Manchester Arena bombing report finds “significant failings”

Sir John Saunders, the Chair of the Manchester Arena Inquiry has published volume two of his report into the death of the 22 victims of the attack on 22 May 2017. This volume focuses on the emergency response following the terrorist attack on the Arena and it contains 149 recommendations for change.

In the Chairman’s statement published alongside the extensive report, he said, “I am highly critical of many aspects of the rescue operation. Those criticisms must not overshadow our admiration for the courage of those who went into the City Room without any hesitation to help the dying and the injured.”

His report begins by summarising the tributes paid during the Inquiry to those who died. He notes in his statement that while the summaries do not do justice to the moving evidence heard, he hopes that it does “to some extent, capture the individual qualities of each of them.”

Organisational and individual failings

Sir John levels criticism at both organisations and individuals involved with the response, including Greater Manchester Fire and Rescue Service, Greater Manchester Police and North West Ambulance Service. He said, “The criticisms that I have made are principally directed at organisations and there were significant failings by a number of organisations in preparation and training for an emergency such as this and in their actions on the night of the attack.”

Providing some explanation of why he had singled out individuals, he said, while it may be harsh to do so when they were faced with an extremely difficult situation, “We rely on people in command positions to make the right decisions when faced with a complex emergency.”

He added, “It has been my job to identify when and how things went wrong so when incorrect decisions have been made, however understandable, I have had to identify them. I have not looked for scapegoats and everyone who I have criticised has had the opportunity to respond to those criticisms and I have taken their observations into account in my Report to the extent that I accepted them.”

Key failings

Setting his conclusions about the failings of the response to the attack, Sir John makes it clear that there were heroic acts by numerous people. “These people ignored the risks to their own safety to try to do what they could to help the dying and the injured.” He said a great deal went wrong with the emergency response including not implementing changes resulting from previous tragedies and ensuring that all personnel know what plans were in place to respond to a terrorist attack. He highlights single points of failure at command level in at least two responding organisations.

Describing the immediate aftermath, he said, “The failure of the paramedics to arrive in numbers was a terrible disappointment to the injured and the rescuers.” He is equally critical of the delayed response of fire and rescue service personnel, and responding to evidence that it was because GMFRS staff were risk averse, he said, “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.”

Problems with using JESIP

Focusing on the way that the emergency services should work together, he highlighted the way in which JESIP was implemented on the night of the attack. “It is not an overstatement to say that JESIP almost completely failed on the night of the Arena attack. JESIP is designed to ensure that any rescue attempt involving more than one of the emergency services is coordinated so that all follow the same plan and share information so that well informed decisions can be taken.” He provides recommendations about how it can work better in the future, noting that it had failed in previous incidents as well.

The time between an incident occurring and the arrival of the emergency services is described in Sir John’s report as a ‘care gap’. He said there should be suitably trained people on site who can give emergency assistance, “Which may result in people surviving who otherwise would not if they had to wait for the arrival of medical professionals.” He encouraged the Government to impost legislation for a Protect Duty for companies who manage and own venues like the Arena as soon as possible and not wait for a wider ranging approach to capture more venue types.


The recommendations in the report are given to different organisations, with four specifically targeted at GMFRS covering knowledge of how to use operational discretion during an incident; the role of the incident commander; the receipt and passage of information between officers and record-making procedures. Sir John also recommends that the National Fire Chiefs Council and the the Fire Service College should establish a scheme for ensuring that all firefighters are trained in first responder interventions.

GM Police recommendations also include one about record-making and highlight the need to review plans, be aware of other agencies’ roles in incidents and have access to information about roles using role cards.

The recommendations for NWAS are more extensive and there is again a focus on planning and record-making as well as training, mobilising specialist resources and the number of those available at any one time including the tactical advisors and the national interagency liaison officers (NILO). NWAS should also review its procedures about how it dispatches patients from a major incident to NHS settings.

There are many other recommendations focused on other organisations including the local resilience forum, British Transport Police and North West Fire Control; in addition, the report makes recommendations applicable at a national level that would require government action and for bodies like the National Ambulance Resilience Unit and the Security Industry Association.

Sir John has grouped the recommendations into what he has called Monitored Recommendations where he has allocated a lead organisation and defined the period of monitoring and report back. He said, “I intend to scrutinise what has been done in response to the Monitored Recommendations and use all of the powers available to me, if required, to achieve transparency and accountability.”

A fervent hope

Bringing his report to a close, he said, “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.”