The Inquiry’s terms of reference require me to assess the impact of any inadequacies in the planning and preparation by the emergency services, and in the emergency response. This includes whether any inadequacies undermined the ability of the response to save life or contributed to the extent of the loss of life.
For this reason, most of Volume 2 is focused on what went wrong on the night of 22nd May 2017. That does not mean that I have ignored the evidence of what went well.
The heroism shown by very many people that night is striking. Considerable bravery was shown by members of the public who were visiting the building, those who were employed to work at the Victoria Exchange Complex and personnel from the emergency services.
I have seen the terrible footage from the CCTV and body‑worn video cameras of the scene of devastation in the City Room. The description of that area as being like a “war zone” was used by a number of witnesses.That is an accurate description.
To enter the City Room or remain there to help victims required great courage. Nothing I say in this Volume of my Report is intended to diminish that fact. I pay tribute to all those who selflessly went to the aid of others.
In addition to the individual acts of courage, there were some parts of the emergency response that worked well. Notwithstanding the concerns I expressed in Volume 1 about the conduct of some in the period before the explosion, British Transport Police (BTP) officers who were present in the Victoria Exchange Complex at the time of the explosion responded immediately and rushed to the City Room. More BTP officers from elsewhere mobilised urgently. Greater Manchester Police (GMP) also mobilised a very significant number of firearms officers and unarmed officers. There were more than sufficient rank and file police officers from both GMP and BTP to assist with the response.
I am satisfied that the way in which the firearms officers acted meant that, had there been a threat from marauding terrorists with firearms, it would have been neutralised very quickly. I was impressed by the professionalism of those officers.
Similarly, while I have concerns about many aspects of the command of the emergency services, there was much evidence of collaboration by junior police officers. There was also ingenuity and initiative displayed, such as when, due to the unacceptable failure to make stretchers available to those in the City Room, makeshift platforms were used to carry people out.
I have no doubt that lives were saved by the emergency response. There were many grave injuries sustained. Without the care of members of the public, those who worked at the Victoria Exchange Complex and emergency services personnel, more lives would have been lost. While I am critical of the emergency response overall, I recognise that, at an individual level, many people did their jobs to a high standard and were a positive influence on the outcome. There will be some who owe their lives to those who worked tirelessly to assist them.
During the Inquiry, many have acknowledged that mistakes were made in the aftermath of the explosion. I have been concerned with analysing why those mistakes were made and what can be done to prevent them happening again. I have also been concerned with analysing whether, when things went well, they could have been done better.
It may be inevitable that when a sudden and very shocking event happens, such as the detonation of a bomb, things will go wrong. People panic. Courageous people rush in to do what they can to help, and there is a risk that nobody stands back to consider what is the best way to organise the response.
By no means all the mistakes that were made on 22nd May 2017 were inevitable. There had been failures to prepare. There had been inadequacies in training. Well‑established principles had not been ingrained in practice.
Why was that? Partly it was because, despite the fact that the threat of a terrorist attack was at a very high level on 22nd May 2017, no one really thought it could happen to them. This was the case even though such a high‑profile concert in a very large arena might obviously attract the attention of a terrorist intent on killing and injuring as many people as possible. Maybe it is also because, fortunately, this sort of tragic event is rare.
Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been. GMP did not lead the response in accordance with the guidance that it had been given or parts of its own plans. Greater Manchester Fire and Rescue Service (GMFRS) failed to turn up at the scene at a time when they could provide the greatest assistance. North West Ambulance Service (NWAS) failed to send sufficient paramedics into the City Room. NWAS did not use available stretchers to remove casualties in a safe way, and did not communicate their intentions sufficiently to those who were in the City Room.
The purpose of Volume 2 of my Report is to analyse why these problems occurred.
It is not to apportion blame but rather to scrutinise whether systems worked, whether individuals were able to perform in accordance with their training and, if they did not, to understand why. It is only through careful analysis that we can learn from errors and failures to prevent repetition. That is why this Volume is so long and so detailed.
I have criticised a large number of people whom I consider to have made mistakes on the night. Some of those criticisms may seem harsh, particularly given the situation that those individuals were faced with. They were trying to do their best. I do understand the enormous pressures that they were acting under. They had to do many things in a short time and it may not be surprising that things went wrong. I am not unsympathetic to them. But I need to identify mistakes where they have been made because otherwise there is no prospect of preventing them in the future. Safeguards need to be put in place to try and prevent, as far as we can, mistakes being made due to the stress caused by being involved in an appalling event such as this.
At the centre of my Inquiry is the terrible loss of twenty‑two lives. Each family and each person at the Arena has a deeply personal story to tell about the impact of the Attack on them. My Report cannot change what has happened. My intention is to uncover what went wrong and find ways of improving practices so that no one has to suffer such terrible pain and loss again.
Volume 2 is divided into two sub‑volumes, Volume 2‑I, comprising Parts 9 to 16, and Volume 2‑II, comprising Parts 17 to 21 and the Appendices. It is laid out as follows:
- Part 9 remembers each of those who died. They are at the heart of the Inquiry and it is appropriate that Volume 2, which deals with their deaths, begins by remembering who they were.
- Part 10 is a narrative summary of the emergency response and what went wrong with it. It does not set out my reasoning, which comes in later Parts. So far as is possible, it sets out events in a chronological order.
- Part 11 considers the overarching framework in place in 2017 for an emergency response. This includes the relevant legal provisions and the guidance documents that applied on 22nd May 2017.
- Part 12 addresses the preparedness of a number of organisations: the Greater Manchester Resilience Forum; BTP; GMP; NWAS; North West Fire Control (NWFC); and GMFRS. Part 12 also deals with two particular areas of preparedness, which apply across the emergency services in Greater Manchester: the setting up of a multi‑agency control room talk group; and multi‑agency exercising, in particular one called Exercise Winchester Accord, which took place almost exactly a year before the Attack.
- Part 13 considers the police services emergency response to the Attack: that of BTP, GMP and Counter Terrorism Policing Headquarters. Along with the ambulance and fire and rescue services discussed in Parts 14 and 15, these organisations represented the state’s immediate response to the Attack. In this Part, I summarise the help BTP and GMP police officers sought to provide to those who died.
- Part 14 considers the ambulance service emergency response to the Attack from NWAS. In this Part, I record the help NWAS personnel sought to provide to those who died.
- Part 15 considers the fire and rescue service emergency response to the Attack from NWFC and GMFRS.
- Part 16 deals with a number of other organisations that were present on the night of the Attack and whose staff went to help. The principal focus is on SMG, the Arena operator, and on the organisation that SMG contracted to provide healthcare services, Emergency Training UK (ETUK). Part 16 also considers the response of: Showsec, the crowd management and security company retained by SMG; employees of TravelSafe, which provided security to parts of the railway network; and Network Rail. Part 16 concludes with a section that sets out the important contribution that members of the public made to the response. In this Part, I identify the members of the public and staff working in the Victoria Exchange Complex who tried to help those who died.
- Part 17 sets out the effect of the explosion. It includes a record of the accounts that some of those who survived gave me.
- Part 18 is focused on the twenty‑two who died. It sets out in relation to each of them, in summary form, what happened from the point of the explosion. I heard detailed, and often traumatic, evidence in the hearings about the experience of each of those who died. I only set out in this Part the details that I think are necessary to record the circumstances of their deaths. It also deals with the question of whether any of those who died might have been able to survive had the emergency response been better.
- Part 19 reviews the stages and investigations that have preceded this Inquiry. I draw out ways in which investigations following mass casualty incidents may be improved in the future.
- Part 20 is concerned with a period that, during the course of the Inquiry, was termed ‘the Care Gap’. This is the inevitable period of time between an incident that causes injury and the arrival of the emergency services, particularly the ambulance service. I explain why change needs to occur in order to both narrow and fill that Care Gap. I make recommendations that seek to achieve this.
- Part 21 sets out my conclusions, lists the recommendations made across the course of this Volume and specifies those recommendations that I shall monitor.