Families of those who died in the Manchester Arena terror attack today called on the government and police to act to ensure lessons are learned after the long-running public inquiry into the atrocity came to a close.
The three-year £32m independent inquiry came to a close today (Wednesday) after three days of hearings to establish if a series of bodies - including Greater Manchester Police and government departments - had acted on a series of 'monitored recommendations' made by chairman Sir John Saunders, who had found a series of catastrophic failings by the emergency and security services.
Sir John said some organisations had been 'somewhat slow' to act and he urged the Home Secretary to ensure public scrutiny of the implementation of his recommendations continues to be done, potentially by the home affairs select committee of Parliament.
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He expressed frustration that the Department of Health and Social Care appears to have blocked efforts by the Care Quality Commission (CQC) to ensure the 'unregulated' healthcare provided at large events such as pop concerts and music festivals comes within its powers. The inquiry heard thousands of people are 'exposed to danger' because the sector was not regulated.
After the public inquiry came to a close, families expressed anger at an apparent reluctance by the government to act, particularly as the CQC has told the inquiry the sector had been responsible for 'unsafe care, abuse and deaths'.
They also took fire at GMP, which the inquiry has heard, although it had accepted the vast majority of Sir John's recommendations, was still not providing 'bleed control training' so cops who are first on the scene of an incident have the skills to use tourniquets to stem catastrophic bleeding.
GMP have said in response that one of the changes the force has made since the Arena attack is that: "All frontline officers attend a two-day training course, which includes training in relation to major bleeds and the use of tourniquet."
As the inquiry drew to a close, Pete Weatherby KC, who represents one group of families, told the chairman: "Nothing that has been or could be said in this process can reverse the catastrophic loss to the families by the Arena outrage. However, this inquiry process has been vital to them."
The barrister said it had been important for establishing facts, accountability and ensuring change. He noted, however, that there had been 'dismay' among the families that some of the recommendations weren't being acted on.
Sir John Saunders told the families the inquiry team was not 'congratulating [themselves]' as this could only be possible if 'lasting change' was achieved. "Nothing will be worse than the same thing happening all over again despite the considerable efforts of everybody concerned to actually make a difference," he said.
Sir John said 'on the whole', organisations called to answer questions about his monitored recommendations had implemented them or had taken steps towards implementing them, although some had been 'somewhat slow'.
He went on that it was important that public scrutiny should continue so the lessons learned during the inquiry aren't allowed to 'drift into the background'.
"It's essential that lessons are learned and the same mistakes are not made again. It's much more likely those mistakes will not be made again if the monitoring process continues," he said, adding that it would be for the Home Secretary to decide how that is achieved in the future.
The inquiry ended with counsel to the inquiry Paul Greaney KC reading out the names of the 22 innocents who died in the atrocity. Some families hugged each other and wept as this happened.
A minute of silence followed.
After the hearing, Kim Harrison - who represents the largest group of families at Slater and Gorton solicitors - expressed anger at the apparent reluctance of some organisations to embrace change.
Flanked by Figen Murray, whose son Martyn Hett died in the bombing, as well as relations of Kelly Brewster and Liam Curry who also died in the attack, Ms Harrison told members of the press: "Our families have been present in court every day of the inquiry and listened to failing after failing from all involved on that terrible night of 22 May 2017. We welcome each and every recommendation made by Sir John to try and make our country a safer place and to prevent more families finding themselves in our horrific position in the future.
"We were present this week with the hope that our government and emergency services will have at least begun to change and implement these recommendations, sadly that has not been the case for so many of them. Some, like [the fire service] have embraced the recommendations and have moved swiftly to ensure that all have been implemented. In fact, they have gone beyond the recommendations in some situations and we thank them for that.
"However, other blue light services, and indeed our government, have yet to show enough improvement, phrases like ‘we aspire to’ just aren’t good enough. Actions need to be taken so that when this happens again there is a very different outcome and other families won’t have to go through the heartbreak we have. Some of the recommendations made, such as the gap in bleed control training for first responders was clear following 22 May 2017 and we are astounded to hear that six years on this is still not fully embedded within the police and call for this to happen without any further delay."
She said the families were 'absolutely devastated' that no further hearing had set up to continue to monitor how effectively the inquiry's recommendations are being implemented and they had 'little faith that changes will be followed through'.
GMP has since told the M.E.N. that "all frontline officers attend a two-day training course, which includes training in relation to major bleeds and the use of tourniquet."
The families had found the morning's evidence 'absolutely heartbreaking' listening to alleged 'excuses' from the Department of Health and Social Care six years after their lives had been 'ripped apart'.
"Our plea to the government now is - 'please don't forget us and our loved one's names, but do the right thing in their memory'," added Ms Harrison.
Yesterday (Tuesday, June 8), Joyce Frederick, CQC director of policy and strategy, revealed at the inquiry it had been lobbying the Department of Health and Social Care to bring the 'unregulated' healthcare at large events sector under its sphere, to enable it to take action against poor providers. It was the CQC's 'number one priority'.
Today Emma Reed, Department of Health and Social Care director for the Emergency Preparedness and Health Protection Directorate, was grilled at the inquiry about why the department appeared to have blocked the move.
Pressed by counsel to the inquiry Paul Greaney KC, Ms Reed conceded the sector was indeed unregulated and that this would be reviewed. She said the department recognised that 'no adequate standards were in place'.
Asked by inquiry chairman Sir John Saunders whether it needed to be regulated, Ms Reed said she recognised the 'need for clear standards across the sector', but went on that 'further work' was required to establish if regulation was appropriate.
Sir John said he believed it 'ought to have been done already' and it was a 'long time in coming'.
Ms Reed pointed out work with CQC had to be paused because of the pandemic but was being resumed. A 'post implementation report' was 'imminent' after which the department could make a decision, she said.
Ms Reed agreed with Mr Greaney that the healthcare at events sector was unregulated and also that this gave rise to a 'risk of injury and death'. It 'cried out' for regulation, said the KC.
The witness said that work still had to be done to decide 'which is the right mechanism' to regulate the sector. "It's not only important to establish if regulation is required but how to achieve this," said Ms Reed, who went on it was important to establish if regulation was 'the right route'.
Pressing the witness further, Mr Greaney said: "If there's a state of affairs where thousands of people are going to venues for events and they are at risk of injury and death as a result of a lack of regulation, there needs to be some sort of regulation."
Ms Reed said: "That's absolutely going to be the question we are going to answer."
The response prompted exasperation from families inside the inquiry room.
The damning second report of inquiry chairman Sir John Saunders heaped criticism on Arena operator SMG and its contracted medical services provider at the time, Emergency Training UK (ETUK). He said their relationship didn't operate as it should have, adding: "In relation to healthcare, inadequate consideration was given to the welfare of the event-goers."
Ten years before the 2017 blast, which killed 22 people after an Ariana Grande concert, Arena operators SMG contracted out medical and first aid services on concert nights to ETUK. It has now been replaced by another provider, Medicare.
The first of three inquiry reports, published in June 2021 by inquiry chairman Sir John Saunders, found 'serious shortcomings' by the venue's owners SMG, their security contractor Showsec and British Transport Police (BTP). Sir John ruled the terrorist should have been identified that night and, had he been, 'the loss of life and injury is highly likely to have been less', a conclusion that angered families of those who died.
Sir John's second report ruled one of those who died, John Atkinson, could have survived if the emergency services response had been better. It also highlighted a series of failures by the emergency services on the night of the attack. Mr Atkinson wasn’t tended to by any paramedics in the foyer where the bomb went off and his early care was left to former pizza shop boss Ronald Blake, who held a makeshift tourniquet fashioned from his wife's belt and folded t-shirts for almost hour.
Partly because of austerity cuts, Greater Manchester Police failed to keep up-to-date plans in place for major incidents and then, when a key training exercise revealed a key command position would become overwhelmed in the event of a real attack, they failed to learn lessons, Sir John's highly-critical report said.
Because of previous training exercises and experience of major incidents, GMP 'knew' its force duty officer - a key hub who is supposed to communicate with the other blue light services - would become overwhelmed during a terror attack. The failure of the FDO on the night of the 2017 attack, Insp Dale Sexton, to communicate with other blue light agencies 'played a major part in the total failure of joint working that night', said Sir John.
His report on the role of the security services published in March this year that said they had missed opportunities to stop the attack, prompting MI5 to apologise.
A Department of Health and Social Care spokesperson said: “We recognise the importance of regulation and enforcement of healthcare services standards at events.
“The statutory post implementation review is being finalised. Once published that will enable the review of the CQC regulations to start which will include the proposal to remove exemptions for medical treatment for temporary events”
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