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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)


A number of debriefs took place following the Attack. Some were termed “hot debriefs”.20 These were proximate to events and were intended to capture raw impressions of what had occurred. There were also more formal debrief processes where individuals completed questionnaires and attended debrief meetings.21

The debrief process provides an invaluable opportunity for organisations to understand what may have gone wrong and how improvements in their practices can be made. They must be conducted constructively and candidly. Given the importance of joint working, the debrief process of Major Incidents involving more than one emergency service should be overseen by the local resilience forum.

Particular care will need to be taken for debriefs following Major Incidents which may give rise to a criminal investigation. In these circumstances, the investigators will need to provide input on the management of those areas which might prejudice the investigation.

Operation Newtown was the name given by GMP to the response to the Attack. In a document dated 16th June 2017, GMFRS Deputy Chief Fire Officer Paul Argyle, Chair of the Greater Manchester Resilience Forum (GMRF), set out the principles, scope and process that were to be adopted for the Operation Newtown debrief.22 There were two stages. The first comprised a “strategic multi-agency debrief” undertaken by GMRF and “tactical organisational debriefs” conducted by individual GMRF member organisations.23 The two elements were conducted in parallel. The second stage took place at multi‑agency level and aimed at testing the findings, developing the learning and making recommendations.24

A large number of Operation Newtown debrief questionnaires were completed during July 2017. Each questionnaire required the person completing it to identify what aspects of the multi‑agency response did not go well, what aspects did go well and any key recommendations that they had.

Operation Manteline was the name given by GMP to the criminal investigation into the Attack. Debrief questionnaires were also completed within Operation Manteline.25

It is important that I acknowledge that an enormous amount of work went into all of the debrief processes following the Attack. I detected no lack of willingness by those who participated to get to an understanding of what went wrong, what went well and what recommendations might be made. However, I was struck by the lack of critical detail in the content of some of the debrief questionnaires prepared by witnesses who were called to give evidence. It is essential that everyone who needs to complete a debrief questionnaire is encouraged and supported to be constructive, objective, open and comprehensive.

ACC O’Callaghan was asked about the effectiveness of BTP’s debrief process and whether it was effective in revealing problems. His answer was that “[t]here’s certainly work still to be done in that area”.26 He agreed that there was a danger that a debrief process could be defensive. This is an understandable reaction which is difficult to overcome. ACC O’Callaghan stated that BTP had retained an external consultant to ensure that BTP’s review of what has emerged from the Inquiry is robust.27

I have a concern that the debrief processes following the Attack did not reveal several of the issues that they should have. It is beyond the scope of the Inquiry’s terms of reference for me to conduct a minute examination of why this was the case.

I recommend that each emergency service involved in the response to the Attack seek to understand why the issues considered in Volume 2 of my Report were not identified sooner. This is intended to be a constructive exercise aimed at improving the current system. I recognise that the answer to some may simply be attributable to the highly detailed and forensic process that the Inquiry has been able to undertake, but not all.