- The decision to contact the Greater Manchester Fire and Rescue Service (GMFRS) National Interagency Liaison Officer (NILO) before mobilisation was reasonable.
- There were repeated failures to pass on relevant information by North West Fire Control (NWFC) staff. Responsibility for this lies with NWFC. This failure contributed to GMFRS’s failure to arrive at the scene before 00:36 on 23rd May 2017.
- The NWFC Team Leaders should have acted when they realised the divergence in approach between GMFRS and other emergency services, by drawing it to the attention of GMFRS senior officers.
In Part 12, I addressed how NWFC prepared itself for an event such as the one that occurred on 22nd May 2017. In this section, I consider the key points of NWFC’s involvement in the response to the Attack. I do not provide an exhaustive rehearsal of all of NWFC’s actions. I have focused on the events that determined the direction of the involvement of GMFRS in the response.
I have adopted as chronological an approach as possible to NWFC’s response to the Attack. However, where appropriate I have grouped calls together where they are related to each other. I have used the start time of the calls when arranging this section. I have borne in mind that relevant information was not always passed on at the start of the call. Where appropriate, I have drawn attention to the stage of the call at which the key moments occurred.
NWFC staff on the night of the Attack
On the night of the Attack, the duty Team Leader was Michelle Gregson. Lisa Owen was in the role of administrative Team Leader. There were a number of Control Room Operators who took important calls. They were: David Ellis, Joanne Haslam, Dean Casey and Rochelle Fallon.
Also involved in important calls was Vanessa Ennis, a trainee. As at the night of the Attack, Vanessa Ennis had not been signed off as competent to act independently as a Control Room Operator. Rochelle Fallon was acting as Vanessa Ennis’s mentor. For this reason, for the purpose of the NWFC staff rota, Vanessa Ennis was not counted as one of the Control Room Operators.
When NWFC was first notified of the Attack at 22:34, Vanessa Ennis, her mentor Rochelle Fallon, and Michelle Gregson were having a meeting which may have resulted in Vanessa Ennis being signed off as able to act independently.
Rochelle Fallon stated that she believed Vanessa Ennis was competent to act unsupervised.Michelle Gregson, the Team Leader, disagreed. In a meeting at which Rochelle Fallon was not present, three days before the Attack, Michelle Gregson had expressed concerns about putting the control room in a vulnerable situation by including Vanessa Ennis as an independent Control Room Operator, due to the lack of opportunity to assess her.
Managers were also called out during the response. They travelled to NWFC from home. First to be notified was Operations Manager, Janine Carden. Janine Carden contacted Senior Operations Manager, Tessa Tracey. Tessa Tracey alerted Sarah‑Jane Wilson, the Head of NWFC.
Call from GMP Control (22:34)
At 22:31, David Ellis was in the course of a telephone call with GMP Control about an unrelated incident. At 22:34, GMP Control asked him if he had been told about “an explosion in the city centre”. Over the course of the next six minutes, GMP Control provided David Ellis with more information about the Attack.
He was told it was in the “foyer area of the Manchester Arena”. He was told that “a bomb has exploded” and that there were reports of 30 to 40 casualties.At 22:38, he was informed of the “RVP [Rendezvous Point] car park area outside the Cathedral”. At 22:39, David Ellis stated: “Just bear with me a second while I see if we need to get anyone on the wire, we just need to mobilise our officers.” He was provided with the BTP and NWAS log numbers.
As David Ellis was receiving this information, he was entering it into the NWFC system.“explosion”. He then selected the “Explosion” incident type, which was prompted by the system. This has an “Explosion” action plan associated with it. He did this because he understood this was the appropriate incident type for an exploded bomb.To do so, he had to create an entry for the incident (the Arena log). He started typing
In order to mobilise the pre‑determined resources under the “Explosion” action plan, David Ellis needed to take two further steps. First, he needed to select the “proposed resource” button. This would inform him of what resources were to be sent. The “Explosion” action plan required resources to be sent directly to the scene. The system would also send a pre‑alert automatically to the nearest fire station. The nearest fire station to the Arena was Manchester Central, which was less than a mile away. Second, he needed to initiate the mobilisation of the proposed resources.
David Ellis took the first step, but he did not take the second.“Explosion” action plan, because he was told not to by Lisa Owen.David Ellis did not initiate the mobilisation of the proposed resources to the scene, in accordance with the
In the early stages of the call with GMP Control, David Ellis had realised he was dealing with a very significant event. In accordance with his training, he raised his hand to attract the attention of the Team Leaders. There were two Team Leaders on duty that evening. One, Michelle Gregson, was in a meeting when the GMP call came in. The other, Lisa Owen, was sitting at the Team Leader position. For an understanding of the layout of the control room, see Figure 33 in Part 12. Lisa Owen approached David Ellis and reviewed his screen. At this point, David Ellis was advised not to mobilise resources until the on‑call NILO had been spoken to.This was at approximately 22:39.
Given the nature of the information that NWFC had received at this point, the decision not to mobilise immediately and first to call the NILO was reasonable.“Operation Plato Standby phase” incident type. If he had selected that incident type, the first prompt would have been to telephone the NILO before mobilising any resources.Although it did not occur to David Ellis to do this, for the reasons I gave in Part 12, it would have been reasonable for him to select the
The consequence of the decision not to mobilise to the scene immediately was a delay to the arrival of GMFRS at the scene. If mobilisation to the scene had been justified, NWFC was entitled to rely on the duty NILO to point this out immediately. The delay need not have been a long one provided there was rapid communication with the duty NILO and a quick decision from him.
David Ellis continued his call with GMP Control.“[W]e have an absolute load of officers going down.” A minute later, he was told: “[W]e’ve got an off duty PCSO [Police Community Support Officer] who is on scene.” At 22:43, he was informed that “ambulance state they have [up] to 5 vehicle on route as well” and “officers are now landing on scene”.At 22:40, David Ellis was told:
At 22:44, David Ellis raised the fact that NWFC had received reports of a “possible shooting”. This information came from NWAS Control in a call that I will deal with in paragraphs 15.32 to 15.39. In reply, GMP Control told David Ellis that the police were “getting reports of a shooting”. David Ellis said “so police, are you confirming this”. The response from GMP Control was, “Yeah police officer has just said injured party with gunshot wound to the leg.” David Ellis made an entry in the Arena log at 22:45: “**** POL HAVE CONFIRMED A GUNSHOT TO LEG OUTSIDE ENTRANCE TO VICTORIA STATION ****”.
In an update three minutes later, GMP Control stated, “[T]hese are not gunshot … not gunshot wounds … look like shrapnel wounds.” David Ellis made the following corresponding entry in the log at 22:48: “*** FROM POLICE – NOT GUNSHOT WOUNDS LOOK LIKS [sic] SHRAPNEL WOUNDS ****”.
At 22:49, GMP Control stated: “[W]e are in the booking office over the main bridge to the main entrance, looks like a bomb has gone off 30 casualties every available ambulance to here.” Having repeated this back to GMP Control, David Ellis said: “[W]e’ve got a muster point of Philips Park … we’ve got 4 pumps mustering there … we are going to use that as our holding point for now.”
Five minutes later, at 22:54, GMP Control informed David Ellis: “The paramedic bronze has just arrived on scene as well.” This was a reference to Patrick Ennis, an NWAS Advanced Paramedic whom Inspector Michael Smith, the GMP Operational/Bronze Commander, had mistakenly thought was the NWAS Operational Commander. When David Ellis asked whether this meant the “paramedic bronze” was at the Rendezvous Point (RVP), he was told: “No, I think he is actually at the scene.” GMP Control followed this up with: “He’s here now all NWAS to attend booking office asap.” GMP Control confirmed that NWAS was asking everyone to go to the booking office. This was repeated at 22:56, when GMP Control said, “all the ambulance crew have being [sic] sent to the booking office”.
At 22:57, David Ellis had an exchange with GMP Control during which David Ellis stated: “[E]verything we’re doing is going round Philips Park fire station.” He went on to say that NWFC would be contacting its senior officers and “we will be RVP and contacting your guys”. GMP Control replied: “Ok that’s not a problem.”
A couple of minutes later, the telephone call ended. Before it did, David Ellis asked, “are you ok to stay on the line? I’ve asked my team leader if I’m ok to stay, to keep a line open. Are you ok to do the same thing?” This was a sensible suggestion from David Ellis, even though it was not as efficient as using a multi‑agency control room talk group. That would have allowed all three control rooms to speak together, without occupying a telephone line. This was not an option open to NWFC. This was for two reasons. First, there was the failure by GMP, NWAS and GMFRS to make operational the proposed multi‑agency control room talk group. Second, there was the Force Duty Officer’s (FDO) failure, after he was informed of the Attack, to nominate a talk group for use by control rooms and notify them to dial into it.
The response to David Ellis by GMP Control was: “I’m going to have to clear the line because they said my silver controllers will be getting back in contact with you.” The phrase “silver controllers” was a reference to contact from the Silver Control Room at GMP Headquarters (GMP HQ). At this time, Ian Randall, the GMP Force Duty Supervisor, was getting ready to leave GMP Control to set up the GMP Silver Control Room.
The call was ended. From about 23:40, the Silver Control Room began to be operational.NWFC did not receive a call of any substance from the GMP Silver Control Room prior to GMFRS’s arrival at the Victoria Exchange Complex at 00:36 on 23rd May 2017. Shortly before 00:00, a radio operator in the GMP Silver Control Room performed a check to see if NWFC and NWAS were monitoring the proposed multi‑agency control room channel. This was the extent of the contact before 00:36 from the Silver Control Room.
The circumstances in which this telephone call between GMP Control and NWFC ended, and the subsequent lack of contact, was a failure on the part of GMP. It was inevitable that it would take a substantial amount of time to establish the GMP Silver Control Room. It would have been better if GMP Control had stayed on the line with David Ellis in order to continue the sharing of situational awareness.
David Ellis’s user handle on the NWFC system was 50061.As information was given to him, David Ellis added to the NWFC log under that user handle. He captured the substance of all the matters I have set out above.
By 23:00, David Ellis’s entries in the Arena log made clear that police officers and NWAS staff were being directed to, and had arrived at, the Victoria Exchange Complex. At 22:43, he entered into the log: “SEVERAL OFFICERS ALLOCATED AND MAKING WAY”. One minute later, he added: “AMB HAVE 5 VEHICLES ON ROUTE – POL HAVE ADVISED OFFICER LANDING ON SCENE”. At 22:46, he wrote: “POL ADVISED MORE OFFICERS ARRIVING ON SCENE”. At 22:55, he recorded: “** PARAMEDIC BRONZE COMMANDER IS AT SCENE **”. At 22:58, he input: “ALL THE AMB HAVE BEEN DIRECTED TO THE BOOKING OFFICE”.
So far, communication was working in accordance with the expectations of the Joint Emergency Services Interoperability Principles (JESIP). GMP Control had received reports from the scene. GMP Control had conveyed these reports to NWFC. NWFC had recorded the reports on its incident log.
The exception to this is that David Ellis did not ask GMP whether it had received a METHANE message. If he had, it is possible it would have prompted GMP to seek one. I am not critical of David Ellis for this. It was not an embedded part of NWFC operation at the time, in circumstances such as these, to ask for one.It should have been.
Call from NWAS Control (22:37)
While David Ellis was on the telephone to GMP Control, at 22:37, NWFC Control Room Operator Joanne Haslam received a call from NWAS Control. Joanne Haslam was informed by NWAS Control that a “bomb had gone off” at the “MEN Arena”. In the course of the call, Joanne Haslam made entries on the Arena log. Joanne Haslam’s user handle was 50032.
Joanne Haslam also relayed to NWAS Control the information that GMP Control had given to David Ellis. This included telling NWAS that GMP had declared an RVP.In doing this, Joanne Haslam was doing what was expected of her by JESIP.
At one point in the call, NWAS Control suggested that there might have been an “active shooter”. Joanne Haslam carefully and calmly explored this information with NWAS Control, establishing that this had not been confirmed by the police. Joanne Haslam also relayed to NWAS Control the information from GMP Control that the previously reported gunshot wounds were shrapnel injuries.
At 22:49, Joanne Haslam concluded the call. While that call was taking place, NWAS declared a Major Incident,Patrick Ennis reported to NWAS Control that the best access was Hunts Bank, and NWAS Control was in the process of mobilising ambulance personnel to Manchester Central Fire Station and the scene. This information was not passed to NWFC by NWAS Control. It should have been.
Joanne Haslam did not ask whether NWAS had received a METHANE message. Patrick Ennis provided a METHANE message five minutes after this call ended, so there was not yet one for NWAS to share.Nevertheless, asking for a METHANE message should have formed an automatic part of Joanne Haslam’s approach, particularly as the Arena log marked that ambulances were going to the scene. As I explained in paragraph 15.31, responsibility for this omission lies with NWFC.
Joanne Haslam could have asked whether NWAS had declared a Major Incident. She explained to me, when asked about METHANE messages, that she “felt like the operator I was speaking to was panicky and I felt like the questions I was asking, I wasn’t getting clear answers back”. Having listened to the call, I accept Joanne Haslam’s evidence. It was a difficult call which she managed well in the circumstances. While it would have been better if Joanne Haslam had asked NWAS Control whether NWAS had declared a Major Incident, I am not critical of her for not doing so.
Joanne Haslam did not inform NWAS Control that fire appliances were being mobilised to Philips Park Fire Station. At 22:40, Joanne Haslam can be heard saying to NWFC colleagues, “I’m still on hold at the moment to the ambulance just finding out further information. I know David is turning out on it.” Less than two minutes after this, the GMFRS duty NILO had issued the instruction to mobilise fire appliances to Philips Park Fire Station.
At 22:48, approximately one minute before Joanne Haslam ended the call, Michelle Gregson created a new log for the Philips Park mobilisation (the Philips Park log).
Call from GMP Control (22:40)
At 22:40, NWFC received a second call from GMP Control. This call was answered by the Control Room Operator Rochelle Fallon. The call was just over two minutes long. There was an exchange of incident log numbers. At 22:40:43, the GMP incident log number was entered on the Arena log.“Do you have any additional information on it [the incident]?” She was told 30 to 40 people had been injured following an explosion at the Arena. This information had been given to GMP by Paul Johnson, the SMG Fire Safety Officer, who had called GMP immediately after the explosion.At 22:40:48, the NWFC incident log number was entered into the GMP incident log. Following this, Rochelle Fallon asked:
While the call between GMP Control and NWFC was going on, Inspector Smith contacted GMP Control and said, “rather than the RV point, can you ask officers to make it to the scene directly”.
GMP Control informed Rochelle Fallon that the RVP “is car park area outside cathedral”. Rochelle Fallon confirmed that NWFC already had that fact recorded.
In fact, as I set out in Part 13, Inspector Smith had passed a message to GMP Control at 22:40:45, by which he intended to change the RVP to Manchester Victoria Railway Station. Inspector Smith’s message at 22:40 to GMP Control was not relayed to NWFC at any point.
It is possible that if NWFC had been provided with the updated RVP this would have improved GMFRS’s response. The effect of the change in RVP was to move the location for where the emergency services should have come together from a place several hundred metres away from the Victoria Exchange Complex to the scene itself. From this, it could have been inferred that, following initial caution, the scene had now been determined to be an appropriate and sufficiently safe area for the non‑specialist emergency services personnel to co‑locate. That interpretation of the change in RVP was capable of informing the duty NILO’s decision‑making in the course of the calls he had with NWFC prior to 23:00.
Towards the end of the call, GMP Control informed Rochelle Fallon: “[W]e’ve got the RVP. We’ve got all our supervision there and all the … all our officers going as well.” This information was consistent with what David Ellis was simultaneously being told during his ongoing call with GMP Control. By the time this information was provided to NWFC, GMP officers were responding to Inspector Smith’s message at 22:40 that they should attend the scene.
Call from member of the public (22:41)
During Rochelle Fallon’s call with GMP Control, a member of the public who had called 999 was connected to NWFC. The call was answered by the Control Room Operator Dean Casey. The connection to NWFC appears to have been a mistake by the person triaging the 999 call. The member of the public stated, to Dean Casey, that he had asked for the ambulance service.
The member of the public informed Dean Casey of injured people in the area of the NCP car park within the Victoria Exchange Complex. Dean Casey was informed, “It sounded like a big blast and looking at the people, I would suggest it’s a dirty bomb of some description.”
Call from BTP Control (22:44)
At 22:44, Vanessa Ennis answered a call from BTP Control.Because Rochelle Fallon was on another call at the time, she was not supervising Vanessa Ennis during the call with BTP.
Michelle Gregson stated in evidence that on the night of the Attack, because Vanessa Ennis had not been signed off as competent to act independently as a Control Room Operator, she informed Vanessa Ennis to “step back”. Rochelle Fallon stated that she was unaware of that instruction being given at the time. Rochelle Fallon stated in evidence that she had told Vanessa Ennis, “I’m not going to be able to listen to your calls, I’m going to have to take calls myself … If anybody tells you anything, just tell everybody.”
The fact that Rochelle Fallon did not register a clear instruction from Michelle Gregson is significant. Further, it is unlikely that anyone in such a position would act as Vanessa Ennis did, by answering and making calls, if they understood that they had been firmly instructed by a Team Leader that they were forbidden from doing so.
I accept that Michelle Gregson gave some direction to Vanessa Ennis about not taking or making calls. However, I find that Michelle Gregson did not give a sufficiently clear instruction to Vanessa Ennis that she should not have any further involvement in events on 22nd May 2017.
Vanessa Ennis should not have been put in the position she was in. I accept that it was Rochelle Fallon’s view, given how close she was to the end of her training, that Vanessa Ennis was competent to handle calls.However, she had not been signed off as ready, she was not part of the NWFC roster for that night and NWFC was in the midst of managing an extremely complex and difficult situation. If Rochelle Fallon was too busy to provide supervision to Vanessa Ennis, which was a reasonable view for Rochelle Fallon to take, Vanessa Ennis should have been told to step away from the telephones and take further instructions from the Team Leaders.
In the call at 22:44, BTP Control asked Vanessa Ennis if NWFC was aware of the reports from the Arena. She confirmed that NWFC was. She asked BTP Control for the BTP incident log number. Vanessa Ennis then went on to say: “WOULD YOU LIKE ME TO CALL YOU BACK WHEN I HAVE GOT SOME MORE INFORMATION?” She and BTP Control agreed that she would.
At no stage in the call did Vanessa Ennis ask BTP Control what information BTP had on the incident. She should have done so.Given her inexperience, it was not her fault that she did not. Responsibility for this lies with Michelle Gregson and Rochelle Fallon.
I am also critical of BTP Control for not offering the information it had. At 22:44, BTP was the only emergency service with personnel in the City Room. The BTP incident log, by this stage, recorded highly relevant information for GMFRS, including: BTP’s Major Incident declaration; that a METHANE message was being sought; that GMP had 15 units making their way to the scene; that GMP firearms officers were on the scene; and, before the call concluded, it also contained the fact that BTP had declared an RVP at Fishdock car park.
None of this information on the BTP incident log was provided to NWFC in this call. As a result, none of this information was available to be passed on to Station Manager Andrew Berry or any other GMFRS officer. Despite the shortcomings in NWFC’s training of its Control Room Operators, it is likely that, had a more experienced person than Vanessa Ennis answered this call, this information would have been given to NWFC.
Call from Lancashire Fire and Rescue Service officer (22:55)
At 22:55, Rochelle Fallon received a call from a Lancashire Fire and Rescue Service (LFRS) officer. The caller informed Rochelle Fallon that he had received a call from relatives who were at the Arena. He said that one of his relatives was injured, and that there were other casualties and fatalities. He stated: “[T]hey need the paramedics there sharpish at the main entrance to the stairs.”Rochelle Fallon informed the LFRS officer that she would contact NWAS.
Calls from NWFC to other emergency services before 23:30
Call to NWAS Control (22:57)
As soon as the call with the LFRS officer ended, Rochelle Fallon telephoned NWAS Control. She passed on the information received in her previous call. Rochelle Fallon reported one of the entries in the Arena log: “ALL THE AMBULANCE HAVE BEEN DIRECTED TO THE BOOKING OFFICE.” In response, NWAS Control asked: “ARE YOU GUYS ON SCENE?” Rochelle Fallon replied that GMFRS was not on the scene. She referred to the need for a specialist unit, possibly the terrorist unit. The call concluded with Rochelle Fallon providing NWAS Control with an update from GMP about certain injuries being shrapnel not gunshot wounds.
There were JESIP elements to this call from NWFC’s point of view. Rochelle Fallon passed on the information she had received from the LFRS officer. She also reviewed the Arena log and passed on significant information, such as the latest information on whether or not there was an active shooter. However, she did not pass on to NWAS any information about GMP deployments; she did not check that NWAS was aware of the RVP the police had declared; and, like Joanne Haslam, she did not inform NWAS that the fire appliances had been mobilised to Philips Park Fire Station. She received the first two pieces of information from GMP Control fewer than 20 minutes earlier. They were also recorded on the Arena log. Rochelle Fallon should have provided this information to NWAS Control. NWFC bears responsibility for these omissions due to the failure to embed the practicalities of JESIP in the responses of the Control Room Operators.
From the point of view of NWAS Control, there were also key pieces of JESIP information that were omitted. NWAS Control failed to inform Rochelle Fallon of either NWAS or BTP’s Major Incident declarations. NWAS Control did not inform Joanne Haslam of the content of Patrick Ennis’s 22:54 METHANE message. NWAS Control did not provide Rochelle Fallon with any information about its approach to RVPs.
Rochelle Fallon’s omissions were not capable of adversely affecting NWAS’s response. By 22:57, NWAS had already committed to an approach that would not have changed had Rochelle Fallon provided all the information she should have reported. By contrast, the information NWAS Control omitted was capable of influencing subsequent decisions by GMFRS, provided it was relayed on by NWFC. However, given that GMFRS did not act on the information it was provided with by NWFC, I consider that this missing information would have been unlikely to have made a difference.
Call to GMP Control (23:02)
Having relayed the information received from the LFRS officer to NWAS, Rochelle Fallon telephoned GMP Control. She provided GMP Control with the information from the LFRS officer. Rochelle Fallon stated, “I’ve let ambulance know … but obviously just sharing all information.”
Rochelle Fallon’s actions provide a good example of the need for a multi‑agency talk group for control rooms. It was not efficient for Rochelle Fallon to have to contact NWAS Control and GMP Control in order to provide them both with the same information. This was not her fault.
Rochelle Fallon provided GMP Control with the information from NWAS about the number of casualties. GMP Control provided Joanne Haslam with GMP’s understanding of the casualties. They discussed the information each had in relation to the issue of an active shooter.
Rochelle Fallon did not provide GMP Control with any information about NWAS deployment or GMFRS deployment. GMP Control did not provide any information to Rochelle Fallon about GMP deployment or NWAS deployment. There was no discussion about METHANE, Major Incident declaration or RVPs. By this stage, over 30 minutes had passed since the Attack. The location of a Forward Command Post (FCP) should have been firmly in the minds of all inter‑agency communication in relation to the incident. All of these topics should have been covered, however briefly. I regard NWFC as being responsible for the fact that Rochelle Fallon did not discuss these things.
Call to BTP Control (23:17)
Vanessa Ennis’s call with BTP Control at 22:44 ended with her offering to call back with further information. At 23:17, she did so. She notified BTP Control that the RVP for GMFRS was Philips Park Fire Station. BTP Control responded by enquiring if anything further was required or if the call was just for their information. Vanessa Ennis stated that it was just for information purposes.
Neither BTP Control nor Vanessa Ennis sought to share any other information. This was an opportunity for them both to do so. Since the 22:44 call, the BTP incident log had been updated to include: “AMBO – WE HAVE BEEN ASKED TO RVP AT HUNTS BANK BY THE BOOKING OFFICE”, “ALL AVAILABLE PARAMEDICS ATTENDING”, “RVP – FISHDOCK CARPARK – GMP GOING TO SEARCH”, “AMBO COMMANDER ON SCENE” and “6/7 AMBO ON SCENE”.
Also recorded on the BTP log at 23:04 was BTP Sergeant David Cawley’s METHANE message. This included a reference to a fire and rescue service, which BTP Inspector Benjamin Dawson, who made the entry, intended to indicate that the local fire and rescue service was required at the scene.
NWFC also had other information that could have been shared. By reason of having officers at the scene, BTP already knew what NWFC knew. However, that was not a reason for information not to be offered. Given her trainee status, it was not Vanessa Ennis’s fault that she did not seek to provide an update. Responsibility for that lies with NWFC.
BTP was also at fault for not seeking to provide important information to NWFC. While NWFC had already been told much of that information, it was still a significant failure by BTP not to provide it. In contrast to BTP, NWFC and GMFRS had no personnel at the scene. Consequently, NWFC and GMFRS were entirely dependent on others for situational awareness. Further information confirming what NWFC already knew was capable of giving GMFRS decision‑makers greater confidence in their decision‑making about deployment.
Many of these problems would have been avoided if there had been a multi‑agency control room talk group on the night of 22nd May 2017. There should have been one.
Contact with GMFRS duty NILO before 23:00
Call to Station Manager Berry (22:40)
The GMFRS duty NILO on the night of 22nd May 2017 was Station Manager Berry. At 22:40, he was telephoned by NWFC Team Leader Michelle Gregson. Lisa Owen had spoken to Michelle Gregson immediately after telling David Ellis not to mobilise. They agreed that calling the duty NILO was the appropriate next step. As I have said, I regard this as being a reasonable decision.
Before telephoning the duty NILO, Michelle Gregson made an announcement to the rest of the control room, “to remember any information they received in relation to the incident and were not sure if and who to share it with to refer to me or Lisa [Owen] and to remember our JESIP training and multi-agency working”. This was a sensible announcement for Michelle Gregson to make. However, the fact that this timely reminder was given makes the subsequent failures in communication all the more stark. Having made that announcement, Michelle Gregson telephoned Station Manager Berry.
The conversation began with Michelle Gregson informing Station Manager Berry of reports of an explosion. She told Station Manager Berry the police “are saying it is a bomb”. She said that the police had provided an RVP of “the car park area outside the cathedral”. Shortly afterwards, she said, “obviously we are not mobilising at the moment”. Michelle Gregson asked Station Manager Berry if he could speak to the police.
The use of the word “obviously” was unfortunate. It implied that the decision not to mobilise immediately to the GMP RVP was inevitable. It may have been so in Michelle Gregson’s mind, but it was not a decision that resulted from following any particular action plan. As the Fire and Rescue Expert put it, the decision not to mobilise “was presented [to Station Manager Berry] as a fait accompli”. It would have been better if Michelle Gregson had not used the word “obviously”. On the other hand, whether to mobilise was a decision for Station Manager Berry to make. He should not have been unduly influenced by the use of the word “obviously” by Michelle Gregson.
Station Manager Berry asked about the RVP and then said, “but we would normally muster them [the fire appliances] at one of the stations wouldn’t we?” He went on to comment that Manchester Central Fire Station was too close. Station Manager Berry settled upon telling Michelle Gregson that NWFC was to muster four fire appliances at Philips Park Fire Station “for now”. He stated that he was going to speak to the FDO.
Michelle Gregson said that she was “thrown” by Station Manager Berry’s suggestion about what would normally occur as she was not aware that that was the procedure. Her response was “Right, ok.” She did not say that, so far as she was aware, what he was suggesting would not normally occur. It would have been better if she had. As Team Leader, Michelle Gregson was of sufficient seniority to be expected to speak up immediately if she believed that Station Manager Berry was not correctly expressing the expected procedure.
At the end of the call, Michelle Gregson did not anticipate that Station Manager Berry would have any difficulty contacting the FDO.GMP had known for a significant period of time that the FDO may become uncontactable in an event such as the Attack. Steps could and should have been taken to ensure that this single point of failure was avoided.
Shortly after the call with Station Manager Berry ended, Michelle Gregson contacted Philips Park Fire Station. She informed Watch Manager Neil Helmrich that Philips Park Fire Station had been made a muster point and “we are just onto the Force Duty Officer at the moment for the police, confirming further incident details”.
At 22:48, Michelle Gregson created the Philips Park log.Her explanation for creating a new incident log was because the incident log created by David Ellis was recorded against the Arena address and had an RVP of the car park area outside the Cathedral. She stated that mobilising resources against that incident log would result in them automatically being sent to one of those two locations.
Michelle Gregson accepted, in evidence, that she could have amended the RVP to Philips Park Fire Station. This was not something that occurred to her at the time. I am not critical of Michelle Gregson for this. This situation had not been considered in any of her training.I am critical of NWFC for this situation. By the end of this incident, there were four incident logs. The creation of multiple incident logs for the same incident risked key information being overlooked by control room staff.
As a result of Michelle Gregson’s mobilising instruction, fire appliances from Manchester Central Fire Station, less than one mile from the Victoria Exchange Complex, began to drive in a direction away from the Arena. At 22:54, they arrived at Philips Park Fire Station.
Call to Station Manager Berry (22:44)
Rochelle Fallon called Station Manager Berry at 22:44. She did so because two minutes earlier she had received a call from a member of the Specialist Response Team.She tried to transfer that call to Station Manager Berry, but had been unsuccessful. As a result, Rochelle Fallon telephoned Station Manager Berry to pass on the message.
The call Rochelle Fallon made to Station Manager Berry at 22:44 connected to his answerphone. Rochelle Fallon left him a message. In that message, she informed Station Manager Berry of the call from the Specialist Response Team. Her message went on to say: “We’ve just literally had a call from ambulance now, stating that people are being shot.” This was a reference by Rochelle Fallon to the call Joanne Haslam took from NWAS at 22:38, which was ongoing as Rochelle Fallon was leaving her message for Station Manager Berry. Rochelle Fallon had taken this information from the Arena log.
Rochelle Fallon was correct to seek to provide Station Manager Berry with an update from the Arena log. She stated that she chose to pass on “what I’d seen and what information I thought was important”.
Station Manager Berry did not listen to this message until after all of the events of that night were over.
Call from Station Manager Berry (22:48)
At 22:48, as Michelle Gregson was creating a Philips Park log, Station Manager Berry telephoned NWFC. He spoke to Control Room Operator Dean Casey. Station Manager Berry began the call by saying, “I’ve been trying to get hold of the Force Duty Officer, but they’re not picking up for obvious reasons, they’re probably really busy.” Station Manager Berry asked to be told “what other information we’ve got about this incident”.
Dean Casey told Station Manager Berry that there were “over 60 casualties” and “reports that there’s an active shooter”. Seconds before Dean Casey provided this information, David Ellis had updated the Arena log to include “*** FROM POLICE – NOT GUNSHOT WOUNDS LOOK LIKS [sic] SHRAPNEL WOUNDS ****”.
Also included on the Arena log, before the call between Dean Casey and Station Manager Berry, was “AMB HAVE 5 VEHICLES ON ROUTE – POL HAVE ADVISED OFFICER [sic] LANDING ON SCENE” and “POL ADVISED MORE OFFICER [sic] ARRIVING ON SCENE”.
Dean Casey failed to communicate the content of these three entries on the Arena log. They were highly relevant to the decisions that Station Manager Berry had to take. They went to the heart of whether or not it was safe to mobilise firefighters to the scene. If Dean Casey had told Station Manager Berry that the police and paramedics were travelling to the scene, it is possible that he would have reviewed his decision to mobilise firefighters to Philips Park Fire Station.
Dean Casey accepted, in evidence, that he should have shared this information with Station Manager Berry. He was not certain whether or not his screen had refreshed and the updated log was visible to him.This may provide the explanation for Dean Casey not seeing the entry in relation to shrapnel, which was made during his conversation with Station Manager Berry. However, the information indicating that the police and paramedics were attending the scene was input prior to the entry that he read out to Station Manager Berry.
Information was constantly being entered into the Arena log. For an incident like the Attack this is to be expected. NWFC staff should have been trained to refresh their screens constantly, so that they could have the latest information. They should also have been better trained in reviewing the log in a careful and systematic way in order to pick up any earlier relevant information.
Dean Casey was not alone in failing to pass on important information. The number of occasions on which important information was not passed on reveals that NWFC training of its staff was not good enough in this area.I will return to this when I have completed my review of other important contact between NWFC and GMFRS.
After Dean Casey’s update, Station Manager Berry informed him that the GMFRS capability for a Marauding Terrorist Firearms Attack had been mobilised to Philips Park Fire Station.
Call from Station Manager Berry (22:52)
Shortly after Station Manager Berry’s call with Dean Casey, Station Manager Berry telephoned NWFC again, at 22:52. The call was answered by Vanessa Ennis.For the reasons I have given, Vanessa Ennis should not have been the person to answer the call from Station Manager Berry. It was not her fault that she did. In the event, her inexperience probably did not make any difference to the content of the call.
Station Manager Berry did not ask Vanessa Ennis for an update. Vanessa Ennis did not offer one. The purpose of Station Manager Berry’s call was to notify NWFC that three NILOs should be allocated to the incident.
This call was an opportunity for Station Manager Berry to be provided with the information that Dean Casey had previously omitted to give to Station Manager Berry. I am not critical of either Vanessa Ennis or Station Manager Berry for the fact that this opportunity was missed. NWFC should have ensured that their staff always offer a situation report or update when speaking to a GMFRS officer.
The NWFC training was that staff should offer an update, if they were not asked for one.This training had not been assimilated, as was revealed by the events of 22nd May 2017. NWFC should have done more to ensure that the offering of updates formed part of every call.
Had an update been offered, Station Manager Berry may not have wanted to receive it: he had spoken to Dean Casey only three minutes earlier. He may have asked only to be updated on anything new. Despite this, the importance of passing on information is such that an offer of an update should have been a standard part of this particular, and all, conversations.
Call from Station Manager Berry (22:57)
At 22:57, Station Manager Berry telephoned NWFC again. The call was answered by Joanne Haslam. Station Manager Berry was told by Joanne Haslam that the GMFRS duty Group Manager, Dean Nankivell, had been spoken to. Joanne Haslam told Station Manager Berry that Group Manager Nankivell wanted the Technical Response Unit mobilised to Philips Park Fire Station. I will address that call in paragraphs 15.114 to 15.120. Station Manager Berry confirmed that he had mobilised the capability for a Marauding Terrorist Firearms Attack and had allocated three NILOs to the incident.
Station Manager Berry did not ask for an update and he was not given one. By 22:57, the Arena log did include “** PARAMEDIC BRONZE COMMANDER IS AT SCENE **”. Joanne Haslam knew this: she had informed Group Manager Nankivell of that fact seconds earlier. She stated that she was not aware that Station Manager Berry did not know this fact. She assumed that he did know. Joanne Haslam should have given Station Manager Berry this information. It is another example of the lack of effectiveness of NWFC’s training in relation to offering updates.
Had Joanne Haslam offered an update, she may have included information that Station Manager Berry had not been given, specifically David Ellis’s entry in the Arena log that the injuries thought to have been caused by gunshots were shrapnel wounds.
NWFC had failed to embed in its staff the practice of offering updates to GMFRS officers, just as GMFRS had failed to embed in its staff the practice of asking for updates.
The fact that NWAS had a Commander “at scene” was highly significant information. Station Manager Berry had made mobilisation decisions for GMFRS on the basis that the scene was not a safe place for them to go. Had he been updated, it may have caused him to reflect on his approach.
Mobilisation of senior NWFC staff
Call to Operations Manager (22:44)
At 22:44, Lisa Owen called Janine Carden. Janine Carden was the Operations Manager at NWFC.Ordinarily, the activity of the control room at NWFC was managed by a Team Leader. However, for a serious incident such as the Attack, under the NWFC escalation policy it was appropriate for the Operations Manager to be contacted.
Lisa Owen reported to Janine Carden that there had been an explosion at the Arena. She gave the number of known casualties. Lisa Owen explained that Station Manager Berry had directed appliances to Philips Park Fire Station. Reading from the Arena log, Lisa Owen reported that there were “GUN SHOP [sic] WOUNDS AS WELL”. Janine Carden asked the question “WHAT TALK GROUPS IT [the incident] ON?” Lisa Owen responded, “AT THE MOMENT WE HAVENT TURNED OUT WE ARE JUST CREATING.” The call concluded with Janine Carden informing Lisa Owen that she was coming into NWFC.
Janine Carden then made her way to NWFC, arriving at around 23:09.She received a briefing from Michelle Gregson and read the three incident logs that had been created. Having done so, at around 23:30, Janine Carden took charge of the management of the incident on behalf of NWFC. She did not announce that fact to the control room or record it on the incident log. At the time, it was not NWFC policy that she should do so. The policy should be improved to include this.
Janine Carden was in charge of NWFC’s response for the duration of the second hour.
Contact with Senior Operations Manager (22:48)
At 22:48, Janine Carden sent a text message to her superior, Senior Operations Manager Tessa Tracey. The text message read: “Tessa, on way into Control. Incident in Manchester Arena and Victoria Train Station. Dirty bomb and gunshots, 30 casualties.” Tessa Tracey did not see the text message from Janine Carden straight away but called her when she had seen it a few minutes later and spoke to her briefly.
Tessa Tracey called Michelle Gregson at 23:08. Michelle Gregson provided a summary of the information NWFC had received. In respect of David Ellis’s call with GMP Control, she stated: “We asked David to stay on the phone to get the JESIP information … because I said this ‘we’ve got to share the information and make sure we get everything’.” At the end of the call, Michelle Gregson commented that Janine Carden had “just arrived now”.
Michelle Gregson’s comment about “JESIP information” demonstrates that she understood, at the time, what NWFC’s role was on the night of the Attack. It was not, therefore, a lack of understanding on the part of NWFC management of what was required that led to the communication failures by NWFC. Those failures were caused by a lack of understanding on the part of the Control Room Operators. The Control Room Operators’ lack of understanding was a product of a lack of training and exercising.
After her call with Michelle Gregson, Tessa Tracey set off for NWFC. En route, she spoke to Sarah‑Jane Wilson, the Head of NWFC.Tessa Tracey travelled from her home, which was about 40 miles away from NWFC. On the way, she was delayed by roadworks. She arrived at NWFC at 00:18 on 23rd May 2017. Very shortly before she arrived at NWFC, GMFRS had begun to deploy resources to the scene for the first time.
Notification of the Head of NWFC (23:15)
At 23:15, Sarah‑Jane Wilson was notified of the incident via a telephone call from Tessa Tracey. Sarah‑Jane Wilson decided to travel in to NWFC. She arrived at 00:01 on 23rd May 2017.She did not relieve Janine Carden, but acted in a supporting role.
Initial calls with GMFRS duty Group Manager
Call to Group Manager Nankivell (22:52)
On the night of the Attack, Group Manager Nankivell was on call. His role as duty Group Manager was to provide support to an incident. When required, he was expected to travel to the Command Support Room at GMFRS HQ.At 22:52, Group Manager Nankivell was telephoned by Joanne Haslam.
At the start of the call, Joanne Haslam provided Group Manager Nankivell with a situation report. At one point during this report, Group Manager Nankivell interrupted to ask, “[H]as anyone declared a major incident or anything on this yet?” By the time Group Manager Nankivell asked this question, both NWAS and BTP had declared a Major Incident. Joanne Haslam had just finished speaking to NWAS Control. She replied, “no as far as I know”.
Group Manager Nankivell’s question about the Major Incident cut Joanne Haslam off as she was informing Group Manager Nankivell of the location of the RVP. She got as far as saying, “The rendezvous car park …”. The only other reference to an RVP was a little later in the call when Joanne Haslam said, “[W]e’ve created a job because they’ve got a rendezvous point.” She went on to say, “[W]e’ve created a job at Philips Park Fire Station.” As a result, Group Manager Nankivell was not told that the police had declared an RVP at the car park area by the Cathedral, a short distance from the Victoria Exchange Complex.
Group Manager Nankivell informed Joanne Haslam that he intended to call the Assistant Principal Officer. He also instructed Joanne Haslam to mobilise the Technical Response Unit to Philips Park Fire Station.
Shortly before the end of the call, Joanne Haslam stated: “Also another little message gone on, there’s a paramedic bronze commander is at the scene.” Group Manager Nankivell agreed, in evidence, that this was important information. He agreed that it revealed that NWAS had a command presence at the scene. He also agreed that “this was an indication that the Fire and Rescue Service should also be at the scene”.
Group Manager Nankivell stated that he “failed to acknowledge” the information, as he was thinking about his next actions. The content of the call bears this out. I accept Group Manager Nankivell’s evidence. He did not register and process the information he was given. As a result, he did not communicate it to anyone else or act upon it in any way.
It was a failing on Group Manager Nankivell’s part that he did not realise the significance of what he was being told.However, it is inevitable that such individual lapses will occur in the course of a response to an emergency of the magnitude of the Attack. What is important is that the system operates in such a way as to provide safeguards against an individual lapse in concentration. In this situation, the simple safeguard was to ensure that all NWFC operatives informed all the GMFRS personnel they spoke to of all vital information. On the night of the Attack, Group Manager Nankivell was the only GMFRS officer informed that the NWAS Operational Commander was at the scene.
Call from Group Manager Nankivell (23:06)
At 23:06, Group Manager Nankivell called NWFC and spoke to Joanne Haslam. His call was in response to a telephone message left by Joanne Haslam. In the telephone call, Joanne Haslam informed Group Manager Nankivell that, although Station Manager Berry had requested three additional NILOs to be allocated to the incident, only two had been identified: Group Manager Carlos Meakin and Group Manager Ben Levy. Group Manager Nankivell instructed Joanne Haslam to leave the position as just two further NILOs.
Call to Group Manager Nankivell (23:11)
At 23:11, Joanne Haslam called Group Manager Nankivell. The purpose of the call was to update him on mobilising decisions. Group Manager Nankivell informed NWFC that Chief Fire Officer Peter O’Reilly was making his way to the Command Support Room.
Initial contact with GMFRS additional NILOs
Call to Group Manager Meakin (23:10)
Group Manager Meakin was one of a number of on‑call incident commanders.He was also qualified as a NILO. At 23:06, he received a pager message from NWFC mobilising him to Philips Park Fire Station. The pager message was sent at 23:03 by Joanne Haslam. It was the result of Station Manager Berry’s instruction at 22:52 to increase the number of NILOs involved in the incident by three. In an incident of this nature, a 14‑minute delay between instruction and the mobilising message coming through is too long.
The pager message included: “NILO THREE AND MTS CAPABILITY 2 TO RVP AT PHILLIPS PARK.” The reference to ‘MTS’ was a typographical error. It should have read ‘MTFA’. Group Manager Meakin suspected this when he read it. He tried to contact NWFC, but could not get through.
At 23:10, Rochelle Fallon telephoned Group Manager Meakin. She provided a summary of the incident including that GMFRS was being mobilised to Philips Park Fire Station. She did not inform Group Manager Meakin of a significant amount of relevant information. This included the fact that NWFC had been told that paramedics and police officers had been deployed to the scene, that NWAS had a “Bronze Commander” on the scene by 22:55, and that GMP had provided an RVP near the scene.
Rochelle Fallon stated that she did not include this information in her call with Group Manager Meakin because of how difficult it was to scroll back and read the Arena log.
It is notable that Rochelle Fallon did not include any multi‑agency information in her report to Group Manager Meakin. This was despite the fact that there were numerous entries in the incident log about other emergency services, including one which was marked with asterisks. I accept that Rochelle Fallon was doing her best to explain why she omitted key information, but I have concluded that the information was not included because she did not realise at the time the importance of that information. Her focus was on looking for other information in the log. This was because she had not been adequately prepared by NWFC for an incident such as the Attack.
Call from Group Manager Levy (23:12)
Group Manager Levy was on call as a duty NILO.A pager message was sent to him at 23:04 by Joanne Haslam. He received it at 23:06. At 23:12, Group Manager Levy telephoned NWFC and spoke to Michelle Gregson.
Group Manager Levy’s first question was: “What’s the incident we are proceeding to please?” Michelle Gregson informed Group Manager Levy that he had been mobilised to Philips Park Fire Station following a report from the police at 22:38 of an explosion at the Arena. She repeated what she had told Tessa Tracey: “[W]e got the operator to stay on the phone to the police to get the JESIP information … to make sure we were sharing all the information that was coming into the police at the time.”
The reference to 22:38 was to the time when David Ellis created the Arena log. In fact, the notification from the police had come four minutes prior to this. Given the stage the incident had reached, this error did not make any difference. However, it is important that accurate information is communicated.
Later in the call, Michelle Gregson stated: “I’ve just recommended that we set up a link so that we can speak to them [GMP], to again make sure we maintain this JESIP information … that we are all sharing information that we are getting in.” Group Manager Levy asked which officers had been allocated to the incident. Michelle Gregson told him which fire appliances had been mobilised. They also had a discussion about a hazard zone. This was to prevent mobilisations to other incidents nearby.
Despite mentioning JESIP twice, Michelle Gregson did not provide Group Manager Levy with any JESIP information. She did not inform him of the movements of the police or paramedics. She did not inform him that NWAS had a “Bronze Commander” at the scene, or that GMP had provided an RVP, which Station Manager Berry had rejected.
At the time that she was speaking to Group Manager Levy, Michelle Gregson was looking at the Philips Park log.The Philips Park log had no relevant information about emergency service partners. This is a clear example of the problem caused by operating multiple logs for a single incident. Because she was not looking at an incident log which contained JESIP information, Michelle Gregson did not provide JESIP information to Group Manager Levy.
Michelle Gregson bears very little personal responsibility for not bringing up the Arena log and providing relevant information to Group Manager Levy from it. Principal responsibility for this failure lies with NWFC, both in terms of preparing Michelle Gregson for an event such as the Attack and in operating multiple incident logs for a single event.
Group Manager Levy stated in evidence that, having listened to the audio of this conversation, he felt he interrupted Michelle Gregson at a point where he believed she may have been about to look at the incident log. He stated that he regretted interrupting Michelle Gregson, as he wondered whether she may have given him more information had he not.
This was a thoughtful concession for him to make. In my view, having listened to the call, I consider Group Manager Levy was being overly critical of himself. His conduct during the call was courteous, calm and professional.
The repeated mention of JESIP by Michelle Gregson, while at the same time failing to provide any JESIP information, demonstrates that Michelle Gregson did not understand during that call what she was supposed to be doing with the multi‑agency information. This lack of understanding was shared by a number of her colleagues at NWFC. The consistency of this failure suggests that it was a systemic problem at NWFC.
As a result of this failure, Group Manager Levy, like his fellow NILO Group Manager Meakin, mobilised to Philips Park Fire Station without knowing that the police and paramedics were at the scene and had been for some time.
Further calls with GMFRS duty Group Manager
Call from Group Manager Nankivell (23:24)
At 23:24, Group Manager Nankivell called NWFC. He spoke to David Ellis. The purpose of Group Manager Nankivell’s call was to instruct NWFC not to deploy firefighters to any incident in Manchester City Centre unless a person’s life was in danger. David Ellis referred Group Manager Nankivell to Group Manager Levy, who had already given NWFC instructions in relation to a hazard zone.
Call from Group Manager Nankivell (23:33)
At 23:33, Group Manager Nankivell spoke to David Ellis again. In the call he asked for NILOs to be paged in order to alert them to an ongoing incident and ask them to monitor their radios.
Call to Group Manager Nankivell (23:42)
At 23:42, Dean Casey called Group Manager Nankivell. This was to notify Group Manager Nankivell that his instruction to David Ellis was being actioned. It was also to ask if there were any talk groups he wished the NILOs to monitor. Group Manager Nankivell said that he only wanted pagers monitored at that time.
Call from Group Manager Nankivell (23:46)
At 23:46, Group Manager Nankivell telephoned NWFC. He spoke to Janine Carden. Group Manager Nankivell informed Janine Carden that he and Area Manager Paul Etches had arrived at the Command Support Room. I will address Area Manager Etches’ involvement in paragraphs 15.159 to 15.163. In the course of the call, he asked: “[H]ave you had any more updates that we’re … not privy of?” Janine Carden answered: “No we haven’t.” She provided information about the activities of GMFRS officers. Group Manager Nankivell asked: “[W]e’ve got no pumps down at the actual scene of it, have we?” Janine Carden told him that the appliances were at Philips Park Fire Station.
NWFC’s management of further calls with duty Group Manager
At the point that David Ellis spoke to Group Manager Nankivell for the first time, over 30 minutes had passed since Group Manager Nankivell’s last update from NWFC. David Ellis could have offered an update in that call or his subsequent one.
David Ellis was an experiencedand competent Control Room Operator. I do not criticise David Ellis for not offering updates. This is further evidence of NWFC’s failure to prepare its staff for an event such as the Attack and of its inadequate systems.
Dean Casey, who was less experienced than David Ellis and not fully qualified as a Control Room Operator,could also have offered an update. NWFC should have prepared him better for his role.
Group Manager Nankivell should have asked both David Ellis and Dean Casey for an update.
In reaching the conclusions I have about the need to offer and ask for updates, I am conscious that since David Ellis terminated his call with GMP at 23:01, no new information had come into NWFC from GMP, BTP or NWAS. Had the call with BTP at 23:17 been adequately managed, it should have resulted in important information being passed to NWFC. Information was also being received during this period from Philips Park Fire Station. I turn to those calls now.
First two calls from Philips Park Fire Station
Call from Watch Manager Simister (23:06)
Watch Manager Andrew Simister was stationed at Manchester Central Fire Station on the night of 22nd May 2017.At 22:38, he received a mobilisation pre‑alert. This pre‑alert was automatically generated as a result of David Ellis creating an incident log for the Arena. Manchester Central Fire Station was the closest fire station to the Arena.
Manchester Central Fire Station crews received a mobilisation to Philips Park Fire Station.“ALL THE AMBULANCES PULLED ON AT CENTRAL AS WE LEFT.” Lisa Owen responded by confirming that it had been the NILO’s decision to mobilise to Philips Park Fire Station and that further information was awaited.Watch Manager Simister and his two fire appliances drove to Philips Park Fire Station. Once there, at 23:06, Watch Manager Simister called NWFC and spoke to Lisa Owen. Watch Manager Simister stated:
Lisa Owen stated that when Watch Manager Simister informed her that “ALL THE AMBULANCES” were arriving at Manchester Central Fire Station, she assumed those ambulances were doing that in order to follow the fire appliances to Philips Park Fire Station. Lisa Owen made no entry in the incident log in relation to the information she had been given. She should have done so.
In addition to making a record, Lisa Owen should also have asked Watch Manager Simister whether the ambulances did, in fact, follow the fire appliances. There was no basis in the incident log or in anything that NWFC had been told until that point to conclude that ambulances were being sent to Philips Park Fire Station. The information in the incident log was to the opposite effect: ambulances were being deployed to the scene. Lisa Owen should not have made the assumption she did. As a result, a further opportunity to note the contrast in the approach being taken by NWAS and that being taken by GMFRS was missed.
Call from Watch Manager Simister (23:25)
At 23:25, Watch Manager Simister again contacted NWFC. On this occasion, he spoke to Rochelle Fallon. He asked her for an update. He gave the following reason for the request: “I’VE GOT A FIREMAN HERE WHOSE WIFE IS A PARAMEDIC AND SHE’S ON SCENE AND WE ARE STOOD BY DOING NOTHING AND HE’S GETTING A BIT FRUSTRATED.” Rochelle Fallon explained that Group Manager Meakin and Group Manager Levy were on their way to Philips Park Fire Station. She apologised for the lack of update. Watch Manager Simister asked if there were “ANY FIRE SERVICE THERE YET ACTUALLY ON SCENE”. Rochelle Fallon replied: “NO.” She stated: “BECAUSE … THERE WAS WELL THERE WAS BELIEVED TO BE … A SECOND BOMB I THINK, I THINK THAT IS WHAT THE POLICE WERE SEARCHING FOR … I DON’T KNOW.”
The reference by Watch Manager Simister to “A FIREMAN” was to Crew Manager Nicholas Mottram. His wife, the “PARAMEDIC … ON SCENE” was Helen Mottram. She attended the Victoria Exchange Complex that night as part of NWAS’s response to the Attack. Watch Manager Simister’s call contained important information. The contrast between NWAS’s approach and GMFRS’s approach was starkly revealed by his subsequent question about whether there were any firefighters at the scene. Watch Manager Simister had reliable information directly from the scene. He passed it on. It should have been acted upon.
The Control Room Operator, Rochelle Fallon, should have immediately escalated this information to a Team Leader. It was an opportunity, more than 45 minutes after the Attack, for NWFC to re‑evaluate their approach. If she had escalated this information, it would have led to a realisation, even at this late stage, that GMFRS had taken a completely different approach to that of NWAS. It was obvious to Watch Manager Simister that this was so. It was a failure in NWFC training that resulted in Rochelle Fallon not doing this.
On a separate point, it is regrettable that Rochelle Fallon gave Watch Manager Simister inaccurate information about why NWFC had not mobilised GMFRS to the scene. No harm resulted from it, but Rochelle Fallon should not have speculated as she did. It was capable of being repeated and confusing the picture.
There is no record of Rochelle Fallon’s call with Watch Manager Simister on any of the logs. Rochelle Fallon stated that she may have made an entry on an incident log to reflect that Watch Manager Simister was seeking an update about the NILOs. She stated that sometimes the NWFC system does not record entries. She stated that this was something she and others had raised with NWFC. By the time she gave her evidence in July 2021, Rochelle Fallon said that it had still not been resolved.
In light of her evidence, I am unable to reach a firm conclusion about whether or not Rochelle Fallon attempted to record her conversation. It is imperative that NWFC ensures that all entries are saved to an incident log. Rochelle Fallon’s evidence about this issue was of concern to me.
In evidence, Rochelle Fallon stated that if she had made an entry in the incident log it would have read: “Call from Golf 16, asking for an update off a NILO.” This would have been inadequate, as it would not have recorded the important and reliable information about paramedics being at the scene.
Initial call from GMFRS duty Assistant Principal Officer
Call from Area Manager Etches (23:11)
After the call with Group Manager Meakin, Rochelle Fallon took an incoming call from Area Manager Etches at 23:11. He was the duty Assistant Principal Officer for GMFRS that night. The Assistant Principal Officer’s role during any substantial incident is a strategic one, considering the impact of the incident on GMFRS’s capabilities across its entire area.Area Manager Etches had been contacted about the Attack by Group Manager Nankivell at 22:57.
The purpose of Area Manager Etches’ call was to inform NWFC that he was making his way to the Command Support Room at GMFRS HQ. Area Manager Etches wanted to be marked on the incident log as such. In the course of the call, Area Manager Etches said: “I we … had anything back from anywhere? I’ve just spoken to Dean Nankivell and obviously I think at the moment we’ve just got standby’s at Philip’s Park.”
Area Manager Etches stated that, in asking his question, he was “seeking further information”. He stated that he was not seeking information specific to the movements of the police or paramedics. In response, Rochelle Fallon confirmed that GMFRS was mustering at Philips Park Fire Station and that NWFC was receiving “more information from ambulance and police every time they get anything about a fatality”. Rochelle Fallon did not provide any information about the deployment of the police and paramedics to the scene.
It was not clear from Area Manager Etches’ question what he wanted to know. Consequently, I am not critical of Rochelle Fallon for not interpreting it as a request for JESIP information. It does not appear that Area Manager Etches was seeking that information in any event.However, it was the first time Area Manager Etches had made contact with NWFC about the incident. Rochelle Fallon should have offered a situation report based on the latest information. This should have included information about what the other emergency services were doing.
An entry was made in an incident log at 23:13 by Rochelle Fallon to record the fact that Area Manager Etches was mobilising to the Command Support Room (the Command Support Room log). This incident log had been created at 22:44 by Dean Casey. The 23:13 entry by Rochelle Fallon is the first substantial action recorded in it. It was subsequently used to mobilise other GMFRS officers to the Command Support Room. It was also used to record Group Manager Nankivell’s decision to deploy himself to the Command Support Room.
Calls from GMFRS Contingency Planning Unit manager
Call from Group Manager Fletcher (23:22)
Group Manager John Fletcher called NWFC at 23:22. Group Manager Fletcher was qualified as a NILO. He was the manager of the Contingency Planning Unit at GMFRS. In this management role he had responsibility for GMFRS’s NILOs.Group Manager Fletcher had received a WhatsApp message about the Attack. As a result, he telephoned and spoke to Station Manager Berry. He also spoke to other GMFRS officers. I will address these calls in the section about the GMFRS response.
In his call to NWFC at 23:22, Group Manager Fletcher spoke to Joanne Haslam. He informed her that he was booking himself on duty and making his way to the Command Support Room. In the course of the conversation, a proposed multi‑agency control room talk group was mentioned. Group Manager Fletcher stated: “THIS IS WHAT WE WERE PUTTING IN AFTER DOING THE EXERCISES.” He went on to say: “CAUSE IT MIGHT BE A WAY THAT THE POLICE CONTROL GET IN TOUCH WITH YOURSELVES.”
This call was another occasion on which an NWFC operative did not offer a situation report or update to GMFRS. Joanne Haslam was a very experienced Control Room Operator.This is another example of the failure by NWFC to embed the offering of updates.
Following the call with Group Manager Fletcher, Joanne Haslam spoke to Janine Carden about the proposed multi‑agency control room channel.Group Manager Fletcher’s self‑deployment to the Command Support Room and reference to the proposed multi‑agency control room channel were recorded in the Command Support Room log.
Call to Group Manager Fletcher (23:25)
At 23:25, Janine Carden called Group Manager Fletcher on his mobile. The call lasted just over a minute.They discussed the proposed multi‑agency control room talk group. Group Manager Fletcher asked for that channel to be monitored.
Group Manager Fletcher stated in evidence that during this call he asked Janine Carden if there were “any further updates, particularly on the status of the active shooter and the ambulances, where are the ambulances are going?” He stated that he heard Janine Carden ask a colleague this question. He said the reply was that NWFC did not have any updates at that moment in time.
Group Manager Fletcher stated that his question to Janine Carden was poorly phrased. He said that he believed Janine Carden misunderstood what he was asking.“update” to give him.At the time of his call, NWFC had not had any updated information from NWAS or GMP for nearly 20 minutes. In Major Incident terms, that meant that NWFC had not recently received an update. Understanding Group Manager Fletcher’s question in this way, it is easy to see why there was no
At 23:36, Janine Carden made the following entry on the Command Support Room log: “From GM [Group Manager] Fletcher can we monitor police [proposed multi-agency control room talk group].” Approximately 15 minutes later, the GMP Silver Control Room broadcast on this channel. NWFC acknowledged that broadcast. I will deal with it in paragraph 15.198.
The miscommunication between Janine Carden and Group Manager Fletcher is a good example of the need for a clear understanding between GMFRS and NWFC of the process for passing on information during Major Incidents. For any update, it is important to establish when the person receiving the update was last provided with information.
Call from Group Manager Fletcher (23:41)
At 23:41, Group Manager Fletcher called NWFC a second time. He spoke to Janine Carden. The purpose of his call was to have Merseyside Marauding Terrorist Firearms Attack capability put on standby. In the course of the call, he stated: “OBVIOUSLY I’VE BEEN A BIT INFO BLIND WHILE I’VE BEEN EN ROUTE TO HEADQUARTERS, I’M NEARLY THERE NOW.” Janine Carden did not offer to provide Group Manager Fletcher with a situation report or an update either at that point or when he arrived. She should have done so.
Third call from Philips Park Fire Station
Call from Group Manager Meakin (23:28)
Group Manager Meakin arrived at about the time of Watch Manager Simister’s second call to NWFC. Upon arrival, he spoke to the GMFRS officers present.“HAVE WE GOT A BRIEF OR ANY INSTRUCTIONS?” In reply, Lisa Owen informed him of the movements of GMFRS personnel, but that “WE’VE GOT NO INSTRUCTIONS WITH REGARDS TO MOBILISING YET.”At 23:28, he called NWFC and spoke to Lisa Owen. He began by stating he was at Philips Park Fire Station and that he had not had a briefing or instructions. He asked:
Group Manager Meakin continued the conversation by saying: “I’VE JUST HAD REPORTS FROM CREWS AT PHILIPS PARK THAT I THINK THERE FROM CENTRAL … THAT THEY’VE BEEN SENT HERE FROM THE STATIONS YET WE’VE HAD NWAS STAFF TURNING UP ON THE FORECOURT.” The reference to “the forecourt” was to the forecourt of Manchester Central Fire Station. Given the terms of her response, this was the way in which Lisa Owen understood it. Lisa Owen’s response was to say that the deployment to Philips Park Fire Station was Station Manager Berry’s decision. She went on to say to Group Manager Meakin: “AMBULANCE OBVIOUSLY I CAN’T SPEAK OF WHY THEY’VE SENT THEM THERE BUT THEY ARE AWARE THAT OUR RENDEZVOUS POINT IS PHILIPS PARK.”She stated that it was possible that Station Manager Berry was speaking to the FDO at GMP.
There was a substantial body of information that Lisa Owen did not provide to Group Manager Meakin. She did not provide any information relating to the deployments of the paramedics or police. Group Manager Meakin had asked directly for a briefing. She should have provided him with that “critical” information.
This was the second call Lisa Owen had taken from Philips Park Fire Station. In both calls, the GMFRS officer calling deliberately drew attention to the contrast between GMFRS’s approach and that of NWAS. Her assumption at the end of the first call was that ambulances were following fire appliances to Philips Park Fire Station. Just 22 minutes later, it should have been apparent from Group Manager Meakin’s call that no ambulances had arrived at Philips Park Fire Station.
Lisa Owen was a Team Leader. She should have appreciated the significance of what she was being told and sought to contact NWAS to find out what was going on.She should also have sought to contact Station Manager Berry.
GMP, NWAS and the Forward Command Post
Call from GMP Control (23:44)
At 23:44, GMP Control contacted NWFC. Rochelle Fallon answered the call. GMP notified NWFC that the Silver Control Room at GMP HQ was being set up. A request for the attendance of a “liaison officer” was made by GMP. Rochelle Fallon stated that she would “ring one and ask them to attend”.
Call to Station Manager Berry (23:46)
Rochelle Fallon telephoned Station Manager Berry at 23:46. By this time, Station Manager Berry and Group Manager Levy had reached Philips Park Fire Station. Station Manager Berry was with Group Manager Levy when Rochelle Fallon called. Rochelle Fallon relayed GMP’s request. Group Manager Levy replied that Station Manager Michael Lawlor was en route to GMP HQ. Station Manager Berry then asked: “Ok is there anything else … have we got any further information at all? Anything confirmed so far?” Rochelle Fallon gave the latest number of casualties. Group Manager Levy asked if there was a Forward Command Post (FCP) “to co-locate with police and ambulance”. Rochelle Fallon said she would ring back.
Rochelle Fallon did not know what an FCP was.This was a shortcoming in her training. If the importance of an FCP had been adequately communicated to Rochelle Fallon, I have no doubt she would have understood what it was and why GMFRS was asking for it.
Call to GMP Control (23:47)
At 23:47, Rochelle Fallon called GMP Control. This was the second time NWFC proactively contacted GMP Control. As with the previous call Rochelle Fallon made at 23:02, it was for a specific purpose rather than to obtain a general situation update. Rochelle Fallon informed GMP Control that Station Manager Lawlor was on his way to GMP HQ. She asked if there was an FCP. GMP Control informed her that “someone will call you back as soon as we can with the info”.
This sequence of calls contains a familiar pattern of omissions on the part of NWFC. In the call with GMP at 23:47, Rochelle Fallon did not take the opportunity to obtain an update from GMP Control. Over 40 minutes had passed since Rochelle Fallon had last spoken to GMP Control. No one from NWFC had spoken to GMP Control in the meantime. This was an obvious opportunity for Rochelle Fallon to take.
In the call a minute earlier with Station Manager Berry and Group Manager Levy, Rochelle Fallon did not provide a comprehensive update. She should have enquired when each had last received an update. She should have informed Station Manager Berry and Group Manager Levy that GMP and NWAS had been at the scene for at least 45 minutes and that NWAS had a “Bronze Commander” present. She should also have been placed in a position in which the BTP METHANE message was available.
The call with GMP Control at 23:47 presented another opportunity to obtain a situation update from GMP. Instead, Rochelle Fallon confined herself to the narrow question she had been instructed by Group Manager Levy to ask. When it became apparent that the answer to this was not immediately available, Rochelle Fallon should have taken the opportunity to obtain other important information from GMP Control.
Had Rochelle Fallon requested any information held by GMP Control between 23:00 and 23:45 she could have been told that the GMP incident log included:
- “WE NEED AS MANY STAFF TO THE FOYER INSPECTOR HAS ASKED ALL CASUALTIES OUT OF THE AREA ASAP.”
- “CONFIRMED WITH AMB – THEY HAVE 11 AMB AND A NUMBER OF RESPONSE VEHS EN ROUTE.”
- “PATROLS TO MAKE HUNTSBANK.”
- “CONFIRMED OFFENDER IS DEAD.”
- “INJURED PARTIES ARE BEING MOVED OUT.”
- “SECONDARY CORDON AT HUNTSBANK TO EASE ACCESS OF EMERGENCY VEHICLES.”
All of the above information was capable of being of assistance to the GMFRS decision‑makers who were at Philips Park Fire Station.
Call to NWAS Control (23:50)
As a result of not receiving an immediate answer from GMP Control to Group Manager Levy’s request for an FCP, at 23:50 Rochelle Fallon called NWAS Control.This was the first contact with NWAS Control by an NWFC operative since Rochelle Fallon had called to pass on the information about the LFRS officer’s relative. That call had concluded 50 minutes earlier.
This was an unacceptably long period of time for NWFC not to be in contact with NWAS Control. The contact only occurred because Rochelle Fallon had been asked a question that GMP Control was not able to answer.
Rochelle Fallon asked NWAS Control if there was an FCP. NWAS Control replied: “A LOT OF OUR VEHICLES ARE GOING TO THOMPSON STREET FIRE STATION.” Rochelle Fallon asked, “SO HAVE YOU GOT AMBULANCES ON SCENE?” It was surprising that Rochelle Fallon asked this question as, in her call with NWAS Control at 22:57, Rochelle Fallon had informed NWAS Control from the Arena log that “ALL THE AMBULANCE HAVE BEEN DIRECTED TO THE BOOKING OFFICE.”
In the call at 23:50, NWAS Control responded: “WE’VE GOT EVERYBODY THERE.” Given the time that had passed since the previous contact with NWAS Control, Rochelle Fallon should have asked for a general update from NWAS. It was a further opportunity for NWFC to be provided with the NWAS Advanced Paramedic Patrick Ennis’s METHANE message.
Although Rochelle Fallon did not ask for it directly, the information provided by NWAS Control was important. Rochelle Fallon stated in evidence that she intended “ON SCENE” to be a reference to Manchester Central Fire Station, rather than the Arena or the Victoria Exchange Complex. She stated that she did not understand NWAS Control to be confirming that there were ambulances at the scene of the Attack. This was an unfortunate interpretation by Rochelle Fallon, as it affected what information she relayed to GMFRS.
Rochelle Fallon’s understanding of the phrase ‘on scene’ is of wider concern. She interpreted ‘on scene’ as meaning ‘at your RVP/FCP’, rather than ‘at the scene of the explosion’. By contrast, it is likely that NWAS Control understood Rochelle Fallon’s use of ‘on scene’ to mean ‘at the scene of the explosion’ or ‘at the Victoria Exchange Complex’. That is because, at 23:50, NWAS had only two vehicles at Manchester Central Fire Station; but had 21 vehicles on Hunts Bank or Station Approach at that time. Gerard Blezard, NWAS Director of Operations, who produced and released statements on behalf of NWAS as an organisation, described these 21 vehicles as “Total ambulances at scene”.
The JESIP publication Joint Doctrine: The Interoperability Framework (the Joint Doctrine), under the title of “Communication”, had a section headed “Common terminology”. Within that section it stated: “Using terminology that either means different things to different people, or is simply not understood is a potential barrier to interoperability … Agreeing and using common terminology is a building block for interoperability.” It went on to refer to the ‘Lexicon of UK civil protection terminology’. In that document, ‘scene’ is defined as: “Point or area of the immediate impact of an incident or emergency”.
It is important that GMP, BTP, NWAS and NWFC consider their use of terminology to ensure that they are all using the same definitions for key terms. Given the stage at which this conversation was taking place, this misunderstanding was incapable of affecting the treatment of casualties in the City Room. However, it may have delayed the GMFRS arrival time.
Call to Group Manager Levy (23:52)
At 23:52, Rochelle Fallon called Group Manager Levy. She informed him that she was waiting to hear back from GMP in relation to the FCP. She went on to say that NWAS had “ADVISED THAT A LOT OF THEIR APPLIANCES ARE RENDEZVOUSING AT THOMPSON STREET”. Group Manager Levy replied: “THOMPSON STREET WHAT, BY OUR FIRE STATION THOMPSON STREET”.Rochelle Fallon confirmed this. Group Manager Levy asked her to stand by.
The information provided to Group Manager Levy by Rochelle Fallon about Manchester Central Fire Station confirmed what he had been told by firefighters when he arrived at Philips Park Fire Station.
Proposed multi-agency control room talk group
Broadcast from GMP Silver Control Room (23:58)
At 23:58, GMP Police Constable (PC) Ian Carter used the proposed multi‑agency control room talk group. He broadcast: “Silver Control to any … to any Ambulance or Fire monitoring this channel please.” The response by Janine Carden was not recorded. However, her response was that NWFC was listening. PC Carter replied: “Yep, that’s received, thank you very much. Any Ambulance on this Channel please?” For the reason I gave in Part 14, NWAS did not respond.
Following her reply, Janine Carden entered into the Command Support Room log: “Call on [proposed multi-agency control room talk group], GMP Silver asking if fire or amb monitoring confirmed fire monitoring. Group Manager Fletcher informed and asked for Group Manager Levy to be informed.”
Final calls with GMFRS prior to GMFRS arrival at the scene
Call from Group Manager Levy (00:15)
At 00:15 on 23rd May 2017, Group Manager Levy called NWFC. He spoke to Rochelle Fallon. By the time of this call, Group Manager Levy and others from Philips Park Fire Station had moved to Manchester Central Fire Station.
Rochelle Fallon stated: “The police still haven’t advised us on this … going forward point.” This was a reference to the FCP. GMP had had over 25 minutes to provide NWFC with the FCP. This was an unacceptable period of delay. At 23:54, GMP Control had provided Station Manager Berry with “the old Boddingtons car park” as an FCP. This did not negate the need for GMP to answer the request from NWFC.
Group Manager Levy asked: “I don’t believe that anyone has declared Operation Plato yet have they?” Rochelle Fallon replied: “No.” Group Manager Levy asked Rochelle Fallon to record him as the Incident Commander. Group Manager Levy stated in evidence that the reason he had asked whether Operation Plato had been declared was because, until that point, he had considered that he was responding to “a Plato-style incident”. At Manchester Central he had found non‑specialist ambulances and this had prompted his question.
At the same time as Group Manager Levy made the enquiry about Operation Plato, GMP Temporary Superintendent Christopher Hill informed Station Manager Lawlor that GMP had declared Operation Plato. Station Manager Lawlor subsequently communicated this to the NILOs over the NILO talk group.
Call from Group Manager Nankivell (00:18)
At 00:18 on 23rd May 2017, Group Manager Nankivell called NWFC. He spoke to Joanne Haslam. He informed Joanne Haslam that two standard fire appliances were being deployed to Corporation Street with Station Manager Berry. Joanne Haslam informed Group Manager Nankivell about the RVP at the “car park outside the Cathedral”. Group Manager Nankivell asked when this RVP was provided. Joanne Haslam stated: “That was from the initial call.”
Joanne Haslam had begun to tell Group Manager Nankivell about this RVP in her call with him at 22:52, but had been cut off by Group Manager Nankivell who asked a question about whether a Major Incident had been declared.
There were a number of areas in which NWFC’s response to the Attack was inadequate. There was a failure on a number of occasions to offer or provide adequate information or updates to GMFRS officers when speaking to them. There was a failure on a number of occasions to seek JESIP information when speaking to BTP, NWAS and GMP. There was a failure to contact BTP, NWAS and GMP for the purpose of gaining situational awareness.
Most fundamentally, there was a failure by NWFC staff to recognise and act upon the fact that the approach being taken by GMFRS was obviously divergent from the approach NWAS and the police were known to be taking. Control Room Operators should have been escalating the inconsistency in approach to the Team Leaders. The Team Leaders should have been proactively contacting and challenging GMFRS officers in light of what was known about other emergency services.
By 23:00, the Team Leaders should have identified that over 15 minutes had passed since Station Manager Berry had said he would contact the FDO. The Team Leaders should have contacted Station Manager Berry and enquired whether a different approach was required. They should have offered to help him get the information he needed. They should have considered contacting GMP, BTP and NWAS to obtain a full situation report to give to Station Manager Berry to assist him in his decision‑making. This was not something they had been trained to do.
I have identified throughout the section above where individuals should have acted differently. NWFC as an organisation is responsible for these failures. There was a failure to prepare staff adequately for an incident such as the Attack.
The important calls for this incident were managed by eight people. This seems to be one of the things that caused problems on the night. It meant that the information was not concentrated in one or two people’s minds, but spread across several people. David Ellis, Joanne Haslam, Rochelle Fallon, Dean Casey, Vanessa Ennis, Lisa Owen, Michelle Gregson and Janine Carden all took part in important calls within the first 75 minutes.
I recommend NWFC consider whether a better system can be devised where fewer people manage calls relating to Major Incidents.