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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)

Part 20: The Care Gap

In the event of a mass casualty incident, the public expect ambulances to travel to the scene quickly and in large numbers. The public also expect that, once on the scene, paramedics will attend to casualties immediately, with treatment starting within minutes of the incident occurring. The evidence demonstrates that, following the current approach, this is unlikely ever to be achieved. That is the case for at least four reasons.

First, the reality of the resourcing of ambulance services around the UK is that ambulances do not wait around for a Major Incident to occur. In the event of a mass casualty incident, it is inevitable that all, or at least most, ambulances in the geographical area of the incident will already be engaged in dealing with other events. That is likely to lead to a delay in the deployment to the scene of the number of ambulances and ambulance personnel needed to deal comprehensively with the incident.

Second, even when ambulance personnel begin to arrive at the scene of a mass casualty incident, the treatment of casualties is unlikely to commence immediately. Long‑established policy within the ambulance service is that the first paramedic on the scene of a Major Incident will become the acting Operational Commander.1 In that role, they are instructed not to treat casualties.2 Instead, the acting Operational Commander is expected to assess the scene and pass a METHANE message to the control room, then seek to establish command and control, before co‑ordinating with incident commanders from the police and fire and rescue services.3 All of that takes time.

Third, once the command structure at the scene is in place, the expectation is that triage will commence. The nature of a mass casualty incident is that the needs of the casualties will almost certainly exceed the capacity of the paramedic resource initially available. The seriousness of the injuries may well vary considerably. Established practice is that it is vital that those in most need of medical intervention are identified quickly. This is the purpose of triage. It should be undertaken before any treatment, except for urgently required life‑saving interventions. Once again, this takes time.

Fourth, where the mass casualty incident causes the police to declare Operation Plato, that is likely to have an impact on the time it takes for the treatment of casualties in any hot or warm zone. That is so even though the current Joint Operating Principles (JOPs) provide greater flexibility for forward deployment than was the position in 2017.

Witnesses explained that the consequence of these factors is that, in a mass casualty incident, it is inevitable that there will be a delay in paramedics and/or other healthcare staff arriving at the scene and commencing treatment.4 During the Inquiry, this period was described as ‘the Care Gap’.

I heard from witnesses with the expertise and experience to assist me on two issues: first, how is the Care Gap to be made as short as possible? And, second, how are we to achieve a situation in which those who are present at the scene before professional clinical staff arrive are able to provide vital life‑saving interventions?

One witness, Philip Cowburn, the Medical Advisor to the National Ambulance Resilience Unit (NARU), summarised these two issues as “narrowing the gap” and “filling the gap”.5 I will use these terms but I consider that there are some matters relating to treatment that do not fall neatly into either category. I will deal with the issues in the following order: matters that will narrow the gap; matters relating to treatment during the gap; and matters that will fill the gap.