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Freelance journalist

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Ron Alalouff is a journalist specialising in the fire and security markets, and a former editor of websites and magazines in the same fields.
November 17, 2022


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Manchester Arena Volume 2 Report highlights uncoordinated and risk averse response from emergency services

Volume 2 of the report of the inquiry into the Manchester Arena bombing examines the response of the emergency services, which was at times uncoordinated and risk averse, as Ron Alalouff reports.

Read more about the first Manchester Arena Inquiry report, which focused on “missed opportunities” in the security arrangement for detecting and stopping the bomber, here.

Better co-ordination and communication between individual emergency services and a less risk-averse approach to some decisions ­may have helped saved the lives of one and possibly two victims, and helped the injured receive quicker treatment.

Those were two of the main conclusions of volume 2 of the report of the inquiry into the Manchester Arena bombing in May 2017, published earlier this month, which focussed on the emergency response after the explosion.

In his conclusions at the inquiry Chairman, Sir John Saunders, said the best risk assessment in such situations is a joint one between all the emergency services on the scene. When one rescue service has more situational awareness than others, there would need to be a good reason for that assessment not to be accepted by everyone. Officers from British Transport Police and Greater Manchester Police (GMP) had the best situational awareness and the GMP Bronze Commander’s view was that it was safe enough for rescuers to be there without special protection. But nobody from GMP or the other emergency services asked for his opinion. The only paramedic present in the first 44 minutes also thought it was relatively safe.

The report also focusses on the Joint Emergency Services Interoperability Principles (JESIP) which came about in response to the recommendations made at the inquest into the 7/7 bombings. It emphasises the need for co-ordination between emergency services, either by locating commanders at the same place or – if that’s not possible – by having effective communications between all services. But as on previous occasions, the system failed at the Manchester Arena – commanders did not co‑locate and there was no effective communication.

Emergency services in the UK attending a scene

Credit: Jeff Gilbert/Alamy Stock

Recommendations on JESIP

The inquiry report makes recommendations to help ensure that JESIP works in practice as well as in theory. More training, more practice and the right sort of practice are needed, and lessons need to be learned and changes implemented when things go wrong in exercises or in a real emergency. Most importantly, individual emergency services must respect and understand the contribution that can be made by – and respect the views of – other emergency services, particularly when it comes to assessing risk.

“Those who were having to make decisions assessing risk did not receive information from those who were in the best position to provide the necessary situational awareness to assess that risk,” said Sir John. “That should not have happened.”

In discussing what was referred to during the inquiry as the ‘Care Gap’ – the time lag between the incident happening and the arrival of emergency services able to assist casualties – the report says it’s vital that venues of a similar size to the Arena have a reasonable number of adequately trained and equipped medical staff on hand to give emergency care, to bridge the gap before the ambulance service and the fire and rescue service arrives. There needs to be liaison between site operators, event healthcare staff and the ambulance service to co‑ordinate their responses to an emergency. In the case of the Arena on 22 May 2017, this was inadequate.

While Sir John said he understood that checking that subordinates have done what they were supposed to have done could be counter-productive, it is sometimes necessary. “In at least two of the emergency services, there were single points of failure. Had checks been made by more senior officers as they took up their position in the command structure, serious omissions could have been quickly rectified.”

Quick initial response

The response to the explosion started well, in that firearms officers were quickly deployed to establish that there were no armed terrorists in the City Room and, by placing armed guards on the entrances to that location, were able to ensure that none could enter. Casualties and emergency service personnel quickly gathered in the City Room.

“From that start, it ought to have been possible to get medical assistance to the injured in the City Room speedily. This would have allowed victims to be removed safely on stretchers to the station entrance; from there they could have been put into ambulances and taken to hospital, where they would have received the best treatment. That is not what happened.”

This was due to an element of risk averseness and a failure to co-ordinate and communicate between services. It resulted in the injured hearing the ambulance sirens outside and expecting to see paramedics arriving imminently, while eventually only three paramedics went into the City Room to carry out triage and any life-saving interventions.

Lack of fire and rescue service help

Turning to the fact that police officers and Arena staff carried the injured along the raised walkway and down a series of stairs on advertising hoardings, crowd barriers and tables, the report highlights that fire and rescue personnel are trained to give such assistance and have equipment such as suitable stretchers.

Firefighters-Charity-20The fact that most of the other emergency services did not notice that officers from Greater Manchester Fire and Rescue Service were not there helping in the rescue suggests a lack of appreciation of the part that fire and rescue services can and do play. “If JESIP had been fully embedded in the muscle memory of responders, that would not have happened.”

Sir John introduced the publication of the report by saying that although he was 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.

“Having said that, many things did go badly wrong, and it has been the job of this Inquiry to identify them, work out if possible why they went wrong, and make recommendations to try and ensure that they don’t happen again.”

Responding to the findings, Greater Manchester Fire and Rescue Service’s Chief Fire Officer, Dave Russel, said:

“I want to start by wholeheartedly apologising to the families of the 22 innocent people who lost their lives on that tragic night of 22 May 2017, and to the survivors whose lives are changed forever.

“Our response that night was wholly inadequate and totally ineffective, and that will forever be a matter of deep regret for our Service. We let the families and the public down in their time of need and for that I am truly sorry.

“I know that no apology will take away the pain and suffering of the families who lost loved ones and of the survivors. But I want them to know that I fully accept the Inquiry’s criticisms of our Service and I accept the recommendations in full.

“While we have already made significant changes to address the failings in how we responded on the night, the inquiry’s recommendations provide a critically important framework for ensuring we take all the necessary steps to always be ready and able to respond to a terrorist attack anywhere in our city-region.”


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