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

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

SMG and Emergency Training UK preparedness

Key findings

  • SMG had an obligation under the premises’ licence to ensure that an adequate number of staff trained in first aid were present at every event.
  • SMG was responsible for ensuring adequate healthcare services to event‑goers and visitors to the City Room.
  • In 2007, SMG and Emergency Training UK (ETUK) reached a contractual agreement that ETUK would supply healthcare services at the Arena.
  • The SMG–ETUK contract required attendance at every event by a person from ETUK qualified in Major Incident response.
  • The SMG–ETUK contract required information about the training and qualification level of ETUK staff to be provided for every event. ETUK did not provide this information. For reasons that were not satisfactorily explained, SMG did not insist on its provision.
  • The SMG Operational Procedures document was not provided to North West Ambulance Service (NWAS) as it should have been.
  • The ETUK Major Incident Plan anticipated that a METHANE message would be passed to NWAS in the event of a Major Incident.
  • SMG’s event healthcare provision document anticipated that the number of healthcare staff would be determined by an event‑specific risk assessment. No adequate risk assessment was carried out for the Ariana Grande concert on 22nd May 2017.
  • ETUK Director Ian Parry presented himself as having a Major Incident management qualification and an Advanced Life Support qualification. He had obtained such qualifications. However, both had expired six or more years prior to the Attack. He had not undertaken the required refresher training.
  • Ian Parry did not require a sufficiently high standard of skill from ETUK staff members. It was his, not the staff’s, responsibility to ensure that there was a sufficient skill level across the staff for every event at the Arena.
  • Not all ETUK staff on duty on the night of 22nd May 2017 were trained in the application of tourniquets.
  • The arrangement between SMG and ETUK in relation to equipment was unsatisfactory. It led to individual members of staff providing their own first aid equipment.
  • ETUK engaged in exercising prior to the Attack. However, this engagement was inadequate. As a result, staff were not adequately prepared for a real‑world mass casualty incident.
  • ETUK and NWAS had not developed a sufficiently close relationship prior to the Attack.
  • Neither SMG nor ETUK took an adequate approach to considering how the healthcare service at the Arena would respond to a mass casualty incident.


SMG had an obligation under the Arena’s premises’ licence to “ensure that an adequate number of staff trained in First Aid is present at every event”.1 The premises’ licence also imposed other relevant obligations. These included: the requirement for a contingency plan formulated in conjunction with the emergency services; provision of a first aid room; ensuring that all crowd stewards had received basic training in first aid; making checks before every event in relation to “first aid rooms and equipment”; and ensuring that “the necessary first aiders are present and in post”.2

James Allen, Arena General Manager for SMG, rightly accepted that SMG was responsible for ensuring adequate healthcare services to event‑goers and visitors to the City Room.3 He also accepted that he had a personal responsibility for the adequacy of that provision as Arena General Manager.4

ETUK was incorporated in 2005.5 From the start, ETUK was run by Ian Parry, who owned the shares in it.6 At first, its sole director was Ian Parry’s daughter. In due course, Ian Parry’s wife also became a director. Neither Ian Parry’s daughter or his wife had any involvement with the operation of the company.7

By a contract with SMG dated 1st June 2007 (the SMG–ETUK contract), ETUK agreed “to provide overall management of medical and first aid services at an event”.8 From that date, ETUK provided healthcare services at the Arena on a continuous basis up to and including the night of the Attack.

As I set out in Part 11, guidance on how to make adequate provision for healthcare services at events was provided in The Purple Guide to Health, Safety and Welfare at Music and Other Events, known as the Purple Guide.9

I recognise that, in a mass casualty incident, an event healthcare organisation will not be able to provide the level of care that is provided by the combination of an ambulance service and hospital staff. However, such an organisation has an extremely important role to play in keeping the injured alive while the ambulance service get to the scene. I will address this further in Part 20 in Volume 2‑II when I consider ‘the Care Gap’.

SMG and Emergency Training UK’s contract

Ian Parry’s relationship with SMG did not begin on 1st June 2007. He had worked at the Arena since 1999, initially as part of AAA Training and Technology, then as part of Emergency Training Limited. ETUK was set up when, in 2005, Emergency Training Limited was dissolved, and ETUK continued to provide healthcare services on the same basis.10

The SMG–ETUK contract was signed following a tender process. James Allen stated that the tender process was triggered, in part, by his concern about the behaviour of ETUK.11 The concern was based around allegations that ETUK had failed to pay its staff promptly, and that there had been a refusal to treat people in areas outside the Arena bowl and concourse, such as the City Room, as ETUK staff were concerned that insurance would not extend to that area.12

The tender was based upon a document prepared by James Allen. James Allen did not have any healthcare expertise. SMG did not seek the support of anyone with healthcare expertise when creating the tender document or when considering the three submissions made to it.13 Expertise was required because of the size of the Arena and the number of people attending events. Three organisations, including ETUK, tendered for the work. James Allen’s review of the tender submissions described ETUK as “the easy option”.14 By contrast, James Allen described one of the other organisations who tendered as “the safe option”.15

As part of his internal report on the tender process, James Allen noted of the ETUK submission: “Ian Parry is the only one qualified to deal with emergency situations. A lot of EMT [Emergency Medical Technician] technically proficient staff have left to setup their own company leaving Ian as lone highly experienced medical figure.”16 James Allen agreed that the situation he was describing was not an ideal state of affairs.17

Shortly after the SMG–ETUK contract was signed, James Allen prepared a note, the content of which he said he put in an email. In the note, he recorded:
“[P]art of the reason for the changes in the contract … is a concern we have records that in 2 or 3 years’ time we can pinpoint members of staff that were on duty and the minimum qualifications that person had at that time … I need to be confident that everyone on every show has reached this minimum level and that someone as part of your event team has the ability to deal with a major incident, ie is MIMMS qualified.”18

‘MIMMS’ stands for Major Incident Medical Management and Support and was a qualification provided by the Advanced Life Support Group.19

James Allen said that the content of this note was sent in an email to Ian Parry. Ian Parry denied having received it.20 I do not need to resolve this dispute, given the terms of the agreement and what occurred after it was signed. It is relevant, though, to James Allen’s and SMG’s state of mind about ETUK.

The SMG–ETUK contract required ETUK to “[p]rovide full training, qualifications and experience of first aiders and EMTs on duty which must be submitted to the venue Duty Manager for all events as part of their pre-event checks.21 ‘EMTs’ stands for Emergency Medical Technicians. The title ‘EMT’ was not a protected title within the healthcare regulatory framework. This means that the qualifications for this role were not specified by law, and a person claiming such a title was not necessarily regulated by any professional body.

I do not doubt James Allen’s evidence that he was unhappy about the practices of ETUK towards its staff before 2007. His contemporaneous note shows that, before entering into a new contract in June 2007, he was also worried about the standard of the training of ETUK staff and whether there would be someone present from ETUK able to respond to a Major Incident.

Despite the pre‑contract concerns and the terms of the SMG–ETUK contract, SMG did not require the training, qualifications and experience of the ETUK staff to be disclosed before each event.22 James Allen’s explanation was vague when asked why this was. He suggested that the contract had been amended, potentially for confidentiality reasons. He stated that there was nothing in writing to this effect.23 James Allen agreed that the requirement would have been a “very sensible” idea.24

This is unsatisfactory. No adequate reason was advanced for why SMG did not operate the safeguard it had built into its agreement with ETUK. SMG should have done so.

A further aspect of SMG’s failure towards ETUK was the lack of any formal review of ETUK’s preparedness and performance, whether internally or by obtaining the opinion of anyone independent with relevant expertise.25 Over the ten years between the agreement being signed and the Attack, SMG took its reassurance from its day‑to‑day experience of ETUK. This was insufficient, as SMG should have realised. Judging ETUK solely by reference to past events was incapable of providing any reassurance about how prepared ETUK was to respond to an event like the Attack, as nothing like it had occurred.

If SMG had conducted proper checks on ETUK’s performance, it would have discovered that ETUK was not meeting an adequate standard, particularly in relation to preparedness for a mass casualty incident. This was a significant failure by SMG. I will examine in paragraphs 16.43 to 16.53 how the level of training of ETUK staff who were present on the night of the Attack had an impact upon the adequacy of the response.


SMG Operational Procedures document

In Part 6 in Volume 1, I considered SMG’s written risk assessment document, Operational Procedures: Emergency and Contingency Plans (the Operational Procedures document). This contained inadequate risk assessments in relation to the threat of terrorism. It included a generic risk assessment entitled “First Aid Injuries: Multiple and Major Injuries” “Caused by Explosions”.26 The event risk assessment was driven by the risk from the attendees, not to them.27 It produced the same total score regardless of the size of the audience.

James Allen accepted that the approach taken in this risk assessment was “nonsense”.28 In the event, this inadequate generic risk assessment made no difference, as SMG did not use this part of the Operational Procedures document.29

Two other parts of the Operational Procedures document were directly relevant to the response to an attack. The first was entitled “Bomb and Terrorist Threats”.30 This set out the response plan in the event of a bomb detonation at the Victoria Exchange Complex. It envisaged a controlled evacuation via appropriate exits. It also provided for a handover process to the emergency services by “the most senior member of staff onsite” using a form in the appendices.31

The second was entitled “Medical Incidents”.32 This stated: “In the event of a Major Medical Emergency Medic 1, having completed an Internationally recognised Major Incident Training course, will assume overall control until the arrival of the Statutory Emergency Services.”33 The ‘Medical Incidents’ part continued by setting out a “Major incident medical emergency plan”.34

This plan anticipated a number of steps. These included: “Medic One will allocate Medic Two to alert team to rendezvous point”; and “Once a major medical incident has been identified Medic One will notify Greater Manchester Ambulance Service and assume overall control until arrival of first unit.”35

SMG has no record of the Operational Procedures document being sent to North West Ambulance Service (NWAS). NWAS has no record of receiving it.36 This is unsurprising. The circulation list of the Operational Procedures document records that the consultation copy and final copy should be sent to “Greater Manchester Ambulance Service”, the predecessor ambulance service to NWAS in the Greater Manchester area.37 Whether or not this occurred, it should have been sent to NWAS when NWAS came into being. It was a significant failure on the part of SMG not to share its plan with NWAS. This failure forms part of a wider problem in terms of co‑operation and communication between staff working at the Arena and NWAS. I recommend SMG review its processes to ensure that it has shared with Greater Manchester Police (GMP), Greater Manchester Fire and Rescue Service (GMFRS), BTP and NWAS the most current emergency response plans and policies for dealing with an incident at the Arena. It should also apply this approach more generally to its operations.

Emergency Training UK’s Major Incident Plan

ETUK had a document entitled ‘Emergency & Contingency Plans’ (the ETUK Major Incident Plan).38 This was drafted by Ian Parry and mirrored, in substantial part, the SMG Operational Procedures document. Ian Parry copied the content of the ETUK Major Incident Plan from a document given to him by a person at Greater Manchester Ambulance Service.39

The ETUK Major Incident Plan stated: “Once a major medical incident has been identified Medic One will notify North West Ambulance Service and assume overall control until arrival of first unit.”40 It anticipated that a METHANE message would be passed on by Medic 1.41 In Part 11, I set out in detail what a METHANE message is and its importance. ETUK’s Major Incident Plan anticipated that Medic 1 would liaise with NWAS personnel and ensure a smooth handover.42

In all three of these respects, the ETUK Major Incident Plan reflected the expectation of the Purple Guide. On the night of the Attack, Ian Parry, in the position of Medic 1, did not do any of these things. Nor did Ian Parry allocate particular roles, such as “Safety Officer” and “Medical Teams”, as was envisaged by the ETUK Major Incident Plan. This should have been done by Medic 1 in conjunction with Medic 2.43

The ETUK Major Incident Plan indicated that “Medical Teams” will “provide basic first aid … following triage”.44 On the night of the Attack, a number of ETUK staff present in the City Room were not “versed” in triage and needed the support of a colleague.45

The ETUK Major Incident Plan stated that, in the event of a “Wilful Terrorist/ Criminal Act – … no entry will be made into the primary area of this type of incident until agreed by the Senior Fire Officer/Police. Fire Brigade have absolute control of the forward aspect of this type of incident. Control of the overall scene is the responsibility of the Police.46 This is not consistent with the approach to terrorist incidents that would generally be taken by emergency services. Other than in the most exceptional circumstances, the police will be the lead agency in the event of a terrorist attack.

On the night of the Attack, Ian Parry did not make any enquiry of any emergency service personnel about the safety of the area on behalf of the ETUK staff. He should have done so. In the event, this failure did not have an impact upon the response or result in any adverse consequence to ETUK staff. It does show that Ian Parry had little regard for the plan he wrote. When directed by Miriam Stone, Event Manager at SMG on the night of the Attack, to send his staff into the City Room, Ian Parry did enquire of her whether it was safe for his staff to go in. Miriam Stone, who could see the City Room on her monitor, responded that it was as far as she could tell. I will set out more detail of this conversation at paragraphs 16.122 to 16.123.

Ian Parry said that his failure to follow the plan was because “in the real world you don’t expect these things to happen”.47 He also stated that, “in the heat of a real-life situation”, none of the requirements of the ETUK Major Incident Plan were followed.48 He went on to say, “For want of a better word, the whole system fell apart that night.”49 He was wrong to say that there can be no expectation that a plan will be followed. The plan should have been followed, but it required proper preparation by ETUK. While Ian Parry did not expect there to be an explosion caused by a bomb, he should have been aware of, and prepared for, the possibility that this might happen.

While it is inevitable that not every aspect of a plan will necessarily be followed, as the Ambulance Service Experts stated, “[T]he whole idea of developing the plan is that, in extremis, you turn to the plan and follow the concepts in the plan.”50 If Ian Parry had engaged in adequate Major Incident training, planning and exercising, it is likely that he would have remembered what his role was: the basic requirements of the plan would have been followed.

SMG event healthcare provision document

The number of ETUK staff for any particular event was determined by SMG.51 The procedure involved SMG notifying ETUK of the number of staff required. Staff were then allocated by ETUK.

In 2003, James Allen created a document entitled ‘Event Medical Provision at the Manchester Evening News Arena’ (the SMG event healthcare provision document).52 The purpose of the SMG event healthcare provision document was to determine the number of healthcare staff required for any given event. James Allen did not seek any external advice or assistance from someone with healthcare qualifications when drawing it up.53 It was not reviewed in light of the reissue of the Purple Guide in 2015.54 Both of these things should have occurred.

The SMG event healthcare provision document provided for three levels of staff: EMT‑A, EMT‑B and first aider. EMT‑A stands for ‘Emergency Medical Technician – Advanced’. EMT‑B stands for ‘Emergency Medical Technician – Basic’.55 For an event the size of the Ariana Grande concert, it specified one “EMT-A/MIMMS”, a second EMT‑A and ten first aiders.56 This is described as “a base provision”, which was said to be subject to an individual event risk assessment.57

As I set out in Part 6 in Volume 1, SMG’s individual event risk assessment process was flawed. It was a box‑ticking exercise, which did not include any assessment of the threat of a terrorist attack. This meant that the “base provision” was unaffected by any increased risk of a mass casualty incident caused by a terrorist.

Emergency Training UK staff training

The SMG–ETUK contract expected at least one “EMT-A” and one “EMT-B” “on a typical show”.58 The EMT‑A was expected to act as Team Leader and “must be MIMMS trained”.59 The EMT‑B was expected “on all shows normally above 5000 or depending on event risk assessment”.60

According to the SMG–ETUK contract, the EMT‑A was also expected to have an Advanced Life Support qualification and be able to administer prescription‑ only medications, including cardiac drugs following Advanced Life Support protocols.61 The Ambulance Service Experts considered that some of the activities the SMG–ETUK contract expected the EMT‑A to undertake would require professional registration.62

Ian Parry’s evidence was that, around 2012 to 2013, the Advanced Life Support Group, the company responsible for the Advanced Life Support qualification, required a person to be a registered medical, nurse or healthcare practitioner in order to undertake the Major Incident Medical Management and Support and Advanced Life Support courses.63 Ian Parry was not a registered practitioner in any of those categories.64 This meant that he was no longer eligible to undertake either of those courses or any refresher training in them from 2013.65

Ian Parry’s initial Major Incident Medical Management and Support qualification was gained in 2002. It was valid for four years. He renewed it, after it had expired, in 2007. The renewal expired in 2011, but was not renewed again. In 2002, Ian Parry obtained his Advanced Life Support qualification.66 In 2005, he renewed this. It expired in 2009, but it was not renewed again. His explanation for not renewing these qualifications was the change in requirement by the Advanced Life Support Group.67

In the CV he drafted in 2015, Ian Parry described himself as “EMT.ALS.PLS. MIMMS”.68 He wrote “ALS MIMMS” next to his name on SMG sign‑in sheets in 2017.69 An ordinary reading of these entries is misleading to a reader. Ian Parry’s evidence was that he had told James Allen or Miriam Stone about the Advanced Life Support Group’s change in requirement. He asserted that because he had undertaken the Major Incident Medical Management and Support and Advanced Life Support training, he was entitled to describe himself in that way.

James Allen stated that he did not know Ian Parry could not re‑accredit with the Advanced Life Support Group. I accept James Allen’s evidence on this point. It is clear that SMG regarded the Advanced Life Support Group qualifications as important: they were specified in the SMG–ETUK contract.70 SMG was misled by Ian Parry. As a result, SMG wrongly believed that Ian Parry had a current qualification in Major Incident management and Advanced Life Support, when he did not.

There was no evidence that any of the other ETUK staff had undertaken the Major Incident Medical Management and Support or Advanced Life Support training specified in the SMG–ETUK contract.71 The training they received had varied. The only formal qualification some had was the first aid at work certificate. Others had undertaken further courses. Some had received training through the university courses they were undertaking.72

Ian Parry accepted that a first aid at work qualification was insufficient on its own for any of his staff to be regarded as competent to discharge the role of event first aider. He stated that he provided training for the staff.73 Ryan Billington, an ETUK member of staff, also provided some training.74

One member of staff, who had been working at the Arena for nine years by the time of the Attack, characterised “in-house training” at ETUK as “ad hoc sessions, things like observation taking. They weren’t regular, but I do remember there were some on occasions.75 Another member of staff described doing her “oxygen and Entonox training, defibrillation through ETUK”.76 A third member of staff stated: “I don’t believe I did [receive any training], certainly not medically.77

Given the evidence of staff from ETUK, I accept that some training was provided to some staff while they were at ETUK. However, there were no records available to the Inquiry that permitted a proper assessment of the extent, regularity and adequacy of any training provided to staff by ETUK. Ian Parry said that ETUK records had been disposed of following the repossession of the ETUK offices after the Attack.78

In light of all the evidence about the level of training received by ETUK staff, I am satisfied that Ian Parry did not require a sufficiently high standard for those staff members he used at events. This was not the staff members’ fault. Responsibility for this lies with Ian Parry. I shall return to the issue of ETUK training when considering those staff members on duty on the night of the Attack.


The premises’ licence required a check to be made on the “first aid rooms and equipment”.79 There was one first aid room at the Arena. No inventory was maintained of the content of that room.80

The SMG–ETUK contract specified that “5 wheelchairs and 4 medical stretchers and evac. chairs are on site”.81 James Allen stated that two of the four trolley‑ style stretchers had been damaged.82 He said that, in addition to the remaining two trolley‑style stretchers, there were at least two or three canvas pole stretchers, one orthopaedic spine board, three or four carry‑chairs and seven or eight wheelchairs.83 A number of these items were stored in the first aid room.84 Ian Parry broadly agreed with James Allen’s evidence, although he suggested that there was only one basic stretcher in the first aid room.85

Tourniquets were not issued to staff as part of the first aid bags provided by ETUK.86 Ian Parry claimed that all staff were trained in the application of a tourniquet.87 In fact, many staff were not trained in their use.88 The events of 22nd May 2017 tragically demonstrate that at a mass casualty incident there is likely to be a need for tourniquets. In future, all event healthcare staff should be trained in and have immediate access to tourniquets.

I recommend that the Department of Health and Social Care (DHSC) consider introducing guidelines to ensure that all event healthcare staff are trained in how to use tourniquets and other basic life‑saving techniques for treating blast, bullet and knife wounds.

Tourniquets were included among the trauma equipment that was stored in the cupboard in the first aid room.89

Regarding first aid and medical equipment, the SMG–ETUK contract stated: “An agreement should be reached during the planning stage about who will provide such items.”90 There was no evidence of an agreement in writing. According to James Allen, SMG put some equipment in the first aid room, and it was for ETUK to add “to that to ensure they had what they needed”.91 Ian Parry stated that the costs of any items ETUK contributed were only reimbursed when they were used.92 He observed that if an item did not get used then it was down to him “as an expense”.93

The consequence of SMG’s approach was that Ian Parry was reluctant to buy first aid equipment in case it did not get used and resulted in an uncompensated expense to ETUK. This led to individual ETUK members of staff providing their own equipment because that provided by SMG and ETUK was inadequate.94

This was an unacceptable state of affairs. It resulted in financial considerations being placed ahead of patient welfare. It gave rise to a risk to patient safety. It placed the burden on individual members of staff to determine what might be required. It put those members of staff in a position where they had to purchase equipment in the hope of being reimbursed if they used it. Its effect was to pass on the initial cost SMG should have borne to individuals in low‑paid positions.

SMG should have purchased whatever medical equipment ETUK recommended, provided the recommendations were reasonable. This would have required ETUK to take a more proactive approach than it did as to what equipment was needed. Particular consideration should have been given to making sure there was sufficient equipment for a mass casualty incident, should one occur. If there was a query about the justification for any particular item, SMG could have taken external advice. SMG had an obligation to ensure adequate equipment under the premises’ licence. While SMG could have sought to discharge this through ETUK, a more robust system, which removed financial considerations and ensured ETUK’s competence, was required.

I recommend that the DHSC and, if appropriate, the Home Office consider issuing guidance on the first aid equipment that event providers are expected to have available on their premises, as well as where that equipment should be stored to ensure that it is readily accessible when required and how often it should be checked to ensure that it is up to date and in good working order. It may be that a minimum standard of first aid equipment forms part of the Protect Duty.


As I set out in Part 6 in Volume 1, SMG had a programme of exercises created by Miriam Stone of SMG and Thomas Bailey of Showsec. An exercise on 17th December 2014 was designed around the scenario of a terrorist attack in the City Room.95 It was attended by “Medic Supervisors – from our first aid contractors, Emergency Training Ltd”.96 This was one of a number of exercises.

Ian Parry stated: “There were a number of desktop exercises over the years involving NWAS, the Fire Service, the police, ourselves.” Of these, he said:
“[I]n desktop exercises, medical was right at the bottom of the pile. You’d spend 95% of the time talking about police, security and traffic management. So rightly or wrongly, yeah, I should be planning for a major incident, but when it comes across that your role is right at the bottom of the pile.”97 As I have emphasised elsewhere, full participation in well‑run exercises is essential.

Ian Parry also invited ETUK staff to attend “workshops and tabletop exercises” in their spare time.98 These occurred approximately every six months and included Major Incident response as a topic. They were not attended by all ETUK staff.99 As events on the night were to prove, these activities failed to instil the necessary knowledge and understanding in the ETUK staff who had attended. Aside from the issue of the quality of the training Ian Parry provided, staff should have been paid to attend important training such as this. A responsible organisation would make them compulsory.

ETUK’s participation in exercising did not lead to the learning and development that needed to occur in order for its staff to be adequately prepared for a mass casualty incident. Responsibility for this failure lies with Ian Parry.

I recommend that the DHSC consider introducing compulsory minimum standards of training for event healthcare staff to ensure that they are familiar with how to assist those injured in a terrorist attack and what will be expected of them in the golden hour, the first hour of the emergency response; see Part 10.

Emergency Training UK and NWAS

When asked about the requirement to pass a METHANE message to NWAS, Ian Parry asserted: “[I]t was made quite clear that NWAS would refuse to accept a major incident declaration from us.”100 He later suggested that the organisation who told him this may have been Greater Manchester Ambulance Service, NWAS’s predecessor in the Greater Manchester area. On the basis of what he had been told, he said that any further conversations on the subject would have been pointless.101 He stated that he had been told that a private healthcare provider’s METHANE message would not be accepted by the ambulance service.102

While the ‘M’ in METHANE does relate to whether or not a Major Incident had been declared, the remaining letters relate to other important information. I do not accept Ian Parry’s evidence that he was told that an ambulance service would not accept a METHANE message from a private healthcare provider. Such a statement is at odds with the national guidance in the Purple Guide. The Ambulance Service Experts stated that event healthcare providers can reasonably be expected to pass a METHANE message.103 ETUK’s Major Incident Plan envisaged that this would occur.

I am prepared to accept, as Ian Parry said in his answer when first asked about this topic, that the ambulance service in question told him that they would not accept a Major Incident declaration from a private healthcare provider. But that is not the same thing as saying it would not accept any part of a METHANE message.

If Ian Parry had taken a diligent approach to his own Major Incident training and had engaged with NWAS more constructively than he did prior to the Attack, this would have been apparent to him. As it was, he was in error. His error denied NWAS a METHANE message before Patrick Ennis, Advanced Paramedic with NWAS, arrived at the Victoria Exchange Complex.

The Purple Guide envisaged a substantial degree of liaison between the event healthcare provider and the local ambulance service.104 It expected a communication plan to have been drafted and shared. It expected Rendezvous Points (RVPs) to have been identified, shared with staff and provided to ambulance control rooms and other emergency services. It expected the medical plan to have been shared with the local ambulance service and local authority.

Responsibility for the lack of a more developed relationship between NWAS and ETUK lies on both sides.105 Had there been proper communication between them, a stronger relationship could have developed. ETUK and NWAS never jointly agreed or rehearsed what was expected of each in the event of a Major Incident. A closer relationship would have led to the discussion of such matters.

For an organisation like NWAS, which covers a large geographical area, it is not necessarily going to be possible for it to develop a strong relationship with every event first aid provider in their area. However, ETUK had been established as the sole healthcare provider at the Arena for over a decade.106 The Arena is one of the largest and busiest events venues in Europe. It could host events of up to 21,000 people.107 ETUK was regularly responsible for the healthcare of thousands of people. On its own, simply attending the six‑monthly meetings hosted by SMG was insufficient engagement by NWAS. Each meeting provided the opportunity to develop the relationship and to have further exchanges as to how an emergency would be managed. It is surprising that this did not happen.

SMG and Emergency Training UK preparedness conclusions

An issue was raised in the course of questioning as to whether SMG’s approach to ETUK was driven by a money before safety attitude. The same issue arose in relation to SMG’s approach to preventative safety measures. I addressed that concern in Part 2 in Volume 1.

James Allen denied that SMG put money before safety.108 When put to him in evidence, Ian Parry agreed with the suggestion that SMG took a “bargain basement” approach.109 He stated that SMG “would not pay for the level of cover that the Purple Guide mandated”.110 He claimed that he had asked for more stretchers and been given an answer that he regarded as unsatisfactory as it related to cost.111 He said that he had got to the point “of don’t bother asking”.112 In many respects, I did not find Ian Parry to be a reliable witness and have been cautious about accepting any part of his evidence.

Looking at the evidence as a whole, I am satisfied that SMG took an unacceptable approach to ensuring that there were adequate healthcare services at the Arena. SMG failed to carry out basic checks that would have revealed major deficiencies in ETUK’s approach.

I accept that Ian Parry perceived that SMG would not sanction substantial additional expenditure.113 However, he lacked sufficient understanding of the required standards to be capable of making a cogent case to SMG for an increase in funding to an acceptable level. Given the importance of healthcare services, SMG should have given him the opposite impression to the one he held.

Whether SMG would have refused if Ian Parry had made a cogent case for a significant increase in funding, I am not able to say. There was no clear example of them doing so. What is clear is that the relationship did not operate as it should have. In relation to healthcare, inadequate consideration was given to the welfare of the event‑goers. SMG was content to leave ETUK to run itself. SMG should have been checking ETUK was meeting an adequate standard.

SMG should have brought in external expertise to make this scrutiny meaningful. The effect of doing neither was that SMG saved money. SMG should have emphasised that it was open to further expenditure, if justified.

Ian Parry should have informed himself of the minimum standard of healthcare services and had the courage to persist in asserting the need for additional funding for staff and equipment, even if it meant souring the relationship. His failure to raise issues was a product of concern for his own self‑interest and a lack of understanding of what was required.

Neither SMG nor ETUK gave adequate thought to how the healthcare services that were in place would cope with an event such as occurred on 22nd May 2017. As a result, ETUK was not adequately prepared to respond.