"A litany of failure" - Nick Aldworth on the Manchester Arena inquiry report
"Enough is enough.... Saffie's life is not a practice exercise…. if we're still learning lessons on terrorism in 2020, nothing will ever change"
These were the words of Andrew Roussos at the start of the Manchester Arena Inquiry in September 2020. Andrew is the father of the Manchester Arena attack’s youngest victim, Saffie-Rose. She was 8 years old when she died.
Last week, Andrew and his family learned that there was a ‘remote’ chance that Saffie might have survived if she had received specialist trauma care earlier. I’ve met Andrew and his family and we remain in touch; I know how strongly he believes that Saffie was a fighter and could have survived. I can only imagine how painful, and enduring, carrying that thought will be.
I don’t know John Atkinson’s family, but the inquiry also found, with greater certainty, that his were survivable injuries with earlier intervention. When you read the detail of his treatment, or lack of it, in The City Room (where the attack happened) and beyond, a lay person is likely to be deeply concerned about how this man came to die.
What Went Wrong
At a thousand pages long, I’m not sure I even know where to start commenting on this report. It’s taken me the better part of three days to read it, and even then I’ve had to skip through some parts. It will need to be read again and again to fully comprehend its totality.
Every page is a litany of failure, across all three emergency services, their leadership, their processes, and their absorption of learning. In the middle of it, there are failures by individuals to be bold, to be inquisitive and, frankly, to apply even a modicum of common sense. There are some who have excelled, been brave and made positive contributions but, as individuals, were not going to change the outcome.
Saffie and John didn’t get the help they deserved because they found themselves in the middle of an emergency services response full of catastrophic failures of well-established processes and command structures. At some points, I can’t even see the most basic of Gold, Silver and Bronze (GSB) command structures being implemented in a way that provides coherence and compatibility.
Everybody seems to have forgotten the first principle of the Joint Emergency Services Interoperability Procedures (JESIP), colocation, and throughout my read of the document I found my inner-self screaming to everybody, ‘for the love of God, just get some people to a forward control point’.
I’m genuinely shocked at the failure to implement even the most basic principles of incident management, the most basic communication practices, and an abject lack of competence among some. Some of the individual failures are so profound, they are close to being malfeasance. This wasn’t failure of resolving a terrorist incident, this was a failure of core policing. I’m not qualified to comment on what core competence looks like in the ambulance or fire services, but as a casual observer, it’s hard to see leadership and processes that would match my expectation.
Sir John Saunders, chairman of the inquiry and author of the report, has been more compassionate than me by saying that he recognises that people he has named found themselves in the most awful and extreme of circumstances but qualifies this by saying that taking on such responsibilities should come with a requirement to be able to execute them effectively. He is correct and repeatedly highlights that some of those individuals were let down through lack of training.
He is of course right. The seeds of failure were not sown on the night, they had been germinating for years and are systemic across policing. They are fertilised by the inadequate implementation of learning, promotion processes that rely on story telling not competence, and budget. The fact that a significant number of recommendations have been referred to national bodies such as the College of Policing, CTPHQ and the Home Office is indicative of this being systemic national failure.
After the report was published, I received an email from a renowned journalist that said, “My biggest worry is that Manchester may well have improved things, but I bet many others haven’t”. Looking at how basic many of these failings were, I sense that their concern is valid.
One of the alarming things I read in this report was that Greater Manchester Police (GMP) had conducted over 100 relevant exercises in the two years leading up to 22 May 2017. One exercise, about 12 months before the bombing and named Winchester Accord, highlighted that there were weaknesses in how the emergency services in Manchester worked together. Importantly, Winchester Accord highlighted that the Force Duty Officer (FDO) became overwhelmed, but because they were testing whether that role could work from their force HQ and not their control room, they chose not to recognise that this was likely to happen in any environment. That is a lack of common sense and experience.
During Winchester Accord, Greater Manchester Fire and Rescue Service (GMFRS) considered that GMP forgot to include them in a deployment to help evacuate the injured. GMP dispute this, but the evidence in this inquiry suggests otherwise. Winchester Accord, and its failures, have chilling resonance with what happened on the night of 22 May 2017.
The GMP planning team had been decimated by funding cuts, and revisions to important documents, like PLATO plans were done at pace and without the consultation and scrutiny that might make them more likely to succeed. GMP had been one of the worst hit forces, losing roughly 25 per cent of its officers and budget. How can that be right?
The GMFRS consistently failed to include North West Fire Control (NWFC) in exercising and testing thereby missing opportunities to identify weaknesses, especially in how tri-service communication takes place. GMFRS’s approach to incident command didn’t map directly into the standardised GSB structure, but the greatest failure is probably their practice of not having tactical commanders who operated away from the scene. Had this happened, a tactical commander might have gone to GMP force HQ and obtained situational awareness much earlier than was the case. I’ve worked with many fire services, they are rigid on the rules and procedures that exist and operate to the most hierarchical governance of all three services. You can see this throughout this inquiry.
North-west Ambulance Service (NWAS) are not without fault; they didn’t even have a site-specific incident plan for what is one of the largest arenas in the country. Crucially, they operated a non-discretionary policy that non-specialist responders should never go into a PLATO warm zone. On the night this became critical, for despite knowing that some NWAS responders were operating in the City Room, they failed to provide support until much later in the evening.
There is so much more in the report indicating failures to learn, prepare, and engage effectively through the Greater Manchester Resilience Forum (GMRF), that it would be impossible to cover all of it in this article. Needless-to-say, the old 6-Ps saying of ‘prior preparation and planning prevents poor performance’ was never truer.
Command and Control
The GMP Force Duty Officer, Inspector Dale Sexton, is singled out for significant criticism. It is right and justifiable criticism, well evidenced by Sir John. It becomes even more significant because the police were the lead agency for this incident.
He failed at so many different stages, it is difficult not to sympathise with the families who believe that he was wrongly awarded for his contribution on that night. But he is not alone in this failure. He was leading a response in a control room where there was insufficient support for him, excessive access to him while he was trying to coordinate the response, burdened with firearms command for an excessive period, and unsupported by his tactical (Silver) commander, T/Supt Arif Nawaz. T/Supt Nawaz was so out of his depth that he had to be replaced, but by that time, the conditions that he and Sexton had created were probably irrecoverable.
An added complication was the division of responsibilities between BTP and GMP, although I cannot see that this was the greatest contribution to failure, and those BTP officers deployed to the City room, the seat of the explosion, were brave and did their best.
The starting point for command failures were set by GMP failing to declare events at Manchester Arena as a Major Incident. BTP declared it as such but didn’t inform GMP or GMFRS. Emergency service professionals will know that by declaring a major incident, you immediately create awareness among the other emergency services, and other responders and receivers, such as hospitals and local authorities, all of whom can significantly add to the overall effectiveness.
Operation Plato, the response to a marauding terrorist firearms attack (MTFA) was declared quite quickly by Inspector Sexton and this was described as a right and proper decision, by Sir John Saunders. However, Sexton did not inform the other services of this decision nor undertake the critical element of Plato, zoning. If Plato is to be declared, the creation of Hot, Warm and Cold zones is vital as it is these classifications that define what emergency service works can enter each area. Sexton was not alone in failing to do this. He was subsequently relieved by a ground-assigned firearms commander who also failed to grasp the importance of this.
In his evidence, Sexton maintained that he deliberately decided to not inform the other services that he had declared Plato. His grounds for this are not clear, and Sir John highlights many inconsistencies in this, especially the fact that it was being openly referred to in telephone calls and radio messages, and became known to those in the Arena environs. Failure to notify the other services of Plato, was another missed opportunity to get a joint enterprise underway.
The inquiry found that critical medical support was denied to those inside the City Room because there was a perception that it was a warm zone, which limits the nature of NWAS staff who can enter. In reality, the GMP firearms team had boldly taken control of the area very quickly and the area was in fact a cold zone. There was a residual concern of a secondary device being present and it took an excessively long time for an EOD search dog to be deployed. However, the fact that NWAS paramedic Patrick Ennis was allowed by his tactical controller to move in and out of the City Room, suggests a significant inconsistency in the risk assessment.
My view is that the single biggest failure of the night, and one repeatedly referenced in the inquiry, was a failure of the emergency services to follow the Joint Emergency Services Interoperability Programme (JESIP) principles.
JESIP sets out 5 principles that underpin working together. While not mandated, there is an expectation that they work best in the following order: Collocate; Communicate; Coordinate; Jointly Understand Risk; and Shared Situational Awareness.
All of the failings that led to inadequate casualty management on 22 May 2017, would have been overcome if all three emergency services had attended a single rendezvous point (RVP) and sent commanders to a forward control point (FCP). So much of this was inhibited by the failure to set the Plato zoning, however it was also set by individuals who failed to exercise sufficient attempts, and persistence, to get JESIP working effectively.
There is also a strong indication that the failures in joint preparedness meant that GMP and NWAS didn’t fully appreciate the role that GMFRS could play in casualty management. This included supporting evacuation with stretchers carried on each appliance. GMFRS has been subject to significant, justified, criticism both in this inquiry and in the earlier Kerslake report. What this inquiry has shown is that their failures are shared by others and, to a significant degree, created by them.
Sir John has identified 149 individual recommendations, a great many of which are then clustered into 21 monitored recommendations. The implication of this is that he will require updates on his recommendations in 3 months’ time followed by witness statements from individuals tasked with making progress, 3 months after that. In summer of next year, he will ask some of those witnesses to give live evidence.
This scrutiny is to be welcomed but I don’t believe it goes far enough. Many of the recommendations are organisation-specific. For example, recommendation 2 states: “BTP should ensure that all its Inspectors are trained to undertake the Bronze Commander role in the event of a major incident”.
When I revert to my journalist friend’s concerns, I wonder how many other police services have the same deficiencies as BTP and would benefit from the application of such learning.
The Home Office, The College of Policing and the National Police Chief’s Council will be unwise to not recognise that these were failures waiting to happen in many places. There is nothing in the evidence that would imply these are problems unique to the North West. Failure to nationalise the opportunities presented by this inquiry would be indicative of how I think learning is treated now inside policing. There is a pervasive attitude of ‘it wouldn’t happen here’ and the implementation of learning is seldom sustained. If it was, the same mistakes wouldn’t keep occurring.
While my summary of the evidence is as harsh as the inquiry’s, I do recognise that at the heart of every disaster are people who don’t intend to fail. There are people who fail to rise to the occasion, and others who exceed all expectations. Some of the public compassion and bravery on the night brought a tear to my eye.
Many people will have been adversely affected by the events of 22 May 2017. Some will have experienced physical and mental pain, some will have experienced unbearable grief, and many will carry scars forever. Some will have suffered vicariously, that is the nature of stress.
The best that we can do to honour those who have suffered so much is to not waste the opportunities that this inquiry has identified. This inquiry shows that so much of what prevented the saving of lives, or the reduction of trauma in those that survived, was entirely avoidable. I can only imagine how some victims and survivors will feel about that.
While we continue to absorb this report, we must also brace ourselves for more bad news to come. Both the intelligence and police services could have done more to manage the threat posed by the attacker and his conspirators. Part 3 of the report is unlikely to be comfortable reading.
Image: By G-13114 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=79239409