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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 response

Key findings

  • The healthcare service provided by Emergency Training UK (ETUK) on the night of the Attack was inadequate.
  • The combined skill level of those on duty from ETUK on 22nd May 2017 was too low. It was a long way short of the guidance provided by the Purple Guide.
  • Contrary to the requirement of the SMG–ETUK contract, there was no one on duty that night with a Major Incident qualification.
  • Within 15 minutes of the explosion, 6 members of ETUK staff had made their way to the City Room.
  • Contrary to the ETUK Major Incident Plan, no METHANE message was sent to North West Ambulance Service (NWAS) before paramedics arrived.
  • The ETUK Director, Ian Parry, did not liaise with NWAS in the way the ETUK Major Incident Plan, which he had written, identified that he would. This role was carried out by a more junior member of staff.
  • The ETUK staff did their best to help those injured by the explosion.
  • There was a failure to provide any adequate standard of care by ETUK. This was as a result of a lack of preparedness and inadequate staff skill level. Responsibility for this lies with ETUK and Ian Parry.
  • Shortly after the explosion, the SMG Event Manager made a request over the radio for all SMG first aid trained staff to make their way to the City Room.
  • Members of SMG staff went to the City Room and offered what help they could to those affected by the explosion.

Emergency Training UK staff on duty

Taking the evidence as a whole, the healthcare service provided by ETUK on the night of 22nd May 2017 was inadequate. While the number of staff may have been adequate, they did not have anything like the necessary skill level for a concert of this size.114 This was for three reasons: first, because SMG’s specification of the level that was required was too low; second, because ETUK and Ian Parry provided an even lower mix of skills than SMG thought it was receiving; and third, because the minimum standard Ian Parry and ETUK set for its first aiders was too low.

As set out in Part 11, the Purple Guide indicated that for an event such as the Ariana Grande concert on 22nd May 2017, the following healthcare services should be present on site: 1–2 doctors; 2–4 nurses or Extended Nurse Practitioners; 2–4 paramedics or Emergency Care Practitioners; and 10–11 first aiders. First aiders were required to have more than just a first aid at work qualification. It also indicated a minimum of one ambulance and crew and one rapid response vehicle.

For the night of 22nd May 2017, SMG required 2 Emergency Medical Technicians and 12 first aiders from ETUK.115 The ambulance ETUK owned had not been booked for the event and was not at the Victoria Exchange Complex.116 ETUK also owned a response vehicle. This was at the Victoria Exchange Complex that night, but it was not used.117

Ian Parry claimed the healthcare provision made by ETUK at the venue was in excess of the Purple Guide requirement.118 This claim was wrong. The reason he made it was because he had not read the relevant part of the 2015 Purple Guide.119 Ian Parry’s lack of knowledge of which guidance was in force is concerning.

James Allen stated that the healthcare staff numbers were decided by reference to the Purple Guide and by SMG’s “experience of doing shows and also the data that we’d collected over the previous years”.120 The flaw in this approach, as SMG should have realised, was that the Arena had not previously been the subject of a mass casualty incident. Consequently, none of the data in the past was capable of informing the cover that would be required for such an eventuality.

Explaining why SMG’s requirements were not aligned with the Purple Guide, James Allen asserted that “when you read” the Purple Guide, “it is very much focused on festivals and one-off events”.121 I disagree. While such events receive substantial attention, the part dealing with resources at an event does not have an exclusive focus.122 Instead, it provides “some outline guidance” and “is not intended to be prescriptive in any way”.123 It encourages a risk‑driven approach.124 It provides a non‑exhaustive list of factors to be included in the risk assessment. Some of these, such as “Overnight camping” and “Time of year”, are irrelevant to the Arena, but several factors are relevant.125

The 14 staff ETUK had on duty126 on the night of the Attack fell a long way short of the Purple Guide expectation in terms of relevant skills.127 None of those present was qualified in any of the protected title professions listed in the Purple Guide. While there were two trainee doctors and a trainee paramedic among those on duty, these members of staff had not completed their training and were not fully registered in those professions.128

Ian Parry asserted that there was also a trainee nurse among the ETUK staff.129 That was not correct. The person in question had not started the nursing course at the time of the Attack.130

According to the SMG–ETUK contract, the EMT‑A role required Major Incident Medical Management and Support and Advanced Life Support qualifications.131 As explained in paragraphs 16.43 to 16.49, none of the ETUK staff on duty on the night of the Attack had these qualifications. Ian Parry had misled SMG in relation to the state of his own qualifications.132 This meant that, within the terms of the SMG–ETUK contract, Ian Parry was not able to act as more than EMT‑B. Ian Parry stated that he was acting as EMT‑B on the night of the Attack.133

Also acting as EMT‑B was Ryan Billington, according to his evidence.134 He was a second‑year student paramedic and 20 years old.135 Ian Parry claimed Ryan Billington was in the role of EMT‑A.136 I reject this evidence. The confirmation email Ryan Billington received booking him for the shift identifies his role as EMT‑B.137

As a result, there was no one acting in the EMT‑A role, as defined in the SMG–ETUK contract.

So far as the other ETUK staff were concerned, they were all retained that night as first aiders.138 They had a mix of qualifications. At one end of the spectrum, one staff member was weeks away from qualifying as a medical doctor.139 At the other, several did not have formal qualifications beyond a first aid at work course.140 To take one example at the latter end of that spectrum, one member of staff had only undertaken a three‑day course in 2012/13, followed by a one‑day refresher in the two years before the Attack.141

Before the concert

Ian Parry provided the ETUK staff with a briefing before the concert began. The briefing was “generic”.142 In the briefing, he informed ETUK staff of the crowd profile, crowd numbers, event timings and how many ETUK staff were on duty.143 The risk of a terrorist attack was not mentioned.144 It should have been. Ian Parry was not aware of the threat level at the time.145 He should have been.

Ian Parry paired the ETUK staff. Each pair was given a radio.146 One member of ETUK staff was allocated to the Sierra Control Room in the Arena.147 As Medic 1, Ian Parry was not paired with anyone.148

Response by Emergency Training UK’s Emergency Medical Technicians

Ian Parry

Shortly after the explosion, Miriam Stone spoke to Ian Parry over the radio. She informed him that his staff were needed in the City Room.149 ETUK staff made their way to the City Room. Ian Parry entered the City Room at 22:36.150 Six minutes after Ian Parry, Ryan Billington entered the City Room.151 Ryan Billington’s arrival brought the total number of ETUK staff in the City Room to six.

Ian Parry’s explanation for not sending a METHANE message was, “I was sent out there to look after the patients. The idea of a METHANE message just went out the windowThe system fell apart.”152 This evidence was in contrast with his claim at another stage of his evidence that no METHANE message was sent because he believed NWAS would not accept it.153 He stated that his “assumption” was that SMG staff were informing NWAS.154

As Medic 1, it was Ian Parry’s responsibility to carry out the command functions envisaged by the SMG and ETUK plans.155 His role was to “assume overall control until the arrival of the Statutory Emergency Services”.156 He stated that the ETUK first aiders acted under his direction and that of Ryan Billington and Elizabeth Woodcock.157 He stated that the ETUK staff knew their roles but did not follow them on the night of the Attack.158

Ian Parry did not discharge his command role to an adequate standard. Had he attended to Major Incident training and exercising more diligently, he would have been much better placed to do so. Ian Parry did not liaise with NWAS, although there was at least one point when he was close to Patrick Ennis.159 He stated that he left Ryan Billington to do this as he was “probably the best-placed person to do the handover because he knew specifically how NWAS work and he would know their policies”.160 He went on to say he did not make a call to NWAS because, “I was busy doing what I was told to do and couldn’t have got through anyway, probably.”161

Ian Parry went around the City Room. He informed ETUK staff that if a person was not responding they should move on.162 Of his own approach to triage, he stated in evidence: “[N]o breathing, move on to somebody else, leave them alone and move on to somebody else — or catastrophic bleeding.163 He described his role as “doing the assessment of those who we couldn’t do any more for and … eventually I was directing others who to treat and how to deal with them”.164

Ian Parry checked Kelly Brewster.165 He spoke to those assisting Jane Tweddle166 and Megan Hurley.167 He covered Michelle Kiss168 and re‑covered Martyn Hett.169 He assisted in moving John Atkinson from the City Room.170 Ian Parry had a tourniquet in his pocket. He did not use it as he forgot he had it on him.171 In his evidence, he said that he covered one or two people whom he thought were dead.172

Ryan Billington

Shortly after Ryan Billington entered the City Room, he broadcast a message over the ETUK radio channel.173 He requested that all trauma equipment be brought to the City Room.174 He then made a broadcast, stating: “This is a major incident. Follow major incident protocol. If people have no pulse, we can’t help; treat catastrophic bleeding.175

I can understand that some reading it will find this message upsetting. It was fortunate that Ryan Billington took control as he did. In a mass casualty situation, an approach that focuses on those with catastrophic bleeding is established to be the most likely to save lives.176 Ryan Billington’s message was in accordance with NWAS’s triage tool.177 The message he sent was an important reminder to the ETUK staff of how to approach a mass casualty incident.

At 22:57, Ryan Billington approached NWAS Advanced Paramedic Patrick Ennis and GMP Inspector Michael Smith.178 The conversation with Patrick Ennis continued for over a minute.179 Ryan Billington provided an initial handover to Patrick Ennis.180 He told Patrick Ennis how many dead and injured there were. Patrick Ennis informed Ryan Billington that ETUK staff should not perform CPR and should focus on those who were bleeding. Ryan Billington relayed this message over the ETUK radio channel.181

Ryan Billington became aware that there were no stretchers immediately to hand. He instructed people nearby that they should use whatever they could find in order to get people out of the City Room.182 SMG accepted in its oral closing statement that insufficient equipment was brought into the City Room.183

Patrick Ennis left the City Room after he had spoken to Ryan Billington.184 Having spoken to Daniel Smith, Consultant Paramedic and Operational Commander for NWAS, on the station concourse,185 Patrick Ennis returned to the City Room at 23:05.186 Upon his return, Ryan Billington spoke to him again.187

By speaking to Patrick Ennis, Ryan Billington undertook the important liaison role between ETUK and NWAS. Ryan Billington had had some Major Incident training as part of the paramedic undergraduate course he was undertaking.188 He had not completed that course at the time of the Attack.189 He had not undertaken the Major Incident Medical Management and Support training.190

It should not have fallen to Ryan Billington to undertake this role. It was not the role he was retained to undertake on the night.191 He did not hold the qualification SMG expected him to hold for this purpose. In saying this, I am not critical of Ryan Billington for engaging with NWAS. On the contrary, it is commendable that he stepped into the void created by Ian Parry. However, relying upon people in the midst of a serious incident to act as Ryan Billington did is not an appropriate way to prepare for and respond to a mass casualty incident.

In the course of the critical period of the response, by which I mean the period up to the removal of the final living casualty from the City Room at 23:39, Ryan Billington went on to be involved in the care of Megan Hurley,192 Kelly Brewster,193 Martyn Hett194 and John Atkinson.195

Emergency Training UK’s Emergency Medical Technicians conclusions

ETUK lacked highly skilled staff on the night of 22nd May 2017.196 Had ETUK adhered more closely to the guidance provided by the Purple Guide, there would have been more highly skilled members of ETUK staff on hand to help. Two EMT‑Bs, of the standard defined by the SMG–ETUK contract, were insufficient for an event such as the Ariana Grande concert.197

This lack of highly skilled staff resulted in a lower standard of care being provided to the injured during the period before NWAS could arrive. The timing and number of NWAS paramedics entering the City Room meant that the impact of this continued longer than it would have done had more paramedics been committed to the City Room.

Response by Emergency Training UK’s first aiders

Elizabeth Woodcock was designated “Medic 2” by Ian Parry for that shift.198 She had received very little Major Incident training.199 She stated that the training was that ETUK staff should evacuate; that they should only enter when told it was safe; and that someone would take the clinical lead and advise them what to do.

She was aware of the ETUK Major Incident Plan. She stated: “[W]e didn’t use that plan on the night.”200 She stated the use of tourniquets did not form part of that training. Her evidence was that some staff were happy to use them, had been shown how to use them, “but we did not carry them on us”.201 This is consistent with Ryan Billington’s evidence on tourniquets.202

Elizabeth Woodcock entered the City Room at 22:34.203 She attended to Saffie‑Rose Roussos,204 Wendy Fawell,205 Sorrell Leczkowski,206 Kelly Brewster207 and Georgina Callander.208

Marianne Gibson entered the City Room at 22:40.209 She attended to Saffie‑Rose Roussos,210 Jane Tweddle,211 Kelly Brewster,212 Alison Howe,213 Sorrell Leczkowski,214 Megan Hurley215 and John Atkinson.216

Other ETUK first aiders in the City Room had involvement with those who died. Kristina Deakin checked Martyn Hett217 and attended to Georgina Callander.218 Sarah Broadbent checked Wendy Fawell.219 Craig Seddon assisted in the treatment received by Jane Tweddle.220 Zak Warburton checked Angelika Klis221 and Kelly Brewster.222 Ken O’Connor knelt beside Saffie‑Rose Roussos,223 covered Angelika Klis224 and checked Philip Tron.225

ETUK staff did what they could for members of the public in or around the City Room. This included assisting with transporting a casualty to hospital,226 and transporting the child of another ETUK staff member away from the scene.227 A number of ETUK staff also offered assistance in the Casualty Clearing Station.228

I am not critical of the individual ETUK first aiders for what they did or did not do. Those that went into the City Room showed courage in doing so. Any failure to provide a reasonable standard of care for an event healthcare service was as a result of failures by ETUK and Ian Parry. ETUK and Ian Parry did not adequately prepare the ETUK first aiders. In the case of some ETUK first aiders, they did not have sufficient qualifications or skills to perform to the standard that should be required of an event healthcare service.

I accept that this standard of care will not be as high as that provided by an ambulance service.229 However, the minimum requirement expected by Ian Parry of event first aiders was too low. The first aiders were not supported by sufficient ETUK staff who had a high level of qualifications and skills.

Response by SMG staff

At 22:31, Miriam Stone was watching the CCTV monitors in the Sierra Control Room.230 Those relating to the City Room “went white”. After a few seconds the monitors cleared. It was apparent to her that there was white smoke in the City Room. She stated: “As the view became clearer I could see the scene of devastation and carnage.”231 It was obvious to Miriam Stone that an explosion had occurred.232

Miriam Stone instructed Thomas Rigby, the Showsec Head of Security, to close the City Room.233 She contacted Ian Parry and informed him that ETUK staff needed to go to the City Room. Ian Parry raised the issue of whether it was safe for his staff to enter the City Room. Miriam Stone replied that there was “no obvious visible threat and very little movement in the area and it appeared to be safe visually”.234 She stated: “[A]s far as I can tell, it is safe.235

Jacqueline Day was Head of Merchandising from SMG. She was in the City Room when the bomb detonated. She briefly left, before returning. She approached Saffie‑Rose Roussos. She went to find help.236

Paul Johnson, the SMG Fire Safety Officer, was in the Whisky Control Room when the bomb detonated. He saw the City Room through the CCTV monitors. He immediately telephoned 999.237 At 22:34, he spoke to a GMP operator. He reported that a “bomb” had detonated in the City Room. He informed GMP that there were “a lot of casualties on the floor”.238

Once she had spoken to Ian Parry, Miriam Stone made a broadcast on the SMG radio channel for any first aid trained staff to make their way to the City Room.239

John Clarkson was employed by SMG as a Senior Event Technician. His role was to build and dismantle stages for Arena events. He had held a basic first aid qualification since 2004 and undertaken a refresher course in February 2017.240 Paul Worsley worked for SMG as a Senior Engineer. His duties included setting up equipment and managing the electrical systems.241

Upon hearing the explosion, they immediately made their way towards the City Room. Miriam Stone warned John Clarkson of the “horrific” scene and stressed that he did not have to go there. She recalled that he “replied to me very determinedly ‘I’m going!.242

In the hours that followed, John Clarkson and Paul Worsley worked together to assist a young and seriously injured casualty. They transported her to the Casualty Clearing Station, where they stayed with her until an ambulance arrived.243

They used a trolley‑style stretcher to move this casualty to the Casualty Clearing Station. This trolley‑style stretcher had been brought from the first aid room by two members of SMG staff.244 This was the only trolley‑style stretcher used on the night of the Attack to evacuate anyone from the City Room.

At 22:55, James Allen, the Arena General Manager, arrived at the Victoria Exchange Complex. He went to the Whisky Control Room. Once there, he liaised with firearms officers in relation to their search of the Arena.245