Manchester Arena Inquiry: Lessons for Everyone?

Volume 2 of the Report of the Public Inquiry into the Attack on Manchester Arena on 22nd May 2017, focussing on Emergency Response, has been published.  A lengthy tome, with Part 1 coming in at 716 pages, I can only claim to have read the first half of the first volume, but it proves stark and fascinating reading. 

Cover of Manchester Arena Inquiry Report

I don’t intend to summarise the findings of the Manchester Arena Inquiry report here; they have been widely covered in the media.  Instead, I am going to highlight a number of lessons that a pertinent for those involved in crisis management response for all organisations.  This series of blogs will highlight some of the key points that I have identified; I will write more when I have read some more!

Joint Emergency Services Interoperability Principles (JESIP)

The report makes frequent references to (JESIP), and highlights five principles for joint working:

  • co-location;
  • communication;
  • co-ordination;
  • joint understanding of risk; and
  • shared situational awareness.

These would seem to be to be good principles for any form of crisis or incident response, and I will blog about these in the future (I may even write a paper!)

Golden Hour

The report highlights the importance of the ‘Golden Hour’; the first hour of the response, highlighting the need for leaders to ‘gather information and decide what needs to be done, putting in place structures that bring order to the inevitable chaos as quickly as possible.’

If a Crisis Management Team is able to quickly and effectively decide what needs to be done, and to get the right structures in place for command and control, then this will ease decision-making and the on-going response and recovery.


It is clear from the report that there was confusion between the responding agencies.  However, the report does quote one particular example of good practice, stating that a Police Officer ‘‘Inspector Smith ‘formed his own plan. He decided that, first, the casualties needed expert treatment and evacuation. That was the priority. Second, once lives had been saved, steps needed to be taken to preserve the area as a crime scene’. 

This demonstrates the need for a simple and clear strategy which will then enable the implementation of sensible plans.

Crisis Management Team Staffing

Most Crisis Management Teams will have identified primary and secondary personnel for the individual roles.  However, flexibility may be required.  As an example, the report highlights the Police Officer who ‘concluded that the role of Bronze Commander needed to be undertaken by someone of seniority. As a result, his focus was not on finding a more junior officer to fulfil the role of Bronze Commander for BTP as quickly as possible. This was an error on his part.’

It may be that, in the event of absence or delay, someone more junior will not be able to fulfil a particular role, but those responsibilities should be delegated to someone that is able to provide the cover rather than leaving the tasks unfulfilled and unmonitored. 

Equally, the report highlights the case of one of the Fire Officers who chose to go to the rendezvous apparently managing the response whilst on the move, stating that the Officer ‘should have remained at home and mobilised another officer who lived closer to go to the scene.’

Again, this has relevance to any organisational crisis management response, particularly in the post-Covid, remote-working world. It is important to consider the location of Incident Management Team members and, if there is a requirement for staff to travel to the location, organisations should consider transferring responsibilities to those who are not on the move to ensure continued communications and control.

Scroll to Top
Scroll to Top