Manchester Arena Attack: Emergency response "Far below standard it should have been"

A lack of communication between the emergency services in Greater Manchester led to a "chaotic" response on the night of the Manchester Arena attack, according to a new report.

22 people were killed when suicide bomber Salman Abedi detonated a device after an Ariana Grande concert at Manchester Arena in 2017.

The second volume of findings from the inquiry into the blast has today revealed a series of events that led to confusion and a breakdown of the command structure at the top of the emergency services.

The report details significant failures that occurred in the first hour after the explosion took place and beyond.

After the first 999 call was placed 52 seconds after the attack, a breakdown in communication between the commanders of the police, fire and ambulance service meant the response was not well organised.

After the alarm was raised the report says GMP's Duty Officer, Inspector Dale Sexton quickly became overburned by the number of tasks he had.

He failed to declare a major incident, something the report calls "a significant mistake" which was "duplicated by other GMP commanders" and not rectified until 1am.

Inspector Dale Sexton also failed to communicate the declaration of Operation Plato (code for a marauding terrorist attack with a firearm) and the Temporary Superintendent at the time, Arif Nawaz, "had no idea what Operation Plato was" according to the report.

It says: "Because of this lack of understanding the Temporary Superintendent was not competent to perform the role of Tactical/Silver commander."

Meanwhile although British Transport Police's Force Incident Commander, Inspector Benjamin Dawson had declared a major incident, that was not communicated to GMP or the fire service.

The report says "This was an error and an early example of many failures in communication that were to emerge across the multi‑agency emergency response."

No common meeting point

Sir John Saunders sets out the expectation in guidelines that a common meeting point or RVP (Rendezvous Point) should be set up where emergency service personnel can meet.

However the report says "In the first quarter of an hour after the Attack and thereafter, there was substantial confusion over the location of an RVP. Each emergency service chose its own. In some cases, this was passed on to other agencies. In others, it was not.

"Before the arrival at the scene of Inspector Smith, BTP Sergeant David Cawley was one of two Sergeants present.

One of his first actions was to reject a request made at 22:40 by a BTP Sergeant in Liverpool for an RVP. Sergeant Cawley said that it was not possible to identify an RVP because of the need to focus on treating casualties.

"This was an error. It was his responsibility as a supervising officer to assess the situation and to identify how best to coordinate the response on the ground with the resources he had.

"It is a difficult thing to do. It requires training and experience. A multi‑agency RVP was urgently required. It was an important step that would have helped to co‑locate resources for the emergency response."

While driving away from the incident, fire engines drove past ambulances travelling in the opposite direction

The confusion about a common meeting point, combined with a lack of clarity about if the scene at the arena was now safe led to two-hour delay in the arrival of the fire service.

The report reads: "Station Manager Andrew Berry directed NWFC (North West Fire Control) to mobilise GMFRS (Greater Manchester Fire and Rescue Service) resources to Philips Park Fire Station, three miles from the Victoria Exchange Complex.

"He should not have done this. Station Manager Berry’s rejection of the Cathedral car park RVP set in motion a series of events that resulted in GMFRS not arriving at the Victoria Exchange Complex until over two hours after the Attack occurred.

"The effect of Station Manager Berry’s decision to mobilise to Philips Park Fire Station was that the fire appliances at Manchester Central Fire Station drove away from, not towards, the incident.

"While driving away from the incident, the Manchester Central fire appliances drove past ambulances travelling in the opposite direction."

Later that evening Station Manager Berry decided to drive from his home to Phillips Park Station where he had directed fire crews to rendezvous but got lost on the way due to diversions.

"The report says he "Was not to know the difficulties he would encounter... but it should have been obvious to Station Manager Berry that his geographical location meant that a substantial amount of time would be spent driving, rather than being devoted to developing and advancing the GMFRS response.

"The GMFRS response was already significantly out of step with that of BTP, GMP and NWAS. Travelling at such a critical time was not going to improve that."

Lives could have been saved

The breakdown of the command structure and lack of communication between the various agencies involved in the response meant help that was needed to treat the injured was delayed in getting to the scene.

The report concluded that had there not been "Inadequacies" in the emergency response, at least one and possibly two of the victims could have survived.

Chairman Sir John Saunders, details how "The performance of the emergency services was far below the standard, it should have been" and one of the victims, John Atkinson, "probably would have survived."

Mr Atkinson was around six metres from the bomb when it went off and suffered serious injuries, mainly to his legs.

Mr Saunders writes: "More NWAS paramedics should have been in the room before 23:16. If that had occurred, it is likely that they would have identified the need for urgent treatment and/or evacuation of John Atkinson.

"That did not occur. Responsibility for that failure rests with NWAS. Such treatment would, I am satisfied, have enabled John Atkinson to arrive at hospital prior to having a cardiac arrest and would probably have saved his life."

Experts say a second victim of the attack, 8-year-old Saffie-Rose Rousso also could have had a chance of survival if the emergency response had been better coordinated.

However, Sir John Saunders concluded, "It is highly likely that her death was inevitable even if the most comprehensive and advanced medical treatment had been ignited immediately after her injury."

The report concludes the injuries sustained by the other 20 victims of the attack; Alison Howe, Angelika Klis, Marcin Klis, Chloe Rutherford, Liam Curry, Courtney Boyle, Eilidh MacLeod, Elaine McIver, Georgina Bethany Callander, Jane Tweddle, Kelly Brewster, Lisa Lees, Martyn, Hakan Hett, Megan Joanne Hurley, Michelle Kiss, Nell Jones, Olivia Paige Campbell-Hardy, Philip Tron, Sorrell Leczkowski and Wendy Fawell were "unsurvivable."

"No one really thought it could happen to them"

Sir John Saunders writes: "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.

Concluding the report, Sir John Saunders has made 142 separate recommendations to various organisations aimed at preventing similar mistakes from being made in future.

Key Recommendations:

• More common reviews of major incident plans.
• Inspectors and Sargents at British Transport Police should be given the training to ensure they are capable of taking up a commander role during major incidents.
• Greater clarity from the Home Office, British Transport Police and local forces about where responsibilities lay during a major incident.
• Greater Manchester Police's major incident plans should make clear the capabilities of other emergency services
• More multi-agency training exercises
• The Home Office should consider if different funding arrangements are necessary for metropolitan forces if future public spending cuts are necessary
• Standards are enforced to ensure large venues have a reasonable number of trained and equipped medical staff to provide help until paramedics arrive
• National curriculum should include first responder training and incentives for those who to learn who have left school

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