Manchester Arena Inquiry

A clean start should be possible when a student moves from school to college or higher education, such that it would not be appropriate for a general file on significant behavioural problems to follow them at that point. However, there may still be value in passing on a record of any behaviour that is assessed to indicate vulnerability to radicalisation. It's recommended that the Department for Education consider whether this is workable and, as with the school record, what nature of incident and level of seriousness should be included in this kind of record.

All ambulance service trusts should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and externally to the extent appropriate.

All fire and rescue services should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and externally to the extent appropriate.

Ambulance service trusts should review their capacity to respond to a mass casualty incident. That should include an assessment of whether they have an adequate number of trained specialist personnel to respond effectively to a mass casualty incident.

A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department of Health and Social Care and the National Ambulance Resilience Unit should consider how to resolve that problem. Consideration should be given to the training of other emergency service personnel in driving ambulances.

As of September 2020, all primary and secondary school pupils were required to be taught health education, including first aid, as part of the National Curriculum. This involves children aged over 12 being taught CPR. This is necessary. The Department for Education should ensure that it continues.

British Transport Police should ensure that all its Sergeants are trained in what is required of a Bronze Commander in the event of a Major Incident. This will help to make sure that the first Sergeant on scene can undertake the initial steps in the emergency response, prior to the arrival of an Inspector.

British Transport Police should work with the Home Office police services with which it shares policing responsibilities at or for a particular location: a. to agree which police service has primacy in the event of a Major Incident; b. to put in place appropriate plans to make clear the responsibilities of each police service in the event of a Major Incident; c. to conduct regular exercises, including joint exercises, to test those plans; and d. to ensure that all police officers and police staff are adequately trained in what will be required of them.

BTP and all Home Office Police Services should conduct a review of the areas in which their jurisdictions overlap. In the case of areas which have a significant footfall by members of the public which are not part of the railway estate, a review should be conducted by both BTP and the Home Office Police Services. Following the review, agreement as to primacy should be reached and recorded in writing.

Counter Terrorism Policing Headquarters and the College of Policing should ensure that all firearms officers, including firearms commanders, receive adequate training in Operation Plato, including in what such a declaration means and the demands it will place upon them. This should include instruction in the importance of zoning, communicating zoning decisions to other emergency services and joint working with those other services in the course of the response to an Operation Plato situation.

Counter Terrorism Policing Headquarters and the College of Policing should ensure that all unarmed frontline police officers receive training in what Operation Plato is and what will be expected of them following such a declaration. The training should include the importance of zoning, the identification of who can ordinarily work in different zones and the importance of joint working.

Counter Terrorism Policing Headquarters and the College of Policing should issue guidance on the circumstances in which a police officer or officers with responsibility for the tactical/silver command of the unarmed officers at the scene or scenes of a Major Incident should deploy to that scene or scenes.

Counter Terrorism Policing Headquarters should review the evidence heard during the Inquiry, including that heard in restricted sessions, to consider the advantages and disadvantages of embedding doctors with some police firearms teams, and how, if that is advantageous, it could be achieved.

Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated in the UK or some further learning taken from them.

Given the broad command responsibilities that the Force Duty Officer or Force Incident Manager will have in the early stages of the response to a Major Incident, the Home Office and the College of Policing should develop nationally accredited training to prepare those officers for that role.

Greater Manchester Fire and Rescue Service and North West Fire Control should conduct a joint review of the circumstances in which it is appropriate for Greater Manchester Fire and Rescue Service personnel to check the North West Fire Control incident log. Policies should be written by both organisations to reflect the outcome of this review. Training should be delivered to embed it into practice.

Greater Manchester Fire and Rescue Service should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the person receiving the update was provided with information, to ensure that they are completely up to date.

Greater Manchester Police should ensure that its plans for responding to a Major Incident, including a terrorist incident, are reviewed regularly by those with the appropriate skills and experience to make meaningful improvements to each plan. This must include a regular review of the Operation Plato plan, which must include obtaining the views of those with experience of firearms policing and of performing the role of Force Duty Officer.

Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of Greater Manchester Fire and Rescue Service, including its Specialist Response Team, as well as on the importance of joint working.

Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of North West Ambulance Service, including its Hazardous Area Response Team, Ambulance Intervention Team and Special Operations Response Team, as well as on the importance of joint working

SMG should review its processes to ensure that it shares with Greater Manchester Police, Greater Manchester Fire and Rescue Service, British Transport Police and North West Ambulance Service its most current emergency response plans and policies for dealing with an incident at the Arena. It should apply this approach more generally to its operations.

Guidance should be provided to event healthcare providers, to emergency service responders other than paramedics and to the public generally about the circumstances in which those who are believed to be dead should be covered. The guidance should make clear that this step should only be taken by a paramedic or other healthcare professional. The guidance should also make clear that paramedics at the scene of a mass casualty incident should inform others present that only healthcare professionals should cover those believed to be dead. The Department of Health and Social Care and the National Ambulance Resilience Unit should provide guidance addressing this important issue.

Having carried out that review, the trusts should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the numbers required.

His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, Counter Terrorism Policing Headquarters and the College of Policing should take steps to ensure that all police services have in place effective systems for the prompt deployment of explosives detection dogs in circumstances in which such animals are needed.

His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should issue guidance for all police services on how often operational plans for responding to a Major Incident, including a terrorist incident, should be reviewed, how that review should be conducted, and what rank and experience the officers involved should have.

His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should work together to put in place robust systems, policies and guidance to ensure that all police services have sufficient resources dedicated to the development of operational and contingency plans, particularly for responding to Major Incidents, including terrorist attacks.

If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other specialist operatives, as part of their basic equipment, and to paramedics more generally.

It is recommended that the Crown Prosecution Service establish a written protocol in relation to its approach to any application from an inquiry Chairman for a section 35 prosecution to be taken over under section 6(2) of the Prosecution of Offences Act 1985.

It is recommended that the Department for Education consider whether schools should include notes of any significant behavioural problems on the Common Transfer File, or some other suitable new form of record which follows a student if they move school. The focus should be on any behaviour that may be indicative of violent extremism, such as physical aggression or misogynistic conduct. This kind of behaviour is consistent with the development of a violent extremist mindset, but is not necessarily an indication of it by any means. Details as to what nature of incident and level of seriousness should be included in such a record will therefore require careful thought by the Department for Education, alongside consultation with relevant stakeholders.

It is recommended that the Home Office consider introducing a system based on a robust assessment of the risk a prisoner poses for radicalisation of others. This system should allow for proportionate restrictions to be applied to visitors to that person. Controls such as prohibiting vulnerable visitors where justified or ensuring conversations are supervised should be among the options available in the case of a prisoner who poses a particular risk to others

It is recommended to all educational establishments and the Department for Education that images of school pupils or college students handling firearms, explosives or other weapons that come to the attention of staff be recorded as a potential indicator of violent extremism, unless there is a very clear innocent explanation, so that this can be taken into account in any assessment of vulnerability to radicalisation.

Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those events.

Local resilience forums should monitor attendance and participation at their meetings, and flag promptly any concerns about attendance by members to the leadership of the organisation concerned. The Home Office should ensure that this is being done by local resilience forums.

North West Ambulance Service should review how it rosters Tactical Advisors and National Interagency Liaison Officers so as to ensure that there is adequate geographical coverage enabling those on duty to arrive promptly at the scene of any Major Incident.

North West Ambulance Service should review its Major Incident Response Plan to consider whether, in order to speed up mobilisation, it should provide pre-determined attendances for the Hazardous Area Response Team, Ambulance Intervention Team and Special Operations Response Team crews for Major Incidents.

North West Fire Control should review how it allocates the best-trained and most suitable Control Room Operators to roles during a Major Incident. It should consider whether it is beneficial to allocate a Control Room Operator to monitor communications on a multiagency control room talk group and another Control Room Operator as the specific point of contact for the fire and rescue service. Both roles could be supervised by a Team Leader.

North West Fire Control should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the person receiving the update was provided with information, to ensure that they are completely up to date.

North West Fire Control should take steps to ensure that it is involved in multi-agency exercises, particularly those that test mobilisation and the response to a Major Incident in line with the Joint Emergency Services Interoperability Principles (JESIP).

That standard needs to be regulated and enforced. The Care Quality Commission is the appropriate body to provide regulation and enforcement. The Department of Health and Social Care should give urgent consideration to making the necessary changes in the law to enable the Care Quality Commission to become the regulator for this sector.

The College of Policing and Counter Terrorism Policing Headquarters should ensure that all firearms officers are trained to understand that, while their primary role in an Operation Plato situation is to neutralise any armed terrorist, their role also involves providing Care Under Fire.

The College of Policing and Counter Terrorism Policing Headquarters should take steps to ensure that each police service establishes a hotline that enables those within the command structure of the three emergency services to make contact with the Force Duty Officer in the event of a declaration of Operation Plato.

The College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should ensure that each police service has in place a system that means appropriately qualified and experienced personnel are rostered 24 hours each day so that, in the event of a terrorist attack or any Major Incident, a prepared and effective command structure can be geared up swiftly.

The College of Policing should consider whether the current process for maintaining and storing training records for all police officers can be improved. That should include assessing the following: a. the introduction of electronic training records in a standard form across all police services; b. the introduction of centrally held electronic training records for all police officers; and c. the introduction of a system whereby each police officer is required to view their record each year and identify any errors or omissions within it.

The College of Policing should issue guidance to all police services to ensure the following, in the event of a Major Incident: a. The Force Duty Officer is not expected to deal with media enquiries. b. The important task of ensuring that the media is kept informed is done in a way that does not interfere with the work of the police control room.

The Ministry of Housing Commuities and Local Government should review the guidance given to all licensing authorities on the decisions they make in relation to venues that hold events, and on what level of event healthcare services may be required at the events likely to be held at those venues. The guidance should indicate appropriate licence conditions to be used. The licensing authorities should then impose conditions accordingly or make those standards a requirement of meeting existing conditions.

The Department of Health and Social Care and the Medicines and Healthcare products Regulatory Agency (MHRA) should consider urgently whether the regulatory regime should be altered to enable analgesia, such as fentanyl lozenges or sufentanil sublingual tablets, to be given by paramedics to injured persons.

The Department of Health and Social Care and the National Ambulance Resilience Unit should consider ensuring that there is further training of HART personnel so that at least one member on every HART deployment has the ability to deliver the most enhanced care interventions.

The Department of Health and Social Care and the National Ambulance Resilience Unit should consider whether the Advanced Medical Priority Dispatch System is fit for purpose and, if it is, whether it can be improved. Particular consideration should be given to how the system prioritises emergency calls.

The Department of Health and Social Care and the National Ambulance Resilience Unit should develop a system for ensuring that the duty command structure in each ambulance service has notice of any significant pre‚Äëplanned event, such as a major concert or sports match, taking place within the ambulance service area.

The Department of Health and Social Care and the National Ambulance Resilience Unit should develop procedures to ensure that, so far as possible, each ambulance service trust is able to deploy or call upon HART resources immediately in the event of a Major Incident. As part of that, the Department of Health and Social Care and the National Ambulance Resilience Unit should develop procedures to ensure that, so far as possible, each ambulance service trust can call upon cross-border support in respect of HART resources immediately in the event of a Major Incident. There may be some incidents that are so significant that an individual ambulance service will need to mobilise its own HART resources and also draw upon cross-border support. Procedures need to accommodate this.

The Department of Health and Social Care and the National Ambulance Resilience Unit should ensure that all ambulance commanders receive regular Major Incident training. The training should include training on HART capabilities, on all the command roles and where they will be located, on how to gain situational awareness through the deployment of sector commanders and other roles, on the importance of getting ambulance personnel to casualties without delay and on the circumstances in which they may use operational discretion.

The Department of Health and Social Care should consider issuing guidance on the first aid equipment that event providers should have available on the relevant premises, as well as where that equipment should be stored to ensure that it is readily accessible when required and how often it should be checked to ensure that it is up to date and in good working order.

The Department of Health and Social Care should undertake a review, with input from other bodies as the Department considers appropriate, in order to identify the type of stretcher that is of the greatest utility in the event of a mass casualty incident. The product of that research should be rolled out to all of those with responsibility for the response to a mass casualty incident, including a terrorist attack, whether in the public or private sector.

The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider issuing guidance on how to ensure that specialist paramedics take with them, into a warm zone, equipment that enables them to carry out bridging interventions.

The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider whether all Hazardous Area Response Team operatives should be deployed with freeze-dried plasma and trained in its use.

The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should review the current model for evacuation to hospital operated in the UK by reference to the different approaches around the world in order to see whether triage at different times and in different places remains best practice, or whether there should be a greater emphasis on rapid evacuation to hospital.

The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should undertake a review into whether frontline ambulances should carry intramuscular tranexamic acid or TXA.

The Department of Health and Social Care, the NHS, the National Ambulance Resilience Unit, ambulance service trusts, Air Ambulances UK, Counter Terrorism Policing Headquarters and JESIP should consider what staff training and resources would be required to integrate air ambulance organisations into the emergency response to Major Incidents, including terrorist attacks.

The Department of Health and Social Care, the NHS, the National Ambulance Resilience Unit, ambulance service trusts, Air Ambulances UK, Counter Terrorism Policing Headquarters and JESIP should consider whether air ambulances should be integrated into the emergency response to Major Incidents, including terrorist attacks, and, if so, how that is to be achieved.

The Greater Manchester Resilience Forum should oversee, at least every six months, a regular tri-service review of the Major Incident plans used by Greater Manchester Police, Greater Manchester Fire and Rescue Service and North West Ambulance Service. The purpose of that review should be to ensure that there is a common understanding by each emergency service of the plans of the other emergency services. It should also ensure that the importance of joint working is embedded within each emergency service.

The Home Office and College of Policing should ensure that any police officer whose position carries with it the expectation that they will assume a Tactical/Silver Commander role in the event of a spontaneous Major Incident (e.g. Night Silver in Greater Manchester Police) has undertaken an accredited course preparing them for that role.

The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems and sufficient resources to make sure that the debrief process following multi-agency exercises is effective to capture the lessons that need to be learned.

The Ministry of Housing, Communities and Local Government should ensure that there exist robust national and local systems to identify and record the lessons learned from all multi-agency exercises and ensure that change is implemented as a result, where change is indicated.

The Home Office, College of Policing and Counter Terrorism Policing Headquarters should ensure that all police officers to be appointed to the role of Force Duty Officer or Force Incident Manager attend a comprehensive training course dedicated to Operation Plato before they take up their role. Such courses must ensure that those attending understand the exceptional demands that will be placed upon them in the event of an Operation Plato declaration. Any course should include training in the following: a. the need, following a declaration of Operation Plato, to carry out regular reviews of that declaration; b. the need to identify with clarity the Operation Plato zones at the scene or scenes covered by the declaration; c. the need to communicate those zones to all emergency services promptly; d. the need to keep zoning decisions under review; and e. the need to work jointly with emergency service partners in the response to an Operation Plato situation.

The Home Office, Counter Terrorism Policing Headquarters, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should consider introducing the use of regular 'high fidelity training' to give emergency responders better experience of the stress, pressure and pace of a no notice attack.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, and the Fire Service College should develop a system for ensuring that the duty command structure in each fire and rescue service has notice of any significant pre-planned event, such as a major concert or sports match, taking place within the fire and rescue service area.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should oversee the development and implementation of action cards for the police, fire and rescue service, and ambulance service for use in a Major Incident.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and all local resilience forums should take steps to ensure, whether through multi-agency training and exercising or otherwise, that the members of each emergency service are aware of the specialist capabilities of every other emergency service.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the Operation Plato hot, warm and cold zones and all have a common understanding of those terms.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the zoning of hazardous areas in non-Operation Plato Major Incident situations and that all services have a common understanding of those terms. The terms should be different from those used when Operation Plato is declared.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit, individual police services and JESIP should review what changes need to be made to the Major Incident plans and Counter Terrorism Policing Headquarters Operation Plato guidance in order to achieve the aims set out in R45.

The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unity, individual police services and JESIP should develop a nationally agreed format for all plans, placing JESIP at their centre.

The Home Office should consider empowering the leadership of local resilience forums to compel the attendance of a senior representative of its Category 1 and Category 2 responders at all local resilience forum meetings. Inspections by His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should include an analysis of a service's engagement with its local resilience forum or forums. Consideration should be given to putting this on a statutory footing.

The Home Office should consider the introduction of a national standard requiring a meeting of the Strategic Co-ordinating Group to take place no more than two hours after the declaration of a Major Incident where more than one emergency service is engaged in the response to that incident.

The Home Office should consider the introduction of a requirement into law, for example through regulations issued under the Health and Safety at Work etc. Act 1974, that employers train all employees, or certain categories of employees, in first responder interventions.

The Home Office, the College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should develop a system for ensuring that the duty command structure in each police service has notice of any significant pre-planned event, such as a major concert or sports match, taking place within the police service area.

The Home Office, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should consider together whether an app giving ready access to the contact details for all on-duty and on-call commanders is feasible and, if so, likely to be of benefit in the response to a Major Incident.

The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are issued with a means to record what they say, hear and see unless there are good reasons why they should not be so equipped.

The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that, in the course of exercises, such equipment is used by those who would use it in the circumstances of a real-life incident.

The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that training is given to all who are issued with such equipment, on the circumstances in which it should be used and the importance of its use

The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should take steps to ensure that all emergency services understand the importance of promptly obtaining comprehensive accounts from commanders as part of the debrief process following a Major Incident.

The Home Office, the Department of Health and Social Care and the National Ambulance Resilience Unit should consider how to ensure that the role of an Ambulance Liaison Officer is properly resourced and also whether venue operators should fund the presence of an Ambulance Liaison Officer where one is required.

The Home Office, the Department of Health and Social Care, the Department for Transport and the Department for Levelling Up, Housing and Communities should conduct a review to ensure that stretchers that are appropriate in design and adequate in numbers are always available for use by the emergency services and in appropriate locations in the event of a mass casualty incident.

The Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College should develop guidance as to where commanders should locate during a spontaneous Major Incident. Steps should be taken to ensure that a consistent approach is taken so that equivalent commanders locate in the same place. During the response to a terrorist attack, the need for commanders on scene who are not engaged in directing individual actions should be recognised and accommodated.

The Inquiry heard evidence that the impact of public funding cuts fell disproportionately hard on metropolitan police services, such as Greater Manchester Police, compared with non-metropolitan services. In the event that public funding cuts are in the future considered necessary by the government, the Home Office should consider whether some funding arrangement for police services different from that applied in the post-2010 period is necessary.

The Security Industry Authority should take urgent steps to devise a training scheme in first responder interventions that educates all of those licensed by it, both existing licensees and new licence applicants. The Security Industry Authority may find it helpful to consult with the College of Policing in this, since it is apparent that the College of Policing has already undertaken a good deal of work in this regard.

The team led by Philip Cowburn has devised a tool that is designed for use by a wide range of emergency responders in a mass casualty situation. It is known as Ten Second Triage. The National Ambulance Resilience Unit, the College of Policing and the Fire Service College should consider as a matter of urgency whether all of their frontline staff should be trained in the use of Ten Second Triage.

The team led by Philip Cowburn has devised a tool that is designed to replace the existing systems of primary and secondary triage. It is known as the Major Incident Triage Tool. It already has the support of NHS England. The National Ambulance Resilience Unit and all ambulance services should consider introducing the Major Incident Triage Tool as a matter of urgency.

The terms Casualty Collection Point and Casualty Clearing Station are capable of being confused, one for the other, particularly in circumstances of stress. That happened on the night of the Attack. The National Ambulance Resilience Unit should consider whether different and more distinct terms should be used for these two locations.