Manchester Inquiry: Emergency Response to Arena Bombing Went ‘Badly Wrong’
Many of the emergency response failures that occurred after a bombing at Manchester Arena on 22 May 2017 had happened before either in genuine emergencies or in exercises designed to test procedures, according to new analysis from the Manchester Arena Inquiry released on Thursday.
The best example of this failure was the nearly complete foundering of the Joint Emergency Services Interoperability Program (JESIP), which was designed to ensure that rescue attempts involving one or more emergency services are coordinated so everyone is following the same plan, sharing information, and making well-informed decisions.
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“Had JESIP worked on the 22nd of May, things could and should have been very different,” said Sir John Saunders, who is leading the inquiry and gave a statement to the press on Thursday. “There would have been a joint assessment of risk taken by all the emergency services, and the result of that should have been that there would have been more paramedics in the City Room [where the bomb exploded] using their skills to triage—and where necessary using their life saving skills to aid those who could not wait.”
Instead, Saunders said, “we heard heartbreaking evidence of the injured and rescuers in the City Room hearing the sirens of ambulances, knowing paramedics were close by, expecting their imminent arrival, only for them not to arrive in the sort of numbers that were needed.”
The extensive evidence Saunders and his inquiry team reviewed is detailed in the 1,808-page report that forms Volume 2 of the inquiry’s work. The volume assesses the role of emergency responders after Salman Abedi detonated a knapsack bomb in the foyer of Manchester Arena during an Ariana Grande concert, killing 22 people and injuring scores of others as they were leaving the show.
The inquiry found that while numerous individuals—from emergency responders to members of the general public—made individual, courageous sacrifices to help people following the detonation of the bomb, many aspects of the overall emergency response went “badly wrong.”
In the report, Saunders said some of these failures were due to the lack of preparation and training that emergency response teams underwent prior to the event.
“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,” according to the report. “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.”
The inquiry reviewed CCTV footage, body camera video, and interviewed victims, survivors, and emergency response personnel to assess how the response to the bombing played out and where mistakes were made.
One of the major findings was that Greater Manchester Police (GMP) did not lead the emergency response—which was the original guidance it was meant to follow. The Greater Manchester Fire and Rescue Service (GMFRS) also did not arrive at the scene at a time when it could have provided the most assistance, and the North West Ambulance Service (NWAS) did not send sufficient paramedics into the arena or use stretchers to remove casualties in a safe way while failing to communicate their intentions.
Communication failures were a common theme throughout the inquiry report, including instances where individuals misunderstood the situation or where agencies failed to communicate with others—limiting the overall response effort.
For instance, instead of using a multi-agency control room talk group that would have allowed the operational stage of the emergency response to progress more quickly, emergency service agencies were making calls to other services and then waiting to be connected to pass on information.
“If all the control rooms had been communicating with each other on a single radio channel, this information could have been disseminated to all other emergency services at that time,” the inquiry found.
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Additional failures included sending ambulances to the wrong location after the bombing, delaying paramedics arrival on the scene. The emergency response agencies also failed to establish a rendezvous point—part of their overall emergency guidance—to enable the overall response effort.
Other inquiry analysis found that some emergency response failures began far before the attack occurred. For instance, there was no system in place to ensure that emergency response personnel from some agencies learned from the training and exercises they participated in. The inquiry also found that on-duty first aid personnel were not adequately prepared to respond to the types of injuries they needed to treat, and that none of these personnel had a major-incident qualification—despite a requirement for at least one individual on duty to have this qualification.
The inquiry includes criticism of individual commanders and actors who were part of the emergency response effort. Saunders said that while this might be considered harsh, “we rely on people in command positions to make the right decisions when faced with a complex emergency. None of them intended to make the wrong decision. Some had not had sufficient instruction or training and others were doing their best to balance the need to help those who were injured with ensuring that people under their command were not put in a position which carried excessive risk.”
One of the early individual mistakes in the response was the failure of a GMP commander to declare a major incident after receiving 999 calls for help in response to an explosion at the arena where many people were injured. The inquiry found that several other commanders made a similar mistake, which meant the bombing was not categorized by GMP as a major incident until nearly three hours after the explosion. Additionally, failing to categorize the major incident as a terrorist operation meant that emergency services were not able to work together to jointly understand the risks involved with responding to the attack.
Based on its analysis, the inquiry made more than 140 recommendations to improve emergency response measures and overhaul JESIP to ensure it does not fail during future emergencies.
The inquiry also recommended that individuals in command positions for emergency response situations are issued a technology means to record what they say, hear, and see, both to share information and to collect evidence for after-incident reviews. Saunders made this recommendation because he used these tools to gather data to create the inquiry’s findings.
Saunders particularly focused on recommendations to improve the Care Gap—the gap between an event, such as a bombing, and the arrival of people trained to give expert medical help.
“We need to ensure that there are suitable people onsite at places such as the arena who are able to give emergency lifesaving assistance, which may result in people surviving who otherwise might not if forced to wait for emergency services,” Saunders said.
This could be done, for instance, by amending the Protect Duty legislation to require places that operate as large venues for entertainment have trained staff on site to provide emergency first aid.
The inquiry also suggested that the Security Industry Authority (SIA), which provides licenses to security staff, take urgent steps to create a training program for first responder interventions for all licensees as well as “encourage the security industry generally” ensure members of staff without SIA licenses also develop basic trauma care skills.
The inquiry further recommended that police and fire personnel also receive lifesaving instruction to be able to provide immediate care when responding to an emergency, as well as training opportunities be created for members of the public who might be attending an event that is attacked.
“Members of the public made an enormous contribution on the night of the 22nd, but it would have been even greater if they had all had the training to deal with the sort of injuries that they were faced with,” Saunders said.
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Volume 2 was shared with the UK Parliament, as required by law, but it is unclear what action legislators will take on the inquiry’s recommendations. In a statement on Twitter, UK Prime Minister Rishi Sunak retweeted the announcement of the publication of Volume 2 and pledged his support to the victims and survivors of the bombing.
“Nothing will ease the pain of the families of those killed during the cowardly terrorist attack at Manchester Arena,” Sunak wrote. “It is my solemn commitment to the victims, survivors and their loved ones that we will learn from the lessons of this inquiry.”
This week’s report is the second of a planned three volumes the inquiry will release. The first volume was published in 2021 and detailed how the attacker carried out the bombing. The third volume, which does not have an expected publication date, will focus on whether the security service and counter terrorism police could—and should—have prevented the attack.