The Law vs. the Truth: What Happened in Manchester?

Part 9 - The Emergency Response

Part 9 - The Emergency Response

This is the ninth article in a series on the Richard D. Hall case and the Manchester Arena incident. If you have not already done so, you should begin at Part 1 and work your way forwards, as each part builds on the last.

Introduction

I previously indicated that this would be a nine-part series. But, as my research has progressed, it has become clear to me that several further parts are required to do justice to the Richard D. Hall case and all that it represents.

The first two parts of this series set the scene in terms of the basics of the case and a summary of Hall’s (and Davis’) evidence calling the official account of the Manchester Arena incident into question. Parts 3-7 exposed the travesty of justice that took place in the High Court to find Hall guilty of harassing Martin and Eve Hibbert. Part 8 turned to looking at what is really behind Hall’s persecution, with a focus on the state’s attempt to discipline the independent media not to challenge politically sensitive narratives such as Manchester.

This part explores further what it is about the Manchester Arena incident that the state does not want the public to know and, through its resort to lawfare, seems desperate to cover up.

The focus here is on the emergency response on the night of May 22, 2017. The emergency services which responded were:

• British Transport Police (BTP);

• Greater Manchester Police (GMP);

• North West Ambulance Service (NWAS); and

• North West Fire Service (NWFS)/Greater Manchester Fire and Rescue Service (GMFRS)

As we will see, there were anomalies in the responses of all four emergency services. Most significantly, the fire service did not arrive for over two hours post-detonation (the nearest fire station was seven minutes away), and only three paramedics entered the City Room to deal with a reported scene of carnage involving 22 fatalities and dozens more seriously injured casualties. How could that have been so?

No critic to date has looked in-depth at the failures of the emergency response. To do so requires painstakingly going through the 916 pages of Volume 2 of the Inquiry Report (which is on the emergency response). The report itself is dry and tedious, but contains essential factual information that correlates with the Inquiry hearings and the CCTV footage released by the Inquiry.

The Inquiry report is arranged in such a way that no clear picture emerges of which key actors did what on the night. Plenty of important facts are provided, but, for each individual, the information is scattered across multiple different sections of the report, making it difficult to assess individual contributions. In my opinion, this was done deliberately, to obfuscate, and to make it difficult to assign responsibility.

I have, therefore, approached Volume 2 of the Inquiry report much as Hall approached the CCTV footage released by the Inquiry, namely, by seeking to bring a large amount of disparate information into some kind of coherent order and structure.

Rather than a wide array of individuals chaotically making error after error in the heat of the moment, which is the impression conveyed by the Inquiry report, it becomes clear that the command structures of all four emergency services were compromised.

For each service, there are three levels of command: Strategic (Gold), Tactical (Silver), and Operational (Bronze):

The Strategic/Gold Commander sets the strategic direction, co-ordinates and prioritises resources. The Tactical/Silver Commander interprets the strategic direction, develops the tactical plan and co-ordinates activities and assets. The Operational/Bronze Commander executes the tactical plan, commands his or her service's response and co-ordinates actions. (§10.18)

Thus, for each of the four emergency services, there were, or should have been, three senior commanders, at Gold, Silver, and Bronze levels, for a total of 12 key individuals in charge of the overall emergency response.

The picture is complicated slightly by the fact that other individuals assumed the role of initial commander for some of those positions until they could hand over to the appropriate person. GMP had two Bronze commanders on the night (one for unarmed officers, the other for firearms officers). The GMFRS command structure did not map as neatly onto the Gold/Silver/Bronze model as did those of the other emergency services, and GMFRS’ National Inter-Agency Liaison Officer (NILO) played a disproportionately significant role.

Nevertheless, it is possible, based on the Inquiry report, to identify the 12+ key individuals who were responsible for each of the four chains of command, and to track their decisions and actions on the night.

In so doing, what emerges is not just a tale of inadequate training, confused protocols, breakdowns in communication, and poor decision making, as the Inquiry Chairman, Sir John Saunders, would have us believe.

Instead, a picture of glaring incompetence across all but one of the senior command posts renders it virtually impossible that the failure of the emergency response was just down to “mistakes.” The more parsimonious explanation is the command chains were deliberately inhibited, although we cannot say exactly how.

In what follows, I work through each of the four emergency services in turn: BTP, GMP, NWAS, and NWFS/GMFRS. Following some preliminary observations, I discuss the roles of the Gold, Silver, and Bronze Commanders for each service.

British Transport Police

No BTP Officers Present in the City Room at the Moment of Detonation

The expectation communicated to BTP officers by Sergeant Gareth Wilson on the day was that “at least one officer should have been in the City Room from approximately 22:00” (§7.31).

However, on May 22, 2017, of all nights, “There was a complete absence of any BTP officer in the City Room from around 22:00 until after the explosion. No satisfactory justification has been provided for this” (§7.38). Saunders blames it on lack of on-the-ground leadership by PC Corke, who should have been on site much earlier (§7.41).

Instead, four BTP officers were standing at the war memorial downstairs on the station concourse.

Four BTP officers standing near the war memorial at 22:31:09. Source: Richplanet.

According to the Inquiry report,

there were no BTP officers in the City Room during the period 22:00 to 22:31. There should have been at least one. Responsibility for this failing lies with PCs Bullough and Corke and PCSOs Renshaw and Morrey. (§1.40)

BTP Initial Response

BTP Inspector Benjamin Dawson declared himself Force Incident Manager (the equivalent of GMP’s Force Duty Officer) at 22:35, which also made him the initial Silver Commander. Within four minutes he declared a Major Incident (§10.36). This was not communicated to either GMP or GMFRS at any stage, however.

BTP Inspector Benjamin Dawson. Source: Manchester Evening News

For example, BTP was “still on hold with GMP” at 22:37 (§10.37). The GMP incident log indicates that contact was made by BTP at 22:39, when it was placed in the 999 queue along with many others. Why did BTP use the public 999 emergency number instead of police backchannels, such as the “radio channel reserved for police services to contact each other” (§10.37)?

BTP officers who rushed to the City Room showed initiative in fetching first aid kits from vehicles and “providing what assistance they could” to casualties (§13.32).

The Role of Gold Commander Robin Smith

Assistant Chief Constable (ACC) Robin Smith took over as Gold (Strategic) Commander at 22:56 (§13.122).

BTP Gold Commander Robin Smith. Source: BBC

He had not read or received any training on BTP’s Major Incident Manual (§13.121).

He failed to check whether a tactical plan had been developed (§13.123).

At no point did he try to contact the NWAS or GMFRS Gold Commanders before he arrived in Manchester from the south of England at 04:00 on May 23 (§13.130).

He did speak with GMP Gold Commander Deborah Ford between 01:16 and 1:22, when it was agreed that GMP was the lead agency, but by then it was “too late to make any meaningful difference to the response” (§13.128).

In any case, it had been clear from the outset that “GMP was the lead agency” (§10.135).

The Role of Silver Commander Allan Gregory

At 23:05, Chief Superintendent Allan Gregory received a telephone call from Gold Commander Smith, and took over from Inspector Dawson as Silver (Tactical) Commander (§10.158).

BTP Chief Superintendent Allan Gregory. Source: Manchester Evening News

Gregory failed to produce a tactical plan (§13.85) and made no attempt to contact his counterparts at NWAS and GMFRS (§13.92-13.93).

Gregory did not try to find out which officer present at the scene might take charge of the BTP response until a more senior officer arrived, wrongly in Saunders’ judgment (§10.161). This was perhaps because BTP’s policy on command requires a person to hold the rank of Inspector or above in order to be approved as a Bronze Commander (§13.35).

Instead, at 23:12, Gregory directed Superintendent Kyle Gordon to travel to the scene from Blackpool, anticipating that the journey would take about an hour (§10.193-10.194). That would have meant there being no Bronze Commander on site until 00:12, over 90 minutes post-detonation. In the event, the gap was 159 minutes.

The Role of Bronze Commander Kyle Gordon

A BTP Bronze (Operational) Commander was not on site during the entire critical period of the response (§10.197), defined by Saunders as “the time from the explosion to the removal of the final living casualty from the City Room: 22:31 to 23:39” (§10.9).

BTP Commander Kyle Gordon, promoted since 2017. Source: BBC

Superintendent Gordon purportedly could not secure a police vehicle or a police radio and instead ordered a taxi. He failed to notify anyone of the delay in his journey (§13.102) and had no influence on operational decisions during that time (§10.196).

The lack of a BTP Bronze Commander meant that BTP officers de facto fell under the control of GMP on the night. For example, they remained without a command presence until GMP Bronze Commander Michael Smith entered the room at 22:47 (§13.32). At 23:43:35, GMP Sergeant Kam Hare directed BTP personnel to leave the City Room, and “a large number of officers” then walked in that direction.

BTP CI Andrea Graham, who had become aware of the incident and put herself on duty, arrived on site at 23:56. Learning of this, Gregory intended for Graham to assume the Bronze Commander role until Gordon arrived (§10.229). However, a “breakdown in communication” meant that Graham did not understand this (§10.230).

Gordon did not arrive until 01:20, 41 minutes after the last casualty had been evacuated from the City Room, “too late to make a meaningful contribution” (§10.196). He “did not ever take up the role of Bronze Commander in any meaningful sense” (§13.110).

Summary

The BTP chain of command was ineffective. Gold Commander Smith made no meaningful difference, Silver Commander Gregory enabled a situation in which there would be no Bronze Commander at the scene during the critical period of response. Bronze Commander Gordon arrived too late to make a meaningful contribution. Consequently, BTP officers de facto fell under GMP command.

Greater Manchester Police

The Role of Gold Commander Deborah Ford

GMP’s Gold (Strategic) Commander was Assistant Chief Constable Deborah Ford. By her own admission, her role proved largely redundant on the night. She was asked at the Inquiry:

In terms of what actually happened on the ground and in particular in the period … to one hour after the declaration of Plato, so we are at 11.47, did anything happen, either in the Gold Command Suite or in the Silver Command Suite that made any difference to what happened on the ground?

Ford replied “Probably not, no” (§13.511). Saunders finds that she made no difference to the emergency response on the night (§13.527).

GMP Gold Commander Deborah Ford. Source: BBC

Ford did not check that a Major Incident had been declared (§13.513). She did not consult with anyone regarding whether the Operation Plato declaration should continue (and, if so, what zoning should be applied within and outside the Arena) (§13.514). She failed to register the absence of the fire service (§13.516). She failed to provide adequate support to FDO Sexton by relieving him of the Initial Tactical Firearms Commander role (§13.518). She failed to establish that a common RVP and FCP had been established (§13.520).

The Role of Initial Silver Commander Dale Sexton

The Initial Silver Commander, Force Duty Officer (FDO) Inspector Dale Sexton, was also acting as Initial Gold Commander, Initial Tactical Firearms Commander, and Strategic Firearms Commander (§10.31).

Chief Inspector Dale Sexton. Source: BBC

Sexton failed to declare a Major Incident, an error that was not rectified until nearly 01:00 in the morning (§10.33).

He declared Operation Plato at 22:47 but failed to communicate this to the other emergency services (§10.76).

He should have ascertained from PC Richardson at 22:48 that the City Room had been swept by two separate teams of experienced firearms officers who were confident that there was no active shooter, that no armed terrorist could gain access, and that there was no evidence of a secondary device (§13.341).

When asked by PC Richardson at 22:53 for “more ambo staff, paramedics, anyone that they can get hold of please” (§13.326), Sexton replied that he would feed the request back to NWAS, but “took no steps to secure that outcome” (§13.330).

Saunders finds that Sexton was overburdened by the number of tasks he had to perform (§10.32).

Nevertheless, Sexton was promoted and in 2019 was awarded a Queen’s Police Medal.

Dale Sexton, having been promoted, receives the Queen’s Police Medal. Source:Mirror

In July 2023, Sexton’s deliberate decision not to communicate the Operation Plato declaration to the other emergency services was deemed so serious a violation of duty that he was referred to the Crown Prosecution Service for potential criminal charges by the police watchdog, the Independent Office for Police Conduct.

The Role of Silver Commander Arif Nawaz

The Night Silver, which is “the most senior GMP officer on duty at night” (§13.441), was Arif Nawaz, who assumed Tactical Command from Sexton at 22:50 (§10.82). Incredibly, Nawaz did not know what Operation Plato was, nor did he admit that crucial fact to anyone (§13.457-§13.458).

GMP Silver Commander Arif Nawaz. Source: BBC.

Had Nawaz communicated with Bronze Commander Michael Smith, he would have known that Smith had, at 22:50, assessed the City Room as “safe enough” for non‑specialist emergency responders and members of the public to be in (§10.106), i.e. a cold zone in Operation Plato terms, where there is no immediate threat to life from a terrorist armed with a firearm (§10.105).

Instead, the Operation Plato declaration remained formally active, creating the misimpression for anyone who knew about it — and only the firearms officers did (§10.31) — that there was indeed a threat to life from a marauding terrorist.

Nawaz was almost immediately directed to GMP HQ by Gold Commander Ford, leaving a command vacuum at the Victoria Exchange Complex (§10.136). He did not think to designate someone on site to set up a Forward Command Post where commanders from different emergency services could meet to share situational awareness and assess risk (§10.136).

The Victoria Exchange Complex is delineated in red. Source: Volume 1 of the Inquiry report, p. 194.

When CI Mark Dexter arrived at the scene at 23:23, he realised that no Silver command for unarmed officers was present, so assumed that role himself, despite attending in his capacity as Ground Assigned Tactical Firearms Commander (§10.71).

As late as 23:34, Nawaz still did not know that Inspector Michael Smith was Bronze Commander (§13.464), or what Smith was doing in the City Room, or what help and resources he needed (§13.465). Saunders finds this “inexplicable and inexcusable” (§13.465).

In a three-minute phone call with Smith at 23:38, Nawaz sought an update but provided no tactical plan or tactical guidance (§13.466). At no stage on the night was a tactical plan formulated or adequately communicated to Smith (§13.508).

Nawaz had not read the Silver Commanders Guide and he “failed to discharge all or almost all of the responsibilities of a Tactical/Silver Commander” listed therein (§13.454). Saunders finds that Nawaz was “not competent” to perform the role of Night Silver (§13.454).

Nawaz was replaced as Silver Commander by Temporary Superintendent Christopher Hill at 00:00 on May 23, after all casualties had been removed from the City Room (§12.326, §13.476).

The Role of Bronze Commander Michael Smith

Unlike every other Gold, Silver, and Bronze Commander, GMP Bronze Commander Michael Smith comes across in glowing terms in the Inquiry report. If Saunders is to be believed, then Smith did virtually everything right.

GMP Chief Inspector Michael Smith, promoted since 2017. Source: Hall, Manchester on Trial

Smith was an experienced (since 2012) and trained Bronze Commander (§12.324), described by the Policing Experts as “an officer with considerable experience, command ability and fortitude” (§13.367). In Saunders’ view, Smith “conducted himself with bravery, authority, resourcefulness and skill” on the night of May 22, 2017 (§13.367).

Within only two minutes of being notified about the incident by GMP Control at 22:34 (§10.48), Smith had read the master incident log and was speeding towards the Arena with blue lights and a siren, accompanied by Sergeant James McGowan (§13.370). On the way, he asked the Control Room Operator to seek further information from a 999 caller about casualties and to contact Night Silver Nawaz (§13.372). He also designated a rendezvous point (§10.48). Saunders comments that “This was good leadership” (§13.373).

Smith entered the City Room at 22:47:51, only 14 minutes after being notified about the incident three miles away (§13.368), and contacted GMP Control to direct that a GMP officer should meet arriving paramedics (§10.80). He communicated the need for ambulances at 22:48, 22:50, and 22:51 (§10.104), indicating that “The booking hall [City Room] is the seat of the explosion. It’s not the Arena itself” (§10.82).

In a further radio conversation with GMP Control, Smith indicated that he wanted the railway entrances sealed off and instructed that one of the PCs outside should tell any NWAS staff to “get in here as soon as” (§13.403).

NWAS advanced paramedic Patrick Ennis entered the City Room at 22:53:27, and Smith spoke with him straight away, mistaking him for the NWAS Bronze Commander (§10.128).

Smith assessed the City Room be “safe enough” for non‑specialist emergency responders and members of the public to be in (§10.106). Having not been provided with a tactical plan by Nawaz, he decided to prioritise expert treatment and evacuation for the casualties and, once lives had been saved, to take steps to preserve the crime scene (§10.103).

Even though Joint Emergency Services Interoperability Principles (JESIP) meant that another senior officer should have been present in the City Room, Smith provided effective command to the unarmed police officers there (§10.175). He directed Sergeant Hare and his team to check the casualties (§13.411).

After Ennis informed Smith at 23:12 that the Casualty Clearing Station was being set up on the station concourse (§10.182), Smith was “heavily involved” in directing the work of evacuating casualties (§13.429). In so doing, Saunders finds that he “provided real leadership to the rescuers and compassion to the injured. His decision-making was prompt and effective” (§13.433).

Smith also discussed cordons, obtaining CCTV and additional resources with BTP Superintendent Andrea Gordon following her arrival in the City Room at 23:56 (§13.117).

Smith Could Do No Wrong

Saunders in the Inquiry report is keen to stress that any mistakes that Smith made were not his fault.

For example, although Smith “should have taken steps to ensure that a Major Incident had been declared and, on establishing that it had not been, should have taken that step himself” (§13.378), that omission is attributed to being “largely a consequence of the FDO and the Night Silver’s lack of communication with him” (§13.379).

Although Smith, as an experienced and trained Bronze Commander, did not know what Operation Plato was, this was “entirely GMP’s fault” (§12.338) and “represents a failure in his training” (§13.394).

Although the evacuation of casualties from the City Room was far from perfect, the problems with it were “not the fault of Inspector Smith or any of the officers under his direction. They were doing the best that they could in extremely difficult circumstances” (§13.431).

Anomalies in the Michael Smith Account

For all of Saunders’ effusive praise of Smith, there are certain details which do not add up.

For example, Smith understood, “shortly after 23:00, that resources able to evacuate casualties in a conventional way were not going to arrive imminently” (§13.429). This obviously refers to the fire and ambulance services. Yet, this contradicts the unlikely claim that “neither Inspector Smith nor any of the others working to evacuate casualties were aware of their [GMFRS’s] absence. (§13.432)

It is intriguing that although Smith and Ennis spoke in the City Room at approximately 22:53, “By the time they gave evidence, neither could recall what was discussed” (§13.405). One would imagine that the need for paramedics was the obvious topic of conversation, but we cannot know for sure. It is possible that they discussed something else entirely.

Although Smith went straight over to speak to Ennis at 22:53, he did not, at any point, speak to the Operational Firearms Commander, PC Richardson, who was present in the City Room from 22:49 (§10.132). Why not? Not only were they the two GMP Bronze Commanders, but they were the only emergency service commanders present in the City Room at that time. Are we really to believe that the two GMP Bronze Commanders, located in the same room for most of the critical response period, did not exchange a word?

Equally implausible is that “Inspector Sexton did not speak to Inspector Smith at any point” (§13.159). Sexton was in tactical command of the firearms response, above Richardson. How could there have been no communication between the commanders of the armed and unarmed GMP response teams?

Despite operating in the same room as firearms officers and their Bronze Commander, Smith claims to have been unaware of the Operation Plato declaration until 23:25 (when the Ground Assigned Tactical Firearms Commander, CI Mark Dexter, entered the room), because he was “not operating on the firearms channel that night” (§13.395). Why did he not speak directly with his firearms colleagues?

The Role of Bronze Commander PC Edward Richardson

There were two GMP Bronze Commanders in the City Room “from a very early stage”: Inspector Michael Smith (for unarmed officers) and PC Edward Richardson (for firearms officers) (§11.43). Neither was provided with a tactical plan (§13.386).

A Restriction Order meant that no images of PC Edward Richardson were shown, either on CCTV or during the Inquiry hearings (00:01:50). This was granted on the basis that Richardson “does work as a covert officer” and was “concerned that he and his family may be subject to threats from the public if his occupation becomes generally known” (§46). The identity of another police officer, known simply as “F1,” was also concealed (§49-50), adding another layer of secrecy to proceedings.

Operation Firearms Commander PC Edward Richardson. Source: Richplanet.net

Richardson had sufficient training and was competent to operate as an Operational Firearms Commander (§12.328), which he had been since 2008 (§13.297). On the way to the Arena, he appropriately declared himself the Operational Firearms Commander (§13.300).

He entered the City Room at 22:46 (§10.85) and immediately deployed firearms officers to create what he called a “spiky bubble” around it, which resulted in “firearms protection on the Arena side of the City Room and the railway station side of the City Room” (§10.86). He and PC Adams then performed a second sweep of the City Room (following the “raw check” by PC Moore and PC Simpkin ahead of their entry [§12.296]) and “were clear that there was no armed terrorist and no obvious secondary device within the City Room” (§13.303).

Inspector Sexton declared Operation Plato at 22:47, but, peculiarly for a self-declared Operational Firearms Officer, Richardson did not understand that Operation Plato relates to a response to marauding terrorists with firearms (§12.337) His understanding of “zoning” under Operation Plato was also inadequate (§13.298).

In his witness statement, Richardson mistakenly recollected having discussed Operation Plato zoning with FDO Sexton at 22:48 (§13.304-13.311). He then returned to the City Room, where he remained until 23:30 (§13.317). During this time, he provided situation reports to the FDO over the firearms channel (§13.324).

At 22:53, Richardson called over radio for more medically trained staff to come to the City Room (§13.326), a request that fell on FDO Sexton’s deaf ears.

Richardson made three requests by 23:00 for explosives detection dogs; one did not arrive, however, until 23:47 (§10.126).

Around 23:30, he confirmed to CI Dexter that a search of the Arena bowl was under way (§13.563). At 23:32, he told CI Dexter that both the City Room and the Casualty Clearing Station/concourse were to be regarded as Operation Plato warm zones, which was a false assessment (§13.570).

Summary

Gold Commander Ford made no difference to the emergency response on the night. Initial Silver Commander Sexton failed to declare a major incident, did declare Operation Plato when he should not have done so, and failed to communicate the need for more medically trained personnel to NWAS. Night Silver Nawaz was not competent to perform the role and had to be replaced. Bronze Commander Richardson, bizarrely for a firearms officer, did not know what Operation Plato was or how its zoning requirements worked.

In contrast, Saunders effusively praises Bronze Commander Smith. Smith appears to have been operating in splendid isolation: not only did PC Richardson and FDO Sexton not speak to him at the scene, but “no attempt was made by GMP strategic/gold or tactical/ silver command to obtain the views of Inspector Smith about the issue of safety in the City Room” (§13.399). We will revisit those anomalies in Part 10.

North West Ambulance Service

Lack of Paramedics in the City Room

Incredibly, only three paramedics were present in the City Room during the critical period of the response, despite 38 casualties needing to be evacuated to the Casualty Clearing Station on the station concourse downstairs, including two of the 22 eventual fatalities (§14.264; §18.189). A third fatality had already been evacuated at 22:57 (§14.189), meaning that there were officially 57 deceased or seriously injured people for the three paramedics to attend to — 19 each. A fourth paramedic, Ian Devine, entered the City Room at 23:40, by which time the last casualty had been evacuated (§14.353).

Advanced paramedic Patrick Ennis was the first paramedic to arrive at the scene. He entered the City Room around 22:53, i.e., 22 minutes post-detonation (§10.120).

NWAS advanced paramedic Patrick Ennis. Source: Manchester Evening News

HART paramedics Christopher Hargreaves and Lea Vaughan entered the City Room at 23:15:10, fully 44 minutes post-detonation (§14.155). Nearby hospitals, such as Salford Royal, were only ten minutes away.

HART-trained parademic Christopher Hargreaves. Source: BBC

HART-trained parademic Lea Vaughan. Source: BBC

Vaughan and Hargreaves’ team leader, Simon Beswick, changed his radio to the Major Incident channel, cutting off his direct communication channel to them (p. 7).

The Role of Gold Commander Neil Barnes

NWAS Gold (Strategic) Commander, Neil Barnes, was first informed of an incident at the Manchester Arena by Silver Commander Annemarie Rooney just after 22:41 (§10.60).

NWAS Gold Commander Neil Barnes. Source: Daily Mail.

Barnes’ response was to request an update following receipt of a METHANE message (which is used to declare a Major Incident).

This was “unacceptably passive” in Saunders’ view (§14.593). Instead of establishing with Rooney what her tactical plan was and making arrangements for their next contact, Barnes spent the time watching the television while waiting to hear from her (§14.495-14.496, §14.594).

At approximately 23:00, the NWAS Chief Executive Officer, Derek Cartwright, called Barnes, suggesting that he should mobilise to GMP HQ. Barnes, however, decided to remain at home (§14.598).

At approximately 23:20, NWAS Control called Barnes, informing him of offers by staff to come on duty. Barnes replied: “Right, well we don’t know the situation yet do we? I haven’t had a full SITREP [situation report] yet … I am waiting for the Silver Commander to get back to me” (§14.602).

NWAS Control informed Barnes during the same call that there were at least 18 fatalities and that police had asked NWAS to send as many vehicles as possible. Barnes replied: “We need to wait until our bronze commander makes decisions in terms of resourcing rather than listening to the police at this stage” (§14.604).

He did not ask when the incident had occurred, whether a Major Incident had been declared, whether Operation Plato had been declared, how many casualties there were, or how many paramedics were present (§14.605-§14.610). He made no attempt to contact Rooney. His only instruction was to ignore the police’s request for assistance.

By 23:40, Barnes was still at home, having made no attempt to speak to the Gold Commanders of any other emergency service (§10.426). The last of the casualties was being evacuated from the City Room around that time.

At the Inquiry, Barnes denied that having a flight to catch at midday the following day had anything to do with his decision to stay home.

In the first two hours of the emergency response, Barnes failed to do “a number of important things” required of him by the action card that the the Strategic Commander is required by the Major Incident Response Plan (§14.622).

In sum, “The NWAS Strategic Commander made no significant or meaningful contribution to the emergency response” (§10.428).

The Role of Silver Commander Annemarie Rooney

NWAS on call Silver (Tactical) Commander, Annemarie Rooney, upon learning of reports of a bomb, told NWAS Control at 22:39 “We need to get HART [Hazardous Area Response Team]” (§10.58).

No image of Rooney appears to exist in the public domain.

There were six HART staff operating in Greater Manchester that night, three of whom (Simon Beswick, Christopher Hargreaves and Lea Vaughan) had just arrived in Stockport (28 minutes’ drive from the Arena) when the bang happened, on what proved to be a needless callout.

This meant that they “had much further to travel than would have been the case if they had been at their headquarters in Manchester” (§14.281). Presumably, if it was Rooney who sent the HART to team to the Arena at 22:39, she may also have been responsible for needlessly sending HART to Stockport before then. If so, then she bears primary responsibility for the delayed paramedic response.

No sooner had Rooney ordered the deployment of HART to the scene than she telephoned Consultant Paramedic Daniel Smith at 22:41, directing him there also (§10.60). It is unclear why she did so, given that there were already two Bronze (Operational) Commanders on call that evening, one of whom, Senior Paramedic Derek Poland, arrived on site before Smith, having been mobilised there in that capacity (§10.150).

At 22:46, NWAS declared a Major Incident (§14.597), but Rooney did not communicate this to Gold Commander Barnes, as per his request at 22:41 (§10.60).

It was Rooney’s role to provide Daniel Smith, who declared himself Bronze Commander, with a tactical plan and to ensure that Smith did not overlook important actions (§14.483). Following an action card would have helped her to do this (§14.485), but she did not do so. For example, she failed to obtain a full briefing from Smith, as she was required to do (§14.486). Major decisions by Smith, such as that non-specialist paramedics were not to be deployed to the City Room, were not discussed with Rooney (§14.486). Smith’s failure to appoint staff to certain key roles (see below) should have been picked up on by Rooney (§14.487).

At 23:47, NWAS National Inter-Agency Liaison Officer (NILO), Jonathan Butler, was only two minutes away from the Arena having driven from his home 45 minutes away. Yet, as he approached, Rooney instructed him to attend GMP HQ instead, a decision which he queried but followed (§14.530). Why was he diverted away?

The Role of Bronze Commander Daniel Smith

Daniel Smith, who was not part of NWAS’s planned command structure for the night, and who must have known that his training in operational command training was years out of date, assumed the role of Bronze Commander almost immediately upon arrival (§10.146). Why was he so keen to do so?

Bronze Commander Daniel Smith. Source: Manchester Evening News

Derek Poland was better qualified than Smith for the role of Bronze Commander:

He was Special Operations Response Team (SORT) and Ambulance Intervention Team trained. He was also a trained Operational Commander, having held that position for five years at the date of the Attack. He had a balanced and well-informed understanding of the approach that ought to be adopted to the deployment of NWAS assets into different zones. […] He would have been a more obvious choice for the role of Operational Commander than Daniel Smith, whose training in operational command was years out of date. (§14.220)

Therefore, there is something odd about Smith appearing out of nowhere, at Rooney’s behest, to nominate himself for the Bronze Commander position.

Although Saunders generously attributes the best of intentions to Smith (§14.224), the brute reality is that Smith got nearly every key decision wrong.

While driving to the Arena, Smith radioed NWAS Control, instructing that the rendezvous point should be Manchester Central Fire Station and not the Victoria Exchange Complex (§10.83). This farcically meant that, as fire engines were departing that station to go to one two miles further away from the Arena, six ambulances arrived on its forecourt between 22:50 and 23:02 (§10.84). Smith was not formally part of the command structure at that point, yet already he was contributing to delays in the paramedic response.

Having arrived on the scene, Smith had a much too brief conversation at 23:01 with Patrick Ennis, who minutes earlier had conducted the first medical assessment inside the City Room. Ennis told him that there had been fatalities and that police officers, members of the public, event healthcare staff and security staff were helping casualties (§10.149). They did not discuss whether the City Room was a safe place for non-specialist paramedics like Ennis to be working, and Ennis returned there.

Despite having been passed this information by Ennis, Smith refused Poland’s offer to support Ennis in the City Room, instructing him to remain on the station concourse (§10.150) and later assigning the role of Parking Officer (§14.226).

Despite allowing Ennis to re-enter the City Room, Smith told the Inquiry that he believed he was prohibited from deploying any non‑specialist paramedics into the City Room (§10.154) for safety reasons.

He told Joanne Hedges, who viewed herself as Secondary Triage Officer at the Casualty Clearing Station, “not to go up the stairs” to the City Room (§14.432). Similarly, James Birchenough, whom Smith assigned the role of Casualty Clearing Officer, understood that “he was not to go up the staircase to the raised walkway” (§14.439).

NWAS Deputy Director of Operations, Stephen Hynes, told the Inquiry that “there was a discretion to send nonspecialist paramedics into both the inner cordon and an Operation Plato warm zone” (§12.425). NWAS Gold Commander Barnes gave evidence that “there was a discretion to deploy nonspecialists into the inner cordon” (§12.426). Saunders finds accordingly that “Daniel Smith did have a discretion to send nonspecialist paramedics to work in the City Room on the night of the Attack” (§12.427).

However, Smith made no attempt to find or speak to the GMP or BTP Bronze Commander to confirm this (§10.155), nor did he seek out the GMP Forward Command Post (§14.231). In fact, he was not even aware of the presence of GMP Bronze Commander, Inspector Michael Smith, in the City Room, because he did not enter the City Room himself (§14.232)

Consequently, NWAS’ Daniel Smith was unaware that his Bronze counterpart, GMP’s Michael Smith, had already, at 22:50, declared the City Room to be “‘safe enough’ for non‑specialist emergency responders and members of the public to be in” (§10.106). As a result, many non-HART-trained BTP and GMP officers were allowed into the City Room, making a further mockery of the NWAS response.

Without the necessary tactical guidance from Rooney, Smith failed to appoint a Safety Officer, who “would have been likely to have ascertained the true situation in the City Room” and communicated it back to him (§14.233). He also failed to appoint an Equipment Officer (who would have mitigated the lack of stretchers) and a Forward Doctor capable of categorising victims as P4, i.e., expected to die (§12.404, §14.233).

When HART-trained paramedics Beswick, Hargreaves, and Vaughan arrived on site and spoke to Smith and Poland at 23:11 (§14.292), Smith inexplicably decided to deploy only Hargreaves and Vaughan to the City Room (§14.230), tasking Beswick to operate on Station Approach instead (§14.299).

Station Approach. Source: Google Maps

When the remaining three HART-trained paramedics arrived (Ian Devine at 23:14, Nicholas Priest and Stephen English — who had also been sent to Stockport — at 23:18), Smith directed them, too, to stay on Station Approach instead of going to the City Room (§14.288, §14.300, §14.303).

Smith should have instructed all arriving paramedics to bring their stretchers with them but did not (§14.243). The lack of available stretchers delayed the evacuation of casualties from the City Room (§14.246).

When Matthew Calderbank, who was one of two on-call Bronze Commanders contacted by NWAS Control on the night (§14.441), arrived at Hunts Bank at 23:28, he was allocated the lesser role of Ambulance Loading Officer by Smith (§14.442).

Smith was relieved of the role of Bronze Commander by NWAS Deputy Director of Operations, Stephen Hynes, at 23:57 (§10.239, §14.227). Hynes did not consult Silver Commander Rooney about this. He must have been very concerned about what he was seeing.

Summary

It only required three individuals — Gold Commander Barnes, Silver Commander Rooney, and Bronze Commander Smith — to vitiate the NWAS response to such an extent that only three paramedics set foot on the scene of an alleged major terrorist attack. Barnes stayed at home watching the television. Rooney kept Barnes out of the loop while bringing in Smith, whom she failed to provide with the necessary tactical guidance. Smith, who should not have been part of the command structure that night, assumed the role of Bronze Commander when he should not have done so, and proceeded to get every key decision wrong.

Greater Manchester Fire and Rescue Service

Failure to Respond In Time

The fire service notoriously did not arrive at the Arena for over two hours after the detonation that was officially timed at 22:31. Manchester Central Fire Station is only a seven-minute drive away from the Arena.

Police and ambulance services arrived outside the Victoria Exchange Complex during the critical period of response, but not the fire and rescue service. Source: BBC

The Inquiry report records that, “Had the response proceeded as it should have, GMFRS would have had personnel at, or very close to, the Victoria Exchange Complex by 22:50,” i.e., with 19 minutes (§10.111). This would have been achieved had any one of the following three things happened:

1. the multiagency control room talk group had been used (§10.112);

2. a METHANE message (declaring a Major Incident) had been passed to North West Fire Control in the first 15 minutes stating that GMFRS was required at the scene (only BTP and NWAS had declared a Major Incident at that stage) (§10.113);

3. the duty National Inter-Agency Liaison Officer (NILO) had accepted GMP’s proposed rendezvous point (RVP) (§10.114).

Instead, Saunders finds that “GMFRS operated in a silo during the critical period of the response” (§12.625). The same is true of all four emergency services.

Is it really plausible that the emergency services in one of Britain’s largest cities would fail to communicate with one another about a major terrorist incident that was all over the news and social media?

The Role of Duty Principal Officer Peter O’Reilly

Although GMFRS recognised the Strategic, Tactical, and Operational Commander roles, its approach “did not map exactly onto the Strategic/Gold, Tactical/Silver and Operational/Bronze Commander roles operated by other emergency services” (§12.625).

The Gold Commander equivalent was the duty Principal Officer (§12.622), which on the night was Chief Fire Officer Peter O’ Reilly.

Manchester's former Chief Fire Officer Peter O'Reilly. Source: Sky News.

According to the Inquiry report, “The GMFRS duty Principal Officer should have deployed himself to GMP Headquarters rather than the GMFRS Command Support Room” (p. 590).

O’Reilly should also have deployed the Specialist Response Team to the scene when he was informed of the Operation Plato declaration (§15.516). His failure to do so ultimately meant that, while he and duty NILO Andrew Berry were prevaricating about whether or not ballistic protection was needed as late as 00:54, the firefighters themselves, fed up with the failures in command, disobeyed instructions to remain on Station Approach and entered the Victoria Exchange Complex to try to help (§15.545-15.553).

Lack of a Tactical Commander

The Silver Commander equivalent was the GMFRS Tactical Commander, who had to be at the rank of Station Manager and above. Unlike for GMP and NWAS, the GMFRS Tactical Commander required attendance at the scene (§12.621; §12.626).

Because no GMFRS staff were on site for two hours, there was no Tactical Commander when one was needed.

The Role of Operational Commander Ben Ley

The Bronze Commander equivalent was the GMFRS Operational Commander, who was an Incident Commander at the rank of at least Crew Manager or Watch Manager (§12.621).

At 23:45, Group Manager (a higher rank than Crew or Watch Manager) Ben Levy declared himself to be the Incident Commander. Following a miscommunication with Gold Commander O’Reilly, however, Levy thought he had been instructed to go no further than Manchester Central Fire Station (p. 590, §10.252).

Thus, farcically by the end of the second hour, GMFRS resources were back where they started, “still seven minutes away from arriving at the scene” (§10.255).

The Role of GMFRS NILO Andrew Berry

In the absence of Tactical and Operational Commanders during the critical period of response, GMFRS duty NILO, Station Manager Andrew Berry, came to play a disproportionately significant role.

GMFRS NILO Andrew Berry. Source: The Independent.

Berry was notified of the incident at 22:40. He rejected GMP’s proposed rendezvous point (RVP) “because he was not confident that it was safe” (§10.61), even though that would presumably have been for the police to decide. Had he accepted it, there would have been timely interaction between the police and the fire and rescue service.

Berry instead sent GMFRS crews to a different RVP, two miles further away from Arena (the fire crews passed ambulances travelling in the opposite direction [§10.63]).

Fire crews were sent from Manchester Central Fire Station (G16) to G18, in the opposite direction to the Arena (yellow). Source: Volume 2.1 of the Inquiry report.

Berry set off from his home to the new RVP at 22:49, a journey of over 20 miles, and supposedly got lost along the way because of diversions (§10.95). Saunders finds that “Berry should have remained at home and mobilised another officer who lived closer to go to the scene,” as a matter of standard procedure (§10.171).

Although the NILO role is not a command role, Berry “was effectively in charge of the GMFRS response throughout the entire time he was driving” (§10.99). On the way, he “spoke only to NWFC and GMFRS officers,” thus developing no situational awareness (§10.98).

At 23:40, 50 minutes after setting off to complete a 20-minute journey, Berry reached the alternative RVP at G18 Philips Park Fire Station (§10.249). The last of the casualties was being evacuated from the City Room around that time.

The Role of North West Fire Control

North West Fire Control (NWFC), which provided the control function for Greater Manchester Fire and Rescue Service (GMFRS), was informed by GMP Control of “an explosion in the city centre” and created an entry on its system in readiness to mobilise GMFRS resources (§10.34). However,

that mobilisation order was not given by NWFC, as a supervisor intervened and decided that the GMFRS duty National Interagency Liaison Officer (NILO) should be consulted before any mobilisation took place. (§10.35)

That supervisor appears to have been Janine Carden, NWFC’s designated Single Point of Contact with GMFRS (§12.549). Her training was that “if a Marauding Terrorist Firearms Attack were suspected, NWFC should not mobilise immediately and should instead speak to the NILO” (§12.549).

Former NWFS employee Janine Carden. Source: BBC

NWFC’s Michelle Gregson testified to the Inquiry that in her confusion on the night, she, too, felt the need to contact the duty NILO (§12.567).

Michelle Gregson. Source: BBC

It is unclear, however, why an explosion in the city centre was treated as reason to suspect a marauding terrorist firearms attack. The NWFC “Explosion” action plan involved deploying firefighters straight to the scene immediately (§12.584). In contrast, the first step of the “Operation Plato (Standby)” action plan was to contact the duty NILO before any mobilisation (§12.584). At no point, however, did an Operation Plato declaration reach NWFC or GMFRS.

Therefore, it was unnecessary to contact the duty NILO.

Having contacted GMFRS duty NILO Berry, NWFC did not inform him at 22:44 that GMP had an officer at the scene, or, at 22:46, that there were more GMP officers on the way (§12.556).

At 22:52, Berry called NWFC asking for three additional NILOs to be mobilised. NWFC did not contact them for another 14 minutes (§10.118). At this point, NWFC could have informed Berry that ambulances were being deployed to the scene and that police officers were already there, but it failed to do so.

Consequently, Berry, for no good reason,

remained of the view that there was a risk that a Marauding Terrorist Firearms Attack was under way. GMFRS resources continued to be directed away from the scene, out of step with the other emergency services. (§10.119)

At 22:55, NWFC was informed by GMP Control that NWAS had a Bronze Commander (Patrick Ennis) on the scene. However, “This information was passed on to only one GMFRS officer, who failed to register it” (§10.128). Why was it not shared with Berry, who spoke with NWFC just two minutes later (§10.129)?

Farcically,

At 23:06, NWFC was informed by one of the fire crews who had left Manchester Central Fire Station and travelled to Philips Park Fire Station that ambulances were arriving at their home station as they departed. This was important information that NWFC failed to act upon. It was not passed on to Station Manager Berry. (§10.162)

Thus, having insisted that any mobilisation of GMFRS be contingent on Berry’s approval, it would appear that NWFC systematically failed to pass on key information to Berry. As Saunders puts it, “The duty NILO was not informed of critical information” (§12.556).

At 23:25, the Manchester Central Fire Station Watch Manager telephoned NWFC with news that he was with a firefighter whose wife was a paramedic on the scene. Again, this information was not passed to Berry (§10.213).

Summary

Duty Principal Officer (the Gold Commander equivalent) O’Reilly failed to deploy himself to GMP HQ and failed to deploy the Specialist Response Team to the scene when he was informed of the Operation Plato declaration, an error which ultimately led to firefighters disobeying orders (§15.545-15.553). There were no GMFRS Tactical or Operational Commanders during the period of critical response, meaning that NILO Berry assumed disproportionate influence. However, Berry directed fire crews away from the scene and then “got lost” on his way to meet them, all the while being deprived of critical information by NWFC.

Summary of Command Failures on the Night

The failure of the emergency services’ response in Manchester on May 22, 2017, may be attributed to the following failures in the chains of command in the respective services.

Failures at the Gold Command Level

BTP Gold Commander Smith was unfamiliar with the Major Incident Manual (§13.121), failed to check whether a tactical plan had been developed (§13.123), did not try to contact the NWAS or GMFRS Gold Commanders, and was “too late to make any meaningful difference to the response” when speaking with GMP Commander Ford at 01:16 (§13.128).

GMP Gold Commander Ford failed to check basic things, such as whether a Major Incident had been declared, whether Operation Plato had been declared, whether a common RVP and FCP had been established, and whether the fire service was present. Saunders concludes: “she should have made a difference to the emergency response itself. She did not do so” (§13.527).

NWAS Gold Commander Barnes sat at home watching the television for over an hour after the incident occurred, taking no action other than to instruct the NWAS Control Room to ignore the police’s request to send as many vehicles as possible to the scene. He made “no significant or meaningful contribution to the emergency response” (§10.428)

GMFRS Gold Commander O’Reilly should have deployed himself to GMP HQ, and he failed to deploy the Specialist Response Team to the scene after being informed of the Operation Plato declaration (§15.516). The latter error ultimately contributed to firefighters disobeying orders.

Failures at the Silver Command Level

BTP Silver Commander Gregory did not appoint a temporary on-site Bronze Commander and instead directed Superintendent Kyle Gordon to travel to the scene from Blackpool, guaranteeing that there would be no on-site Bronze Commander until at least 90 minutes post-detonation. It proved to be much longer.

GMP Inspector Dale Sexton, acting as the initial Silver Commander, failed to declare a Major Incident, did not communicate his Operation Plato declaration to the other emergency services, and did not attempt to contact NWAS regarding the need for urgent medical support in the City Room.

GMP Night Silver Arif Nawaz, who relieved Sexton, was incompetent to perform that role and did not even get the basics rights. For example, he did not set up a FCP or establish any communication with Bronze Commander Smith until the “Golden Hour” had passed.

NWAS Silver Annemarie Rooney was responsible for the delayed arrival of paramedics at the City Room, for the dubious involvement of Daniel Smith as Bronze Commander, and for failing to provide Smith with adequate support.

GMFRS failed to establish a Silver Commander.

Failures at the Bronze Command Level

BTP failed to establish an onsite Bronze Commander during the critical response period. Kyle Gordon “did not ever take up the role of Bronze Commander in any meaningful sense” (§13.110).

GMP Bronze Commander Smith (for unarmed officers) performed the role “to a high standard” (§10.80). However, GMP Bronze Commander Richardson (for firearms officers) did not properly understand Operation Plato and its zoning requirements, and he falsely categorised the City Room and the Casualty Clearing Station as “warm zones” as late as 23:32.

NWAS Bronze Commander Daniel Smith got nearly every key decision wrong, from directing ambulances away from the Arena when not yet part of the command structure, to failing to assess the safety of the City Room for non-specialist paramedics, only directing two out of six specialist paramedics to attend the City Room, failing to attempt to speak to his counterparts in GMP and BTP, failing to appoint staff to key positions, and not addressing the lack of stretchers.

A GMFRS Incident Commander was only appointed after the critical period of response. Meanwhile, NILO Berry made poor decisions while being deprived of critical information by NWFC.

Failures in Inter-Agency Communication

According to the Inquiry report, “there are two key locations that are central to a successful multi-agency response: the Rendezvous Point (RVP) and the Forward Command Post (FCP)” (§10.19). However, the RVP designated by GMP Inspector Smith was not passed on to NWFC and GMFRS (§10.49), and no Forward Command Post was established by GMP (which bore primary responsibility for doing so) or any other agency during the critical response period (§11.105).

Key figures within each emergency service — including BTP Gold Commander Smith, BTP Force Incident Manager Dawson, GMP FDO Sexton, GMP Night Silver Nawaz, NWAS Gold Commander Barnes, NWAS Bronze Commander Smith, and GMFRS NILO Berry — made no attempt to communicate with their counterparts in the other emergency services during the critical period of response. This allowed for a near total breakdown in communication between the emergency services, making the ambulance and fire services hesitant to deploy to the City Room (or even the Victoria Exchange Complex in the case of GMFRS) for safety reasons.

None of the Operational/Bronze Commander talk groups was used “by any emergency service at any point as part of the response to the Attack” (§12.691).

The failures in communication were barely believable in some cases, viz. BTP’s attempt use the public emergency 999 number contact GMP instead of using police backchannels (§10.37), or BTP Superintendent Gordon’s failure to secure a police radio for use during his taxi ride (not blue light journey) to the scene (§10.196). GMP Gold Commander Ford’s inability to reach FDO Sexton after 22:52 because the FDO line had become “overloaded” (§13.499) is another good example. Similarly, the fire service’s “lack of […] use of an alternative route to getting key information was striking” when FDO Sexton did not answer the telephone (§15.566).

Shortly before 01:00 on May 23, 2017, almost two and a half hours post-detonation, “there was no joint understanding of risk across the three emergency services” as a JESIP huddle took place involving GMP’s Mark Dexter, NWAS’s Stephen Hynes, and GMRFS’ Andrew Berry (plus Peter O’Reilly, by phone) (§20.37).

Key Actors Travelling Long Distances

Certain key actors were called in from long distances away, delaying or precluding an effective response. These included BTP Superintendent Kyle Gordon (from Blackpool), the HART paramedics (from Stockport), NWAS NILO Jonathan Butler (from 45 minutes away), and GMFRS NILO Andrew Berry, whose 20-mile journey took an unlikely 48 minutes. In contrast, two GMP Bronze Commanders were at the City Room within 15 minutes.

Conclusion

Following reports of a major terrorist incident at the Manchester Arena on May 22, 2017, the fire service did not arrive on the scene for over two hours. Only three paramedics entered the City Room where dozens of dead and seriously injured people officially lay. It was largely left to BTP and GMP officers, Arena first aiders (ETUK), and security staff (Showsec) to assist, evacuate, and cover the victims. (See Part 10 for more on ETUK and Showsec.)

Such drastic failings, particularly in the ambulance and fire and rescue service responses, are implausible on their face. They require major failures at every level of the command structures of all four emergency services (owing to failures of inter-agency communication), and that is exactly what happened.

Despite Saunders’ attempts, in Volume 2 of the Inquiry report, to present those failures largely as a series of individual mistakes under chaotic circumstances, the odds of every Gold, Silver, and Bronze commander (apart from one) making such serious mistakes are statistically remote.

Are we really to believe that Gold Commanders Smith (BTP), Ford (GMP), and Barnes (NWAS) all failed to make any meaningful difference to the response, with Barnes instead sitting at home watching the television?

Should we really accept that GMFRS, with a fire station seven minutes from the scene, was incapable of establishing a Silver Command there in over two hours? Or that GMP Night Silver Nawaz was incompetent to perform even the basic functions of his role? Is there nothing suspicious about NWAS Silver Commander Rooney (for whom no image appears to be publicly available) keeping Gold Commander Barnes out of the loop while informally roping in Daniel Smith, whom she later provided with inadequate tactical guidance?

Does it really make sense that BTP and GMFRS were unable to establish any meaningful Bronze Command? Or that NWAS Bronze Commander Daniel Smith, who should not have been part of the command structure that night, got nearly every key decision wrong? Or that, in sharp contradistinction, GMP Bronze Commander Michael Smith supposedly, and exceptionally, did virtually everything right?

Following the introduction of NILOs in 2005, countless joint training exercises, and the embedding of Joint Emergency Services Interoperability Principles (JESIP), should we honestly acquiesce to the idea that the emergency services in 2017 were incapable of communicating with one another in any meaningful way during the critical period of response?

This is rather too much for any critically thinking person to swallow.

The scale of failure we are looking at here is not just a matter of “mistakes.” On the contrary, as Hall pointed out in his Summary of Evidence, it seems far more likely that

BTP, GMP, NWAS and GMFRS were all inhibited in different ways by their chain of command from attending to the incident in a normal fashion […] It is entirely possible, considering all the other evidence presented so far, that the inhibition of the emergency services was done deliberately, because somebody high up in the command chain knew that the incident was a pre-planned staged attack, and were trying to prevent responders who were not ‘in the know’ from finding out. (§4.10.7)

We will explore that possibility further in Part 10.