In August 2018, I was appointed by the Lord Chief Justice and the Chief Coroner as the nominated judge to sit as the Coroner to conduct inquests into the deaths of the twenty‑two people who died as a result of the Attack. Following a ruling I made in 2019, the Inquiry was established. The matters which were the subject of that ruling will be dealt with in Volume 3 of my Report.
Both as a Coroner and as a Public Inquiry Chairman, I was granted powers enabling me to carry out a full investigation. Paragraph 5 of the Inquiry’s terms of reference set out the scope of my investigation in this area of the Inquiry.
Support from Operation Manteline
Supporting me in this investigation was a team of GMP officers from Operation Manteline. These officers were not involved in GMP’s response to the Attack beyond the criminal investigation. The part of the Operation Manteline team supporting the inquests and subsequently the Inquiry was headed by Detective Superintendent Teresa Lam. Detective Inspector (DI) Michael Russell was responsible for those who gathered, collated and analysed the hundreds of hours of audio‑visual material.
I am indebted to Detective Superintendent Lam, DI Russell and all those within their team. I received an extraordinary level of support and co‑operation. I pay particular tribute to the work that was undertaken in reconstructing the period post‑explosion. It was of a highly distressing nature. It was painstaking and protracted work. It enabled the clearest possible understanding of what happened to each of those who was killed following the detonation.
Getting to the truth
As I have set out above, there had been numerous reviews and debriefs aimed at identifying what happened on the night of the Attack. For that reason, some may have thought the Inquiry was going to be a re‑analysis of already well‑ established facts. This proved not to be the case.
The forensic process of the Inquiry brought to light many new pieces of information which either had not previously been known or the importance of which had not previously been realised.
A stark example of this was in relation to the important first decision within NWFC. Based upon what the panel was told, Lord Kerslake’s report states:
“On being told on the telephone by GMP at 22:35hrs that ‘there had been an explosion and that a bomb has exploded’, the North West Fire Control operator initially acted in accordance with the action plan for ‘EXPLOSION’ and created an incident log. Following the plan’s instructions, they then opened the action plan for ‘BOMB’.”
Lord Kerslake’s report goes on to identify that the first action of the ‘Bomb’ action plan was to contact the duty NILO, which is what in fact occurred.
This account of what happened was maintained in witness statements submitted to me.“Contrary to what is said in some of the material and evidence gathered, the control room operators at NWFC did not ‘open’ the action plan for ‘BOMB – GENERAL’.”On 19th August 2020, in its opening statement, NWFC stated:
Further witness statements were provided in support of NWFC’s position.These confirmed that the ‘Bomb’ action plan was never consulted and that the decision to contact the NILO was made without reference to any particular action plan.
It is most unfortunate that it was not until days before the oral evidence hearings began that the correct state of affairs was identified. I commend those responsible for identifying it and drawing it to the Inquiry’s attention. However, whether or not a particular action was based on an existing plan formed an important part of establishing what happened. It is remarkable that it took over three years for this misconception to be dispelled.
As I have said, the above represents what is a stark example of an important factual revelation emerging after an extended period during which the opposite had been asserted. There were many other developments which I do not rehearse here. I do not raise this particular example with a view to criticising those who had previously been wrong in their recollection. I raise it because it further underlines the importance of accurate record‑keeping about what was done and why. It also demonstrates the need for early, objective analysis of the known facts.
On 30th January 2020, I issued a ruling directing that each of the public body and corporate Core Participants serve a statement setting out the changes which had been made since the Attack.
Statements setting out post‑Attack changes were served before the start of the oral evidence hearings, in April to June 2020.I found these statements instructive. They demonstrated that there was a genuine commitment to improvement on the part of each of the emergency services.
My investigation did not involve a detailed analysis of the efficacy and appropriateness of the changes that have already been made. Its focus was on what the position was in May 2017. For this reason, I have deliberately refrained from commenting on whether any of the issues I have identified have yet been addressed, whether in full or in part.
In Volume 1, I identified particular recommendations as ones which I intended to monitor. In January 2022, I heard evidence in relation to those ‘monitored recommendations’.This evidence provided an opportunity for those who were the subject of monitoring to share their experience of making necessary improvements with a view to sharing their learning widely.
As I will set out in Part 21, I will adopt the same approach to particular recommendations that I make in Volume 2.
Approach to learning as a result of the Inquiry
I was particularly impressed by the evidence I heard from GMP and BTP about the structures that have been put in place in order to extract and disseminate learning as a result of the Inquiry.
As those efforts may be of more general application to emergency services, I comment on them further below.
Towards the end of 2019, DCC Pilling set up a team within GMP whose task was to review all the recommendations identified from the Attack and from debriefs. The purpose was “to ensure [GMP] could assure [itself] that the appropriate progress had been made”. This team was called “the Arena Recommendations Review Team”. DCC Pilling identified the need for this team when he began to prepare his statement for the Inquiry.
DCC Pilling stated that, out of the work of the Arena Recommendations Review Team, GMP developed what it termed the Organisational Learning Board. DCC Pilling explained:
“What I was conscious of was that given the volume of [the debriefs and reviews], that the organisation wasn’t always pulling them all together and spotting common threads. And the purpose of the organisational learning board … was twofold: first of all, to ensure that we have an effective scanning process across all those threads … The other was to have more of a lessons learning ethos within the whole organisation and encourage … an approach more towards learning lessons.”
I was impressed by DCC Pilling’s commitment to embedding learning within GMP. Establishing a structure of organisational learning officers across all districts and departments in GMP represented a step change for the better. He stated:
“[M]y ethos is that most … learning should take place at a low level, it is a localised piece of learning, but equally some learning will be more strategic and it is issues such as that which are brought to the organisational learning board.”
I recommend that GMP share its approach with other police services through the National Police Chiefs’ Council.
ACC O’Callaghan gave evidence as part of the process of monitoring recommendations made in Volume 1. In January 2021, following the oral evidence hearings relevant to Volume 1, BTP created the “SABRE programme”. SABRE is an acronym which stands for “situational awareness, briefing, response and events”.
ACC O’Callaghan explained the genesis of the SABRE programme in this way:
“British Transport Police started the journey of correcting some of the wrongs as early back as when the Kerslake Inquiry was sitting and started developing some of those streams at that point. And then as further streams were picked up through this Inquiry, they were added to that programme, and those combined pieces of work are what became the SABRE programme.”
A number of those workstreams related to issues with BTP’s involvement in the emergency response. I take two examples from within one of those workstreams to illustrate the approach taken by BTP. First, BTP recognised that there was “a lack of familiarity” with the Major Incident Manual. I have set out my conclusions in relation to this in Part 13 in Volume 2‑I. This led to BTP making changes in its approach.
Second, BTP developed its approach to the use of tourniquets. ACC O’Callaghan told me: “I have now changed my position on [tourniquets] having listened to or watched [Brigadier Hodgetts’] evidence and indeed watching … the video on the citizenAID website.” He went on to say that he had met with Brigadier Timothy Hodgetts and that BTP had recommended all frontline BTP officers be issued with, and trained in the use of, tourniquets. I shall return to the issue of tourniquets in Part 20.
I commend BTP’s approach to learning from the Inquiry. I was impressed by ACC O’Callaghan’s commitment to change.
I recommend that BTP share its approach with other police services through the National Police Chiefs’ Council.
Warning letter process
I am required by Rule 13 of the Inquiry Rules 2006 to send a warning letter to any person who may be the subject of explicit or significant criticism. Rule 15 requires that a warning letter should state what the criticism or proposed criticism is; contain a statement of the facts that are considered to substantiate the criticism or proposed criticism; and refer to any evidence which supports those facts.
I was concerned at the outset of the Inquiry that the requirements of the warning letter process may impact on the timetable for publication of my Report. The requirement to identify every potential criticism and supporting evidence is onerous. It means that warning letters can only be issued when the drafting of the report is well advanced. The responses to warning letters can be lengthy and complex. All this increases the risks of delay while issues are reviewed and the Report updated. That has happened at this stage of the Inquiry.
I have nonetheless found the warning letter process a useful one. As I noted in Volume 1, I have not taken into account fresh evidence or new arguments that were provided in warning letter responses and which could have been, but were not, put forward during the Inquiry’s evidence hearings or in written and oral submissions.
I have adopted that general approach because it is not the purpose of Rule 13 to provide those who may be criticised with an opportunity to reopen matters in order to justify their conduct or to advance submissions that could have been made openly, on notice to the Inquiry and other Core Participants and subject to submissions, but were not.
Over the course of an inquiry’s investigation, the importance of matters may change. New issues may arise. That is how inquiries work. They are not the same as an adversarial process where the issues should be clear before the hearing starts. In an inquiry, issues and proposed criticisms may come into focus only when the report is written. If they have not been explored in evidence, that is a factor I have had in mind when deciding whether or not it is fair and appropriate to make a particular finding. The warning letter process has ensured I have been able to raise matters as potential criticisms which have not been fully explored in evidence and allow an opportunity for a response before I decide whether to include them in my Report. I consider that to be a fair process and one that is essential to enable me to prepare a comprehensive report.
I understand that any person or organisation warned that they may be criticised in a public inquiry report may be distressed by this. I also understand that, where a person does not believe they should be criticised, this distress may be greater. It is important that those subject to potential criticism have the opportunity to respond.
I have found it particularly helpful to be told in an objective, dispassionate way why a proposed criticism is said not to be justified. That is a reasonable and proper use of the warning letter process. Some of the responses to warning letters were phrased in this helpful way; others were not.
Throughout the Inquiry’s public hearings, every organisation committed to assist me in the search for the truth. I am grateful to all those who approached the warning letter process constructively. However, I am concerned that the attitude of others as expressed during a confidential process may stand in the way of further change.
I considered carefully whether to disclose the warning letter responses after the publication of this Report. I have decided not to do so but it is an important reason why I intend to monitor certain recommendations from this Report. It will ensure that everyone considers and reflects on the conclusions in the Report in a constructive manner and with the intention of ensuring that the same mistakes are not made again.