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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)

Record of events

Written notes

There was a requirement imposed by some organisations for written notes or decision logs to be kept relating to the response to the Attack. For example, firearms commanders were expected to keep a record of their decisions.7 Under the third edition of the Joint Operating Principles (JOPs 3), “decision- makers” were required to “record the rationale and information sources for their tactical decisions”.8 Police officers operated under a general expectation to keep notes in their pocket notebooks. North West Ambulance Service (NWAS) expected its commanders to keep a decision log. Greater Manchester Fire and Rescue Service (GMFRS) expected its officers to record decisions in a log or, where this was not possible, to record notes later and within 24 hours of an incident.9

A firearms officer gave evidence that advice had been given that those officers should “just … produce duty statements at [the] time that we were there at the incident, et cetera, but not in detailAt a later date we would give a detailed statement when requested to.10 This was not an assertion that I investigated in detail. However, if it accurately reflects the approach taken, it should be reviewed by GMP. The reason may be because of concern about the wellbeing of officers who had just been through a very traumatic experience, but detailed notes should normally be made as soon as is reasonably practicable.

Making accurate notes forms an important first stage in the recording of what happened and why decisions were made. The need for accuracy cannot be overstated. Inaccurate notes can be worse than no notes: they are presumed to paint an accurate picture but will have the opposite effect. It is through the making of accurate notes that errors will be identified and improvements to what worked well noted.

The timing of record‑making is critical to achieving accuracy. NWAS, for example, required a decision log to be completed within 72 hours of an incident.11 There may be good reason for this. It may be a national standard. However, in my view, this is too long a period to ensure accuracy. NWAS should reflect on this. Unless there are compelling reasons justifying a delay, such records should be completed within 24 hours of an incident.

Ideally, the making of such records should be prioritised so they are completed by the point of command handover. As JOPs 3 stated: “[D]ecision logs can be used to assist future decision-making and ensure clarity of understanding of what will be a rapidly developing and complex situation.”12 I see no reason why this statement of principle should be confined only to Major Incidents in which Operation Plato has been declared. It should be applied to all Major Incidents.

In Parts 14 and 15 in Volume 2‑I, I set out occasions when inaccurate notes were made about the content of important telephone calls. I do not repeat them here. These notes were capable of obscuring the truth of what happened on the night of the Attack. It was only the fact that recordings of the calls existed that enabled the inaccuracies to be exposed and corrected.

Investigators, judges and other decision‑makers have long regarded contemporaneous notes as a more reliable source of evidence than recollections repeated after discussions with others have taken place. As a result, it is all the more essential that accurate notes are made.

I recommend that all emergency services involved in the response to the Attack reflect on their approach to note‑taking during and immediately following Major Incidents with a view to improving the current practice. I recommend that the Home Office, College of Policing, National Ambulance Resilience Unit and Fire Service College ensure that all commanders responding to a Major Incident are trained on the importance of recording their key decisions and rationale.

In the case of those who are responding at the scene, the timely taking of notes will be less practicable. For people in these roles, audio and/or visual technology can provide vital support. In saying this, I am not seeking to confine the use of audio and/or visual technology to those who attend a scene. They are the people who are likely to derive the most benefit from a recording but those remote from the scene, for example Strategic/Gold Commanders, will also see an advantage, as ACC Deborah Ford acknowledged.13

Audio and/or visual recordings

In Part 13 in Volume 2‑I, I addressed the position of firearms officers and body‑ worn video. I will not repeat that here, but it forms an important part of what I say next.

Two of the most important pieces of evidence received by the Inquiry came from Dictaphone recordings. One was made by Chief Inspector Mark Dexter of GMP,14 the other by Inspector Dale Sexton of GMP.15 These recordings were an invaluable source of information for my investigation. They captured important conversations by those individuals. They allowed me to reach conclusions about how busy the people recorded on them were. They permitted me to make informed judgements about how challenging the environments were. They revealed something of the stress levels people were operating under. To some extent, they enabled the listener to put themselves in the situation that was being recorded.

There was inconsistency across the emergency services in relation to the use of Dictaphones. There were a number of important witnesses in command roles who had immediate access to a Dictaphone but did not use it, or used it for only a short period of time.16 There were also some in significant roles who did not have access to a Dictaphone on the night of the Attack.17

I have considered whether those individuals or their organisations should be criticised for this. I have concluded that it is more appropriately treated as an opportunity for improvement. The lack of a recording of what individuals said and heard did not impact on the quality or nature of the response to the Attack, but it may have had an impact on the ability to learn lessons.

There was no evidence to suggest that the use of a Dictaphone would have any adverse effect on any individual’s performance. If anything, knowing that everything that is said is being recorded may lead to a person acting more deliberately and thoughtfully. It may also mean in certain circumstances that a written log is less important, given that a complete record will be captured through an audio recording. This will free up time to focus on more important command activities.

As technology advances and costs reduce, it may be that body‑worn video equipment is regarded as a viable alternative to Dictaphones. A number of police officers who responded to the Attack were issued with such equipment as part of their tour of duty that day. This audio and video footage formed a vital part of reconstructing what happened in the City Room in particular. The content was often too distressing to play publicly. I have viewed a good deal of it. It enabled me to understand better how terrible an environment the City Room was in the period immediately after the Attack. The body‑worn video recordings have been the subject of very detailed analysis.

I recommend that the Home Office, College of Policing, National Ambulance Resilience Unit and Fire Service College ensure that all those who may be required to take up a command position are issued with a means to record what they say, hear and, where appropriate, see. It may also be that key personnel within control rooms would benefit from having such equipment available for activation in the event of a Major Incident. Training should be given to all who are issued with such technology on the circumstances in which it should be used and the importance of its use. Exercises should include the use of contemporaneous recording devices in order to simulate how they will be used in practice.

It is important to make clear that I do not regard the use of audio and visual recording equipment to be a complete substitute for the timely taking of notes. A recording of what occurred will not always capture why an individual made a given decision. Accurately capturing the rationale behind commanders’ decision‑making is important.

Conversations not conducted in person

Generally, radio transmissions and calls to control rooms on the night of the Attack were recorded. Collating these recordings was a substantial undertaking. Once this important work had been undertaken, these recordings formed a vital part of understanding how information moved within and between organisations.

However, as I set out in Part 15 in Volume 2‑I, there were a significant number of conversations between senior GMFRS personnel which were conducted by mobile phone.18 The participants in these calls had different recollections as to what was said in a considerable number of those discussions.19 This required me to resolve disputes of fact, if that was possible, before I could identify where improvements might be made.

This only serves to underline the need for audio and/or visual recordings for commanders and other key personnel.