged on the advertising board by police officers and Ian Parry, of ETUK. John Atkinson held on to the board as he was dragged.³⁰²

By 23:18, John Atkinson was on the raised walkway. Those helping him continued to drag him using the advertising board. He continued to grip the board. The advertising board began to break. A police officer ran on ahead to see if they could use the lift to transport him down to the concourse level.³⁰³

At 23:19, those assisting John Atkinson began to drag him to the lift. They realised the advertising board would not fit. At about the same time, two police officers went back to the City Room. They returned two minutes later with a metal barrier.³⁰⁴

By 23:22, efforts were being made to lift John Atkinson onto the metal barrier. The advertising board he was on gave way. The effect of this was that he fell a short distance onto the metal barrier. Given his injury burden at the time, this must have been very painful for him.³⁰⁵

By 23:23, John Atkinson was being carried on the metal barrier towards the staircase. He was then carried down the stairs. It took approximately two minutes to carry him down to the station concourse. He entered the Casualty Clearing Station area at 23:23:54.³⁰⁶

While John Atkinson was on the raised walkway at 23:20, two GMP officers who had been with him went down to the station concourse to ask paramedics for assistance. They found Daniel Smith. One of those police officers, PC Leon McLaughlin, spoke to Daniel Smith, saying: “[E]xcuse me, I know you’re busy, we’ve got someone stuck on the first ground two fractures to his legs we just can’t move him.”³⁰⁷ Not all of what Daniel Smith said in reply is audible on the body‑worn video, but this was captured: “[J]ust leave him there for now … blanket him up and leave him there.”³⁰⁸ To this, PC McLaughlin responded: “[Y]es, no problem, is there any blankets anywhere?”³⁰⁹

In evidence, Daniel Smith stated he had no independent memory of this conversation. He went on to state:
“I think the only conclusion I can give you in terms of why that was my response was because at that point I think I was becoming comfortable … that a system had been created in terms of moving patients and that if a patient had become stuck … there were systems in place to assist that.”³¹⁰

An appropriate response from Daniel Smith would have been to enquire whether the casualty was being transported on a stretcher, and, if not, he could have instructed the police officers that they could find one in the ambulances. In my view, this is what he should have said.

Daniel Smith’s failure to implement an adequate plan in relation to stretchers is not the only reason for the delay in John Atkinson’s evacuation from the City Room. However, the circumstances of John Atkinson’s evacuation provide a clear illustration of why stretchers were needed in the City Room.

Georgina Callander’s evacuation from the City Room

At 23:06, Patrick Ennis assessed Georgina Callander and said: “We just need to keep her in this position for now and we’ll get her moved as soon as we possibly can.”³¹¹ In a witness statement, Patrick Ennis recalled that he considered Georgina Callander to be the most urgent P1 casualty in the City Room at that time. Conversations then took place between police officers about the urgency of moving her.³¹²

At 23:09, PC Owen Whittell went looking for something on which to carry Georgina Callander. He found a table, and one minute later he and a colleague carried it back to where Georgina Callander was. The police officers then concluded that they would need to speak to Patrick Ennis before moving her.³¹³

At 23:15, another police officer approached PC Whittell and asked if the table was being used. PC Whittell said it was not and the table was used for another casualty.³¹⁴

At 23:17, Georgina Callander was assessed by Lea Vaughan and Christopher Hargreaves. She was assessed to be a P1 casualty, and a label was tied to her. ³¹⁵

Three minutes later, Bethany Crook approached Georgina Callander. Bethany Crook was an off‑duty nurse. She had just finished helping with the evacuation of Saffie‑Rose Roussos. Bethany Crook began to help Georgina Callander. At 23:21, Patrick Ennis told those helping Georgina Callander that she was the highest priority casualty.³¹⁶

At 23:24, police officers began to prepare a board on which to evacuate Georgina Callander. A minute later they succeeded in moving Georgina Callander on the makeshift stretcher. One minute after that, Georgina Callander was carried out of the City Room.³¹⁷

Georgina Callander arrived in the Casualty Clearing Station at 23:28. This was approximately two minutes after she had been carried out of the City Room.³¹⁸

There was a delay of 20 minutes between Georgina Callander being identified by Patrick Ennis as the highest priority casualty in the City Room and Georgina Callander being carried out of the City Room on a makeshift stretcher. In that time, a table was identified by police officers as a possible means of carrying her out. When concerns developed about whether it was safe to move her, that table was used for someone else. A different means of carrying Georgina Callander out was subsequently identified.

The absence of a safe and appropriate way of transporting Georgina Callander out of the City Room caused avoidable delay in getting her from the City Room to the Casualty Clearing Station.

Replacement as Operational Commander

By 23:51, Stephen Hynes had arrived at the railway station.³¹⁹ He was the NWAS Deputy Director of Operations and therefore significantly senior to Daniel Smith. Daniel Smith and Stephen Hynes spoke. At 23:57, Daniel Smith handed over his tabard to Stephen Hynes.³²⁰ He had been replaced as Operational Commander. Daniel Smith’s perception was that this had happened because the senior management of NWAS was unhappy with his command.³²¹

Stephen Hynes stated in evidence that he had not replaced Daniel Smith for this reason but instead because: “I was able to enhance the role with the training, education, experience and knowledge in terms of undertaking that role for the complex incident that we were dealing with at that time.” ³²² Whether Stephen Hynes’ view amounts to the same as Daniel Smith’s perception is not an issue that it is necessary for me to resolve.

Daniel Smith is a good and committed paramedic. He acted with the best of intentions on the night of the Attack, but he did make mistakes, some of them serious. He gave his evidence with candour, accepting many of his mistakes. It was plain to me that he wishes NWAS and the emergency services more generally to learn the lessons of what went wrong.

Hazardous Area Response Team

GM HART crew Team Leader

The post of Team Leader on the GM HART crew was not occupied on 22^nd May 2017. The second in command of the GM HART crew was not working that night. In these circumstances, it was expected that a member of the team would volunteer to act as Team Leader for the shift. On the night of the Attack, Simon Beswick had volunteered to act up as Team Leader.³²³

Simon Beswick qualified as a paramedic in 2006 and joined HART in 2015.³²⁴ There were five other HART operatives on the GM HART crew on 22^nd May 2017.³²⁵ Four of those five had been members of HART longer than Simon Beswick.³²⁶

The role of HART Team Leader in NWAS did not require any set qualifications. Prior to May 2017, NARU had produced an action card for the Team Leader of HART. It had not been adopted by NWAS.³²⁷ Simon Beswick had never had any training in the use of the Team Leader action card produced by NARU.³²⁸

Simon Beswick had not received any training in relation to the issue of whether all available HART resources should be deployed or whether some should be held back.³²⁹

In my view, the system operated by NWAS in relation to the position of HART Team Leader was unsatisfactory for a number of reasons. First, it was not appropriate to have a replacement for such an important role undertaken on a volunteer basis. The volunteer system undermines the need for a clear and established hierarchy where the person in the Team Leader role is appointed on merit grounds. The volunteer system meant that the best person for the role may be receiving orders, rather than giving them.

Second, the lack of any required formal training specific to the role of Team Leader meant that there was no safeguard to ensure that the person who volunteered to undertake the role was, in fact, qualified to do it.

Third, the lack of an action card meant that the person who undertook the role did not have a list of prompts to work from. There was a clear need for an action card given the importance of the role and the lack of other safeguards due to the system operated by NWAS. Simon Beswick’s evidence was that it would have been helpful to have had a prompt to remind him of his key tasks.³³⁰ I agree.

Simon Beswick was an experienced paramedic. But he had been a member of HART for only two years prior to the Attack. By contrast, three of the GM HART crew that night had six years’ or more experience as members of HART.³³¹

When giving evidence, Simon Beswick stated that he did not think he was adequately qualified to act as HART Team Leader.³³² I agree. Responsibility for this unacceptable state of affairs lies with NWAS. Simon Beswick made a number of mistakes during the response to the Attack. In my view, NWAS is responsible for those mistakes. Simon Beswick did his best in extraordinary circumstances, but he should not have been put in the position in which he found himself.

Mobilisation of GM HART crew (22:40)

At 21:53, five of the GM HART crew were assigned to a fire at Unity Mills in Woodley, near Stockport. That crew comprised: Simon Beswick, Christopher Hargreaves, Lea Vaughan, Nicholas Priest and Stephen English. The sixth GM HART crew operative, Ian Devine, was responding to a different incident.³³³

Simon Beswick, Christopher Hargreaves and Lea Vaughan arrived at the fire ground near Stockport in two vehicles shortly before 22:30. Upon arrival, it became apparent that HART was not required.³³⁴ It was a misfortune that the GM HART crew were deployed to an incident away from Manchester City Centre for which they were not needed. The effect of this was that the GM HART crew had much further to travel than would have been the case if they had been at their headquarters in Manchester.³³⁵

I recommend that NWAS consider this issue with great care. The HART resource is a scarce one. It is one thing for it to have been deployed to an incident at which its particular skill set was required. It is another for it to be taken away from Manchester only to discover it was not required. I recognise that the issue is a complex one, which is why I am not critical of anyone for it occurring. For example, I recognise that taking the view that it is better to mobilise HART early to a fire in case it is needed is capable of saving lives.

I was told that HART is frequently deployed but not required.³³⁶ While it is fortunate in each of those circumstances that HART was not needed, it risks creating the situation that in fact occurred on 22^nd May 2017, namely that HART is taken away from where it is needed. One solution to this problem is to increase the number of HART crews on duty. I will address this further in Part 20 in Volume 2‑II.

At 22:40, NWAS Control contacted Christopher Hargreaves and informed him of “a large-scale incident in the city centre”.³³⁷ NWAS Control asked if the GM HART crew could be redirected to that incident.³³⁸ One minute later, Simon Beswick contacted NWAS Control. He was informed of the Attack.³³⁹ He spoke to the incident commander from the fire and rescue service to explain that he was leaving the fire ground.³⁴⁰ At 22:42, Simon Beswick contacted NWAS Control to say that he and his team were able to attend the incident in Manchester City Centre.³⁴¹

Nicholas Priest and Stephen English travelled to the fire near Stockport in a Public Support Unit vehicle. They were still on the M60 at the point at which Simon Beswick spoke to NWAS Control at 22:42. Following that call, Simon Beswick contacted Nicholas Priest and Stephen English and instructed them to drive back to HART headquarters. Simon Beswick instructed them to pick up an additional vehicle and deploy to the Manchester City Centre incident.³⁴²

Shortly after Simon Beswick had left the fire near Stockport, NWAS Control informed him that the RVP was Manchester Central Fire Station. This was confirmed at 22:49. However, at 22:54 Simon Beswick was told that the RVP had been changed to “Hunts Bank Bridge”.³⁴³

At 22:58, the sixth member of the GM HART crew, Ian Devine, was allocated to respond to the Attack. Ian Devine had been “loaned” to the GM HART crew from Merseyside for that shift. By the time he was allocated to respond to the Attack, he had finished attending to the patient he was with and had started to make his way back to HART headquarters for a break.³⁴⁴

Ian Devine should have been allocated to respond as soon as he was finished with the patient, which was, as he told me, earlier than 22:58.³⁴⁵ At the point of allocation, he was only 16 minutes away from the Victoria Exchange Complex.³⁴⁶ When he was allocated, he diverted from the course he was on in order to go to the Arena.³⁴⁷ It is likely that if Ian Devine had been allocated sooner than 22:58, he would have arrived before 23:10. This may have resulted in him going into the City Room as he would have been present when Simon Beswick asked for volunteers.

Arrival of first GM HART crew operatives on Hunts Bank (23:06)

Very shortly after 23:00, Simon Beswick, Christopher Hargreaves and Lea Vaughan arrived on Trinity Way. Simon Beswick informed NWAS Control: “It’s absolute chaos, we can’t get through, traffic’s blocked, we’re currently just outside … I cannot get to the rendezvous point because the traffic is completely blocked.”³⁴⁸

Once on Trinity Way, they encountered Martyn Nealon.³⁴⁹ The HART operatives gave Martyn Nealon a lift back to Hunts Bank. This caused a slight delay to the progress of Simon Beswick, Christopher Hargreaves and Lea Vaughan towards Hunts Bank. Martyn Nealon informed Simon Beswick that Daniel Smith was the Operational Commander.³⁵⁰ At 23:03, Simon Beswick radioed NWAS Control. He informed NWAS Control that Daniel Smith was “already inside the Arena actioning clinical aid”.³⁵¹

The first HART operative to arrive on Hunts Bank was Lea Vaughan. Her single‑crewed vehicle pulled up at 23:06. Less than a minute later, the double‑crewed vehicle containing Simon Beswick and Christopher Hargreaves arrived and parked.³⁵²

GM HART operatives’ deployment to the City Room (23:11)

Simon Beswick made his way to the area outside the War Memorial entrance. By 23:10, he was speaking to Derek Poland on Station Approach. Seconds later, the two men were joined by Daniel Smith. As Simon Beswick was speaking to these two colleagues, Lea Vaughan and Christopher Hargreaves were preparing their equipment. At 23:11, Christopher Hargreaves and Lea Vaughan joined the group.³⁵³

In the course of his conversation with Daniel Smith, Simon Beswick was told that there had been an explosion in the City Room. Daniel Smith informed him that Patrick Ennis “was embedded in the scene and that the scene hadn’t been declared safe”. Simon Beswick interpreted this as meaning that the City Room was within a Major Incident “inner cordon”.³⁵⁴

At the point of this conversation with Daniel Smith, there were only three HART operatives available for immediate deployment: Lea Vaughan, Christopher Hargreaves and Simon Beswick. Nicholas Priest and Stephen English were still more than five minutes away. At this point, Simon Beswick did not know where Ian Devine was.³⁵⁵

Daniel Smith said to Simon Beswick that HART personnel were required to move forward into the City Room to assist Patrick Ennis with primary triage and treatment.³⁵⁶ Simon Beswick characterised it as a joint decision with Daniel Smith for Lea Vaughan and Christopher Hargreaves to be deployed into the City Room.³⁵⁷

Simon Beswick spoke to Christopher Hargreaves and Lea Vaughan. He informed them that there had been an explosion causing mass casualties and mass fatalities. He said that a secondary device had not been ruled out and that there were unconfirmed reports of shootings. He told Christopher Hargreaves and Lea Vaughan that it was not known if the building was safe. He asked if they had the equipment they needed. He concluded by asking if they were “happy to deploy”. Christopher Hargreaves and Lea Vaughan said that they were.³⁵⁸

In order to save time, neither Christopher Hargreaves nor Lea Vaughan had put on their ballistic protection.³⁵⁹ Having received the briefing, it was a brave decision by both of them to unhesitatingly agree to go to the City Room without protective equipment which was available to them.

When they deployed to the City Room, Christopher Hargreaves and Lea Vaughan had four “MTFA [Marauding Terrorist Firearms Attack] bags” between them. These contained tourniquets, haemostatic dressings and blast dressings, among other items.³⁶⁰ They also each took SMART Triage Tags as a means to identify patients as P1, P2, P3 or deceased once they had been triaged.³⁶¹

Deployment of remainder of GM HART crew

Simon Beswick did not go forward to the City Room. Daniel Smith tasked him to operate on Station Approach.³⁶² While he and other HART operatives had relevant skills for supporting a Major Incident response outside the hazard area,³⁶³ the principal attribute of HART operatives is working in hazardous areas. I shall return to the issue of what Simon Beswick was tasked to do by Daniel Smith at paragraph 14.340.

By 23:21, the remaining members of the GM HART crew had mustered on Station Approach with Simon Beswick: Ian Devine had arrived at 23:14 and put on his ballistic kit; Nicholas Priest arrived at 23:18; and Stephen English arrived at approximately the same time as Nicholas Priest.³⁶⁴

Daniel Smith stated in evidence that he deployed only two HART operatives into the City Room because Simon Beswick only “provided me with two”. He stated that he was not told of the arrival of the other HART operatives. He stated that he would not have directed the additional HART operatives to set up a Casualty Collection Point, but that it was “very much likely that I would have said ‘Assist with the establishment of the CCS [Casualty Clearing Station] now that you’re here.’”³⁶⁵ Later in his evidence, Daniel Smith stated he could not recall being told that any further HART operatives were ready to deploy.³⁶⁶ His evidence was that he “thought the operational plan was working and if any more resources were needed, then they would have been requested”.³⁶⁷

Simon Beswick’s evidence was that it was Daniel Smith’s “command decision”, which he supported, for the remainder of the GM HART crew to remain on Station Approach.³⁶⁸

I find that when Daniel Smith became aware of the arrival of three more members of the GM HART crew, he directed that they stay on Station Approach. This was a decision with which Simon Beswick agreed. Both were wrong. The better decision was to deploy all of the GM HART crew to the City Room. I shall turn to this in more detail shortly.

While the responsibility for making this decision lay with Daniel Smith, he did not have the support in his decision‑making that he should have had from Simon Beswick. This lack of support was principally the responsibility of NWAS, for the reasons I gave above at paragraphs 14.271 to 14.279, when considering Simon Beswick’s suitability for the role of HART Team Leader.

Specialist Response Team

Both HART and GMFRS’s Specialist Response Team train together. Simon Beswick knew of the Specialist Response Team’s capabilities. He knew that they had training on performing immediate life‑saving interventions. He knew that they had the training and experience to move casualties safely and efficiently.³⁶⁹

As he made his initial assessment of the scene and considered deployment, Simon Beswick should have been asking himself where GMFRS was. In evidence, he stated that he was aware that GMFRS was not at the scene, but: “[W]e were quite busy managing patients and the actual response.”³⁷⁰

I recognise that Simon Beswick and his team were confronted with an extremely stressful situation, and it was important that the immediate needs of casualties were addressed. However, for good reason, JESIP expects communication, co‑location and co‑ordination. The fact that Simon Beswick did not pause for a moment to consider whether the way his team operated might be enhanced by a co‑ordinated approach with his counterpart team at GMFRS demonstrates that Simon Beswick was not thinking in JESIP terms. Instead, he was focused solely on NWAS’s response.

Simon Beswick should have contacted NWAS Control or the Tactical Advisor/ NILO and asked for GMFRS to be informed that he was on Station Approach and that the Specialist Response Team should co‑locate with him there. Had he done so, it is possible that GMFRS personnel would have arrived substantially sooner than they did. That arrival may have been in time to assist in the removal of casualties from the City Room.

In his evidence, Simon Beswick stated that he thought “action cards, visual prompts” would be beneficial to a response, “especially in stressful situations with a lot of challenges”.³⁷¹ I agree.

GM HART operatives in the City Room (23:15)

The only HART operatives deployed to the City Room during the critical period of the response were Lea Vaughan and Christopher Hargreaves. They walked through the War Memorial entrance to the railway station at 23:13.³⁷² At 23:15, they entered the City Room.³⁷³ They immediately spoke to Patrick Ennis.³⁷⁴

I have explained the two types of triage required in the Major Incident Response Plan in Part 12. Lea Vaughan and Christopher Hargreaves commenced primary triage at 23:16. They carried this out in a clockwise direction. Christopher Hargreaves stated that they had completed primary triage of all the patients in the City Room by 23:27. Having triaged the patients once, they spoke to Patrick Ennis again. They then started on secondary triage.³⁷⁵

During her evidence, Lea Vaughan was asked whether it was good enough that only three paramedics were in the City Room treating those who needed treatment. Her answer was that she did not believe that further paramedics would have been of any help “at that point”.³⁷⁶ In a media interview she gave after her evidence, however, Lea Vaughan stated: “I definitely think more HART paramedics should have been sent in … I did think more HART paramedics would have turned up. Only three paramedics went in. Yes, I am sorry that isn’t enough. I know it isn’t enough. Every person knows that isn’t enough.”³⁷⁷

Following that media interview, Lea Vaughan provided a further statement to the Inquiry in which she stated she stood by her evidence. She stated that by the time the other HART paramedics arrived, she and Christopher Hargreaves had already completed “a large part” of the triaging and stabilisation.³⁷⁸

Christopher Hargreaves’ evidence was that at no point while in the City Room did he think that further paramedics were required. However, he went on to say: “Ultimately, I think if we would have had extra personnel there, it would have helped.”³⁷⁹ He stated: “I don’t want to make it sound like we were struggling there or anything like that, because I don’t honestly believe at any point we were, but ultimately more medics in there would have helped.”³⁸⁰

During the questioning, it was suggested to Christopher Hargreaves that the treatment which was given in the City Room would have occurred earlier had there been more trained paramedics in the City Room. He replied: “Yes. I can’t argue with that.”³⁸¹

Simon Beswick made the point that neither Lea Vaughan nor Christopher Hargreaves requested additional resources in the City Room. His evidence was that, although he had not briefed Lea Vaughan and Christopher Hargreaves to request further members of HART: “I’m aware of my colleagues’ traits and I know if they’d needed extra assistance, they’d have contacted us.”³⁸² Simon Beswick stated he believed that Patrick Ennis “would act in a sort of forward operating role”. He accepted that he should have made direct contact with Patrick Ennis to establish the parameters of his role.³⁸³ In my view, Simon Beswick was wrong to rely on Lea Vaughan or Christopher Hargreaves to inform him if further HART operatives were required in the City Room. I am critical of Daniel Smith as well for adopting the same approach.

First, there was a real risk that Lea Vaughan and Christopher Hargreaves could become completely focused on their task and not take a step back. Simon Beswick accepted that there was a risk of this occurring.³⁸⁴ I agree with Christopher Hargreaves when he stated: “[I]t’s always good to have … a forward incident commander … [or] a sector commander, [who] would have been able to see [the] big picture because you are quite focused on what you are doing at the time.”³⁸⁵

What happened on the night of the Attack demonstrates why a Sector Commander, such as the HART Team Leader, was required in the City Room. Christopher Hargreaves’ belief at the time was that he and Lea Vaughan were coping. He now recognises that more HART operatives would have improved the care given to those in the City Room. I make it clear that I am not critical of Christopher Hargreaves for either his approach at the time or his subsequent evidence.

What Christopher Hargreaves’ evidence demonstrated was the need for someone in the City Room who was not focused on coping with the task of triage and life‑saving treatment, but whose role it was to assess how the best outcome could be achieved. That was the role of a Sector Commander. Simon Beswick accepted during his evidence that he “could have been more effective moving forward”.³⁸⁶ I agree.

Second, there was a risk that an assumption might be made by Christopher Hargreaves or Lea Vaughan that the other members of HART would follow upon arrival. Simon Beswick accepted this.³⁸⁷ In fact, Lea Vaughan made this assumption when she went into the City Room. She stated that her expectation was that the rest of the GM HART crew would follow them into the City Room upon arrival.³⁸⁸

Third, Simon Beswick had only one radio. After Lea Vaughan and Christopher Hargreaves were deployed to the City Room, Simon Beswick switched radio channel from the HART channel to the NWAS Major Incident channel. The effect of this was to cut himself off from direct radio messages from Lea Vaughan and Christopher Hargreaves. There were other ways in which a message could have reached Simon Beswick. However, given that he was relying upon Lea Vaughan and Christopher Hargreaves to tell him if further HART operatives were required, this was a less than ideal state of affairs.³⁸⁹

Simon Beswick should not have left it to Lea Vaughan and Christopher Hargreaves to tell him that further HART operatives were required in the City Room. He should have informed Daniel Smith that the HART Team Leader needed to deploy to the City Room. With Daniel Smith’s approval, he should then have accompanied Lea Vaughan and Christopher Hargreaves into the City Room. He should have informed the rest of the GM HART crew that they should follow.

As an alternative, I would not have been critical of Simon Beswick or Daniel Smith if Simon Beswick had waited for the balance of GM HART crew to arrive and had accompanied them, provided he was confident that their arrival would be imminent.³⁹⁰ Either way, with the approval of Daniel Smith, Simon Beswick should have been deployed to the City Room, as should the balance of the GM HART crew.³⁹¹ They are trained to work in very difficult conditions. That training should have been put to proper use when it was needed.

Daniel Smith should have deployed all members of the GM HART crew forward. The immediate threat to life necessitated as many paramedics in the City Room as could safely go in. By this point, Daniel Smith had reasoned himself into a position that he could not deploy non‑specialists forward. That meant that only HART operatives could provide life‑saving interventions to the standard of a paramedic to those in the City Room.

HART operatives train as a team and operate most effectively as a team.³⁹² Daniel Smith’s decision had the effect of splitting the team up for an important period in the emergency response.

More HART operatives in the City Room from 23:25 would have made a difference to the casualties in there at that time. The final casualty was not evacuated from the City Room until 23:39. If the remainder of the GM HART crew had deployed forward, on arrival, there would have been a total of six paramedics operating, under the supervision of Simon Beswick, in the City Room between 23:25 and 23:39. While it is now known that this could not have saved any lives that night, it would have increased the speed of the triage that was being carried out, provided a greater opportunity for critical clinical interventions where needed by those in the City Room, and resulted in a faster evacuation down to the Casualty Clearing Station.

Involvement with those who died

At 23:17, Lea Vaughan and Christopher Hargreaves assessed Georgina Callander. One minute later, they placed a red label on Georgina Callander to identify her as a P1 casualty. They moved on shortly after that.³⁹³ Georgina Callander was moved out of the City Room on a makeshift stretcher by others at 23:26.³⁹⁴ I shall return to Georgina Callander’s treatment and the treatment she received in the Casualty Clearing Station shortly.

At 23:40, Lea Vaughan and Christopher Hargreaves approached Chloe Rutherford. They lifted the covering which had been placed over her by that time. Lea Vaughan attached a label to Chloe Rutherford identifying that she was dead. Shortly after, Lea Vaughan attached a label to Liam Curry identifying that he was dead.³⁹⁵ This was the first time either Chloe Rutherford or Liam Curry were assessed by a paramedic.

At 23:41, Lea Vaughan attached a label to Nell Jones identifying that she was dead.³⁹⁶ This was the first time Nell Jones was assessed by a paramedic.

At 23:42, Lea Vaughan and Christopher Hargreaves assessed Martyn Hett. This was the first time Martyn Hett had been assessed by a paramedic. Two minutes later, Christopher Hargreaves attached a label to Martyn Hett identifying that he was dead.³⁹⁷

At 23:45, Lea Vaughan attached a label to Eilidh MacLeod identifying that she was dead.³⁹⁸ This was the first time that Eilidh MacLeod was assessed by a paramedic.

At 23:45, Christopher Hargreaves lifted the covering which had been placed on Elaine McIver. He attached a label identifying that she was dead.³⁹⁹

At 23:46, Lea Vaughan attached a label to Sorrell Leczkowski identifying that she was dead.⁴⁰⁰

At 23:47, Lea Vaughan knelt beside Alison Howe. She briefly held Alison Howe’s right arm before standing up and moving away.⁴⁰¹

GM HART operatives on Station Approach

There was some confusion within the evidence as to whether the members of the GM HART crew who did not deploy to the City Room were tasked with setting up the Casualty Clearing Station or a Casualty Collection Point. The distinction may be thought to be an inconsequential one. It is not. The functions of a Casualty Clearing Station and a Casualty Collection Point are different.

As I set out in Part 12, the NWAS Major Incident Response Plan stated that a Casualty Collection Point is “designed to provide basic care for life threatening injuries prior to a casualty being moved to the CCS [Casualty Clearing Station] or direct to hospital. Equipment to establish the CCP [Casualty Collection Point] is carried by the Hazardous Area Response Team.”⁴⁰² A Casualty Clearing Station aims to provide a treatment place to stabilise a casualty with a view to getting them to a definitive point of care “as soon as possible”.⁴⁰³ Once a Casualty Clearing Station has been established: “[A]ll casualties must be directed/ transferred from the site or CCP to the facility for further triage.”⁴⁰⁴

The staging of the two at a Major Incident is important. Any misunderstanding around this indicates a misunderstanding of the correct way to structure a Major Incident response.

Daniel Smith stated in evidence that he had used the terms “CCP” and “CCS” interchangeably in his witness statement. He stated that what he had sought to establish was a Casualty Clearing Station. He stated that there was no Casualty Collection Point.⁴⁰⁵ He stated:
“I just wouldn’t ask somebody to set up a CCP outside of a CCS. If I’ve given that instruction of that nature, then it may be a mis-communication on my part, or both. I am fairly confident it would have been … to set up or assist within the CCS … it would just make no sense to have a CCP outside.”⁴⁰⁶

I agree that in the circumstances of 22^nd May 2017 it would make no sense to have a Casualty Collection Point on Station Approach. This does not explain why Daniel Smith used “CCP” and “CCS” interchangeably in his witness statement. Indeed, it begs the question why he did.

Simon Beswick’s evidence was: “I was tasked by Mr [Daniel] Smith to establish a CCP and support him in his response.”⁴⁰⁷ Setting up a Casualty Collection Point was something in which Simon Beswick had received training.⁴⁰⁸ He agreed that a Casualty Collection Point should sit between the incident and the Casualty Clearing Station. He agreed that the Casualty Clearing Station should then feed into the ambulance loading point.⁴⁰⁹

When asked whether the Casualty Collection Point was being set up in the area of the ambulance loading point, Simon Beswick replied: “It evolved into that, yes. My initial thought process because the scene safety hadn’t been declared was, in discussion, we attempted to get everyone away from the concourse through the Victoria Station doors … to try to give us a barrier, a buffer … a safety zone.”⁴¹⁰ He went on to say that this area “did progress to a casualty clearing station”.⁴¹¹

GM HART crew member Ian Devine’s recollection when he gave evidence was that he was asked to set up a Casualty Collection Point by Simon Beswick when they spoke at 23:21. Setting up a Casualty Collection Point was something that HART had practised during exercises.⁴¹² He stated: “[A]s the incident progressed … [it] then became apparent that where we were actually set up was not a casualty collection point but was a casualty clearing station.”⁴¹³ He stated:
“[I]f I’d had a knowledge of the scene at that time … the CCP could have been positioned closer.” He agreed that there would not have been room between the area they were working in and the ambulance loading area for there to be a Casualty Clearing Station.⁴¹⁴

Both Nicholas Priest and Stephen English stated that they were asked to set up a Casualty Collection Point.⁴¹⁵ In a presentation she gave on 16^th January 2018 about her involvement in the response to the Attack, Lea Vaughan identified Nicholas Priest, Stephen English and Ian Devine as “CCP”. She described the area on Station Approach outside the War Memorial entrance as “HART CCP/ CCS”.⁴¹⁶

The evidence of Helen Mottram, who acted as a triage officer on the station concourse, was that she was working in the Casualty Clearing Station, “but the casualty collection point appeared to be on the pavement outside Victoria, where some of the HART team were operating”.⁴¹⁷

I am satisfied that the instruction given by Daniel Smith at 23:10 was for Simon Beswick to set up a Casualty Collection Point on Station Approach. Whether Daniel Smith meant Casualty Clearing Station and made a mistake, or whether he intended at that time to say Casualty Collection Point, I am not able to say. Either way, I am satisfied that he said Casualty Collection Point. Simon Beswick relayed this instruction to his colleagues in the GM HART crew at 23:21.

Station Approach was not an appropriate place for a Casualty Collection Point. It was too far from the scene to discharge the function of a Casualty Collection Point. HART operatives were well qualified to set up a Casualty Collection Point due to a Casualty Collection Point ordinarily being located close to a hazardous area. As a result of their lack of situational awareness, the GM HART crew on Station Approach followed the instruction they had been given. It very quickly became apparent to those who were setting it up that the Casualty Clearing Station was better located on the station concourse between the bottom of the staircase to the raised walkway and the War Memorial entrance. By 23:17, there were a number of casualties on the station concourse.⁴¹⁸

Two things arise from Daniel Smith’s instruction to set up a Casualty Collection Point on Station Approach. First, by saying “CCP”, Daniel Smith instructed Simon Beswick to do something he had expected to do as a result of his training. The Major Incident Response Plan made clear that HART operatives are Casualty Collection Point specialists.⁴¹⁹ As a result, there was no reason for Simon Beswick to suggest that he was engaging in an activity which HART would not ordinarily be expected to carry out. If Simon Beswick had been instructed to set up a Casualty Clearing Station, I consider it likely that he would have challenged that decision: he certainly should have done. This may have led to a discussion about deploying HART further forward.

Second, Daniel Smith told Simon Beswick when he arrived that nowhere within the Victoria Exchange Complex had been declared safe.⁴²⁰ As a result, Simon Beswick accepted the area of Station Approach as an appropriate location for a Casualty Collection Point.⁴²¹ If Simon Beswick had better situational awareness, it is likely that he would have queried the choice of Station Approach as a location for the Casualty Collection Point.⁴²² He did not have good situational awareness. Obtaining situational awareness was a reason for Simon Beswick to have gone forward into the Victoria Exchange Complex at an early stage.

Both of these factors are relevant to the issue of why the whole GM HART crew did not go into the City Room. They demonstrate part of the breakdown in communication and decision‑making which led to a situation where four HART operatives were working further from any potential hazard than the non‑specialist paramedics.

During the critical period of the response, at around 23:30, Simon Beswick briefly entered the Victoria Exchange Complex.⁴²³ While on the station concourse, he noticed the staircase. The challenge the staircase might present to P1 and P2 casualties did not strike him at the time. He stated this was because, at that time, he “had limited information on the number of casualties in the City Room”.⁴²⁴ By this stage, the Casualty Clearing Station was well established on the station concourse.

Simon Beswick candidly stated that more training would have been helpful to him at the point at which he was discussing with Daniel Smith the setting up of the Casualty Collection Point.⁴²⁵ I agree. Principal responsibility for the shortcomings in Simon Beswick’s approach lies with NWAS. NWAS failed to ensure that an appropriately qualified person was leading the GM HART crew.

The GM HART operatives who did not go up to the City Room contributed to the emergency response in a positive way. I have no reason to think they did other than discharge the role they had been given as well as they could. My concern around their contribution is that they could have been better used than they were.

Further deployment of GM HART operative to City Room (23:40)

Shortly before 23:40, Simon Beswick deployed Ian Devine to the City Room.⁴²⁶ Ian Devine entered the City Room at 23:40.⁴²⁷ By the point at which Ian Devine entered the City Room, the last casualty who was capable of being helped had been removed.⁴²⁸

Simon Beswick deployed Ian Devine to provide SMART Triage Tags to Lea Vaughan and Christopher Hargreaves. These cards were to be used to identify those left in the City Room who had died.⁴²⁹

C&M HART crew

The Team Leader of the C&M HART crew on duty on 22^nd May 2017 was Ronald Schanck. He became aware of an incident in Manchester City Centre, via social media, at around 22:55. At that time, he was at HART headquarters in Merseyside, approximately 30 miles from the Arena.⁴³⁰ He immediately notified the rest of the C&M HART crew to ready themselves. At about 23:06, he spoke to NWAS Control. It was agreed that the C&M HART crew would mobilise to Manchester. Ronald Schanck was formally allocated to respond to the Attack at 23:14. By this stage, he and his team were already on the road.⁴³¹

Ronald Schanck’s evidence was that he would have expected to have been notified by NWAS Control of the incident earlier than he was.⁴³² In my view, Ronald Schanck was correct to have this expectation. There was an unacceptable delay by NWAS Control to notify the C&M HART crew. In the NWAS closing statement to the Inquiry, NWAS accepted this.⁴³³

I have already criticised NWAS Control for the time it took to mobilise the GM HART crew. The mobilisation occurred as a result of a conversation with Annemarie Rooney at 22:39. At that stage, there was no good reason not to mobilise the C&M HART crew towards the Victoria Exchange Complex. Ronald Schanck’s evidence was that he would have expected notification to be given to his team within ten minutes of the explosion.⁴³⁴ Again, I agree with his evidence.

If NWAS Control had notified the C&M HART crew at the same time as the GM HART crew, members of the C&M HART crew could have been on Hunts Bank by 23:15 or just after.⁴³⁵ Had this occurred, based on their travel times from Merseyside, there would have been at least three members of the C&M HART crew available to Daniel Smith at around this time: Ronald Schanck, Ciaran Martin and Garry Blyton.⁴³⁶ It is highly likely in these circumstances that more HART operatives would have been deployed into the City Room. These may have been from the GM HART crew and/or the C&M HART crew.

It was argued on NWAS’s behalf that sending the C&M HART crew straight to the scene at 22:40 would not have been reasonable.⁴³⁷ The evidence of the Ambulance Service Experts was cited in support, namely: “There’s a risk … particularly with a terrorist attack, that you don’t know if it’s going to be multi-sited so there needs to be a caution about sending all specialist assets to a single location.”⁴³⁸

I accept that particular caution was required at 22:40 for the reason given by the Ambulance Service Experts: fewer than ten minutes had passed since the detonation. However, as time passed, the risk of a further attack diminished. By 23:15, over 40 minutes had passed since the explosion without any clear evidence of a further attack. Balanced against that risk was the fact that Daniel Smith had made the decision that only HART operatives could provide assistance to the people in the City Room.

In my view, by the stage at which the C&M HART crew would have been nearing the RVP at Manchester Central Fire Station and the Victoria Exchange Complex, there was a clear justification for deploying them straight to the scene so that they could help casualties. If Daniel Smith had directed non‑specialists into the City Room, then I recognise that holding the C&M HART crew back at this stage would have been justified.

A decision to deploy both HART crews to the scene at 23:15 would have required thought to be given to ensuring that some of the HART operatives at the scene were able to deploy to another scene quickly should they be needed.⁴³⁹ In the circumstances, as far as they were capable of being known, at 23:15 on 22^nd May 2017, I do not accept that it would have been reasonable to withhold badly needed help from casualties in the City Room on the basis of the risk of a further attack.

The mitigation for such a risk was to ensure that the HART crews in Yorkshire and the East Midlands Ambulance Services were alerted at the same time as the NWAS HART crews so that they could be ready to provide support to NWAS if required.

As it was, the C&M HART crew were directed to attend Manchester Central Fire Station. Ronald Schanck arrived at 23:43 in the same vehicle as a second member of his team.⁴⁴⁰ Other members of his team arrived in the minutes that followed. The final members of the team arrived just after midnight.⁴⁴¹ Ronald Schanck explained that he and his C&M HART crew were frustrated that they had been mobilised to an RVP rather than to the scene.⁴⁴² He stated: “[B]ut it’s not unreasonable for the command structure to be a bit cautious because in my mind, as HART team leader, I was concerned this could be … the start of something big, as in attacks across the north west.”⁴⁴³

Ronald Schanck was correct to recognise that the decision as to whether to deploy the second HART crew to the scene required consideration of the risk that they may be required elsewhere as part of an unfolding attack. His evidence echoed that of the Ambulance Service Experts as I set out above at paragraph 14.359.

Just as he was arriving at Manchester Central Fire Station, Ronald Schanck spoke to Daniel Smith to notify him of his location. Daniel Smith informed Ronald Schanck that he was “probably going to move [him] forward” but that he needed to clear the roads a little.⁴⁴⁴

At 23:50, Ronald Schanck contacted the NWAS Merseyside Control Room from Manchester Central Fire Station. He said: “We’ve got a HART team at the RVP now and we’re looking at possibly backing our colleagues up from Manchester HART, closer to where the incident is.”⁴⁴⁵

At 23:54, the NWAS Merseyside Control Room spoke to Ronald Schanck. He repeated that he wanted to know if NWAS Control wanted him to back up his colleagues on scene. The reply he received was: “[I]t might have to come from Manchester.” This was a reference to the NWAS Control Room in Greater Manchester. The NWAS Merseyside Control Room said: “[W]e are just trying to get hold of Manchester but we can’t get any reply from them at the moment, it’s obviously chaos there.”⁴⁴⁶

At 00:13, the C&M HART crew were deployed from the RVP to Hunts Bank. They arrived on Hunts Bank at 00:19.⁴⁴⁷

It is not completely clear to me from the evidence why it took 30 minutes for this to occur. What is clear is that Daniel Smith was in favour of the C&M HART crew coming to the scene. It is also clear that delay was caused as the Merseyside‑based part of NWAS Control sought to contact the Manchester‑ based part of NWAS Control.

If there was a deliberate decision to hold the C&M HART crew back, one relevant consideration was the risk of further attacks. A second relevant consideration was whether or not there was a particular need for HART’s specialist skill set.

As to the first consideration, by 23:43 more than an hour had passed since the detonation. While GMP had investigated other potential threats, there was no clear evidence of a further attack.⁴⁴⁸ The risk of a further attack was diminishing as every minute passed. As to the second consideration, by 23:43 all casualties who could be helped had been evacuated from the City Room and were in the Casualty Clearing Station.⁴⁴⁹

On the available evidence, it is likely that there was no deliberate decision to hold the C&M HART crew back. Indeed, as the C&M HART crew were arriving just under a mile away from Hunts Bank, Daniel Smith was saying to Ronald Schanck that it was only congestion that was stopping him calling the C&M HART crew forward.⁴⁵⁰

Consequently, it is unnecessary for me to resolve whether a deliberate decision to hold the C&M HART crew back was justified. A combination of congestion at the scene and communication breakdown within NWAS Control appears to be the explanation for this delay. Both are likely to happen to some degree during a Major Incident response. However, in my view, half an hour to resolve this combination of factors at that stage in the incident is an unacceptably long period of time. I make clear that the delay was not the fault of Ronald Schanck. He took appropriate steps to convey to NWAS Control that he was eager to move forward and support his colleagues.

It is fortunate that Ronald Schanck put his time at Manchester Central Fire Station to constructive use, acting as a Parking Officer there.⁴⁵¹ It is also fortunate that the urgent need for paramedics who were able to operate in the area Daniel Smith had decided to keep non‑specialist paramedics away from had also passed by this time. Nevertheless, it should not have happened that the specialist resource of the C&M HART crew was delayed in arriving at the scene for the time it was. In the closing statement made on its behalf, NWAS accepted this.⁴⁵²

Casualty Clearing Station before midnight

Prioritisation for transfer to the Casualty Clearing Station

The first two casualties treated in the Casualty Clearing Station arrived on the station concourse at 23:07. One was assisted down from the City Room and treated as a P1 casualty in the Casualty Clearing Station. The other was carried from the City Room on a makeshift stretcher and treated as a P2/3 casualty in the Casualty Clearing Station.⁴⁵³ By this point, Saffie‑Rose Roussos had been evacuated from the City Room to Trinity Way.⁴⁵⁴

The immediate issue arising from these facts is that a makeshift stretcher was used at a very early stage of the evacuation to carry down a person who was not a P1 casualty. I have no doubt that this person was in pain and in need of treatment in the Casualty Clearing Station. However, the reality of a mass casualty situation is that the most seriously injured should be identified and prioritised during the first triage process.⁴⁵⁵ At the point at which that P2/3 casualty arrived in the Casualty Clearing Station, there were 16 P1 casualties in the City Room and one on the raised walkway.⁴⁵⁶

From 23:15, Patrick Ennis received support from two members of the GM HART crew, Lea Vaughan and Christopher Hargreaves.⁴⁵⁷ By this point, one P1 casualty had been carried into the Casualty Clearing Station on a makeshift stretcher. Two more P2 casualties had been carried into the Casualty Clearing Station on makeshift stretchers. A number of P1 and P2 casualties had also reached the Casualty Clearing Station without needing to be carried.⁴⁵⁸

By 23:31, there were 25 casualties in the Casualty Clearing Station. Six were P2 casualties who had been carried out on makeshift stretchers. At that time, there were still four P1 casualties who needed to be carried out of the City Room to the Casualty Clearing Station.⁴⁵⁹

I recognise that in circumstances as difficult as this, it is likely to be impossible to achieve a situation where every P1 casualty is given priority over the P2 casualties for transportation to a Casualty Clearing Station. However, the triage system should have worked better than it did.

I have covered the extent of my criticism of Patrick Ennis for this in paragraph 14.182. It is confined to the fact that he did not ensure he had ‘cruciform cards’ with him as he conducted his triage.⁴⁶⁰ It is very difficult to conduct triage of a large number of casualties without triage cards of some sort. I am not critical of the two GM HART operatives for their involvement with triage. They were overstretched and doing their best.

Had more non‑specialists been deployed to the City Room, the triage system is likely to have worked better than it did. If the whole GM HART crew had been deployed to the City Room upon their arrival, this would also have improved the triage in the City Room. If there had been stretchers used in the City Room, it would have been much easier to arrange a proper order of priority for removal.

In my view, Daniel Smith and NWAS as an organisation share responsibility for the triage system in the City Room not working as well as it should have. There should have been more paramedics, including an NWAS commander, deployed to the City Room to help co‑ordinate the prioritisation of casualties with the police, ETUK and members of the public.

Allocation of resources to the incident

NWAS provided data for its fleet of vehicles. At 22:32, there were 319 vehicles in operation across the region covered by NWAS.⁴⁶¹ Of these, six were available for immediate mobilisation to a new incident.⁴⁶² The Ambulance Service Experts described this as “pretty typical”.⁴⁶³

In the period from 22:32 to 22:46, NWAS Control allocated five ambulances to respond to the Attack.⁴⁶⁴ Patrick Ennis had also been allocated. He travelled in an Emergency Rapid Response Vehicle. A second Emergency Rapid Response Vehicle was also allocated. The second Emergency Rapid Response Vehicle was at Blackpool Victoria Hospital at the time of allocation and understandably took nearly an hour to arrive at Hunts Bank.⁴⁶⁵

At 22:46, Patrick Ennis sent a message just before he entered the Victoria Exchange Complex. Based on what he could see, he told NWAS Control that there were “apparently between six and eight casualties, all appear to be walking wounded”.⁴⁶⁶ He requested “at least four emergency ambulances”.⁴⁶⁷

At 22:54, Patrick Ennis sent a METHANE message from the City Room to NWAS Control. In it, he said: “[W]e’ve got at least 40 casualties approximately 10 er appear to be deceased on scene we’ve got at least a dozen priority 1.”⁴⁶⁸

At 22:56, Nicola Pratt, a duty Manager at NWAS Control, informed Annemarie Rooney that Patrick Ennis had reported “only … six casualties, but that the police are saying there are up to 60”.⁴⁶⁹ Nicola Pratt said that there were nine vehicles allocated to the incident. Annemarie Rooney instructed Nicola Pratt to “aim to get a dozen … and then we’ll review”.⁴⁷⁰

At 22:57, the Chief Executive Officer of NWAS, Derek Cartwright, telephoned NWAS Control. He asked: “So we’ve no sign, we don’t have any casualties yet?”⁴⁷¹ In reply, he was told: “[I]t started off with reports of 30, then 40, then 60, so it’s getting on towards mass casualty.”⁴⁷² NWAS Control went on to inform Derek Cartwright that the casualty numbers came from the police.⁴⁷³ This provides a snapshot of NWAS Control’s understanding of the scale of the incident at 22:57. It is not necessarily the case that all casualties would require transportation to hospital by ambulance.

At 23:06, Derek Poland sent a radio transmission from the scene to NWAS Control saying: “[W]e’re going to need at least 20 vehicles for this … if we can … I’ll give you better updates once I know, there’s quite a few P1’s and quite a few fatalities.”⁴⁷⁴ NWAS Control replied that it was understood that “you need 20 vehicles”.⁴⁷⁵ The reply continued that Nicola Pratt would be spoken to about how many vehicles had been allocated by that time. Derek Poland concluded the exchange by asking what the arrival time for HART was estimated to be. He was told that NWAS Control would get back to him.⁴⁷⁶

Derek Poland’s recollection is that he gave the instruction relating to “at least 20 vehicles” on his own initiative rather than by reason of a request or order from Daniel Smith.⁴⁷⁷

The position by the time Derek Poland gave his instruction at 23:06 was that NWAS Control had allocated 14 ambulances to respond to the Attack.⁴⁷⁸

Following Derek Poland’s instruction, NWAS Control continued to allocate resources to the response. By 23:23, a further 13 ambulances had been allocated, bringing the total to 27.⁴⁷⁹

At 23:23, Daniel Smith sent a METHANE message. He said: “Number of casualties so far, we have confirmed at least 15, one five, priority one patients.”⁴⁸⁰ At the time he sent this message, there were 16 casualties in the Casualty Clearing Station.⁴⁸¹ Given Daniel Smith’s later use of the term P1 at 23:34, 15 must have been a reference to the people in the Casualty Clearing Station, not the total number of patients requiring ambulances at the scene.⁴⁸² His figure took no account at all of the other 22 casualties in the City Room or on the raised walkway who were later to be brought down to the Casualty Clearing Station. This was because of Daniel Smith’s lack of situational awareness of the City Room.⁴⁸³

Between 23:23 and 23:34, NWAS Control allocated another four ambulances to the response. This brought the total at 23:34 to 31 allocated ambulances.⁴⁸⁴

At 23:34, Daniel Smith made a radio call to Annemarie Rooney, in which he said:
“So currently estimating and it is an estimate of around forty, 4 0, P1 patients, that’s 40 P1 patients and multiple walking wounded. We are going to have to start moving them as we’ve got some very critical on scene so we will have to start moving some of the patients soon.”⁴⁸⁵

By this time, there were 29 patients in the Casualty Clearing Station.⁴⁸⁶ Daniel Smith was correct to have now recognised that there were seriously injured people who had not yet reached the station concourse.

In a further radio call to Annemarie Rooney between 23:44 and 23:46, Daniel Smith said: “We need to start moving vehicles down from the RVP to the casualty clearing station. I need to know how many vehicles are at the RVP, how many I’ve got available and so we can start making some decisions on movement of patients.”⁴⁸⁷ He went on: “[W]e’ve a difficult scene, we’ve kind of got 3 places where casualties are lining up … we may have less than we first thought but at the moment let’s just stick with the numbers we know about.”⁴⁸⁸

At 23:47, Daniel Smith informed NWAS Control:
“The RVP is where I want crews being sent to, they should not be coming here without us asking them to come down. At the moment, I haven’t the foggiest how many of these here to be honest as they are spread out all around the area. So, from now on, crews to go to an RVP at Thompson Street [Manchester Central Fire Station] and then mobilised into Hunts Bank off Corporation Street … make ambulance 40, at least, we have got multiple casualties down here, we are going to need at least 40 vehicles.”⁴⁸⁹

Ambulances continued to be allocated from 23:34 onwards, albeit at a slower rate. At 23:54, a 39^th ambulance was allocated to the incident.⁴⁹⁰ At this point, there were the same number of ambulances responding to the incident as there were patients requiring transportation by ambulance from either the Casualty Clearing Station or, in Saffie‑Rose Roussos’s case, Trinity Way.

Ambulances were not the only resources that were allocated by NWAS Control in the period prior to midnight. A total of 11 Emergency Rapid Response Vehicles containing non‑specialist paramedics were allocated.⁴⁹¹ Two Urgent Care Vehicles and an Intermediate Care Vehicle were allocated. The GM HART crew and the C&M HART crew were allocated. A number of other individuals, including Daniel Smith and Derek Poland, attended in unmarked vehicles.⁴⁹²

Allocation of available ambulances

I have considered the evidence provided by NWAS in relation to the ambulances that were allocated to respond. I am grateful to NWAS for providing me with this evidence in the form it did. Many of the ambulances were allocated shortly after they are recorded as “clear”. This evidence suggests that in the case of many ambulances allocated to respond to the Attack, NWAS Control staff were mobilising them to respond as quickly as they were registering as available.⁴⁹³

However, that is not universally the case. During the period before midnight, there were a number of ambulances that were allocated over five minutes after they are shown as being clear by this evidence. I readily accepted that there may be a good reason for some or all of these. My investigation did not extend to examining each of these cases.⁴⁹⁴

This is something that NWAS should examine so as to satisfy itself that the system for allocating available ambulances worked as well as it could. The fact that I am recommending this investigation take place should not be understood as implied criticism of NWAS. I did not receive sufficient evidence on this issue to make any finding.

NWAS resources at Victoria Exchange Complex before midnight

The first ambulance arrived on Hunts Bank at 23:00. At 23:06, the six ambulances at Manchester Central Fire Station set off in convoy for Hunts Bank. The first of them arrived at 23:08. By 23:11, there were eight ambulances on Hunts Bank.⁴⁹⁵

In addition to the ambulance crews who arrived on the ambulances, at 23:11 Daniel Smith also had immediately available to him, in the Victoria Exchange Complex: Senior Paramedic Derek Poland; Advanced Paramedic Patrick Ennis; Dr Daley; and three members of the GM HART crew.

As I set out at paragraph 14.190, a ninth ambulance, A344, was on Trinity Way between 23:00 and 23:15 having been flagged down by those assisting Saffie‑Rose Roussos. It acted independently of the arrangements Daniel Smith was putting in place.⁴⁹⁶

During the next 49 minutes, more ambulances and staff arrived. I will address those staff who were given a functional role below at paragraphs 14.430 to 14.443.

By 23:20, there were 14 ambulances at the Victoria Exchange Complex. At 23:30, as the golden hour ended, the total number of ambulances at the scene had risen to 17.⁴⁹⁷ As I have explained in Part 10, the golden hour refers to the first hour of the emergency response.

The first ambulance to depart from Station Approach left at 23:40.⁴⁹⁸ That ambulance transported Georgina Callander to Manchester Royal Infirmary. By that point, there were 22 ambulances at the Victoria Exchange Complex. Thirty‑seven people remained in the Casualty Clearing Station requiring transfer to hospital. At midnight, a second ambulance left, transporting John Atkinson to Manchester Royal Infirmary.⁴⁹⁹

At midnight, there were 36 patients in the Casualty Clearing Station. There were 20 ambulances at the Victoria Exchange Complex.⁵⁰⁰

Adequacy of number of ambulances

A key question for Daniel Smith was how many people required transportation to hospital. This was something that could have been accurately estimated before 23:20. An NWAS commander located in the City Room could have provided that figure to him. If Daniel Smith had deployed Derek Poland forward to the City Room when Derek Poland offered to go, it may have been possible for this figure to have been provided by 23:10. If Daniel Smith had deployed Simon Beswick forward to the City Room with Lea Vaughan and Christopher Hargreaves, it would have been possible for this figure to have been provided around 23:20, before Daniel Smith’s METHANE message at 23:23.

I have seen no evidence of an accurate number being identified by anyone at the scene before 23:34. It should have been. Identifying the number of casualties requiring transportation to hospital at the earliest possible stage is essential due to the delay that may be caused by how far an available ambulance has to travel.

It is not simply a case of one ambulance for one casualty. The evidence of the Ambulance Loading Officer, Matthew Calderbank, was instructive on this point. During his evidence, he was asked why he thought it took as long as it did to transfer all casualties to hospital. He stated:
“To move all of those people … with a degree of haste, more so than we did, would have required that 19 ambulances at least to provide clinical care and then subsequent ambulances were moving patients.”⁵⁰¹

Matthew Calderbank’s reference to 19 ambulances was based on the assumption that there were two crew in each ambulance, each of which could then be allocated to one of the 38 casualties in the Casualty Clearing Station.⁵⁰² The position on the night of 22^nd May 2017 was more complex than this, as there were other NWAS personnel who attended who did not arrive by ambulance.

The substance of the point Matthew Calderbank was making was that a number of the NWAS personnel arriving in ambulances would not be immediately available to transport patients as their crews would be assisting patients.⁵⁰³ This only serves to emphasise the need for a greater number of ambulances than there were casualties in the Casualty Clearing Station, and for those ambulances to be allocated as soon as possible. This can only be achieved once it is known how many patients there are who need transportation by ambulance. This number was not identified at the scene and communicated to NWAS Control until 23:34.⁵⁰⁴

James Birchenough was allocated the role of Casualty Clearing Officer. He was asked in evidence about the time it took to transport casualties to hospital. He explained:
“A combination of resources, of treatment for those patients. I’m not sure at the time that the detail about the casualty plan came through we – I don’t know how much resource we had on scene, whether we had enough people initially for every patient, so initially they were involved in treatment rather than transportation. Some of the treatments that patients got were quite extensive to make them stable enough to be transported.”⁵⁰⁵

His reference to the “casualty plan” was to 23:39, when Annemarie Rooney provided the numbers for each hospital’s capacity.⁵⁰⁶ At 23:40, there were 22 ambulances at the scene. There were 43 paramedics and Emergency Medical Technicians not in functional or command roles. There were four members of the GM HART crew on Station Approach, one of whom was a Team Leader. There were also a number of student paramedics who had been directed to help P3 casualties. Additionally, there were at least five doctors.⁵⁰⁷

I accept the thrust of what James Birchenough was saying: there needs to be a minimum number of NWAS personnel in a mass casualty situation before transportation to hospital can occur.⁵⁰⁸ I also accept that some patients will need to be stabilised before they are transported. This may require more than one member of NWAS staff.

All of this makes it all the more important to establish at the earliest possible stage how many seriously injured casualties there are.

Even allowing for the fact that an ambulance may transport more than one patient to hospital over the course of the response, it ought not have taken until 23:54 for the same number of ambulances that were required to transport those who needed them to be allocated to the incident. As Matthew Calderbank and James Birchenough explained, more ambulances than there were patients were required for transportation to occur quickly.⁵⁰⁹ However, the limits of my investigation mean that I cannot say whether or not there were ambulances available to be allocated faster than they were.

Requiring more ambulances at the scene than there are casualties needing transportation is an approach which I consider should be reviewed. I recommend that NARU take the lead in investigating this. I consider this issue further when I deal with the Care Gap in Part 20 in Volume 2‑II.

What I can say is that earlier identification of the number of patients requiring ambulances and/or the number of ambulances required should have occurred. That is because it will inevitably take time for an ambulance that has been allocated to reach the scene. Given the number of ambulances that were required, there was substantial travelling time for some. Responsibility for ensuring that the extent of required resources was identified as early as possible lay with Daniel Smith, as Operational Commander.

Location of Casualty Clearing Station

Derek Poland recalled having a conversation with Daniel Smith after Patrick Ennis had returned to the City Room at 23:02.⁵¹⁰ In that conversation, Derek Poland and Daniel Smith discussed casualties being “placed within the concourse of the train station” and being treated there. Also discussed was the fact that no one was to go up the staircase.⁵¹¹

At 23:05, Daniel Smith approached GMP PC David Shott. Daniel Smith pointed to the area of the War Memorial entrance and said: “Casualty clearing is there.”⁵¹² Daniel Smith stated in evidence that he was indicating the area just inside the entrance. He explained:
“[W]hen we do major incident exercises we tend to keep priority 1s on one side of the tent, or whatever we are using, and priority 2s on the other. In my mind, I thought we’d do that at the war memorial entrance and we’d have two nice, neat rows. Clearly it doesn’t work like that in reality, something I learned on the night and obviously that war memorial entrance wasn’t going to be big enough to house the patients we had.”⁵¹³

Daniel Smith’s choice of area reveals his lack of appreciation of the number of P1 and P2 casualties there were. This lack of appreciation was a product of the limited situational awareness he had at this time. A clearer understanding on his part of the scale of the incident would likely have caused him to start the Casualty Clearing Station on the station concourse.

As the number of casualties managed in the Casualty Clearing Station increased, the Casualty Clearing Station area grew, almost to the bottom of the staircase, and out onto Station Approach.⁵¹⁴

Figure 38 depicts the area of the Casualty Clearing Station. The approximate location of each casualty’s arrival, and the timing of their arrival, is marked.
Figure 38: Drawing of the Casualty Clearing Station showing casualties’ locations and arrival times⁵¹⁵

Derek Poland’s evidence was that he recalled it being Daniel Smith’s intention to have a Casualty Collection Point at the bottom of the staircase, with the Casualty Clearing Station further towards the War Memorial entrance.⁵¹⁶ He stated that, ultimately, there was never a Casualty Collection Point at the bottom of the staircase, as this area became part of the Casualty Clearing Station.⁵¹⁷

Functional roles in Casualty Clearing Station

In a radio message at 23:31, Daniel Smith informed Stephen Taylor: “[W]e are just trying to establish functional roles, about to get patients moving. I’ve asked for a tactical decision on hospital destinations because we’ve got multiple casualties obviously with penetrating trauma so we are going to have to activate the Greater Manchester Mass Casualty situation.”⁵¹⁸ Daniel Smith began the process of allocating functional roles before this message.⁵¹⁹

Senior Paramedic Joanne Hedges arrived at the Victoria Exchange Complex as part of the convoy of ambulances that set off from Manchester Central Fire Station at 23:06.⁵²⁰ She arrived on Hunts Bank at 23:10. She was given an initial briefing by Daniel Smith.⁵²¹

In evidence, Joanne Hedges recalled being told that treatment and triage would take place at the bottom of the stairs. She was told not to go up the stairs.⁵²² She was not formally allocated a role. She viewed herself as Secondary Triage Officer. She considered the HART operatives to be acting as Primary Triage Officers.⁵²³

She stated that, when she “went forward”, the area at the bottom of the stairs where she worked was a Casualty Collection Point.⁵²⁴ She also stated that once patients started being laid on the station concourse, the area she was working in became the Casualty Clearing Station.⁵²⁵

Also undertaking triage was paramedic Helen Mottram. Helen Mottram was part of the group who came from Manchester Central Fire Station. She arrived on Hunts Bank at 23:09.⁵²⁶

On arrival, Helen Mottram recalled being spoken to by Derek Poland. In evidence, she stated he said something along the lines of: “I don’t know if it’s safe inside.”⁵²⁷ She stated that he asked for volunteers and that she put her hand “straight up”.⁵²⁸

Helen Mottram was told that she was to undertake the role of “Triage Officer”.⁵²⁹ In this role she was expected to conduct an initial triage of the casualties. She entered the Victoria Exchange Complex by the War Memorial entrance at 23:17.⁵³⁰ She regarded herself as working in the Casualty Clearing Station, but the layout of the arrangements was not explained to her.⁵³¹

James Birchenough was contacted by NWAS Control at 22:50. At the time, he was at a hospital managing a queue of ambulances.⁵³² He was told by NWAS Control that there were reports of shootings at the Arena. He was not asked to mobilise to the Arena.⁵³³

Following his contact with NWAS Control, James Birchenough spoke to a police officer who was nearby. He was told there had been an explosion. Immediately, he informed staff at the hospital that they needed to clear the queue of ambulances in the next five minutes.⁵³⁴ At 22:58, he contacted NWAS Control. He was asked to respond to the Attack. He was told to go to Hunts Bank.⁵³⁵ He arrived on Hunts Bank in an Emergency Rapid Response Vehicle at 23:11.⁵³⁶

James Birchenough spoke to Daniel Smith on arrival. Daniel Smith asked James Birchenough to undertake the role of Casualty Clearing Officer.⁵³⁷ James Birchenough understood from the conversation that the Casualty Clearing Station was on the station concourse and that he was not to go up the staircase to the raised walkway.⁵³⁸

The role of Casualty Clearing Officer gave James Birchenough primary responsibility for the management of all activities within the Casualty Clearing Station, including: triage and treatment; liaison with the Casualty Clearing Station medical lead; and liaison with the Ambulance Loading Officer to ensure casualties were dispatched to hospital appropriate to their priority.⁵³⁹

The Ambulance Loading Officer on the night of the Attack was Matthew Calderbank.⁵⁴⁰ Matthew Calderbank was one of the two on‑call Operational Commanders contacted by NWAS Control on the night of 22^nd May 2017. He was notified of the Attack at 22:42.⁵⁴¹ He arrived on Hunts Bank at 23:28.⁵⁴²

Matthew Calderbank met with Derek Poland and Daniel Smith on Station Approach. Daniel Smith briefed Matthew Calderbank and allocated him the role of Ambulance Loading Officer.⁵⁴³ An Ambulance Loading Officer’s duties included: liaising with the Casualty Clearing Officer; and taking responsibility for ensuring the appropriate and effective loading of casualties from the Casualty Clearing Station onto the next available, appropriate vehicle.⁵⁴⁴ The loading point was chosen to be Station Approach, opposite the War Memorial entrance.⁵⁴⁵

As I have said, the role of Parking Officer was allocated to Derek Poland.⁵⁴⁶ This role included requiring him: to establish an appropriate safe location to park further resources likely to arrive at the incident; to liaise with police officers to ensure that the parking location was secure and that access and egress were maintained; to manage the arrival and safe parking of incoming vehicles; and to brief ambulance crews on any specific routes to and from the Casualty Clearing Station.⁵⁴⁷

Treatment of Georgina Callander in Casualty Clearing Station

Georgina Callander arrived in the Casualty Clearing Station at 23:28.⁵⁴⁸ She had been carried out of the City Room two minutes earlier. During her time in the Casualty Clearing Station, Georgina Callander was assessed and treated by Paramedic Adam Williams, Emergency Medical Technician Lucy Favill and an off‑duty doctor, Dr Jesse Compton.⁵⁴⁹

Georgina Callander was placed into the back of Ambulance A347 at 23:39.⁵⁵⁰ She was driven to Manchester Royal Infirmary by Emergency Medical Technician Sian Edmunds.⁵⁵¹ A347 left Station Approach at 23:40. Accompanying her in A347 were Paramedic John Buchanan, Adam Williams and Georgina Callander’s mother, Lesley Callander.⁵⁵² Georgina Callander was the first casualty to be taken by ambulance from the Casualty Clearing Station.⁵⁵³

Treatment of John Atkinson in Casualty Clearing Station

John Atkinson was carried into the Casualty Clearing Station on a makeshift stretcher at 23:24.⁵⁵⁴ He had been removed from the City Room at 23:17.⁵⁵⁵ He had spent a period of time on the raised walkway due to the inadequacy of the means by which he was being carried. He was conscious and in terrible pain throughout this period.⁵⁵⁶

He was first assessed by a paramedic when he arrived at the Casualty Clearing Station.⁵⁵⁷ A total of 53 minutes had elapsed since the explosion. That delay was unacceptable and should have been avoided by NWAS. He should have been triaged before then.

At 23:29, a P1 casualty label was attached to John Atkinson.⁵⁵⁸ During his time in the Casualty Clearing Station, John Atkinson was assessed and treated by Senior Paramedic Philip Keogh, Senior Paramedic Michael Ruffles, Emergency Medical Technician Laura Worrall and Dr Daley.⁵⁵⁹

At 23:47, John Atkinson went into cardiac arrest. At 23:50, John Atkinson was placed into Ambulance A368. John Atkinson was the second casualty to be taken by ambulance from the Casualty Clearing Station.⁵⁶⁰ At 00:00, A368 set off for Manchester Royal Infirmary. John Atkinson arrived at Manchester Royal Infirmary at 00:06.⁵⁶¹

Tactical command

Annemarie Rooney was the on‑call Tactical Commander for the Greater Manchester region.⁵⁶² She qualified as an on‑call Tactical Commander in June 2014.⁵⁶³

Annemarie Rooney was not able to give oral evidence.⁵⁶⁴ She was able to provide a second witness statement in which she answered a series of detailed questions from the Inquiry Legal Team.⁵⁶⁵ I have had firmly in mind that I did not hear from Annemarie Rooney from the witness box, but I have had no alternative other than to resolve any relevant factual dispute on the basis of the evidence before me. While I have taken fully into account her statements, there is always a risk that evidence given in person will have more impact. I have borne this in mind and done my best to make allowance for it.

Annemarie Rooney was notified of the Attack by NWAS Control at 22:38.⁵⁶⁶ I have already observed that it was during this call that the deployment of HART was raised by Annemarie Rooney. While she was right to do so, Annemarie Rooney should have made clear that it was not just the GM HART crew that needed to be mobilised, but also the C&M HART crew. As Tactical Commander, she had responsibility for ensuring that adequate resources were put in place to support NWAS’s response to the incident.⁵⁶⁷

Decision to go to GMP HQ

At 22:41, Annemarie Rooney spoke to Daniel Smith. During this call, Annemarie Rooney informed him that she would be travelling to GMP HQ. This was in accordance with NWAS’s plan for the Tactical Commander.⁵⁶⁸

Following her contact with Daniel Smith, Annemarie Rooney had three more important conversations before she arrived at GMP HQ. First, she spoke to Neil Barnes, NWAS Strategic Commander.⁵⁶⁹ Second, she spoke to Stephen Taylor, one of the on‑call Tactical Advisors/NILOs.⁵⁷⁰ Stephen Taylor informed her that Jonathan Butler, another on‑call Tactical Advisor/NILO, was travelling from his home to the scene. Annemarie Rooney confirmed that Stephen Taylor should remain at home.⁵⁷¹ Third, at 22:56, she had a further call with NWAS Control in which she said: “I’m going to go towards Central Park as that’s where the TCG [Tactical Co-ordinating Group] is set up.”⁵⁷²

I can see a benefit to there being a Tactical Commander at the scene in response to an incident as complex and large as occurred on 22^nd May 2017. That commander would be able to perform the JESIP role of co‑locating with commanders from other emergency services, allowing the Operational Commander to continue to direct NWAS personnel.

I recognise that there is also a benefit in having a Tactical Commander away from the scene co‑located with other Tactical Commanders, particularly in the event of a multi‑sited incident.

I recommend that DHSC and NARU review and issue guidance on the most appropriate location(s) for ambulance Tactical Commanders in a Major Incident. This review should consider the actions of Stephen Hynes on the night of the Attack, as he carried out Tactical Commander functions as well as Operational Commander functions from the scene. DHSC and NARU should also liaise with other emergency services to ensure that the guidance is consistent.

National Capability Mass Casualty Equipment Vehicle

During the call with NWAS Control at 22:56, Annemarie Rooney was informed: “[T]he police are saying there are up to 60 [casualties], but hopefully most are walking wounded.”⁵⁷³

The Greater Manchester Resilience Forum Mass Casualty Plan defined a mass casualty incident as: “A disastrous or simultaneous event(s) or other circumstances where the normal major incident response of Category 1 organisations must be augmented by extraordinary measures in order to maintain an effective, suitable and sustainable response.”⁵⁷⁴ The plan anticipated that once a mass casualty incident was confirmed, the National Capability Mass Casualty Equipment Vehicle would be deployed.⁵⁷⁵

The National Capability Mass Casualty Equipment Vehicle was not deployed to the Victoria Exchange Complex on 22^nd May 2017.⁵⁷⁶ In her second witness statement, Annemarie Rooney stated that deployment of the National Capability Mass Casualty Equipment Vehicle was within the action cards for NWAS Control. She stated deployment of that vehicle “did not cross my mind”.⁵⁷⁷ She stated that at no stage did anyone tell her that there was a shortage of equipment at the scene.⁵⁷⁸

The National Capability Mass Casualty Equipment Vehicle would not have assisted with the use of stretchers during the response. Not only is this because it is unlikely to have arrived during the critical period, but National Capability Mass Casualty Equipment Vehicles did not carry stretchers.⁵⁷⁹ The Ambulance Service Experts invited me to consider recommending the inclusion of stretchers on National Capability Mass Casualty Equipment Vehicles.⁵⁸⁰ In my view, this is a sensible idea. I recommend that DHSC and NARU review whether National Capability Mass Casualty Equipment Vehicles should carry stretchers.

The Ambulance Service Experts pointed out that the absence of the National Capability Mass Casualty Equipment Vehicle was mitigated in part by how well equipped NWAS was in terms of additional support vehicles. However, they stated that the National Capability Mass Casualty Equipment Vehicle held equipment which may have assisted the casualties in the Casualty Clearing Station.⁵⁸¹ I agree. The National Capability Mass Casualty Equipment Vehicle was intended for use at situations of the scale of the Attack. Its presence would have ensured that there was no risk of equipment shortage in the Casualty Clearing Station.

Annemarie Rooney should have directed that the National Capability Mass Casualty Equipment Vehicle was deployed when she was told at 22:56 how many casualties the police were saying had resulted from the detonation of the bomb. It was her responsibility to ensure that there were adequate resources at the scene. There was a contractual agreement that the National Capability Mass Casualty Equipment Vehicle would be on scene within 60 minutes of mobilisation.⁵⁸² Given the potential time it would take to get the vehicle to the scene, it needed to be deployed early. It is not appropriate to wait for an equipment shortage to become apparent before mobilising it.⁵⁸³

It was accepted on NWAS’s behalf that insufficient consideration was given to the deployment of the National Capability Mass Casualty Equipment Vehicle.⁵⁸⁴ I agree. While Annemarie Rooney as Tactical Commander bears particular responsibility for the failure to deploy the vehicle, I consider that NWAS bears overall responsibility for this failure. The time of 22:56 is the point at which Annemarie Rooney should have identified the need for the National Capability Mass Casualty Equipment Vehicle. Others within NWAS Control had the relevant information earlier than this. However, none of those involved in the response from NWAS thought to suggest that this vehicle was mobilised. This demonstrates a failure to embed the use of this vehicle at an organisational level.⁵⁸⁵

Briefing from GMP

Annemarie Rooney arrived at GMP HQ at 23:12. She made her way to the Silver Control Room. When she arrived, Temporary Superintendent Arif Nawaz and Assistant Chief Constable (ACC) Deborah Ford were both present. Annemarie Rooney was briefed by Temporary Superintendent Nawaz, the GMP Tactical/ Silver Commander. He informed her that a suicide bomber was responsible for the Attack. He told her that there were 20 fatalities at that time, including the bomber. Annemarie Rooney asked Temporary Superintendent Nawaz and ACC Ford whether there was “a shooter” present. Annemarie Rooney was told that it was not a shooting incident.⁵⁸⁶

Annemarie Rooney did not pass this important information on to Daniel Smith.⁵⁸⁷ In the early stages of the incident, there were concerns circulating that there may be an active shooter.⁵⁸⁸ Annemarie Rooney established that GMP’s assessment was that this was not the case.⁵⁸⁹ She should have relayed this to Daniel Smith, as it was capable of informing his risk assessment at the scene.

Fortunately, and without reference to Annemarie Rooney, Daniel Smith had reached his own view at an early stage of being at the scene that it was unlikely to be a firearms attack.⁵⁹⁰ However, that does not mean Annemarie Rooney should not have passed this information on. There was no evidence that Annemarie Rooney knew at the time she was given this information that Daniel Smith held the view he did.⁵⁹¹ Sharing information of this importance was central to establishing good communication.

Annemarie Rooney did not pass on the information she received from Temporary Superintendent Nawaz to NWAS Control.⁵⁹² By this stage, Annemarie Rooney had discussed Operation Plato with NWAS Control. It had been agreed that the Major Incident action card would be followed.⁵⁹³ However, it would have been a simple matter to inform NWAS Control that the GMP Tactical/Silver Commander had confirmed that this was not a shooting incident. As she has accepted in her second witness statement, Annemarie Rooney should have done this.⁵⁹⁴ In doing so, she would have ensured that NWAS Control did not repeat the earlier concerns that it might be a shooting incident.

During her briefing from Temporary Superintendent Nawaz, Annemarie Rooney was not told that GMP had declared Operation Plato approximately 30 minutes earlier.⁵⁹⁵ Annemarie Rooney was not told that GMP had declared Operation Plato until 00:18. She learned of the declaration from Temporary Superintendent Christopher Hill.⁵⁹⁶

I have no doubt that Temporary Superintendent Nawaz’s failure to inform Annemarie Rooney of the Operation Plato declaration was as a result of his own lack of understanding of what that declaration meant, for which both he and GMP bear responsibility.⁵⁹⁷ Regardless of his own ignorance, he should have informed Annemarie Rooney of the Operation Plato declaration when he briefed her shortly after 23:15.

What is striking about the discussion between Temporary Superintendent Nawaz and Annemarie Rooney is the fact that it did not reveal the difference in approach which was being taken by GMP and NWAS towards the issue of the risk in the City Room.⁵⁹⁸ JESIP expects that risk will be jointly assessed.⁵⁹⁹ While commanders at a scene will be best placed to carry out this risk assessment, understanding the extent of any unsafe areas, and the number of casualties who might be in them, is important for a Tactical Commander.

GMP had assessed at 22:50 that the City Room was “safe enough” for all of its personnel to operate in.⁶⁰⁰ That assessment extended to BTP officers, members of the public and a non‑specialist paramedic, Patrick Ennis.⁶⁰¹ By contrast, shortly after 23:00, NWAS assessed that only the specialist members of HART could be deployed to the City Room.⁶⁰² Adequate communication between Tactical/Silver Commanders at around 23:15 should have identified this divergence in approach.

The discussion between Annemarie Rooney and Temporary Superintendent Nawaz did not include any mention of an FCP.⁶⁰³ An FCP is key to ensuring the co‑location of commanders at the scene.⁶⁰⁴ Both Tactical Commanders finished their conversation without any realisation that their respective Operational Commanders had not spoken by this point and had each located themselves in different parts of the Victoria Exchange Complex.⁶⁰⁵

At a fundamental level, the discussion between Temporary Superintendent Nawaz and Annemarie Rooney was not focused where it should have been. The focus should have been on co‑ordinating the efforts of the emergency services.⁶⁰⁶ It was not sufficient for Temporary Superintendent Nawaz to provide Annemarie Rooney with the latest information he had. They should have been working out how the emergency services could best assist each other to work together to save lives. Both Temporary Superintendent Nawaz and Annemarie Rooney bear responsibility for the inadequacies in their discussion at around 23:15.

Communication with GMFRS and BTP during critical period of response

Annemarie Rooney did not seek to make contact with her counterparts at GMFRS or BTP during the critical period of the response.⁶⁰⁷ In her second witness statement, Annemarie Rooney stated: “I co-located at GMP and would have expected all the other key partners to be there.”⁶⁰⁸ Her explanation for not communicating with GMFRS or BTP once she arrived at GMP HQ was: “The communication lines with GMFRS and BTP did not take place as they were not present at that time.”⁶⁰⁹

This is not an adequate explanation for the failure to contact her counterparts at GMFRS and BTP during the critical period of the response. Communication at the Tactical/Silver Commander level is important. It is expected by JESIP. Annemarie Rooney should have tasked NWAS Control or a Tactical Advisor/NILO with finding out the relevant contact details once she realised that they were not at GMP HQ. Alternatively, she should have discussed with GMP the absence of Tactical/Silver Commanders from other services, and decided what action should have been taken.

Tactical plan

The entry in Annemarie Rooney’s decision log timed at 00:54 records: “John Butler assisted Annemarie Rooney with the NWAS tactical plan.”⁶¹⁰ “John Butler” was a reference to Tactical Advisor/NILO Jonathan Butler, who had travelled to GMP HQ.⁶¹¹ I will return to his role on the night at paragraph 14.523.

In her second witness statement, regarding this entry, Annemarie Rooney stated:
“The general tactics were in place as soon as my response to the incident started. They are made up of CSCATTT, which is the prompt used as to how to form tactics and is something at the forefront of my mind when setting them. The details logged at 00:54 was referring to the pre-written template. The principles … of which are the same, it’s just the format is different.”⁶¹²

“CSCATTT” stands for Command and Control; Safety; Communications; Assessment; Triage; Treatment; Transport.⁶¹³

The “pre-written template” was a document dated January 2016, provided by Jonathan Butler to Annemarie Rooney for approval. It contained a generic tactical plan.⁶¹⁴ It included, for example, the need to appoint a Safety Officer.

NWAS’s Major Incident Response Plan stated: “The Tactical Commander … works at the Tactical Level and has responsibility for developing the Tactical Plan … The Tactical Plan provides a framework for the Operational Commander to operate within.”⁶¹⁵

Annemarie Rooney’s communications with Daniel Smith do not reveal any occasion when she set out what her tactical plan was.⁶¹⁶ Annemarie Rooney should have identified the headline points in her tactical plan and communicated them to Daniel Smith as part of her first conversation with him as Operational Commander. Had she done so, it might have highlighted the problems with moving the seriously injured from the City Room. As I shall set out, the action card for Annemarie Rooney’s role was capable of providing her with considerable support in this.

Action card

Annemarie Rooney’s first contact with Daniel Smith in his role as Operational Commander was after she spoke to Temporary Superintendent Nawaz. Annemarie Rooney had an important role to play once Daniel Smith had gained some situational awareness. It was her role to provide Daniel Smith with a tactical plan and to ensure that Daniel Smith did not overlook important actions.⁶¹⁷

In my view, it would have been better if Annemarie Rooney had spoken to Daniel Smith before she received her briefing from Temporary Superintendent Nawaz. In that way, she would have had greater situational awareness, which she could have provided to GMP during that discussion. It would have better placed her to participate in that conversation. It would also have meant that Annemarie Rooney gave direction at a tactical level to Daniel Smith in the early stages of him establishing structures at the scene.

The action card for Annemarie Rooney’s role would have assisted her in this.⁶¹⁸ It contains a number of prompts, which she should have used in an early conversation with Daniel Smith. I will consider the most significant action prompts that Annemarie Rooney overlooked during the critical period of the response.

First, action prompt 3 expected Annemarie Rooney to “[o]btain a full briefing from the Operational Commander”.⁶¹⁹ I do not consider that Annemarie Rooney did obtain such a briefing. At no point did Daniel Smith set out for Annemarie Rooney his plan for organisation of the scene by reference to its layout.⁶²⁰ There was no discussion about major decisions that Daniel Smith was making:⁶²¹ for example, his decision that non‑specialist paramedics were not being deployed to the City Room, in circumstances where police officers were. It was Annemarie Rooney’s responsibility to obtain a full briefing from Daniel Smith as to the steps he was taking and for her to advise him on suitable tactics.

Second, action prompt 10 expected Annemarie Rooney to “[e]nsure that all Operational Command support roles have been allocated, and designate other roles”.⁶²² Action prompt 11 expected Annemarie Rooney to “[m]onitor and ensure a safe working environment, so far as reasonably practicable in conjunction with the Operational Commander and Safety Officer”.⁶²³ Action prompt 22 expected Annemarie Rooney to “[l]iaise with Operational Commander to ensure functional roles are being undertaken”. ⁶²⁴ As I set out at paragraph 14.233, Daniel Smith did not appoint a Safety Officer or an Equipment Officer.⁶²⁵ It was Annemarie Rooney’s responsibility to ensure that all functional roles, including a Safety Officer and an Equipment Officer, were appointed.

Third, action prompt 13 expected Annemarie Rooney to “[c]onsider the sectorisation of the incident, if required and ensure they match Police / Fire sectors. Allocate Sector Commanders via the Operational Commander.”⁶²⁶ In her second statement, Annemarie Rooney stated that she did not discuss with Daniel Smith the option of deploying the HART Team Leader as a Sector Commander in the City Room. She stated that she would have expected this to be “a consideration on his part in fulfilling his role [as Operational Commander]”.⁶²⁷

This is not the approach expected by the action card.⁶²⁸ In my view, this is something that Annemarie Rooney should have discussed with Daniel Smith. Had she done so, he would have had to explain his rationale for holding back the HART Team Leader and a number of HART operatives in the Casualty Clearing Station. This may have led to a different decision being taken.

A conversation of this nature would have required Annemarie Rooney to have an understanding of the scene layout, which is why a full briefing was required as set out at paragraph 14.484.

Fourth, action prompt 16 expected Annemarie Rooney to “[c]onsider the need for other specialist assets eg BASICs [British Association for Immediate Care], SORT, Mass Casualty Vehicle, HART, MERIT [Medical Emergency Response Incident Team], Air Assets”. ⁶²⁹ As I set out at paragraph 14.462, this should have acted as a prompt to Annemarie Rooney to deploy the National Capability Mass Casualty Equipment Vehicle.

Fifth, action prompt 21 expected Annemarie Rooney to “[l]iaise with the Tactical Advisor to ensure that the Major Incident Plan is being followed”.⁶³⁰ Annemarie Rooney spoke to Stephen Taylor, the Tactical Advisor/NILO, once during the critical period of the response. They did not discuss the Major Incident Response Plan.⁶³¹ As I shall set out in paragraphs 14.559 to 14.565, Stephen Taylor provided information in that call and no advice was sought or given.

‘GM Framework for Patient Dispersal in a Mass Casualty Event’

On 29^th March 2017, NWAS tested a draft plan titled ‘GM Framework for Patient Dispersal in a Mass Casualty Event’ (the draft NWAS GM Patient Dispersal Plan).⁶³² This plan included a casualty capability chart in relation to hospitals in and around the Greater Manchester area.⁶³³ This chart provided numbers of casualties over and under 12 years old that each of the local hospitals were able to manage during the first two hours of a mass casualty event.

A copy of the draft NWAS GM Patient Dispersal Plan was circulated by email on 2^nd April 2017. The recipients included Annemarie Rooney and Daniel Smith. The text of the email stated:
“I have attached the draft Mass casualty distribution plan for GM area. Please note this is still in draft, but following 2 successful workshops and exercise Socrates last week … I am sharing this for your information. The final sign off will come from LHRP [the Local Health Resilience Partnership] in the near future but should an incident happen before that this should help inform your decisions at the tactical level.”⁶³⁴

This email was to prove prescient. The draft NWAS GM Patient Dispersal Plan had not been signed off by 22^nd May 2017, but it was used that night to inform command decisions.⁶³⁵

At 23:32, Annemarie Rooney contacted NWAS Control. In that call, she said: “I need to know … about hospitals, … we are going to be activating the Greater Manchester Mass Casualty Plan.”⁶³⁶ She asked whether all the Greater Manchester hospitals were aware of the incident. She went on to observe that the hospitals had “at least a good half an hour’s notice that we are at major incident declared”.⁶³⁷ The call concluded with NWAS Control informing Annemarie Rooney that a check would be made that the hospitals were aware.⁶³⁸

At 23:34, Annemarie Rooney spoke to Daniel Smith. In the course of the conversation, the following exchange took place:
“[Daniel Smith] We are going to have to start moving them as we’ve got some very critical on scene, so we will have to start moving some of the patients soon. So can you confirm that the major incident plan in terms of mass casualties is up and ready. If you can read that out over the air so the cas [casualty] clearing officer can hear he can start then allocating … casualties to hospitals.
[Annemarie Rooney] Sorry, yeah apologies, what is it you want me to read out?
[Daniel Smith] Sorry, just the mass casualty numbers, you know the mass casualty plan for Greater Manchester, just the numbers for each hospital.|
[Annemarie Rooney] I shall come back to you with the … mass casualty numbers shortly.”⁶³⁹
[Annemarie Rooney][three minutes later] I’ve got details for you on the GM casualty capability chart in the mass casualty event.”⁶⁴⁰

At 23:39, Annemarie Rooney read out to Daniel Smith the information contained in the draft NWAS GM Patient Dispersal Plan.⁶⁴¹

Based on the above exchange, it appears that at 23:32 Annemarie Rooney spoke to NWAS Control about activating the Greater Manchester Resilience Forum Mass Casualty Plan.⁶⁴² Two minutes later, Daniel Smith raised with her the need for the chart contained within the draft NWAS GM Patient Dispersal Plan.⁶⁴³

The casualty capability chart in the draft NWAS GM Patient Dispersal Plan was exactly what Daniel Smith needed. It was a simple, practical document, which set out the capacity of the local hospitals. It allowed informed decisions to be made as to where casualties should be transported by ambulances at the scene. It did not matter that this document was, strictly speaking, still in draft. It had been tested and simply awaited being formally adopted.⁶⁴⁴

In her second witness statement, Annemarie Rooney stated: “[T]he timing of the activation of the plan [draft GM Patient Dispersal Plan] itself did not delay processes in terms of patient transportation to hospital in my opinion.”⁶⁴⁵ She pointed out that hospitals were expecting to receive patients following the Major Incident declaration. She stated that in a large mass casualty incident, it is not expected that patients will be transported immediately to hospital.⁶⁴⁶

The Ambulance Service Experts considered the issue of the timing of the use of the draft GM Patient Dispersal Plan. They stated: “In terms of timings, we are of the opinion that it may have been possible to put the transfer and dispatch arrangements in place quicker but this appears to us to be marginal and is unlikely to have made any significant difference to clinical outcomes.”⁶⁴⁷

In my view, first accessing the draft GM Patient Dispersal Plan 68 minutes after the explosion was later than should be expected. Annemarie Rooney should have had this essential information more readily to hand. Although the plan was in draft, Annemarie Rooney was sent a copy and instructed to use it in a mass casualty situation. The need for it should have been among her first thoughts when realising the scale of the incident.

However, there is no evidence that the transportation of any casualty in the Casualty Clearing Station was delayed because of a lack of certainty as to which hospital they should be taken to.⁶⁴⁸ Further, Daniel Smith requested the information in the casualty capability chart five minutes before being provided with it by Annemarie Rooney.⁶⁴⁹

Overall, I agree with the Ambulance Service Experts on this issue. I am satisfied that any delay that there may have been in relation to the transportation of casualties to hospitals from the Casualty Clearing Station was not caused by the timing of communication of the draft GM Patient Dispersal Plan.⁶⁵⁰ It is clear that the Major Incident notification had been communicated to all relevant hospitals at least half an hour before Annemarie Rooney provided the numbers in the casualty capability chart to Daniel Smith.⁶⁵¹

Multi-agency control room communication

At 23:52, Annemarie Rooney spoke to Temporary Superintendent Nawaz. She asked for a multi‑agency control room talk group to be set up.⁶⁵² Shortly after this, a message was sent by GMP from the Silver Control Room using the proposed multi‑agency control room talk group which I examined in Part 12.⁶⁵³ NWFC responded to this broadcast. NWAS did not.⁶⁵⁴ This was because it was not until 00:05 that Annemarie Rooney was provided with the short dial code for this channel. Once she had it, she passed it on to NWAS Control at 00:08.⁶⁵⁵ This talk group was not used again that night by any of the emergency services’ control rooms.⁶⁵⁶

This is just one of a number of examples of time being spent during the emergency response on 22^nd May 2017 seeking to establish a multi‑agency control room talk group. On the night, this issue wasted precious time and diverted attention during a period when that time and attention could have been better spent on other things.

I am not critical of Annemarie Rooney for raising the need for a multi‑ agency control room talk group over an hour and 15 minutes after the Attack. However, the reality is that by this point in the response it was too late to make any difference.⁶⁵⁷ A multi‑agency control room talk group should have been an embedded part of all control rooms’ practice before 22^nd May 2017.⁶⁵⁸ Responsibility for failing to ensure this lies with GMP, NWAS and GMFRS.

Role after midnight

Shortly before midnight, Stephen Hynes relieved Daniel Smith of his role as Operational Commander.⁶⁵⁹ At 00:02, Annemarie Rooney contacted Derek Poland to ask for confirmation of whether Stephen Hynes was now Operational Commander.⁶⁶⁰ This is an inversion of what should have happened. As Tactical Commander, it was Annemarie Rooney’s responsibility to decide whether or not the Operational Commander remained in role.⁶⁶¹

In fact, Stephen Hynes had asked if Daniel Smith minded being relieved of operational command. Daniel Smith had said he did not. At that point, operational command was transferred at the scene.⁶⁶²

Six minutes after Annemarie Rooney had asked Derek Poland if Stephen Hynes had taken over the role of Operational Commander, Stephen Hynes contacted her and provided an update from the scene. In that conversation, Stephen Hynes “inform[ed]” Annemarie Rooney that he had taken operational command.⁶⁶³

Stephen Hynes was a senior figure within NWAS. He was senior to Annemarie Rooney.⁶⁶⁴ The Ambulance Service Experts commented:
“It is unusual for such a senior rank … to take over operational level command … Whilst it is right to say that major incident roles are assigned based on competence to do that role rather than rank or seniority, there is a serious risk that having an Operational Commander who holds significantly senior rank to the Tactical Commander compromises the Tactical Commander’s authority and function.”⁶⁶⁵

In evidence, Annemarie Rooney’s view was that there was “some compromise” in the command structure when Stephen Hynes took over as Operational Commander.⁶⁶⁶ She stated: “This was due to the way Steve Hynes operated in that role.”⁶⁶⁷ She further stated:
“[T]here were some decisions that should have come through the Tactical Commander that did not. Decisions were being made at scene and were only passed to me once completed and that was for information purpose only rather than asking me for a decision.”⁶⁶⁸

Annemarie Rooney’s authority and function were compromised when Stephen Hynes relieved Daniel Smith of the role of Operational Commander. This should not have occurred, as any breakdown in the pre‑arranged command structure creates a risk of miscommunication and a lack of co‑ordinated effort.

However, these difficulties were not the effect of Stephen Hynes’ actions. In fact, Stephen Hynes was able to address some of the shortcomings in Daniel Smith’s command, as I shall set out at paragraphs 14.635 to 14.648. The priority must be making the response as effective as possible. That is what matters to the casualties who urgently need help.

Consequently, my criticism of Stephen Hynes in relation to the circumstances of him taking operational command is more technical than substantial. He should have contacted Annemarie Rooney and made clear that he was seeking her approval of him taking over as Operational Commander. He should have made clear that, despite his rank within NWAS, the command hierarchy was maintained. In these circumstances, I have no reason to think that Annemarie Rooney would not have agreed to Stephen Hynes becoming the Operational Commander.⁶⁶⁹

By describing my criticism of Stephen Hynes as more technical than substantial, I should not be understood to be encouraging others to do what he did. In other circumstances, it might have substantially diminished the effectiveness of the response.

Operation Plato

At 00:18, Annemarie Rooney spoke to Temporary Superintendent Nawaz’s replacement as GMP Tactical/Silver Commander, Temporary Superintendent Hill. In the course of the conversation, Temporary Superintendent Hill informed Annemarie Rooney that GMP had declared Operation Plato at 22:47.⁶⁷⁰ Annemarie Rooney did not inform Stephen Hynes of this declaration until 00:54.⁶⁷¹

Annemarie Rooney stated in her second witness statement that when she was told of the Operation Plato declaration, she asked if anything had changed. She stated that she was told it had not. She accepted that she should have told Stephen Hynes sooner but suggested that the Operation Plato declaration did not make any difference to NWAS’s approach at that time.⁶⁷²

In fact, the delay was not insignificant. At 00:39, Stephen Hynes spoke to Station Manager Andrew Berry. In the course of that conversation, he told Station Manager Berry that inside the Victoria Exchange Complex was a “warm zone”.⁶⁷³ He meant that it was an NWAS Major Incident warm zone, not an Operation Plato warm zone.⁶⁷⁴ Because Station Manager Berry did know about the Operation Plato declaration at this stage, he understood Stephen Hynes to be informing him that the inside of the Victoria Exchange Complex was an Operation Plato warm zone.⁶⁷⁵ This was an unsatisfactory state of affairs.

If Annemarie Rooney had communicated to Stephen Hynes, shortly after she was told by Temporary Superintendent Hill that GMP had declared Operation Plato, this miscommunication about the risk would not have occurred. Annemarie Rooney should have informed Stephen Hynes that GMP had declared Operation Plato shortly after she was told.

When Annemarie Rooney was informed about the Operation Plato declaration, she did not ask about what zones had been imposed; Temporary Superintendent Hill did not discuss zoning until he spoke to Chief Inspector (CI) Mark Dexter at 00:50.⁶⁷⁶ Annemarie Rooney should have asked about zoning at 00:18. The whole purpose of Operation Plato is to ensure that emergency personnel can operate within acceptable risk parameters through the use of zones.⁶⁷⁷ What zones had been imposed was relevant information for Annemarie Rooney to pass on to Stephen Hynes. It is likely that if she had asked about zoning at 00:18, she would have prompted GMP to think more rigorously about the zoning of the Victoria Exchange Complex at that stage.

First Tactical Advisor/NILO

Mobilisation to the scene (22:49)

Jonathan Butler was on call as a Tactical Advisor/NILO on the night of 22^nd May 2017.⁶⁷⁸ As the name suggests, there are two parts to this role. The Tactical Advisor role involves providing tactical advice to NWAS commanders. This advice is not limited to the Tactical Commander. Operational Commanders can use the Tactical Advisor, as can the control room.⁶⁷⁹ The NILO role faces outward from NWAS. This requires liaison with other emergency services.

The explanation for one person discharging both roles is that information received from outside agencies can have an impact on the advice that is given.⁶⁸⁰ NWAS operated an action card created by NARU for the Tactical Advisor/NILO role.⁶⁸¹

The NARU action card anticipates the difficulty which may be caused by having one person discharging both roles. The second action it prompts is: “Activate an additional Tactical Advisor as required.”⁶⁸²

At 22:49, NWAS Control contacted Jonathan Butler. The purpose of the call was “to get you [Jonathan Butler] going” to the incident.⁶⁸³ Jonathan Butler informed NWAS Control that he would speak to Stephen Taylor, the other NWAS on‑call Tactical Advisor/NILO.⁶⁸⁴

After the call with NWAS Control, Jonathan Butler called Stephen Taylor. Jonathan Butler said that he was mobilising to the scene. He asked Stephen Taylor to perform the Tactical Advisor/NILO role from home.⁶⁸⁵ At the time he mobilised, Jonathan Butler considered that the fact he was an Ambulance Intervention Team Commander may have been relevant to NWAS Control’s direction that he attend the scene.⁶⁸⁶

At 22:56, NWAS Control spoke to Jonathan Butler a second time. In that call, he was informed that NWAS had declared a Major Incident. He was also told that the RVP was “Hunts Bank”.⁶⁸⁷ NWAS Control told him that Annemarie Rooney was the Tactical Commander. Jonathan Butler concluded the call by saying: “I’m on me way … Steve [Taylor] will be able to assist you on the phone if you need anything.”⁶⁸⁸

In that call, Jonathan Butler raised the issue of an NWAS Airwave talk group. In evidence, he stated: “Steve [Taylor] was going to be dealing with [the multi- agency talk group].”⁶⁸⁹

Diversion to GMP HQ (23:47)

Jonathan Butler lived approximately 45 minutes’ drive from Manchester City Centre.⁶⁹⁰ He left his home shortly after 23:00.⁶⁹¹ At approximately 23:47, Stephen Taylor contacted Jonathan Butler. Stephen Taylor informed Jonathan Butler that Annemarie Rooney wanted him to attend GMP HQ.⁶⁹² At the time of the call, Jonathan Butler was approximately two minutes from the Victoria Exchange Complex. Jonathan Butler queried the decision, pointing out that he was an Ambulance Intervention Team Commander. He was told he was wanted at GMP HQ.⁶⁹³ As a result, he changed course and drove to GMP HQ.⁶⁹⁴

At 23:49, Jonathan Butler made a radio broadcast to Annemarie Rooney informing her that he was in the city centre. He asked whether she wanted him at GMP HQ or “to assist down on scene”. Annemarie Rooney instructed him to come to GMP HQ for a Tactical Co‑ordinating Group meeting.⁶⁹⁵

Jonathan Butler’s evidence of his experience is highly relevant to the position of his counterpart at GMFRS that night, Station Manager Berry. Jonathan Butler stated: “[Y]ou can’t actually follow an action card while you are driving on blue lights … there’s nothing other than driving.”⁶⁹⁶ In Part 15, I will consider GMFRS’s response to the Attack. As I will explain, one of the problems Station Manager Berry encountered was trying to manage GMFRS’s response to the incident while simultaneously driving a significant distance at speed.

At approximately 00:10, Jonathan Butler arrived at the GMP Silver Control Room at GMP HQ.⁶⁹⁷ Once in the GMP Silver Control Room, he “overheard somebody mention Plato”.⁶⁹⁸ He spoke to Temporary Superintendent Hill, who told him that Operation Plato had been declared very shortly after the Attack had occurred.⁶⁹⁹

Jonathan Butler said that Annemarie Rooney was “extremely busy going from one phone call to a second phone call”.⁷⁰⁰ At approximately 00:25, he was briefed by Annemarie Rooney. He formed the impression that, at that stage, Annemarie Rooney “had a very good handle on the incident”.⁷⁰¹

In his reflection the day after the Attack, Jonathan Butler wrote: “Steve Hynes hampered the normal chain of command that had been agreed for this incident and Annemarie Rooney was always playing catch-up to the scene.”⁷⁰² Stephen Hynes replaced Daniel Smith as Operational Commander at 23:57.⁷⁰³

Jonathan Butler went on to explain during his evidence that he wrote this because Stephen Hynes took a lot of decisions at the scene.⁷⁰⁴ He stated that he did not believe that this hampered or affected any form of patient care. He went on to say that he believes “that NWAS should take a more pragmatic approach to scene management”.⁷⁰⁵ By this he meant that the NWAS Tactical Commander should also consider going to the scene to co‑locate with other Tactical Commanders. Jonathan Butler went on to say that he thought that, on 22^nd May 2017, GMP HQ was the correct place for Annemarie Rooney to go because that was where the GMP Tactical/Silver Commander was.⁷⁰⁶

I recommend that NWAS, in consultation with other emergency services in its area of operation, consider the issue of the location of the Tactical Commander, as this may be capable of improving outcomes at Major Incidents. It will, however, require a co‑ordinated approach to this issue across emergency services.

Jonathan Butler’s final reflection was that he “felt like a spare part as advice was not needed in the TCG [Tactical Co-ordinating Group] due to decisions being made at the [scene]”.⁷⁰⁷ This is unfortunate. Jonathan Butler struck me as being a highly capable member of the NWAS response. It was clear to me that he was able to add a substantial amount to the quality of the NWAS response. In the event, his own view is that he did not.

While I am not prepared to go as far as he does and find that he was a “spare part”, it is clear to me that, through no fault of his own, Jonathan Butler was not able to contribute as much as he might have. This was the result of diverting him away from the scene.

I will consider the wisdom of the decision to divert Jonathan Butler once I have dealt with the second Tactical Advisor/NILO.

Second Tactical Advisor/NILO

Advice during the critical period of response

Stephen Taylor was notified of the incident by Jonathan Butler shortly after 22:49.⁷⁰⁸ Stephen Taylor lived closer to Manchester City Centre than Jonathan Butler. They both proceeded on the basis that Jonathan Butler would travel while Stephen Taylor would operate from his home, covering the period when Jonathan Butler was travelling.⁷⁰⁹ Because of his Ambulance Intervention Team Commander qualification, Jonathan Butler had an additional set of competencies relevant to the response.⁷¹⁰ As a result, I am not critical of the fact that they did not reverse roles.

However, journey time for on‑call staff is capable of building in substantial delay. I recommend that NWAS review its approach to Tactical Advisors/NILOs in light of this issue. NWAS should consider whether it is possible and practical to identify in advance of any shift which of its on‑call NILOs is best placed to travel to a Major Incident should it occur and which of them should operate from home to provide cover for particular areas.

At some point after he agreed this approach with Jonathan Butler, Stephen Taylor spoke to the Tactical Commander, Annemarie Rooney. He informed her of the arrangement, which she ratified.⁷¹¹ I will return to this call at paragraphs 14.559 to 14.565.

At 23:07, Stephen Taylor contacted NWAS Control. In the course of the call, Stephen Taylor enquired about Operation Plato.⁷¹² He was told that Operation Plato had not been declared.⁷¹³ Strictly, this was not correct, as Inspector Sexton had declared Operation Plato at 22:47.⁷¹⁴ However, the inaccuracy was not the fault of NWAS Control. It was a further consequence of Inspector Sexton’s failure to notify NWAS of his declaration.⁷¹⁵

Stephen Taylor was informed by NWAS Control that a Major Incident had been declared. He informed NWAS Control that he had tried to get through to GMP on a number of occasions and had been unsuccessful.⁷¹⁶

At 23:22, Stephen Taylor called NWAS Control. He enquired whether NWAS Control had “done a hailing group call to GMP”.⁷¹⁷ He explained he was “struggling to get hold of them”.⁷¹⁸

Nine minutes later, at 23:31, Stephen Taylor contacted Daniel Smith over the radio. The purpose of Stephen Taylor’s contact was because he was trying to establish where the NWAS Strategic Commander, Neil Barnes, should go. Daniel Smith told him, “I haven’t a clue,” and directed Stephen Taylor to contact the Tactical Commander.⁷¹⁹ In the course of the conversation, Stephen Taylor enquired whether a METHANE message had been sent. Daniel Smith had broadcast a METHANE message eight minutes earlier.⁷²⁰

Inter-agency liaison during the critical period of response

Between 22:50 and 23:33, Stephen Taylor made “numerous phone calls” to try to get through to the FDO. He was not successful during this period. On each occasion, the line he tried was engaged.⁷²¹ Stephen Taylor’s experience was the same as more than one officer from GMFRS who also tried unsuccessfully to get through to the FDO on a number of occasions during the critical period of the response.⁷²²

At 23:33, Stephen Taylor was connected on the FDO telephone line. He spoke to David Myerscough, a police support staff officer.⁷²³ Stephen Taylor enquired whether GMP wanted the NWAS Strategic Commander to go to GMP HQ, as well as the NWAS Tactical Commander. David Myerscough confirmed that the NWAS Strategic Commander should go to the Silver Control Room at GMP HQ.⁷²⁴

Stephen Taylor asked: “Do you want to open up an inter-op channel with our control rooms …?”⁷²⁵ A little later in the call, he said: “Is there any chance of opening that inter-op channel at all? Just to keep them abreast.”⁷²⁶ Stephen Taylor suggested two channels. Neither of them was the proposed multi‑agency control room talk group channel. Towards the end of the call, Stephen Taylor said: “But if we could open up a channel with our control room, that would be ideal really in terms of just sharing information.”⁷²⁷

Stephen Taylor was correct to be raising the issue of a multi‑agency control room talk group. I am not critical of him for suggesting the use of channels other than the proposed multi‑agency control room talk group. However, this conversation further serves to demonstrate the consequences of the failure by all emergency services operating in the Greater Manchester area to agree the Standard Operating Procedure for the proposed multi‑agency control room channel before the Attack.

The use of a multi‑agency control room talk group should have been well established before 22^nd May 2017. This would have led to far better communication between the emergency services. It would also have meant that Stephen Taylor and others did not have to occupy time talking about setting it up. It would have avoided the risk of confusion arising as to which talk group should be used.

At about the same time as Stephen Taylor was raising this issue with GMP, GMFRS and NWFC were discussing the same topic.⁷²⁸ The GMFRS and NWFC conversations focused on the use of the proposed multi‑agency control room talk group. In due course, the proposed multi‑agency control room talk group was used to the extent that GMP checked who was listening. NWAS did not reply. This was because, as I set out above at paragraph 14.506, at the time at which GMP checked, NWAS had not been given the channel number.⁷²⁹

Communication failures during the critical period of response

Stephen Taylor raised the multi‑agency hailing talk group with NWAS Control at 23:22. He accepted he should have raised this earlier than he did.⁷³⁰ He was correct to recognise this. His NILO role required that he communicate with emergency services partners. Having correctly identified that his first contact should be with GMP, he should have systematically worked his way through all means of reaching the FDO. Unlike his counterpart at GMFRS, by remaining at home Stephen Taylor had placed himself in the optimum environment to be able to think clearly and carry out the tasks he needed to.⁷³¹ In these circumstances, not raising the multi‑agency hailing talk group earlier was a failing on his part.

Stephen Taylor did not attempt to contact BTP. He explained that he did not think he had “a direct route to BTP on my phone”.⁷³² This is not an adequate explanation for him not trying. He could have asked NWAS Control to provide him with a number. He is not solely responsible for this failing. NWAS should have ensured that he had the relevant contact numbers for BTP.

Stephen Taylor made no attempt to contact NWFC or GMFRS before 01:00 on 23^rd May 2017. He stated in evidence: “I think my expectation … is that they would have responded. I was aware that they were aware of the call.”⁷³³ Again, this was not an adequate explanation for this failure. Quite aside from the fact that Stephen Taylor’s expectation was wrong, JESIP required that there should be ongoing communication so that situational awareness could be shared, the risks could be jointly assessed and, most importantly, there was co‑ordination between agencies. Stephen Taylor’s explanation suggests a fundamental misunderstanding of these important principles.

At 01:04 on 23^rd May 2017, Stephen Taylor contacted NWFC. He began: “I just wondered have you got a NILO on this incident in Manchester at the moment or is he at scene, or … have you got a liaison officer with you in control.”⁷³⁴ It is extraordinary that, even by 01:04, Stephen Taylor did not know the identity of the GMFRS NILO or have any contact details. Stephen Taylor’s role was an ‘inter‑agency’ one.⁷³⁵

The other side of Stephen Taylor’s role was to provide advice. He spoke to Daniel Smith, the NWAS Operational Commander, during the critical period of the response. He did not offer him any advice. He provided limited advice to NWAS Control during his two calls set out above at paragraphs 14.544 to 14.546.⁷³⁶

Stephen Taylor stated in evidence that he did speak to Annemarie Rooney, the NWAS Tactical Commander, but he was not “100% sure” when.⁷³⁷ He stated that he thought it was before Annemarie Rooney’s conversation with Daniel Smith at 23:39.⁷³⁸ Stephen Taylor stated that in his call with Annemarie Rooney, he discussed the activation of the “Mass Casualty Distribution Plan”. Stephen Taylor’s notes of his involvement indicate that this discussion may have occurred at 22:47, which was before he was even notified of the Attack.⁷³⁹ His witness statement, which was based upon his notes, records that he “recall[s] discussing the Mass Casualty Distribution Plan with Annemarie [Rooney]” in a call at 22:47.⁷⁴⁰

For reasons that I will explain below, I was not able to rely upon Stephen Taylor’s notes. Consequently, I have looked for other evidence on this issue.

Annemarie Rooney recorded in her first witness statement that she spoke to Stephen Taylor as she was travelling to GMP HQ.⁷⁴¹ She stated that, while she is unable to recall the specifics, she reached agreement with Stephen Taylor that he would remain at home while Jonathan Butler travelled. Annemarie Rooney makes no mention of any mass casualty plan being discussed in that conversation.⁷⁴²

Annemarie Rooney referred to the ‘Greater Manchester mass casualty distribution plan’ in her first statement. It is first referenced in the statement in a conversation “at approximately 23:35”.⁷⁴³ That conversation was with Daniel Smith. Annemarie Rooney suggested in that statement that the plan she was referring to was “in draft”. I set out at paragraphs 14.496 to 14.502 that the plan that was being discussed with Daniel Smith was the draft NWAS GM Patient Dispersal Plan. As I set out in Part 12, this draft plan was intended to complement the Greater Manchester Resilience Forum Mass Casualty Plan. When Annemarie Rooney referred in her statements to the ‘mass casualty distribution plan’, I understand her to be referring to the draft NWAS GM Patient Dispersal Plan.

Annemarie Rooney’s second witness statement responded to the question of whether she accepted that in her call with Stephen Taylor, as she was travelling to GMP HQ, he advised her to activate the mass casualty distribution plan. Her reply was: “No, I do not recall any conversation with Mr Taylor about the mass casualty distribution plan. I believe the first conversation about this plan was with Dan Smith at around 23:35 as per my log.”⁷⁴⁴

Given the extent of Stephen Taylor’s timing inaccuracies and given the content of Annemarie Rooney’s witness statements, on the balance of probabilities, I find that Stephen Taylor did not give Annemarie Rooney advice about any mass casualty plan prior to her discussion with Daniel Smith between 23:34 and 23:39 about hospital casualty numbers. Stephen Taylor should have done.

In light of all the evidence, I find that Stephen Taylor did not offer any advice to either the Operational Commander or the Tactical Commander during the critical period of the response.

Record-keeping

Stephen Taylor wrote notes of his involvement. He also completed an incident log. The incident log was written up during the 72 hours following the incident, in accordance with the requirement marked on the front page of the incident log.⁷⁴⁵ The incident log corresponded in substance with the content of the notes Stephen Taylor made. Stephen Taylor’s subsequent witness statement corresponded with the notes and the incident log.⁷⁴⁶

During Stephen Taylor’s evidence, it became apparent that the notes and incident log he had written were inaccurate in a number of important respects.⁷⁴⁷ I accept that this was as a result of mistakes on his part.

Stephen Taylor’s evidence was that he tried to make notes as he went, but that he was “playing catch-up” while he was making and receiving calls.⁷⁴⁸ He stated that some notes were written up “a few hours into the evening”.⁷⁴⁹ Although he was concerned about the accuracy, he did not make any record to indicate this concern.⁷⁵⁰

I am critical of Stephen Taylor for failing to make accurate notes as the incident unfolded, given the circumstances in which he was involved. I recognise that it would not have been easy for him. I also recognise that if he had had a Dictaphone this would have removed the need for him to make notes.⁷⁵¹ However, the notes were so inaccurate, including recording things that were not said, it would have been better if Stephen Taylor had just recorded that he did not have a clear recollection of much of what he did.

The inaccurate entries risked creating confusion immediately after the incident and beyond. They led to an unsatisfactory situation in which another witness who gave evidence before Stephen Taylor was questioned on the basis that Stephen Taylor’s notes were accurate.⁷⁵²

To illustrate the problem this caused, I take but one example of mis‑recording. Stephen Taylor recorded that at 22:50 he spoke to “GMP (FDO), Inspector Dale Sexton”.⁷⁵³ His record goes on, that at 22:51: “Confirmed with tactical commander (AMR) and strategic commander, Neil Barnes, that FDO requested presence at GMP command module – advised to attend.”⁷⁵⁴ At 22:52, he recorded: “[F]rom FDO at this stage no secondary devices or active shooting.”⁷⁵⁵

In fact, at no stage did Stephen Taylor speak to the FDO, Inspector Sexton. His contact with GMP was nearly 45 minutes later than his notes suggest. At that stage, he spoke to David Myerscough, who had identified himself by name at the start of the call.⁷⁵⁶ By that stage, Annemarie Rooney was already at GMP HQ, as Stephen Taylor stated in the call. As such, it was not Stephen Taylor’s contact with GMP that led to Annemarie Rooney going to GMP. In fact, Annemarie Rooney decided to go to GMP HQ during her call with Daniel Smith at 22:41, nearly ten minutes before Stephen Taylor was informed of the Attack.⁷⁵⁷ Further, there was no discussion during Stephen Taylor’s call with GMP about secondary devices or active shooters.⁷⁵⁸

Stephen Taylor’s witness statement did include this statement: “Having had an opportunity to reflect on my involvement with this incident, I know that not all of the calls I made have been recorded within my incident decision log.”⁷⁵⁹ The witness statement said nothing to indicate that the content of the statement was inaccurate in any other way. Indeed, it contained an attestation that the content was true to the best of his information, knowledge and belief.⁷⁶⁰

Jonathan Butler suggested that increasing the Tactical Advisors/NILOs within NWAS may lead to overall improvement.⁷⁶¹ Stephen Taylor said that a third Tactical Advisor/NILO on call “would have been ideal”.⁷⁶² I recommend that NWAS review the number of Tactical Advisors/NILOs it has and whether the number of such specialists, both generally and on call, should be increased.

I will return to this issue of the importance of clear and accurate recording of involvement in Major Incidents in Part 19 in Volume 2‑II.

Ambulance Intervention Team Commander

Mobilising an Ambulance Intervention Team Commander

Jonathan Butler was a qualified Ambulance Intervention Team Commander.⁷⁶³ During his evidence, he explained this role:
“The role of an AITC [Ambulance Intervention Team Commander] … when Ambulance Service staff are actually involved in a ballistic-type attack environment, would be to liaise with the police, agree the risk assessment, and then agree a way in which we can move forward to treat patients and bring them out of that area. It’s about deployment of staff … the AITC has actually undergone further training and liaison with the police to understand when … to commit staff and when not to commit staff.”⁷⁶⁴

He went on to state that the role was:
“not only that [about communicating with the police where is safe], it’s all about getting commanders to the scene as well. So even if the role of an AITC wasn’t actually in play at that point in time, what the [Ambulance Intervention Team Commander] can bring to the table is an extra commander to support the decision-making.”⁷⁶⁵

He stated that an Ambulance Intervention Team Commander would locate herself or himself at the FCP at the scene.⁷⁶⁶

As I set out at paragraphs 14.22 to 14.24, at 22:38 Annemarie Rooney was contacted by NWAS Control. In the course of the call, Annemarie Rooney stated: “[W]e need to get HART, we need to find out who’s the AITC.” ⁷⁶⁷ Annemarie Rooney then said: “Identify your AIT on duty.”⁷⁶⁸

In her call with NWAS Control at 22:56, Annemarie Rooney again brought up the issue of the Ambulance Intervention Team Commander. She asked: “[H]ave we identified an AITC?” This led to a discussion about who might be available to undertake this role.⁷⁶⁹ The call concluded with NWAS Control informing Annemarie Rooney: “I’ll find one, I’ll get one.”⁷⁷⁰

At 23:10, the Greater Manchester Emergency Operations Centre within NWAS Control contacted the Regional Health Control Desk within NWAS Control.⁷⁷¹ The Manchester Control Room asked the Regional Health Control Desk to find an Ambulance Intervention Team Commander. The Regional Health Control Desk agreed to do this.⁷⁷² It is not clear to me whether this happened or not.

It is unsatisfactory that, over 30 minutes after the Attack, NWAS Control had still not identified an Ambulance Intervention Team Commander who could be mobilised in that capacity. NWAS’s plan was that the Ambulance Intervention Team Commander would lead the specialist team responding to a Marauding Terrorist Firearms Attack.⁷⁷³ If there had been marauding gunmen, there would have been an even more urgent need than there was on 22^nd May 2017 for such a commander at the scene.

Diversion of Jonathan Butler (23:47)

Jonathan Butler could have been at the Victoria Exchange Complex by 23:50. He was on call that night, not as an Ambulance Intervention Team Commander, but as a Tactical Advisor/NILO. As I set out above at paragraphs 14.530 and 14.531, at 23:47 and 23:49 it was communicated to him that Annemarie Rooney wanted him to go to GMP HQ rather than the scene.⁷⁷⁴

In my view, Jonathan Butler would have been able to bring his skills both as a Tactical Advisor/NILO and as an Ambulance Intervention Team Commander to bear if he had completed his journey to the scene and operated from there, rather than from GMP HQ. His colleague Stephen Taylor was available on the telephone to provide Annemarie Rooney with tactical advice.

I am not critical of Annemarie Rooney for her decision to divert Jonathan Butler to GMP at 23:47. This is for a number of reasons. First, by 23:47 Annemarie Rooney had been at GMP HQ for over 30 minutes. She had spoken to the GMP Tactical/Silver Commander, but she had not been told that Operation Plato had been declared.⁷⁷⁵ She had received no information, since her arrival, that there were marauding gunmen. As such, Jonathan Butler’s Ambulance Intervention Team Commander qualification, while useful, was not essential at the scene.

Second, the most significant area in which an Ambulance Intervention Team Commander would have been able to assist on the night of the Attack was in relation to entry to the City Room by paramedics. An Ambulance Intervention Team Commander would have been well placed to speak to the police on scene, to assess the risk to paramedics going forward and to support the command decisions around this.⁷⁷⁶ By 23:50, when Jonathan Butler would have arrived at the scene, had he not been diverted, all of the casualties who could be helped had already been removed from the City Room.

Third, around the time that Jonathan Butler could have arrived at the scene, another NWAS qualified Ambulance Intervention Team Commander had arrived: Stephen Hynes.⁷⁷⁷ Stephen Hynes pulled up on Hunts Bank at 23:50. At 23:57, he took up the role of Operational Commander from Daniel Smith.⁷⁷⁸

Fourth, at the time she made the decision, Annemarie Rooney was not to know that Stephen Hynes was imminently to start making decisions without substantial recourse to her. Consequently, she was not to know that the contribution she could make as Tactical Commander would be lessened from this point.

In my view, it would have been a reasonable decision to permit Jonathan Butler to complete his journey to the scene. However, Annemarie Rooney was well placed to decide if she needed a Tactical Advisor/NILO with her at GMP HQ. For the reasons I have given, I am not critical of her for deciding this was the best use of Jonathan Butler.

I will return to Stephen Hynes after I have addressed the role of the Strategic Commander on the night of the Attack.

Strategic command

Initial notification

Overnight on 22^nd May 2017 into 23^rd May 2017, Neil Barnes was the NWAS on‑call Strategic Commander for Greater Manchester.⁷⁷⁹ At approximately 22:40, he missed a call from Annemarie Rooney. He telephoned her back. In the ensuing conversation, Annemarie Rooney informed him that there had been a suspected bombing at the Arena.⁷⁸⁰ She informed him that there were two on‑call Operational Commanders on their way to the scene. She told him that she was going to deploy to the Tactical Co‑ordinating Group at GMP HQ. Neil Barnes told her he approved of her doing this. He asked her to call him again with a METHANE message.⁷⁸¹

Neil Barnes’ impression was that Annemarie Rooney thought that the incident was serious, but he anticipated the possibility it might not be. He had previous experience of incidents that were successfully handled by the Tactical Commander and that did not require a Strategic Commander.⁷⁸²

Neil Barnes’ approach to this initial notification was not adequate. A suspected bombing was likely to require a multi‑agency response. It was highly likely that an NWAS Strategic Commander would be required. Doing nothing until he received a METHANE message from his Tactical Commander was unacceptably passive. NWAS’s Major Incident Response Plan stated: “Whilst it is not the responsibility of the Strategic Commander to make tactical decisions they still have responsibility for ensuring the tactics which are being employed are effective.”⁷⁸³

Neil Barnes should have taken a more proactive approach. He should have established with Annemarie Rooney what her tactical plan was. He should have made arrangements for their next contact, rather than making it contingent on her receiving and passing on a METHANE message.⁷⁸⁴

Following his call with Annemarie Rooney, Neil Barnes switched on his television to see if he could learn anything more.⁷⁸⁵ He was able to learn very little beyond the fact that an incident involving several people had occurred. He began to get the equipment he might need together. He then continued watching the television while he waited for more information from Annemarie Rooney.⁷⁸⁶

Neil Barnes’ decision to wait at home for more information from Annemarie Rooney was not an appropriate one. He should have actively sought out further information.⁷⁸⁷ Annemarie Rooney had told him that she was going to travel to GMP HQ. Accordingly, it was likely that a significant period of time would pass before she spoke to him again. I accept that at that initial stage Neil Barnes would not know that it would be essential for him to travel to GMP HQ. However, having prepared himself, the next obvious step for him was to contact NWAS Control to obtain an update. Relying entirely on the media for information while he waited for Annemarie Rooney to call him back was inadequate.⁷⁸⁸

Had Neil Barnes telephoned NWAS Control a few minutes after he had spoken to Annemarie Rooney, he would have discovered that, at 22:46, NWAS declared a Major Incident.⁷⁸⁹ It is likely he would have been provided with information about the number of known casualties at that time. He would have realised that it was essential that he mobilise immediately. None of these things occurred because Neil Barnes did not contact NWAS Control.

Call from NWAS Chief Executive Officer (23:00)

At approximately 23:00, Neil Barnes received a telephone call from Derek Cartwright, the NWAS Chief Executive Officer. Derek Cartwright suggested that Neil Barnes should mobilise to GMP HQ. Following the call, Neil Barnes decided to remain at home.⁷⁹⁰

Neil Barnes’ reasoning for this decision was that, although Derek Cartwright was the most senior person within NWAS, he was not “part of the command structure”⁷⁹¹ that night. He stated: “I made the decision for the command structure to kick into play, to wait for a response from Annemarie [Rooney] or wait for a response from another area of the command and control structure, such as the NILO or the ROCC [Regional Operational Co-ordination Centre within NWAS Control].”⁷⁹²

I recognise that Derek Cartwright was not formally part of the command structure on the night of 22^nd May 2017. However, as Chief Executive Officer he was the most senior person in NWAS. While Derek Cartwright did not give a command, in my view there needed to be a very good reason for Neil Barnes not to follow his suggestion. No such reason existed.

Neil Barnes should have followed Derek Cartwright’s advice and immediately deployed to GMP HQ. Alternatively, he should have sought further information. This could have been from Annemarie Rooney, NWAS Control, a Tactical Advisor/NILO or his counterparts at the other emergency services. What was not an acceptable course for Neil Barnes was simply remaining at home waiting for information to come to him. However, that was what Neil Barnes did.

Call from NWAS Control (23:20)

At approximately 23:20, NWAS Control called Neil Barnes.⁷⁹³ In the course of this call, Neil Barnes was informed that NWAS Control was receiving offers of staff to come on duty. Neil Barnes stated: “Right, well we don’t know the situation yet do we? I haven’t had a full SITREP [situation report] yet … I am waiting for the Silver Commander to get back to me.”⁷⁹⁴ In response, NWAS Control asked Neil Barnes when he had last had an update. He replied: “I spoke to her briefly about 10 minutes ago, why have you got one?”⁷⁹⁵

NWAS Control provided Neil Barnes with an update. He was told that there were reports of shots fired. He was told that there were at least 18 fatalities. He was told that the police had asked NWAS to send as many vehicles as possible. He was told that the RVP was Hunts Bank.⁷⁹⁶

Neil Barnes asked: “[H]ave they opened a gold?”⁷⁹⁷ This was a reference to GMP opening the Gold Control Room at GMP HQ. He was told that NWAS Control had been unable to get through to find out. The call concluded with Neil Barnes providing the following instruction: “We need to wait until our bronze commander makes decisions in terms of resourcing rather than listening to the police at this stage.”⁷⁹⁸ By “this stage”, GMP had had resources at the scene for 40 minutes.

There are a number of unsatisfactory elements to this conversation. First, Neil Barnes failed to ask when the incident had occurred. Establishing how long had elapsed since the start of the incident by this point was important information.

Second, Neil Barnes failed to enquire whether a Major Incident had been declared. This was an obvious question to ask. The Major Incident Response Plan stated: “The nature of the incident will determine whether all levels of command are required. Most large or major incidents will require a multi- agency approach to command and control.”⁷⁹⁹

Third, Neil Barnes failed to enquire whether Operation Plato had been declared.⁸⁰⁰ Having been informed that there were reports of shots fired and 18 fatalities, the possibility of an Operation Plato declaration should have been obvious.

Fourth, although he was told about the number of fatalities, he failed to ask how many casualties there were.⁸⁰¹ This was also an obvious question to ask.

Fifth, the only direction Neil Barnes gave NWAS Control was to ignore the police’s request for support. He did so on the basis that NWAS Control needed “to wait”⁸⁰² for the Operational Commander’s decision. This was an inappropriate instruction to give.

The emergency services must trust each other. If the police request as many vehicles as are available, steps should immediately be taken to comply unless there is a compelling reason not to. Neil Barnes had no idea at this point where the Operational Commander was or how long NWAS might have to wait for that person to identify the resources that were needed. He took no steps to find out this information before he gave the instruction he did. He did not even find out if there were any paramedics at the scene.⁸⁰³

As I have set out above, I am critical of Neil Barnes for his approach to this conversation. The obvious deficiencies in it are aggravated by the fact that up until this point Neil Barnes had remained at home waiting for information to come to him.

Having received this call and learned that there were at least 18 fatalities, Neil Barnes should have sought to contact Annemarie Rooney, a Tactical Advisor/ NILO and/or his counterparts at GMP, BTP and GMFRS. He did not do any of these things. He continued to wait at home for Annemarie Rooney to call.⁸⁰⁴

Call from Tactical Advisor/NILO (23:40)

During his evidence, Neil Barnes was asked if he would have stayed at home if, during his conversation with Derek Cartwright at 23:00, he had learned that NWAS was responding to a mass casualty incident. He answered that he would not have stayed at home.⁸⁰⁵ I am unable to accept this evidence. When Neil Barnes was told at 23:20 that there were 18 fatalities, he decided to continue waiting at home.⁸⁰⁶

It was not until Stephen Taylor called Neil Barnes at approximately 23:40, to notify him that a Strategic Co‑ordinating Group would be required, that Neil Barnes decided to leave his house.⁸⁰⁷ Neil Barnes should have left his home to travel to GMP HQ following his call with NWAS Control at 23:20. At that point, it was a certainty that a Strategic Co‑ordinating Group would be required. At that stage, Neil Barnes knew that the emergency services were responding to a terrorist incident which had caused 18 fatalities.

Again, Neil Barnes’ approach was not proactive enough. Rather than seize the initiative and start his journey, his approach until 23:40 was to wait to be told that he was required to leave his home.⁸⁰⁸

Silver Control Room at GMP HQ (00:30)

The journey time from Neil Barnes’ house to GMP HQ was approximately 30 minutes. He drove in a vehicle equipped with blue lights and sirens but chose not to use them. He stated in evidence that this was because it takes concentration to drive with blue lights and sirens on. He stated that his journey may have been quicker if he had driven with the blue lights and sirens on.⁸⁰⁹

In the course of his journey, Neil Barnes had further conversations with NWAS Control. At 23:52, he called NWAS Control to obtain the postcode of GMP HQ.⁸¹⁰ Given the time he had before this call, it is surprising that Neil Barnes had not obtained the postcode before his departure. At 00:17, he called NWAS Control because he thought the address he had been provided with was wrong.⁸¹¹ At around 00:30, Neil Barnes entered the Silver Control Room at GMP HQ.⁸¹²

In evidence, Neil Barnes was asked whether it would have been better if he had arrived at GMP HQ sooner than he did. He answered that he did not think so. He stated that his only role before the meeting of the Strategic Co‑ordinating Group was to provide support to Annemarie Rooney, which he could do over the telephone. He conceded that once present he was able to bring his influence to bear to encourage a Strategic Co‑ordinating Group meeting to take place.⁸¹³ For the reasons I have given above, my view is that Neil Barnes should have set off much sooner than he did.

Also arriving at GMP HQ at the same time as Neil Barnes was an NWAS loggist. As the name suggests, this person’s function was to sit alongside a commander and make a record of decision‑making.⁸¹⁴ The first entry in the NWAS Strategic Commander’s log is timed at 00:35.⁸¹⁵ In evidence, Neil Barnes stated that at this point he formulated a strategic plan. He stated he did not write that strategic plan down in the log. He accepted he should have. He stated that before 00:35 he was relying on a generic strategic plan.⁸¹⁶

The Major Incident Response Plan states the following of the role of Strategic Commander:
“NWAS major incident action card 22 outlines the Strategic Commander’s key responsibilities. The action card must be used during the management of the incident.
The Strategic Commander has overall responsibility for the command, response and recovery for any major incident for their organisation. They will set the trust’s strategic aims – ie develop a strategic plan. This provides a framework for Tactical Commander(s) to work within. A generic Strategy can be found at Appendix D. This should be adapted by the Strategic Commander as necessary.”⁸¹⁷

Neil Barnes should have formulated an incident‑specific strategic plan substantially earlier than 00:35. This would have required him to have a much better understanding than he had prior to his arrival at GMP HQ. He should have written the plan down. He should have communicated it to Annemarie Rooney.

The action card that the Strategic Commander is required by the Major Incident Response Plan to follow directed Neil Barnes to do a number of important things he did not do during the first two hours of the emergency response.⁸¹⁸ First, action card 22 directed: “[O]n notification of the incident start an incident log.”⁸¹⁹ There was no good reason for Neil Barnes not to do this: he was at home during the critical period of the response.

Second, action card 22 expected Neil Barnes to “[g]ain assurance from the Ambulance Incident Commander [Tactical Commander] that risk assessments have been carried out as appropriate”.⁸²⁰ He failed to do this. The issue of the assessment of risk was extremely important on the night of 22^nd May 2017. Contrary to the requirements of JESIP, the NWAS risk assessment was conducted by the NWAS Operational Commander without reference to other emergency services. It produced a different conclusion to that conducted by the GMP Operational/Bronze Commander in terms of where unprotected, non‑specialist responders could work.

Third, action card 22 expected Neil Barnes to attend the Strategic Co‑ordinating Group, if established, or to “consider the need to request that an SCG [a Strategic Co-ordinating Group] is set up”.⁸²¹ Although Neil Barnes did attend GMP HQ in expectation of a Strategic Co‑ordinating Group meeting, he only did so when he was advised to do so by Stephen Taylor.⁸²² I have concluded that Neil Barnes failed to consider the need to request that a Strategic Co‑ordinating Group be set up.

Fourth, action card 22 expected Neil Barnes to “confirm the strategy for the incident and ensure that this is disseminated to the Ambulance Incident Commander [Tactical Commander]. Ensure the strategy is documented within the incident log.”⁸²³ He failed to do any of these things during the first two hours of the response, despite being in a position to address these requirements.⁸²⁴

Fifth, action card 22 expected Neil Barnes to “[e]nsure inter service liaison at the appropriate strategic level”.⁸²⁵ It was not until after he arrived at GMP HQ that Neil Barnes spoke to any other Strategic Commander. As I have set out above, he should have sought to do this sooner.

Strategic Co-ordinating Group meeting (04:15 on 23rd May 2017)

I have dealt with the timing of the Strategic Co‑ordinating Group meeting in the section in which I consider GMP’s response to the Attack, in Part 13. It is only necessary to mention it again at this stage of my Report because Neil Barnes did not attend it.

Neil Barnes had a pre‑booked flight to take him on holiday at midday on 23^rd May 2017. Before he came on call on 22^nd May 2017, he had arranged that his period on call would end at 06:00 rather 08:00 on 23^rd May 2017 because of this booking.⁸²⁶ As a result of his holiday, Neil Barnes asked Derek Cartwright if he could be relieved as NWAS Strategic Commander so he could catch his flight later that day. At 04:08 on 23^rd May 2017, a replacement Strategic Commander arrived at GMP HQ. Neil Barnes briefed his replacement for a period of six to eight minutes and left GMP HQ.⁸²⁷

Role of Strategic Commander on 22nd May 2017

Neil Barnes agreed, during his evidence, that prior to 00:30 he “provided no leadership” and “made no decision during that period that made any difference to the response on the ground”.⁸²⁸

The Ambulance Service Experts summarised their opinion of Neil Barnes’ contribution as follows:
“A number of strategic obligations set out in the NWAS plan and the Strategic Commander Action Card were not satisfactorily completed by Mr Barnes.
His delay in obtaining information and responding was unacceptable.
He was in a unique position to take steps to confirm JESIP was being effectively applied and that there was an effective joint response. Had he taken such steps, he should have realised that JESIP was not being effectively applied at the Operational and Tactical level …
It is our opinion that there was a significant lack of decisive and effective leadership at the Strategic Command level. From the evidence it appears that Mr Barnes … made no significant or meaningful contribution [from the time he responded to the time he left].”⁸²⁹

For the reasons I have given above, I agree with the opinion of the Ambulance Service Experts.

Casualty Clearing Station after midnight

At 00:00, the ambulance transporting John Atkinson to hospital left the Casualty Clearing Station. At the same time as that ambulance was leaving, Patrick Ennis radioed Daniel Smith from the City Room. Patrick Ennis said: “We’ve got one – eight, 18, confirmed dead. We have no … priority one, two or three patients here, all patients have been moved down to you or other locations.”⁸³⁰

Daniel Smith replied to Patrick Ennis’s report from the City Room: “Just to confirm then, you’ll stay inside … and you will re-triage to see if there’s any more … can you just shout up on this channel once you are aware … that you are complete inside. Steve Hynes is here now as incident commander.”⁸³¹

At no stage have I lost sight of the fact that many people were badly affected by the Attack. However, the terms of reference require me to focus upon those who died in the Attack. The 36 casualties who remained in the Casualty Clearing Station at the point of John Atkinson’s departure for hospital survived. In these circumstances, it is not for me to subject the period after midnight to the same level of scrutiny as the period before midnight.

Replacement Operational Commander

Stephen Hynes self‑deployed to the scene. He arrived at 23:51. As set out at paragraph 14.268, he discussed taking over the role of Operational Commander with Daniel Smith.⁸³² At 23:57, Stephen Hynes is captured on CCTV wearing the Operational Commander’s tabard.⁸³³ At the point he took over as Operational Commander, Stephen Hynes was not aware of GMP’s Operation Plato declaration.⁸³⁴

From his handover with Daniel Smith, Stephen Hynes understood that Station Approach had been assessed as a Major Incident cold zone and the station concourse was a Major Incident warm zone. He assumed that the site of the explosion was a Major Incident hot zone.⁸³⁵

At 00:10, Stephen Hynes telephoned Annemarie Rooney. The purpose of this call was to inform her that he had taken up the role of Operational Commander.⁸³⁶

At 00:12, Stephen Hynes received a telephone call from the GMFRS Chief Fire Officer Peter O’Reilly.⁸³⁷ I will deal with this call in detail when I consider GMFRS’s response to the Attack, in Part 15.

At 00:16, Stephen Hynes spoke to CI Dexter.⁸³⁸ Stephen Hynes asked:
“[I]s it safe at present?” CI Dexter replied: “I’d say warm … I’ll border on cold but I will stick with warm [inaudible].” A little later in the conversation, CI Dexter stated: “I would declare this cold now.”⁸³⁹ This was a reference to the area of the Casualty Clearing Station. The difficulty for Stephen Hynes was that he did not know about the declaration of Operation Plato at this time. Consequently, he did not appreciate that CI Dexter was talking about Operation Plato zones as opposed to Major Incident zones.⁸⁴⁰

This miscommunication was not Stephen Hynes’ or CI Dexter’s fault. It was the result of the use of the same terminology within NWAS for Major Incidents as was used for Operation Plato.

Following this conversation, Stephen Hynes spoke to NWAS Control. NWAS Control then called NWFC and communicated the request for GMFRS officers at the scene.⁸⁴¹ I shall return to this in the sections dealing with NWFC and GMFRS’s responses in Part 15.

At 00:36, the same issue in relation to terminology recurred. Zoning was discussed again by CI Dexter and Stephen Hynes. CI Dexter made clear that the “cold” zone was not the whole Victoria Exchange Complex, but only outside it.⁸⁴²

At 00:39, GMFRS officer Station Manager Berry approached Stephen Hynes. Stephen Hynes informed Station Manager Berry that inside the station was a “warm zone”.⁸⁴³ By this, Stephen Hynes was intending to communicate that it was a Major Incident warm zone. Stephen Hynes was not intending to say anything about Operation Plato zoning as he did not know at this point that Operation Plato had been declared.⁸⁴⁴

By contrast, Station Manager Berry now knew of the Operation Plato declaration. Consequently, he interpreted what Stephen Hynes was saying as meaning that inside the station was an Operation Plato warm zone. This was capable of having implications relating to which GMFRS personnel were able to operate in that area.⁸⁴⁵

In the course of this conversation, Stephen Hynes asked Station Manager Berry to arrange for blankets to be collected and for firefighters to help P3 casualties who had been directed to the area across the road from the War Memorial entrance on Station Approach.⁸⁴⁶

At some point shortly after 00:50, Stephen Hynes spoke to Annemarie Rooney. In the course of that call, Annemarie Rooney informed Stephen Hynes that GMP had declared Operation Plato. By this point, Stephen Hynes had been on scene for approximately one hour. It was the first time he was made aware of the Operation Plato declaration.⁸⁴⁷

At 00:54, the first tri‑service discussion took place at the scene.⁸⁴⁸ This took place immediately after Stephen Hynes had spoken to Annemarie Rooney.⁸⁴⁹ The participants were Stephen Hynes for NWAS, CI Dexter for GMP and Station Manager Berry for GMFRS.⁸⁵⁰ Chief Fire Officer O’Reilly participated in part of the conversation via telephone. The content of some of that discussion was captured on CI Dexter’s Dictaphone.⁸⁵¹ I set out, in detail, what was said in the section relating to GMFRS’s response to the Attack in Part 15.

In terms of the chronology of Stephen Hynes’ involvement, it is not necessary for me to go beyond 01:00. He continued in his role as Operational Commander until after the last casualty was removed from the Casualty Clearing Station and all the ambulances had left.⁸⁵² While I have identified areas in which he should have done better than he did, overall it is important I acknowledge that Stephen Hynes did address a number of the JESIP failings that had occurred during the first hour and a half of NWAS’s response.

Resources allocated

By midnight, 41 ambulances had been allocated to the response. Within the following 30 minutes, another seven ambulances were allocated by NWAS Control. Nine more were allocated in the period between 00:30 and 00:50, although two of those were stood down.⁸⁵³

As at 01:00 on 23^rd May 2017, 55 ambulances had been allocated to respond to the Attack.⁸⁵⁴

Resources at scene

By midnight, a number of ambulances allocated to respond were being held at Manchester Central Fire Station. This meant they were available to be called forward if and when required.⁸⁵⁵

After the departure of the ambulance transporting John Atkinson to Manchester Royal Infirmary, there were 20 ambulances remaining on Hunts Bank. This number fluctuated over the following hour as ambulances departed to transport casualties to hospital and other ambulances arrived.⁸⁵⁶

At 01:00 on 23^rd May 2017, there were 23 ambulances at the scene and 26 patients in the Casualty Clearing Station.⁸⁵⁷

The high point in terms of number of ambulances at the scene came at 01:30 on 23^rd May 2017, when there were 32 ambulances in attendance.⁸⁵⁸

When the final casualty left the Casualty Clearing Station in an ambulance, there were 16 ambulances at the scene.⁸⁵⁹

Contribution of GMFRS

At 00:37, GMFRS personnel arrived on Station Approach.⁸⁶⁰ I shall deal with the circumstances in which this occurred when I address GMFRS’s response to the Attack in Part 15.

At 00:43, a firefighter was captured on CCTV carrying an oxygen bottle into the Victoria Exchange Complex.⁸⁶¹ Having spoken to Patrick Ennis on Station Approach, at 00:44 firefighters began to move trolleys and other equipment from ambulances into the Victoria Exchange Complex.⁸⁶²

Even at that relatively late stage, GMFRS was able to provide meaningful support to the NWAS response. This evidence only serves to highlight the importance of GMFRS’s arriving two hours earlier.

Transportation of P1 and P2 casualties to hospital

Table 4 shows how many casualties remained in the Casualty Clearing Station during the period after midnight.

Time (by)	Total casualties transported from Casualty Clearing Station	Total casualties remaining in Casualty Clearing Station	P1s remaining in Casualty Clearing Station	P2s remaining in Casualty Clearing Station
00:01	2	36	18	18
00:31	9	29	11	18
01:01	14	24	6	18
01:31	17	21	4	17
02:01	24	14	1	13
02:31	32	6	0	6
02:51	38	0	0	0

During the period from 00:01 to 01:01 on 23^rd May 2017, 12 of the remaining 36 casualties in the Casualty Clearing Station were taken by ambulance to hospital. They were all P1 casualties.⁸⁶⁴

During the period from 01:01 to 02:01 on 23^rd May 2017, 10 of the remaining 24 casualties in the Casualty Clearing Station were taken by ambulance to hospital.⁸⁶⁵ By 02:01, there was one P1 casualty remaining in the Casualty Clearing Station.

During the period from 02:01 to 02:51 on 23^rd May 2017, the remaining 14 casualties in the Casualty Clearing Station were taken by ambulance to hospital.

The fact that only P1 casualties were transported during the period up to 01:01 indicates that the triage system had become more effective in terms of the identification of priority.

I do not have sufficient evidence to determine whether, within the P1 category of casualties, there were any of greater need who were delayed. I accept as a general proposition the evidence of the Casualty Clearing Officer, James Birchenough, that a patient would need to be stabilised sufficiently to be able to travel safely to hospital.⁸⁶⁶

Conclusions on triage, treatment and transfer of P1 and P2 casualties

It was beyond the Inquiry’s terms of reference for me to carry out a detailed examination of the circumstances of each of those who survived. As such, I reach no conclusions in relation to the adequacy of care of any individual who survived the Attack.

As part of my assessment of the overall adequacy of the response, the evidence I heard enables me to reach some overarching conclusions about the running of the Casualty Clearing Station.

The Ambulance Service Experts’ opinion on triage was:
“Triage was accurate, followed NaSMED [sic: National Ambulance Service Medical Directors] requirements and patient distribution was excellent. Proper consideration was given to the allocation of patients to ambulances with appropriately qualified staff, destination, facilities, capabilities and capacity at hospitals and the elimination, as far as possible, of secondary transfers between hospitals.”⁸⁶⁷

The evidence bears this opinion out: speaking generally, P1 casualties were prioritised for transport to hospital from the Casualty Clearing Station. However, I do not have sufficient evidence to comment on any particular case.

The Ambulance Service Experts’ opinion on treatment and management of casualties was:
“The approach to care outside the City Room was generally in keeping with expectations. There was a good mix of highly skilled paramedical and medical staff present. Paramedics were on scene in numbers from around 23:08 …
However there were areas that could have been improved. …
Organisation (logistics / non-clinical management) of patients within the CCS [Casualty Clearing Station] …
Comfort of patients within the CCS (on floor).”⁸⁶⁸

It was accepted on NWAS’s behalf “that some patients were not always given information as to the process”.⁸⁶⁹

The evidence I received from survivors about their experience in the Casualty Clearing Station supports a conclusion that some were not adequately informed about the way it was intended that they would be managed and when they would be transported to hospital.⁸⁷⁰

In relation to the treatment and management in the Casualty Clearing Station of those who survived, I do not have sufficient evidence to justify criticism beyond the Ambulance Service Experts’ opinion. In saying that, I should not be understood to be commenting one way or the other on any other aspect of the adequacy of the care of those patients. If there was any inadequacy, it does not appear to me to have been as a result of a lack of suitably qualified people in the Casualty Clearing Station or their desire to help.

The Ambulance Service Experts’ opinion in relation to transfer to hospital was:
“Given proximity to designated hospitals, patient distribution although effective could have been faster in some cases … The dispatch of casualties from the CCS [Casualty Clearing Station] to hospital was effective and followed the patient dispersal plan … The CCS and dispatch process appears to have been well organised. In terms of timings, we are of the opinion that it may have been possible to put the transfer and dispatch arrangements in place quicker but this appears to us to be marginal and is unlikely to have made any significant difference to clinical outcomes.”⁸⁷¹

In its closing statement, NWAS accepted this evidence.⁸⁷²

At 02:00, there were 28 ambulances at the scene.⁸⁷³ There were 13 P2 and one P1 casualties left to transport to hospital. It took a further 50 minutes for the final casualty to depart the Casualty Clearing Station for hospital.⁸⁷⁴ In the cases of P2 casualties, their categorisation as P2 reveals that the need to stabilise them was less than in the case of casualties categorised as P1. There was no shortage of means to transport those patients.

On the face of it, there may have been undue delay by NWAS. However, I am not in a position to make a finding to this effect. I reach no conclusion about the clinical treatment or outcomes in the case of any of those who survived the Attack. I do not have a complete evidential picture about how they were managed or the transportation phase. However, I have sufficient concern that I invite NWAS to take a careful, objective look at whether things could have been done better. There was concern among a number of those treated in the Casualty Clearing Station that there was undue delay. As part of any review, I encourage NWAS to reflect carefully on the experiences of those people.⁸⁷⁵ In any event, in my view, steps should be taken by NWAS to try to bring such timings down in readiness for any future mass casualty situation that may occur.

Management of P3 casualties

Casualties categorised as P3 have less‑immediate clinical needs during a mass casualty situation than those in the P1 or P2 categories.⁸⁷⁶ Nevertheless, those in the P3 category can be in significant pain. P3 casualties require treatment. This may need to be in hospital. Even if correctly triaged as P3 initially, they may deteriorate, justifying re‑triage into a more seriously injured category.⁸⁷⁷

P3 casualties were directed to the area across Station Approach from the War Memorial. As their numbers grew, the space occupied by the P3 casualties spread towards Hunts Bank.⁸⁷⁸

The Casualty Clearing Officer, James Birchenough, stated in evidence that he thought concerns that P3 casualties were not treated as well as they should have been were justified.⁸⁷⁹

In its closing statement, NWAS agreed: “It is … accepted that those falling into the P3 category of patients and other ‘walking wounded’ could have been managed more effectively as part of the joint-agency response.”⁸⁸⁰

The Ambulance Service Experts identified that treatment of P3 casualties could have been improved.⁸⁸¹ In evidence, they suggested that “perhaps it would have been preferable for the operational commander to assign that [the P3 casualties] as a sector commander role, somebody that is purely responsible for that”.⁸⁸² In my view, that was a sensible suggestion and is one way in which improvement might have been made.

James Birchenough stated that the management of P3 casualties fell under the Operational Commander’s remit.⁸⁸³ In my view that is correct.

At 23:41, Annemarie Rooney asked Daniel Smith over the radio: “Do you want P3 numbers … ?” Daniel Smith replied: “[N]egative for now, we won’t be moving them for a while.”⁸⁸⁴ I have considered whether any deficiency in the way the P3 casualties were managed was Daniel Smith’s responsibility. I have concluded that it was not. He was Operational Commander until 23:57.⁸⁸⁵ Up to the point at which he was relieved, his focus was rightly on those requiring more immediate attention than casualties in the P3 category. He had a significant number of such patients to manage. By 23:57, only one P1 and no P2 casualties had left the Casualty Clearing Station for hospital.⁸⁸⁶ Daniel Smith had imposed structure on the scene: by directing where the P3 casualties should go. Student paramedics had been asked to go to that area.⁸⁸⁷ In my view, that was probably sufficient at that stage, in the circumstances, although in an ideal world more would have been done.

In my view, Stephen Hynes, as Operational Commander from 23:57, and NWAS, as an organisation, bear responsibility for the shortcomings in the way the P3 casualties were managed.⁸⁸⁸

Conclusion

NWAS personnel made an important and positive contribution to the emergency response. However, there were very substantial problems with the NWAS response to the Attack from a command perspective. There is one that bears repetition as, had it not occurred, the NWAS response is likely to have been much better than it was. That is, the fundamental failure to apply the JESIP five principles of joint working to command at the scene.

Daniel Smith failed to communicate and/or co‑locate with the GMP Operational/Bronze Commander, Inspector Michael Smith. As a result, there was no sharing of situational awareness between them and no joint assessment of risk by them. In turn, this meant that they did not co‑ordinate the responses of their agencies in the way they should have.

Had this failure not occurred, it is likely that more paramedics would have been deployed to the City Room. It is also likely that the evacuation plan from the City Room would have been substantially improved.

Although I have been highly critical of a number of decisions made by Daniel Smith, it is right that I acknowledge he did not receive the support he should have received from the Tactical Commander, Annemarie Rooney. In turn, she did not receive the support that she was entitled to from Neil Barnes, the Strategic Commander.