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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 chaired the inquiry, which published its final report on 2 March 2023 containing 169 recommendations across emergency response, security arrangements, and preventability.

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 78 recommendations (46%) are recorded as completed and 91 (54%) remain in progress. Key developments include the publication of Joint Operating Principles Version 3 for responding to marauding terrorist attacks, establishment of a multi-agency radio control system monitored 24/7 across emergency services, and introduction of the Ten Second Triage system for major incidents.

The Security Industry Authority has worked with the Health and Safety Executive to implement sector-specific first aid training incorporating the inquiry's recommendations. NHS England has updated Core Standards for emergency preparedness to include specific requirements for Hazardous Area Response Teams deployment within 15 minutes.

Several significant workstreams remain in development. The Clinical Response to Major Incidents programme has revised its timeline to 2027 due to resource constraints. Legislative changes regarding analgesia administration are at consultation stage. A healthcare standard for events is being drafted following completed research. The Cabinet Office is considering wider reforms to the Inquiries Act 2005.

Five local resilience forums have been selected for a Stronger LRF trailblazer programme launching in spring 2025 to test different models of strengthening accountability, leadership and assurance. Work continues on developing national events guidance, command and control approved professional practice, and a peer review protocol for local resilience forums.
Reforms Attributed to This Inquiry
- Joint Operating Principles (JOPs) Version 3 published and signed off by tri-services for Marauding Terrorist Attack response
- New multi-agency radio control talk group established, shared between police, fire and ambulance services and monitored 24/7
- Ten Second Triage system introduced for first responders at major incidents
- Security Industry Authority requirement for sector-specific Emergency First Aid at Work certificate including additional training areas
- NHS Core Standards for Emergency Preparedness, Resilience and Response (EPRR) updated to include Hazardous Area Response Teams (HART) deployment requirements
- Stronger Local Resilience Forum trailblazer programme launched in spring 2025 with five participating LRFs
- Public Access Trauma Kit contents clinically reviewed and published on PROTECT UK website
- New operational and tactical commanders training devised and launched to police forces
Unfinished Business
- Legislative changes on analgesia administration (consultation document being drafted)
- Review of Inquiries Act 2005 reforms (under consideration by Cabinet Office)
- National Events guidance (currently being developed)
- Healthcare standard for events (research complete, drafting begun)
- Command and control approved professional practice (APP) due for launch in 2025
- Clinical Response to Major Incidents (CRMI) programme timelines revised to 2027
- Operational discretion guidance (under national review)
- Peer review protocol for local resilience forums (proposals being developed)
Generated 18 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: 25 Mar 2026 (import)
How to read this

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

Full methodology

2 debates 25 questions 16 statements since Sep 2020
Written Question Sports: Care Quality Commission
Dame Caroline Dinenage (Conservative)
13 Mar 2026
Written Question Security Guards: Licensing
Melanie Onn (Labour)
11 Feb 2026
Written Ministerial Statement Consultation on Manchester Arena Inquiry recommendations 7 and 8
Dan Jarvis (Labour)
18 Dec 2025
Written Ministerial Statement Consultation on Manchester Arena Inquiry recommendations 7 and 8
Lord Hanson of Flint (Labour)
18 Dec 2025
Written Ministerial Statement Consultation on Manchester Arena Inquiry recommendations 7 and 8
Lord Hanson of Flint (Labour)
15 Dec 2025
View all 46 mentions →
All Activity (46)
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 Terrorism (Protection of Premises) Act 2025, which enacts the Protect Duty into law, received Royal Assent on 3 April 2025 (UK Parliament, April 2025). This Act creates Standard and Enhanced Duties for premises based on capacity, with the Security Industry Authority (SIA) designated as the regulator (UK Parliament, April 2025). A gov.uk progress update (February 2026) notes that the government intends for an implementation period of at least 24 months before the Act comes into force, with enforcement expected around April 2027.
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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
A gov.uk progress update (February 2026) indicates that the rollout of analgesia to Hazardous Area Response Team (HART) and other specialist operatives is proposed to occur in a phased approach once regulatory requirements are confirmed and further evidence regarding use in different patient groups has been reviewed. The government accepted this recommendation in June 2021, committing to review the report and take action on recommendations requiring legislative change (Gov.uk, June 2021).
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
A gov.uk progress update (February 2026) reports that 20 police forces have officers trained in the use of analgesia, predominantly Penthrox. The NPCC Clinical Panel has completed consultation on national guidance for this, which is expected to be published shortly. The Security Industry Authority (SIA), a responsible body, is set to become the regulator under the Terrorism (Protection of Premises) Act 2025, which received Royal Assent in April 2025 but is not yet in force (UK Parliament, April 2025).
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
A gov.uk progress update (February 2026) states that this recommendation has been completed through the Terrorism (Protection of Premises) Act 2025. This Act, which received Royal Assent in April 2025, requires responsible persons for enhanced duty premises and qualifying events to implement appropriate public protection measures aimed at reducing vulnerability and mitigating the impact of terrorist attacks (Gov.uk, February 2026; UK Parliament, April 2025).
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 Home Office launched a government consultation on 18 December 2025, which included reviewing whether in-house CCTV operators should be SIA-licensed (MR7), with the consultation closing on 12 March 2026. A gov.uk progress update (February 2026) states that Home Office Ministers recently committed to reviewing recommendations MR7 and MR8 to enhance private security standards and counter-terrorism measures.
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 Security Industry Authority (SIA) has worked with first aid providers, many of whom have adopted additional trauma care training as a standard across sectors beyond the security industry (gov.uk progress update, 27 February 2026). The SIA has also communicated this requirement, which was a recommendation of the Manchester Arena Inquiry. A Home Office consultation on SIA licensing for in-house CCTV operators and security contractors opened in December 2025 and closed in March 2026 (Home Office Consultation, 18 December 2025).
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 Security Industry Authority (SIA) has collaborated with the Health and Safety Executive (HSE) to implement a sector-specific version of the Emergency First Aid at Work certificate, which incorporates areas recommended by the inquiry for further training (gov.uk progress update, 27 February 2026). The SIA has also engaged with training providers regarding this initiative. A Home Office consultation on SIA licensing for in-house CCTV operators and security contractors opened in December 2025 and closed in March 2026 (Home Office Consultation, 18 December 2025).
College of Policing (Primary) Security Industry Authority
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