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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)

Other matters relating to treatment


As I have explained, a number of issues were raised during the evidence that do not strictly fit into either narrowing the gap or filling the gap. Instead, they relate to the treatment of those injured in a mass casualty incident.

Those issues are: analgesia; blood; freeze‑dried plasma; and TXA. It is convenient to deal with them at this point in my Report before turning to the steps that need to be taken to fill the Care Gap: in other words, the steps that need to be taken to empower those who happen to become caught up in the aftermath of a terrorist attack.


Lea Vaughan was one of two HART operatives who entered the City Room during the critical period of the response.106 Following the Attack, she prepared a PowerPoint presentation. The purpose of this was to provide training, although no such training was in fact provided.107

In a section of the presentation headed “Problems faced”,108 she identified an issue that was subsequently explored at various stages in the evidence. Lea Vaughan confirmed that no analgesia was provided to those in the City Room. She considered that it would have been highly desirable to have been able to give analgesia to casualties, but she explained that, once given, it requires the casualty then to be monitored. This prevents the paramedic from moving on to another patient.109 In other words, the provision of analgesia causes delay.

Christopher Hargreaves, the HART operative who entered the City Room with Lea Vaughan, echoed her views.110

Both HART operatives considered that steps need to be taken to identify a form of analgesia that can be given to casualties in a situation like the one that existed in the City Room. That analgesia must not delay the work of paramedics in dealing with others.

Lieutenant Colonel Park had a clear and well‑informed view about this issue. She explained that, where a casualty is gravely injured, analgesia has a number of benefits. Relieving pain has its own humanitarian value, but it also assists in evacuating casualties who might otherwise not be able to be moved. There is a further way in which pain relief can assist. Splinting a limb and applying traction can reduce bleeding. However, these can be very painful processes. Providing adequate pain relief enables these processes to happen when otherwise they might not be possible.111

Lieutenant Colonel Park recognised the difficulty with administering intravenous analgesia as described by Lea Vaughan but explained that the British Army had found a solution. All soldiers now deploy with fentanyl lozenges, which are sometimes called fentanyl lollipops.112 Fentanyl is a strong opioid painkiller, used to treat severe pain, even in children. Lieutenant Colonel Park described lozenges that simply dissolve in the patient’s mouth. Studies in the US military and also within London’s Air Ambulance have found fentanyl lozenges to be practical and safe and to provide effective pain relief even for those with extremely serious injuries.113

The British Army is able to provide fentanyl lozenges to its soldiers because of a dispensation within the regulatory framework. No such dispensation exists for ambulance services; not even HART operatives are able to deploy with fentanyl lozenges.114 It was clear to me that Lieutenant Colonel Park regarded that situation as anomalous, as did Philip Cowburn.

Philip Cowburn explained that the inability of those in civilian practice to use fentanyl lozenges was a “massive hindrance” in dealing with a mass casualty incident.115 In writing following his evidence, he expressed the view that fentanyl lozenges or sufentanil sublingual tablets are ideal for mass casualty situations. They are rapidly absorbed, they can be self‑administered or easily given and they do not require supervision of the casualty.116

Philip Cowburn regards a situation in which the military can use such analgesia while paramedics and other pre‑hospital care professionals cannot as incongruous and unacceptable. He considers that the current situation deprives those injured in a mass casualty incident of the safe and effective analgesia to which they are entitled.117 I found his views and those of Lieutenant Colonel Park persuasive.

Some of those awaiting evacuation from the City Room were conscious and in severe pain. If effective pain relief can be provided to such casualties without harming their chances of survival or the overall rescue effort, it should be. Both Lieutenant Colonel Park and Philip Cowburn consider that this can be achieved and each speaks from a position of authority and experience.

I recommend that DHSC, the Home Office and the Medicines and Healthcare products Regulatory Agency (MHRA) give urgent consideration to whether the regulatory regime should be altered to enable this to occur. If the decision is that it should, I recommend that NARU consider urgently whether the use of fentanyl lozenges should be rolled out to all HART and other specialist operatives as part of their basic equipment and quite possibly to paramedics more generally.


Obviously, where a casualty has suffered an injury that has caused a catastrophic or heavy bleed, the priority must be to stop the bleeding. The evidence made that very clear; it is, in any event, common sense. However, as the circumstances of the Attack make clear, effective action to stop a bleed may not occur. Also, not all catastrophic haemorrhages can be easily controlled.118 Instinctively, it would therefore seem sensible that ambulances should carry blood or blood products to replace lost volume and help maintain life until the casualty’s arrival at hospital.

The evidence, however, demonstrated that, in practice, a situation in which all frontline ambulances carry blood or blood products cannot be achieved. That is so for a variety of reasons explained by a number of witnesses, all of whom agreed. Among those witnesses were Dr Timothy Smith, an Associate Medical Director of NWAS and an Enhanced Pre‑Hospital Care Consultant with the North West Air Ambulance Charity,119 Philip Cowburn of NARU120 and Lieutenant Colonel Park.121

Two principal objections arise, one clinical and the other logistical.

First, the clinical objection. Pre‑hospital blood transfusion is a recognised practice within the UK. However, the decision whether to administer blood is complex and is one that must usually be made by a senior doctor. Lieutenant Colonel Park told me that the decision whether or not to transfuse a patient is sometimes difficult, even for a senior clinician.122

It is right that some specialist paramedics are able to deal with this procedure, having received advanced training. However, it is not feasible to train all paramedics in the administration of blood replacement. Philip Cowburn explained that frontline paramedics would be likely to encounter a situation in which a patient required pre‑hospital blood less than once a year.123

While I acknowledge that he was indicating a view that was not based on research, Philip Cowburn’s considerable experience entitles him to express the opinion that training all such personnel would be disproportionate, particularly since there are other ways of dealing with the issue. I have already dealt in paragraphs 20.76 to 20.87 with one of the other potential ways of dealing with the issue, namely having a consultant‑led clinical response to a terrorist incident. Below, in paragraphs 20.139 and 20.140, I will deal with another potential way of dealing with the issue, namely the use of freeze‑dried plasma. Other witnesses agreed that it was not feasible to train all ambulance personnel or even all specialist staff in the administration of blood.124 I accept their common view.

Second, the logistical objection. The challenges involved in the movement of blood in the pre‑hospital environment are significant. It is not necessary for me to go into the detail of this, but, in simple terms, blood must be stored in particular circumstances and then heated prior to use. This requires bespoke equipment, which is expensive.125 More importantly, it takes time to prepare.126 Procedures are established for air ambulances to carry and transfuse blood127 but there simply are not the resources available to scale this up so that all or most ambulances have the same capacity.128

Significant issues arise in relation to the traceability of blood products and also, importantly, the scale of supply. Philip Cowburn explained that blood is a precious resource and that having blood in frontline ambulances would give rise to a significant risk of wastage that might result in lives being lost in a hospital environment.129 Dr Hurst of London’s Air Ambulance Charity agreed.130

On the evidence, I accept that equipping all frontline ambulances, or even just all HART vehicles, with blood is not feasible.

Philip Cowburn’s view was that the solution is not to equip all ambulances with blood or blood products, but instead to ensure that there exist mobile resources, such as air ambulances, that possess suitably qualified and equipped staff to transfuse blood into those patients who need it.131 This provides a yet further reason for ensuring that a consultant‑led response occurs as soon as possible. I have already recommended that ways of achieving this must be considered.

Freeze-dried plasma

While he does not consider that HART should carry blood or blood products, Philip Cowburn believes that consideration should be given to all HART operatives carrying freeze‑dried plasma.132 Freeze‑dried plasma is a solution to which water is added in order to reconstitute it. It is then warmed. While it does not carry oxygen, this plasma replaces volume and has an impact on clotting, although not to the same extent as whole blood.133 Overall, it has the potential to benefit those who have experienced catastrophic blood loss in a mass casualty incident.

I recommend that DHSC, the Faculty of Pre‑Hospital Care, the College of Paramedics and NARU consider whether all HART operatives should be deployed with freeze‑dried plasma and trained on its use. This recommendation is dependent on the benefits of the use of plasma being confirmed by research. In considering this recommendation, regard should be had to the following article published online in The Lancet Haematology on 7th March 2022: ‘Resuscitation with blood products in patients with trauma‑related haemorrhagic shock receiving prehospital care (RePHILL): a multi‑centre, open‑label, randomised, controlled, phase 3 trial’.134 This article addresses the benefits of the use of pre‑hospital blood products generally.

Tranexamic acid

TXA is a medication that helps blood to clot. It is useful in a number of situations, including in treating blood loss caused by major trauma.135 TXA was administered to some of those injured in the Attack.136 It was also used in the response to the Bataclan attack.137

Intravenous administration of TXA may be difficult in patients lacking sufficient volume of blood. It takes approximately ten minutes to administer, during which period the paramedic must remain with the patient. That will cause delay in the treatment of other patients in a mass casualty situation. Both problems could be solved by the use of intramuscular as opposed to intravenous TXA.138

Philip Cowburn considered that a review should be carried out into whether frontline ambulances should carry intramuscular TXA.139 I agree. I recommend that the review be undertaken by DHSC, the Faculty of Pre‑Hospital Care, the College of Paramedics and NARU.