Independent review
The Kerslake Report: An Independent Review into the Preparedness for and Emergency Response to the Manchester Arena Attack on 22nd May 2017
Government response
No government response is recorded for this review.
About this review
Summary written by this siteIndependent review of the emergency response to the Manchester Arena bombing. Found significant failings in inter-agency coordination, communication, and the declaration of a major incident.
Recommendations 50
Recommendation 1
Greater Manchester Resilience Forum members should investigate ways to increase their own personnel’s understandings of their partner agencies’ procedures and operational priorities during the first 30 minutes to one hour of a major incident
Recommendation 2
The future role of the Mayor of Greater Manchester in emergencies should be clarified and included in the Greater Manchester Resilience Forum’s plans, training and exercises
Recommendation 3
Greater Manchester Resilience Forum members should develop contingencies to enable METHANE messages to be shared directly between partner agencies’ control rooms immediately upon receipt of a message from the incident scene
Recommendation 4
Greater Manchester Resilience Forum members should adopt the common understanding of specific terms and phrases which impact on multi-agency working that is defined within the Lexicon of UK Civil Protection Terminology (e.g. rendezvous point, forward command point, holding area)
Recommendation 5
Greater Manchester Resilience Forum members should clarify their joint operating procedures in relation to the declaration of multi-agency forward control points, rendezvous points and marshalling arrangements during terrorist incidents and suspected terrorist incidents
Recommendation 6
Greater Manchester Resilience Forum’s Mass Fatalities Plan should incorporate clear roles, expectations and activation protocols for specialist staff such as Bereavement Nurses and counsellors to ensure the added benefits of their deployment would be realised in future incidents
Recommendation 7
Agencies across Greater Manchester should be minded to explore the use of encrypted social media in improving their internal emergency activation arrangements, together with their internal communication systems for updating staff during an emergency
Recommendation 8
All Fire and Rescue Services utilising North West Fire Control as their call management and resolution service should review their service level agreements and build resilient contingencies and capabilities within North West Fire Control to enhance the development of multi-agency shared situational awareness, which can most effectively inform their Fire Service command, control and coordination during no-notice major incidents
Recommendation 9
Greater Manchester Fire and Rescue Service and North West Fire Control should revise their policies and procedures (including action plans) for Bomb, Explosion and Marauding Terrorist Firearms Attack to ensure that greater emphasis is placed on multi-agency co-location, communication and coordination
Recommendation 10
Greater Manchester Fire and Rescue Service should review the procedures, protocols and expectations that underpin communications links between its Inter-Agency Liaison Officers, the GMP Force Duty Officer and other partners’ control rooms and critical response assets (e.g. Hazardous Area Response Teams)
Recommendation 11
Whilst the Panel acknowledges that Greater Manchester Fire and Rescue Service and North West Fire Control have made alterations to the role of the National Inter-Agency Liaison Officer and Pre-Determined Attendance (PDA) protocols for terrorist-related and suspected terrorist-related incidents these organisations should test and further review these protocols to ensure they will be effective and always allocate a ‘command structure’ to the incident and a National Inter-Agency Liaison Officer to act as Tactical Advisor to the incident commander
Recommendation 12
The Chief Fire Officers’ Association, National Fire Chiefs’ Council and Greater Manchester Fire and Rescue Service should revise all policies, procedures and training for National Inter-Agency Liaison Officers and Incident Commanders to ensure that greater emphasis is placed on embedding multi-agency co-location, communication and coordination during major incidents into their standard operating procedures
Recommendation 13
Greater Manchester Police, as lead responder during terrorist incidents and on behalf of the Greater Manchester Resilience Forum, should review the procedures and protocols underpinning the expectations placed on direct communications links between the Greater Manchester Police Force Duty Officer and other partners’ control rooms and critical response assets (e.g. Inter-Agency Liaison Officers)
Recommendation 14
Greater Manchester Police, as lead responder during terrorist incidents and on behalf of the Greater Manchester Resilience Forum, should review the technical capability and capacity of communications links between the Greater Manchester Police Force Duty Officer and other partners’ control rooms and critical response assets (e.g. Inter-Agency Liaison Officers)
Recommendation 15
Greater Manchester Police should initiate a robust testing procedure to ensure the on-going suitability and resilience of its multi-agency emergency call-out procedures to ensure all relevant agencies receive timely notification of and activation in an incident
Recommendation 16
Greater Manchester Police should develop sufficient senior-officer capacity and capability to ensure that single officers are not required to manage multiple strategic roles simultaneously during major incidents
Recommendation 17
Greater Manchester Police should review its Force Duty Officer protocols to identify ways to reduce the task load placed on the Force Duty Officer during major incidents
Recommendation 18
Greater Manchester Police should continue with its plans to relocate the Force Duty Officer into the Greater Manchester Police Headquarters building
Recommendation 19
In order to safeguard the future integrity of the National Mutual Aid Telephony system, the Home Office should urgently secure appropriate guarantees from Vodafone that the necessary fall-back and disaster recovery arrangements are in place to address the failures which occurred on 22nd / 23rd May 2017
Recommendation 20
Operation PLATO should be reviewed and modified as deemed necessary to inform the response to any form of terrorist attack and be referred to as the Joint Operating Principles for Responding to a Terrorist Attack, regardless of whether firearms are thought to be involved
Recommendation 21
The Ministry of Defence should review its procedures for authorising Military Assistance to Civil Authorities requests, for operations which will foreseeably require unvarying resources to be in place for durations beyond 24 hours
Recommendation 22
The response to the Arena attack provided an extraordinary validation of the on-going work within the UK civil protection sector to embed the JESIP Interoperability Framework into practice. Where responders were able rapidly to co-locate, communicate and coordinate their activities, situational awareness was usefully shared, risks were jointly assessed, and pragmatic solutions were developed to mitigate severe, time-critical, challenges. Where unforeseen limitations in guidance, protocol and circumstance collided to block such close collaboration, the response of the organisation affected was paralysed for a crucial period. Accordingly, it is the Panel’s belief that the findings of the Review should provide a critical stimulus for responders nationally to reassess all plans and protocols that include assumptions of interoperability during major incidents; for the response to the Arena attack provides undeniable evidence that such assumptions need to be vigorously tested
Recommendation 23
A national review of the possibility of accrediting charities to deliver effective services in the response to an emergency should be undertaken, avoiding the accreditation process becoming too burdensome for the charities concerned but including a requirement to plan with Local Resilience Fora ahead of emergencies
Recommendation 24
The work being undertaken by the Home Office Victims of Terrorism Unit to identify and consolidate pathways of support to those affected by terrorist attacks draws on the experiences from Manchester in informing their work, and includes producing clear guidance and practical advice. This advice should be made available by the Home Office for victims of terrorism and be widely publicised
Recommendation 25
Consideration should be given by the Home Secretary as to what support could be made available nationally through statutory funding for those affected directly by a terrorist attack
Recommendation 26
Based on good practice reported to the Panel, consideration should be given for a national tribute sites protocol to be developed and incorporated as part of emergency plans
Recommendation 27
Potential Strategic Coordinating Group Chairs should pursue a clear objective to undertake a Strategic Coordinating Group update briefing (physically or virtually) within two hours of the declaration of a major incident
Recommendation 28
The Transport Cell is a critically important component of the Greater Manchester Resilience Forum’s plan. It provides critical business continuity and recovery support and should be adopted as national good practice
Recommendation 29
All Local Resilience Fora should review their planning assumptions and expectations in relation to multi-agency communications during major incidents. Emphasis should be placed on identifying potential single points of failure in communication networks (i.e. technological and command) and building in resilience and/or alternative contingencies to avoid such failures
Recommendation 30
The concept of Suitably Qualified Experienced and Empowered Personnel should be integrated into the doctrine, language and training regimes of all Local Resilience Fora
Recommendation 31
Operators of all key/iconic sites should be actively encouraged and enabled to participate in Local Resilience Forum planning, training and exercising
Recommendation 32
The benefits accrued by the long-term investment in local authority and police neighbourhood and community engagement teams should be preserved where possible by consistent partnership resourcing
Recommendation 33
Public Health England’s guidance on vaccination as a result of blood-borne virus risks in similar incidents should be recirculated nationally
Recommendation 34
NHS participants in the Review told the Panel that some colleagues were not aware previously of their role in the collection and preservation of forensic evidence. It is the Panel's supposition that this partial awareness will be similar across the United Kingdom and the Panel recommends that this should be addressed
Recommendation 35
The Panel heard from NHS and Greater Manchester Police (GMP) personnel about the significant contribution from the military: their positive willingness to share both specialist expertise and equipment was valuable and important in, for example, treating the injured and conducting post-mortem examinations. This approach should be considered for replication in other events
Recommendation 36
The Government should increase its support for public first-aid training programmes (including those for children and young people)
Recommendation 37
All major transport hubs and public venues should possess and provide immediate access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks or other high-threat or dynamic-hazard incidents
Recommendation 38
All emergency services should consider developing a capability to give their staff rapid access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks or other high-threat or dynamic-hazard incidents
Recommendation 39
Emergency plans for major incidents should incorporate comprehensive contingencies for the provision of mental health support to adults, children and young people, families and responders
Recommendation 40
Whilst having regard to the integrity of the formal identification of the deceased victims in mass fatality incidents, those involved in the Disaster Victim Identification process should continue to take every opportunity to share emerging information with families which would indicate that their loved one is more likely than not to be amongst those who have died
Recommendation 41
The National Police Chiefs’ Council and the College of Policing should explore the production of an appropriate written document to be provided to bereaved families in mass fatality incidents, explaining the Disaster Victim Identification process and the amount of time needed to secure an accurate identification in every case
Recommendation 42
Greater Manchester Police’s practice of extending the deployment of Family Liaison Officers to those who were severely injured should be considered for adoption by other Police Forces, if such an arrangement is not already in place
Recommendation 43
In order to achieve consistency in the service provided, where Family Liaison Officers from different police forces have been allocated to families directly affected by a mass fatality incident, they must all operate strictly in accordance with the strategy and associated procedures specified by the lead Family Liaison Coordinator
Recommendation 44
In the immediate aftermath of a mass fatalities incident, police forces should consider how they might establish effective arrangements for the collection, collation and retrieval of potential casualty data, during the inevitable period between the event occurring and the Casualty Bureau being fully operational. These arrangements should be made public at the earliest opportunity so that those wishing to report their concerns have absolute clarity about how to do so. The recent establishment of the Public Portal facility for the casualty bureau will help to address this issue in the aftermath of a mass fatalities incident
Recommendation 45
The Home Office and National Police Chiefs’ Council (NPCC) should actively review and enhance the interoperability of Automatic Resource Location Systems between force areas, with precedence being given to improving the nationwide geo-location of Operational Firearms and Counter Terrorism assets
Recommendation 46
Standardised contingencies should be developed by all councils to enable an official fund to be established urgently following any future incident that attracts financial donations from the public, as was done in Manchester, to avoid misappropriation of donations and to ensure fair distribution of funds
Recommendation 47
The Independent Press Standards Organisation (IPSO) should review the operation of its code in the light of the experiences described by contributors to the Review and consider developing a new code specifically to cover such events
Recommendation 48
The National Police Chiefs’ Council and the College of Policing should review the nationally accredited training programme provided to Family Liaison Officers to explore the opportunities for enhancing their skills in handling media contact with families, without compromising their core role. The potential for collaborative working with the Independent Press Standards Organisation (IPSO) should be considered as part of this review
Recommendation 49
Statutory Responders should engage with local trusted press and broadcasters as key participants in planning and rehearsing responses to major incidents to anticipate and test out ways in which families and victims can be best protected from inappropriate press approaches, whilst recognising the legitimate desire of journalists to report on the human impact of such events
Recommendation 50
First response agencies and local authorities should review the resources available to their Press Offices in response to a major incident and consider whether adequate arrangements are in place to flex capacity quickly if further support is needed to deal with the demands of the media. This could be done by mobilising mutual aid from other Police Forces and partner organisations, including academic institutions with particular experience of social network messaging and communication. Consideration should also be given to allocating sufficient dedicated press handlers at key sites such as hospitals and the centre established at the Etihad Stadium
All text above is the review's.
No recommendations have this response.