Skip to main content

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)


As I said in the Preface to this Volume of my Report, in the immediate aftermath of the Attack on 22nd May 2017 there were heroic acts by numerous people. These were members of the public who were in or around the Arena; people who worked at the Arena or in the Victoria Exchange Complex; and members of the emergency services who went into the City Room in the early stages. These people ignored the risks to their own safety to try to do what they could to help the dying and the injured. They had no protective clothing but they went into the City Room, even though they must have realised that they were putting themselves at risk in doing so. Those acts were acknowledged by me during the Inquiry and I do so again now in this conclusion. Everyone who heard the evidence has great respect and admiration for the people who acted so bravely.

While not overlooking those acts, I have inevitably been concerned with determining what went wrong and why things went wrong, and making recommendations to try to ensure that they do not go wrong again.

The evidence I have heard revealed that a great deal went wrong in the emergency response to the Attack on 22nd May 2017.

Previous tragedies had not resulted in necessary change being implemented. Each of the emergency services had drawn up plans. Those plans had been created with the intention of ensuring that people affected by a terrorist attack would receive the greatest possible assistance. However, on 22nd May 2017, those plans were not known by everyone who should have known about them. Many of those who did respond to the explosion, the non‑specialists, had little or no knowledge of the plans that had been devised. But when the plans were known about, they were not always as clear as they might have been. And when they were clear, they were not always properly understood. And when they were known and understood, they were not always put into practice.

Some of the failures that occurred in the emergency response were down to mistakes made by individuals. It is understandable that individuals under the immense pressure and stress that a terrible incident such as a bombing creates will make mistakes. It is all the more important in those circumstances that there are checks and balances in place. These will ensure that all the things that need to be done have been done, and that the right decisions have been made.

The almost universal response from senior commanders during the Inquiry’s oral evidence hearings was that it was not their job to ensure that their subordinates had done what they ought to have done. Again that is understandable: checking up on others takes time and may show a lack of belief in the abilities of subordinates. Nevertheless, it is necessary. In at least two of the emergency services, there were single points of failure. Had checks been made by more senior officers as they took up their position in the command structure, serious omissions could have been quickly rectified.

The response to the explosion started well. Greater Manchester Police (GMP) directed firearms officers in numbers to the site of the explosion. They were quickly able to establish that there were no armed terrorists in the City Room and, by placing armed guards on the entrances to that location, were able to ensure that none could enter. Unarmed and unprotected British Transport Police (BTP) and GMP officers were quickly on the scene doing what they could.

From that start, it ought to have been possible to get medical assistance to the injured in the City Room speedily. This would have allowed victims to be removed safely on stretchers to the station entrance; from there they could have been put into ambulances and taken to hospital, where they would have received the best treatment.

That is not what happened.

One of the most emotional and upsetting parts of the Inquiry was listening to the evidence of people in the City Room, both rescuers and the injured, who heard the sirens of the ambulances outside and expected to see paramedics arriving imminently, and then hearing of their despair when so many fewer than they reasonably expected actually arrived in the City Room. The failure of the paramedics to arrive in numbers was a terrible disappointment to the injured and the rescuers in the City Room, who did not have the skills to triage the injured and give them the life‑saving medical help they might need prior to being moved. Paramedics had these skills. The injured were desperate for help, not realising that decisions that had been made meant they would not see paramedics in the City Room in the numbers hoped for and expected. I set out in Part 17 of my Report the experiences of the injured and those with the deceased in the City Room as they waited in vain for help to arrive.

Three paramedics went into the City Room to carry out triage and any life‑saving interventions that had to take place before the injured were moved. No stretchers were taken from the ambulances to assist with the removal of the injured. Instead, police officers and members of Arena staff and the public carried the injured along the raised walkway and down a series of stairs to the entrance hall of the station on anything they could find. Advertising hoardings, crowd barriers and tables were used. It was a painful and unsafe way of moving the injured. On the station concourse, a treatment centre was set up where the other paramedics re‑triaged and gave much‑needed treatment to the injured, including stabilising them sufficiently for the trip to hospital.

The situation was undoubtedly difficult, but the evacuation of the City Room would have worked much better for everyone if there had been a more co‑ordinated response. No one wanted the injured and dying to suffer more than they needed. Everyone involved in the emergency no doubt thought that they were doing their best. In some cases, and for reasons I set out in my Report, their best was not good enough.

Members of the fire and rescue services are trained to give assistance in circumstances such as those in the City Room. They would have been of great help. They have stretchers that are suitable for use in such situations. Their absence was significant, as they could have provided very substantial assistance in the safe removal of the injured from the City Room. The fact that most of the members of the other emergency services did not notice that Greater Manchester Fire and Rescue Service (GMFRS) officers were not there helping in the rescue suggests a lack of appreciation of the part that fire and rescue services can and do play. If the Joint Emergency Services Interoperability Principles (JESIP) had been fully embedded in the muscle memory of responders, that would not have happened.

The suggestion was made during the Inquiry’s oral evidence hearings that the reason GMFRS did not turn up and North West Ambulance Service (NWAS) did not go into the City Room in numbers was because they were risk averse.

None of the firefighters I heard from were risk averse. Rather, I heard from a number of very angry firefighters who were ashamed of the fact that they did not get to join in the rescue. They desperately wanted to get involved. I am also satisfied that paramedics would have gone into the City Room, if asked to do so, in order to carry out their work of saving lives.

It is one thing to take risks on your own behalf, but it is quite another for a commander to send people under his or her command into a situation where they may be at risk of death or serious injury. There needs to be an assessment of that risk before others are potentially placed in danger. None of the commanders I heard from was risk averse for his or her own safety, but some were for the people who might be put at risk by carrying out their orders. All members of the emergency services take risks in the course of their work, and do so willingly, but the extent of that risk needs to be properly assessed by commanders before committing rescuers forward. Evaluating the degree of risk that is acceptable is very difficult. Detailed guidance and assistance needs to be available.

The best risk assessment is a joint risk assessment between all the emergency services that are on scene. They need to pool their knowledge. While no service is bound to accept the risk assessment of another, it is important that they listen to the views of others. Where one rescue service has more situational awareness than others, there would need to be a good reason for that assessment not to be accepted by everyone. BTP and GMP had the best situational awareness of the risk of working in the City Room as unarmed police were in there in numbers without any special protection. The GMP Operational/ Bronze Commander’s view was that it was safe enough for rescuers without special protection to work there. He was right, but nobody from GMP or the other emergency services asked for his opinion. Firearms officers who were present also thought it was safe enough for such rescuers to be present. Their views were not sought. The only paramedic present in the first 44 minutes thought the same.

Other inquiries, inquests and investigations have emphasised the importance of the emergency services working together to provide the best result for the injured. Detailed policies, such as JESIP, have been devised, and people trained to put them into practice.

JESIP emphasises the need for co‑ordination, either by locating commanders at the same place and, if that is not possible or is still to happen, by having effective communication between all the emergency services. Manuals have been written on what is needed to make JESIP work; everyone is meant to be trained on the principles. JESIP still failed on 22nd May 2017. Commanders did not co‑locate. There was no effective communication. This is not the first incident in which JESIP has failed.

At one stage during the hearing of evidence, the failures on the night and the failures in JESIP in the past led me to suggest that it should be abandoned.

However, it was the evidence from all of the witnesses at the Inquiry hearings that the application of the principles of JESIP was the best way to assist the injured and get them treated quickly. I accept that it is, in light of that evidence, but it is necessary to ensure that JESIP works in practice and not just in theory. I have made recommendations in my Report about how to achieve this. More training, more practice, and the right sort of practice, are needed. Lessons need to be learned when things go wrong in exercises or in a real emergency, and change implemented as a result. Most importantly, individual emergency services must not operate alone. They must respect and understand the contribution that can be made by other emergency services and they must respect the views of others, particularly when it comes to assessing risk.

The failure of JESIP on 22nd May 2017 meant that those who were having to make decisions assessing risk did not receive information from those who were in the best position to provide the necessary situational awareness to assess that risk. That should not have happened.

Had there been good communication and co‑location on 22nd May 2017, many of the problems that did arise would not have.

The evidence heard at the Inquiry has led me to the view that necessary changes were not always identified and implemented as the result of past mistakes, partly because the debrief processes were not as effective as they might have been, and even when shortcomings were identified they were not always put right. In the Inquiry, I heard evidence of exercises where things had gone wrong that were similar to the things that went wrong on 22nd May 2017. This needs to be improved, and I have made a number of recommendations, which I hope will, if accepted, result in improvements.

There were problems with the debriefing process after 22nd May 2017. It was alarming to hear evidence that the Chief Constable of GMP had informed Lord Kerslake, during his review of the preparedness for and emergency response to the Attack, that GMP could demonstrate that Inspector Dale Sexton had notified the other emergency services of the declaration of Operation Plato. That was incorrect. Inspector Dale Sexton had not done so. The Chief Constable was not deliberately trying to deceive Lord Kerslake; it was what he had been told. It is difficult to understand how that had happened on such a crucial issue.

What I hope was a constructive part of this Inquiry dealt with what I described as ‘the Care Gap’. There will always be a time lag between the emergency having happened and the arrival of the emergency services that are able to assist the casualties. That is a critical time when lives can be lost if no action is taken to save casualties. This makes it essential that as much help as possible can be provided on site by people who are in the vicinity and prepared to help. This means that it is vital that establishments of a similar size to the Arena have a reasonable number of adequately trained and equipped medical staff on hand to give emergency care, to bridge the gap before the ambulance service and the fire and rescue service can arrive. Standards need to be laid down and enforced to ensure that this happens. There needs to be liaison between site operators and event healthcare staff and the ambulance service to co‑ordinate their responses to an emergency. The in‑house healthcare provision at the Arena on 22nd May 2017 was inadequate.

Police officers, who are often first on the scene, should have trauma training so that they can provide life‑saving treatment and do not find themselves in the position that the unarmed officers did on 22nd May 2017. They wanted to provide assistance to casualties but they did not have the necessary training to do so. The same applies to members of the public, who found themselves wishing they had greater first aid skills. Encouragement should be given to the public generally to acquire the skills needed to help casualties who are in a life‑threatening condition. The National Curriculum should include education in first responder interventions and there ought to be incentives to those who have left school to develop those skills.

I have considered in my Report whether different procedures can be adopted by the emergency services themselves to reduce the effect of the Care Gap. The emphasis in the present system is on ensuring that hospitals are ready for the patients before sending them there. I heard about other countries, such as France, where they operate a different system, aiming to get the injured to hospital as soon as possible by whatever means they can.

It is important that we do not close our eyes to new ideas. There is still much work to be done on reducing, as far as possible, the Care Gap and its consequences. The witnesses I heard giving evidence about the Care Gap were very impressive. There is a great deal of innovative thinking going into the reduction of the problems caused by the Care Gap. It is very important that the ideas coming out of the new research are considered with an open mind.

The most important issue in the Inquiry has been whether a more effective rescue effort could have saved the lives of any of those who died. I deal with that question in Part 18 of my Report and I invite readers to read that to get the full detail. As can be seen, I have concluded that one of those who died, John Atkinson, would probably have survived had the emergency response been better. In the case of Saffie‑Rose Roussos, I have concluded that there was a remote possibility that she could have been saved if the rescue operation had been conducted differently. The evidence was conclusive that there was no possibility that any of the others could have survived the murderous actions of SA.

While we do need to consider whether we should move to different systems to get the injured to hospital more quickly, I accept that the draft hospital dispersal plan activated by NWAS worked well. It meant that casualties were sent to the specific hospital best equipped to deal with their particular injuries, and staff were there waiting to receive them. Despite this, I was concerned about the time it took to get patients to hospital. The evidence of the injured, who seemed to wait for a very long time in the City Room and then in the station entrance before going to hospital, was very moving and telling.

A constant criticism of some of the emergency services during this Inquiry has been that they were defensive and, rather than join in a genuine search for what went wrong, they tried to insist that everything they did was correct and, where something went wrong, to blame it on others. If criticism is unjustified, then it does not help a search for the truth simply to accept it. Conversely, it is a natural human reaction to try to avoid blame for some terrible disaster and find some explanation that excuses it, even if it puts the blame on someone else. The real test will be whether action is taken to put right what went wrong, and not just in the short term but until the terrible threat of terrorism has been eradicated.

I believe that I have got to the truth of what happened on that dreadful night. I have certainly had assistance from many clever, hardworking and motivated people to do so. I am very grateful to them all. I also hope fervently that what comes out of this Inquiry will make a difference, and I ask all those concerned with what happens next to ensure that it does.