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"A litany of failure" - Nick Aldworth on the Manchester Arena inquiry report

"Enough is enough.... Saffie's life is not a practice exercise…. if we're still learning lessons on terrorism in 2020, nothing will ever change"



These were the words of Andrew Roussos at the start of the Manchester Arena Inquiry in September 2020. Andrew is the father of the Manchester Arena attack’s youngest victim, Saffie-Rose. She was 8 years old when she died.


Last week, Andrew and his family learned that there was a ‘remote’ chance that Saffie might have survived if she had received specialist trauma care earlier. I’ve met Andrew and his family and we remain in touch; I know how strongly he believes that Saffie was a fighter and could have survived. I can only imagine how painful, and enduring, carrying that thought will be.


I don’t know John Atkinson’s family, but the inquiry also found, with greater certainty, that his were survivable injuries with earlier intervention. When you read the detail of his treatment, or lack of it, in The City Room (where the attack happened) and beyond, a lay person is likely to be deeply concerned about how this man came to die.

What Went Wrong


At a thousand pages long, I’m not sure I even know where to start commenting on this report. It’s taken me the better part of three days to read it, and even then I’ve had to skip through some parts. It will need to be read again and again to fully comprehend its totality.


Every page is a litany of failure, across all three emergency services, their leadership, their processes, and their absorption of learning. In the middle of it, there are failures by individuals to be bold, to be inquisitive and, frankly, to apply even a modicum of common sense. There are some who have excelled, been brave and made positive contributions but, as individuals, were not going to change the outcome.


Saffie and John didn’t get the help they deserved because they found themselves in the middle of an emergency services response full of catastrophic failures of well-established processes and command structures. At some points, I can’t even see the most basic of Gold, Silver and Bronze (GSB) command structures being implemented in a way that provides coherence and compatibility.


Everybody seems to have forgotten the first principle of the Joint Emergency Services Interoperability Procedures (JESIP), colocation, and throughout my read of the document I found my inner-self screaming to everybody, ‘for the love of God, just get some people to a forward control point’.


I’m genuinely shocked at the failure to implement even the most basic principles of incident management, the most basic communication practices, and an abject lack of competence among some. Some of the individual failures are so profound, they are close to being malfeasance. This wasn’t failure of resolving a terrorist incident, this was a failure of core policing. I’m not qualified to comment on what core competence looks like in the ambulance or fire services, but as a casual observer, it’s hard to see leadership and processes that would match my expectation.


Sir John Saunders, chairman of the inquiry and author of the report, has been more compassionate than me by saying that he recognises that people he has named found themselves in the most awful and extreme of circumstances but qualifies this by saying that taking on such responsibilities should come with a requirement to be able to execute them effectively. He is correct and repeatedly highlights that some of those individuals were let down through lack of training.


He is of course right. The seeds of failure were not sown on the night, they had been germinating for years and are systemic across policing. They are fertilised by the inadequate implementation of learning, promotion processes that rely on story telling not competence, and budget. The fact that a significant number of recommendations have been referred to national bodies such as the College of Policing, CTPHQ and the Home Office is indicative of this being systemic national failure.


After the report was published, I received an email from a renowned journalist that said, “My biggest worry is that Manchester may well have improved things, but I bet many others haven’t”. Looking at how basic many of these failings were, I sense that their concern is valid.


Copyright: Counter Terror Business

Read the full article here


Nick Aldworth will present a Protect Duty Update at our 'Safer Streets - Protect & Deter 2023' event next April. More here

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