During the Inquiry’s oral hearings, I heard evidence from 267 witnesses, many of whom were called during the hearings relating to the emergency response. The hearings relating to the response took place between January and October 2021. Additionally, the accounts of many other witnesses involved in the response were read out or summarised. Behind that witness evidence was a very substantial body of documentary, audio and video material which had been assembled, organised and reviewed. I also received opening and closing statements, both written and oral, on behalf of Core Participants, including each of the bereaved families and the emergency services.
Having received and considered all this information, I have been able to reconstruct what happened on the night of 22nd May 2017 and to do so in considerable detail. This has enabled me to identify what went wrong.
The complexity of this process and the necessity to await the conclusion of the criminal trial of HA, coupled with some delay to the start of the oral evidence hearings by reason of the COVID‑19 pandemic, meant this has taken considerable time. Over five years will have passed since the Attack by the time that Volume 2 of my Report is published.
In the course of the oral hearings, I received evidence from a number of very senior members of the emergency services. A number of these people stated that the process of the Inquiry had caused them to identify areas for improvement that had not previously been identified and to implement or start to implement change as a result.
For example, Sarah‑Jane Wilson, the Head of North West Fire Control (NWFC), began her evidence by telling me that, following her review of the Inquiry’s evidence:
“I would like the Inquiry to know that I have followed almost all of the evidence that has been given to the Inquiry. I have also worked through the documents and evidence on the Inquiry’s portal, which is something I did before the Inquiry started and have continued to do ever since … It has become very clear to me that on the night of the Attack, North West Fire Control did not manage communications in the way that would have been expected of them by the public and by the Fire Service. The control room was responsible for significant failures in the management of information throughout that night … I have personally asked for those failures to be fully set out in a sequence of communications which North West Fire Control has provided the Inquiry with.”
Later in Sarah‑Jane Wilson’s evidence, the following exchange took place:
“Q. … has information come to light by reason of the Inquiry, which is relevant to North West Fire Control’s way of operating?
A. Yes, sir.”
Deputy Chief Constable (DCC) Ian Pilling gave evidence on behalf of Greater Manchester Police (GMP). The following exchange took place during his evidence:
“Q. … has the process of the Inquiry led to further relevant information coming to GMP’s attention?
A. Yes, it has.”
DCC Pilling gave an example later in his evidence. He was asked about the gap in police officers’ knowledge about how other emergency services operate and why it took until February 2021 to create training materials to address this. His answer was significant: “I think it’s probably a realisation of the gravity of the problem as we started to look at the evidence from the Inquiry.”
He also observed: “[O]ne of the things that I’ve taken away from this Inquiry so far is around Plato and it needing a good dose of looking at.”
Assistant Chief Constable (ACC) Sean O’Callaghan gave evidence on behalf of British Transport Police (BTP). He was asked about changes which had been identified. This exchange followed:
“Q. And some of what you have already said is as a result, as I understand it, of what has come out in the Inquiry?
A. Absolutely, yes.”
The Inquiry followed a number of earlier evidence‑based investigations into what happened and why. Some commentators have questioned why it required a public inquiry to uncover some of these issues.
In this Part, I review why some of what went wrong only emerged as a result of the work of the Inquiry. The purpose is to show where areas for improvement in the emergency response to tragedies such as the Attack can be identified, without the need for a process as complex and lengthy as this Inquiry.