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Manchester Arena Inquiry

Completed
Chair Sir John Saunders Judge / Judiciary
Established 07 Sep 2020
Final Report 02 Mar 2023
Commissioned by Home Office

Public inquiry into the terrorist attack at Manchester Arena on 22 May 2017, which killed 22 people and injured over 1,000 others.

Evidence & Impact
The Manchester Arena Inquiry was established following the terrorist attack at Manchester Arena on 22 May 2017 that killed 22 people. Sir John Saunders published the final report on 2 March 2023, making 169 recommendations across emergency response, security arrangements, and public safety.

The government accepted 164 recommendations (97%) and accepted 5 in principle (3%). Home Secretary Suella Braverman stated in Parliament on 6 March 2023 that the government would 'carefully consider the report's findings and recommendations in full' and committed to ensuring lessons were learned. A recommendations tracking dashboard was subsequently published.

Progress updates from February 2026 indicate that 78 recommendations (46%) are recorded as completed and 91 (54%) remain in progress. Key developments documented include the publication of Joint Operating Principles Version 3 for responding to terrorist attacks, establishment of a new multi-agency radio control system, and introduction of the Ten Second Triage system for major incidents.

Several working groups and programmes have been established, including the Clinical Response to Major Incidents group and the Stronger Local Resilience Forum trailblazer programme. The Security Industry Authority has worked with the Health and Safety Executive to develop enhanced first aid training incorporating the inquiry's recommendations.

However, multiple recommendations show limited documented progress nearly three years after publication. Several relating to legislative changes, including extending Security Industry Authority licensing and reforms to the Inquiries Act 2005, remain under consideration. The development of a healthcare standard for events, while noted as progressing with research projects complete, is not due for publication until 2026. The Clinical Response to Major Incidents group has revised its timeline to 2027 due to resource constraints.

The Ministry of Justice has stated there are no current plans to increase maximum sentences under the Inquiries Act, despite this being recommended. Various guidance documents and approved professional practices are noted as being developed but have not yet been published according to the available evidence.
Reforms Attributed to This Inquiry
- Joint Operating Principles (JOPs) Version 3 published and signed off by tri-services following the inquiry, containing additional principles for responding to Marauding Terrorist Attacks
- New multi-agency radio control talk group established, shared between police, fire and ambulance services and monitored 24/7 in control rooms
- Ten Second Triage system introduced for first responders at major incidents, including appropriate visible identifiers and triage labels
- Sector-specific Emergency First Aid at Work certificate developed by Security Industry Authority with Health and Safety Executive, incorporating inquiry-recommended training areas
- Clinical Response to Major Incidents (CRMI) working group established to implement healthcare-related recommendations
- Public Access Trauma Kit contents clinically reviewed and finalised, with specifications published on PROTECT UK website
- New operational and tactical commanders training devised and launched to police forces
- Stronger Local Resilience Forum trailblazer programme launched in spring 2025 with five participating LRFs: Cumbria, Greater Manchester, London, Northumbria and Suffolk
Unfinished Business
- Recommendation on extending Security Industry Authority licensing requirements for CCTV monitoring and security contractors - noted as requiring legislative change but no evidence of progress
- Recommendations relating to reforms of the Inquiries Act 2005 - Cabinet Office noted as considering wider reforms but no specific action documented
- Recommendation to increase maximum sentence for Inquiries Act offences - Ministry of Justice stated there are no current plans to increase the maximum sentence
- Multiple recommendations relating to the development of a healthcare standard for events - research projects noted as complete but standard not yet published (due 2026)
- Legislative changes on analgesia - consultation document being drafted by Department of Health and Social Care but not yet published
- National Events guidance - noted as currently being developed but not yet published
- Command and control approved professional practice (APP) - due for launch in 2025 but not yet published
AI-generated narrative. Generated 26 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
2 years, 5 months Duration
£36.3m Total Cost
291 Witnesses
196 Hearing Days
1,346 Report Pages
Inquiry Website Official Statement Terms of Reference
Government Response
Accepted 164
Accepted in Part 5
Total Recommendations 169
Data last updated: 27 Feb 2026 · Source
Data verified: 26 May 2026 (import)
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

Full methodology

2 debates 27 questions 16 statements since Sep 2020
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Tim Farron (Liberal Democrat)
16 Apr 2026
Written Question Athletes: Health Services
Dame Caroline Dinenage (Conservative)
10 Apr 2026
Written Question Health Professions: Culture and Sports
Dame Caroline Dinenage (Conservative)
13 Mar 2026
Written Question Sports: Care Quality Commission
Dame Caroline Dinenage (Conservative)
13 Mar 2026
Written Question Security Guards: Licensing
Melanie Onn (Labour)
11 Feb 2026
View all 49 mentions →
All Activity (49)
22 May 2017
Manchester Arena Attack

Terrorist attack at Manchester Arena killed 22 people.

22 Oct 2019
Inquiry Announced

Home Secretary announced a public inquiry.

Source
22 Oct 2019
Chair Appointed

Sir John Saunders appointed as Chair.

07 Sep 2020
Hearings Begin

Public hearings commenced.

17 Jun 2021
Volume 1 Published

Volume 1 report on security published.

Source
03 Nov 2022
Volume 2 Published

Volume 2 report on emergency response published.

Source
02 Mar 2023
Volume 3 Published

Final volume on radicalisation of the attacker published.

Source
08 Jun 2023
Government Response

Government published response accepting recommendations.

Source
Total Inquiry Cost (Cumulative) £36,323,455
to Aug 2023 Cumulative Total Oct 2019 - Aug 2023
Cost Breakdown (to Aug 2023)
Inquiry Legal Costs £12,933,544 Panel remuneration & Counsel to the Inquiry
Core Participant Legal Costs £12,025,040 Legal funding for core participants
Staff £2,253,186
Accommodation £2,319,627
Technology £5,344,006
Other £1,448,052
Total inquiry cost £36.32 million. Inquiry ran from Oct 2019 to June 2023. Chair: Sir John Saunders. Three volumes of reports published 2022-2023. S40 payments (Core Participant legal costs) totalled £12.03 million.
Cost History
Period Total Inquiry Legal CP Legal Source
Aug 2023 £433,226 £161,032 £50,193
Aug 2023 (cum.) £36,323,455 £12,933,544 £12,025,040
Mar 2023 £2,900,968 £1,518,494 £169,977
Mar 2022 £13,359,502 £4,525,677 £4,421,346
Mar 2021 £15,871,460 £4,700,572 £6,326,137
Mar 2020 £3,758,299 £2,027,769 £1,057,387
Clear

Recommendations (7)

MAI-9
Accepted
Enact Protect Duty into law
Recommendation

A Protect Duty, as set out above, should be enacted into law by primary legislation.

Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "Completed" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The Terrorism (Protection of Premises) Act 2025, known as Martyn's Law, received Royal Assent on 3 April 2025 (Terrorism (Protection of Premises) Act 2025, legislation.gov.uk).
- The Home Secretary stated that the legislation "delivers upon the lessons from the Manchester Arena Inquiry to keep people safe" (Landmark anti-terror legislation gains Royal Assent, Home Office, 3 April 2025).
- The dashboard states the Government intends an implementation period of at least 24 months before the Act comes into force, to allow the regulator function to be established (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
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MAI-49
Accepted
Review analgesia rollout to HART operatives
Recommendation
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 … Read more
Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "In progress" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The dashboard states that once regulatory requirements are confirmed, the proposal is to roll out analgesia in a phased approach as more evidence on use in different patient groups is reviewed (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
National Ambulance Resilience Unit (Primary) Security Industry Authority
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MAI-91
Accepted
Review analgesia deployment for firearms officers
Recommendation

The College of Policing and Counter Terrorism Policing Headquarters should review whether firearms officers should be deployed with analgesia and trained in its use, as part of providing Care Under Fire.

Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "In progress" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The dashboard states that 20 forces are now confirmed as having officers trained in use of analgesia, predominantly Penthrox (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The NPCC Clinical Panel has completed consultation on national guidance which will be published shortly; use of analgesia remains a force-level decision under local clinical leads (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
College of Policing (Primary) Security Industry Authority Counter Terrorism Policing
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MAI-149
Accepted
Healthcare provision under Protect Duty
Recommendation

The Home Office should consider whether the requirement for adequate healthcare provision at events is a topic that should also be addressed by the Protect Duty.

Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "Completed" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The Terrorism (Protection of Premises) Act 2025 requires responsible persons for enhanced duty premises and qualifying events to have public protection measures in place (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The Terrorism (Protection of Premises) Act 2025 received Royal Assent on 3 April 2025 (Terrorism (Protection of Premises) Act 2025, legislation.gov.uk).
- DHSC is working with partners on updated guidance for healthcare at events, and the Event Healthcare Standard will be assessed for potential statutory obligation (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
Home Office (Primary)
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MAI-161
Accepted
Review CCTV monitoring SIA licence requirements
Recommendation

The requirement that only those monitoring CCTV under a contract for services need to hold an SIA licence should be reviewed.

Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "Completed" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- Home Office Ministers committed to reviewing recommendations MR7 and MR8 on licensing of security contractors and in-house CCTV operators (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- A public consultation on these monitored recommendations ran from 18 December 2025 to 12 March 2026, considering options ranging from status quo to mandatory business licensing (Manchester Arena Inquiry: Monitored recommendations 7 and 8 consultation document, Home Office, December 2025).
Security Industry Authority (Primary)
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MAI-163
Accepted
SIA encourage trauma care training for non-licensed staff
Recommendation

The Security Industry Authority should take steps to encourage the security industry generally to ensure that even those members of staff who do not require a licence from the Security Industry Authority develop skills in basic trauma care.

Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "In progress" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The SIA has worked with first aid providers, many of whom have adopted additional training as standard across sectors outside security (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The SIA's reach to non-licensed sectors is more limited but efforts have been made via social media and e-newsletters (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
Security Industry Authority (Primary)
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MAI-164
Accepted
SIA first responder training for all licensees
Recommendation
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 … Read more
Published evidence summary
- The Government's implementation dashboard records this recommendation as accepted in full with delivery status "In progress" (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The SIA has worked with the HSE to implement a sector-specific Emergency First Aid at Work certificate covering areas recommended by the inquiry (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- The sector-specific requirement was featured on the HSE website from September 2024 and will apply to all Door Supervisors and Security Guards seeking new or renewal licences (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
- An adaptation period for those with recent training from outside the sector is planned to end by end of May, in line with a fuller review of SIA first aid requirements (Manchester Arena Inquiry Recommendations Dashboard, Cabinet Office, February 2026).
College of Policing (Primary) Security Industry Authority
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