The Kerslake Report: An independent review into the preparedness for, and emergency response to, the Manchester Arena attack on 22nd May 2017 EMBARGOED UNTIL NOON ON TUESDAY 27TH MARCH kerslakearenareview.co.uk 1 – The Kerslake Report kerslakearenareview.co.uk The Kerslake Report The names of those who lost their lives 4 Executive summary 5 Chapter 1 – Introduction 11 Background and rationale for review – ‘Putting the experience of bereaved families and those affected at the heart of the review’ 11 Panel membership 12 Terms of reference 13 Methodology – information gathering 17 The structure of integrated emergency management in the United Kingdom: key concepts 20 Joint Emergency Services Interoperability Principles (JESIP) 24 Joint Operating Principles – Marauding Terrorist Firearms Attack (MTFA) 26 Greater Manchester emergency management plans 30 Diagrams of the location of the attack 30 Chapter 2 – Those directly affected: the experiences of the bereaved, injured and concert attendees and their friends and families 33 Security at the venue 35 Leaving the Arena 35 Immediate response of emergency services 38 Healthcare 39 Finding family and friends 41 Experiences of the bereaved 42 The ‘We Love Manchester’ fund 45 Guidance and support for those affected 47 The response from Manchester 48 Outside Manchester 50 Access to and provision of mental health support 50 Communications 53 The One Love Manchester tribute concert 54 The Experience of families with the media 54 Chapter 3 – What happened? 22nd – 31st May: the emergency services 58 Timeline of major events 22nd May – 25th May 2017 59 Geographical map of key locations 61 The response of British Transport Police to the Arena attack 63 The response of Greater Manchester Police to the Arena attack 65 The response of the North West Ambulance Service to the Arena attack 84 2 – The Kerslake Report kerslakearenareview.co.uk The response of Greater Manchester Fire and Rescue Service to the Arena attack 91 Military assistance to the civil authorities during the response to the Arena attack 100 Chapter 4 – The response of the community, business, non-‘blue light’ responders and partner organisations 102 The civic response – Manchester City Council 102 Manchester Arena 106 Greater Manchester Health and Social Care Partnership 108 Transport and rail 113 Northern 113 Manchester community groups, charities and business 117 Chapter 5 – Panel conclusions 126 The emergency services – notable practice and lessons identified 126 The role of the military during the response to the Arena attack 184 Operation PLATO 186 The response from Network Rail, Northern and Transport for Greater Manchester 190 Navigating early practical guidance and advice 191 The Manchester focus 193 Community resilience and response 194 Mental health and emotional wellbeing support 195 The Fund and financial assistance 197 Media 198 The Arena 202 The friends and family reception centre 204 VIP visits and involvement 205 Civic leadership 205 Greater Manchester Health and Social Care Partnership 206 Communications 207 Putting families first 208 Contingency planning 208 Chapter 6 – What went well and recommendations 210 Glossary 224 3 – The Kerslake Report kerslakearenareview.co.uk The names of those who lost their lives John Atkinson Alison Howe Courtney Boyle Lisa Lees Philip Tron Nell Jones Kelly Brewster Michelle Kiss Georgina Callander Angelika Klis Olivia Campbell-Hardy Marcin Klis Liam Curry Sorrell Leczkowski Chloe Rutherford Eilidh MacLeod Wendy Fawell Elaine McIver Martyn Hett Saffie-Rose Roussos Megan Hurley Jane Carolyn Tweddle 4 – The Kerslake Report kerslakearenareview.co.uk Executive Summary 1. At just after 22:30hrs on Monday 22nd May 2017, a suicide bomber detonated an improvised device in an area known as the City Room, which is just outside the Arena and which starts a link to Victoria station. For the purpose of this report this City Room will be referred to as the ‘foyer’. Around 14,000 people, mainly teenagers and family, had travelled from across the UK to attend the concert of Ariana Grande, which was just coming to an end. The foyer was busy with exiting concert goers, waiting family members and merchandise sellers. The bomb used was substantial, containing nearly two thousand nuts, and had a devastating impact. 2. The bomb killed twenty-two people including many children. Over one hundred were physically injured and many more suffered psychological and emotional trauma. Paramedics treated many walking wounded in the city centre. Hospitals in Greater Manchester treated people with serious injuries, transported by the Ambulance Service, whilst others made their way to hospitals across the wider region. 3. The Manchester Arena attack was the deadliest in the UK since the London bombings on 7th July 2005. Although the Greater Manchester Resilience Forum had done many planning exercises, the events of 22nd May were something none of those involved had ever encountered before. This was a real-world test of the plans and assumptions. 4. This Review has focused on the response to the attack in the nine days that followed it. There is a lot to be proud of in the response, both for the city-region of Greater Manchester and its emergency services. The benefits of investing in collaborative partnership and emergency planning were demonstrated to the full. We set out in the report and summarise below the highlights of what went well. But we are conscious that we are only touching the surface of hundreds if not thousands of acts of individual bravery and selflessness. 5. As well as celebrating the things that went well however, it is vital that we also learn the lessons of what went less well. This matters for the people of Greater Manchester and beyond who were caught up in the terrible events of that night but 5 – The Kerslake Report kerslakearenareview.co.uk also for other places that might be caught up in such an attack in the future. It is perhaps inevitable that this part of the report will get the most attention in the initial coverage. However, in the Panel’s view, the story of the response is overwhelmingly positive. 6. The Mayor of Greater Manchester has made it clear from the beginning that the experiences of bereaved families, the injured and others directly affected should be at the heart of the process. The Panel was in complete agreement with this view. This focus on those caught up in the attack has been integral to the way that the Review has been conducted and the questions that we have sought to answer. It is inevitable that these individual experiences have not all been the same and we have sought to reflect the different views and perspectives in the way that we have written the report. 7. This Review sits alongside and draws on the numerous single and multi-agency debriefings that have been done by the emergency and other services following the attack. The Review comes ahead of the inquests into the deaths of those who lost their lives as a result of the attack. From the outset, the Panel has been clear that it would not address issues concerning the death of the individuals deceased nor any question of the survivability of the injuries sustained by those who sadly died. 8. In the following paragraphs, we highlight some of the things that went well and the major lessons to be learnt. This is by no means comprehensive; the full recommendations of the report are summarised in Chapter 6. What Went Well 9. First and foremost, the investment in multi-agency planning and exercising as part of the Greater Manchester Resilience Forum resulted in the partner agencies being generally able to act with a high level of confidence. It is notable that there had been a major exercise at the Trafford Centre just months before the attack happened. 10. The actions of the Arena staff, British Transport Police (BTP) and members of the public who stayed to help showed enormous bravery and compassion. Police and 6 – The Kerslake Report kerslakearenareview.co.uk Ambulance personnel were very rapidly on the scene and there followed a remarkably fast deployment of armed officers to secure the area and Ambulance staff to attend to the wounded. 11. At critical points in the evening, key emergency personnel exercised sound judgement in an extremely stressful, chaotic and dangerous environment. Of particular note were the decisions to establish the Casualty Clearing Station on the station concourse and to allow emergency staff and members of the public to remain in the foyer notwithstanding its designation at the time as a ‘hot’ zone. These were vitally important judgements that significantly influenced the course of events over the evening. 12. The civic response of the city-region was by any measure exceptional and demonstrated the enormous strength of the civic leadership and partnership in Greater Manchester. The early press conference by the Leader of Manchester City Council and the Mayor of Greater Manchester, through to the vigil attended by thousands in front of the Town Hall, stands testament to the determination that Greater Manchester would stay open for business. The strength of the civic leadership had a profound impact on how events played out in the subsequent days following the attack. The voluntary, community and faith sector played a vital role in providing support to those affected and in showing solidarity with minority communities who might otherwise have been vulnerable. 13. The Family Liaison Officers and Bereavement Nurses provided a vital source of support and comfort to many of the families which went well beyond their formal roles. The Panel heard many examples of how they had helped individual families deal with the consequences of the attack. This is just one example of the way in which families were put first by the different agencies involved in responding to the attack.