Eleven senior officers went to Greater Manchester Police's headquarters in the immediate aftermath of the Manchester Arena bombing, but it 'didn't occur to anyone' there to send one to the scene to 'get a grip of the situation', an expert told the public inquiry into the atrocity.
The inquiry heard on Thursday experts have identified 'significant' command failures on the part of British Transport Police on the night, although they said frontline officers showed 'exemplary' conduct after the explosion.
Inspector Michael Smith, GMP's 'bronze' commander at the scene, was in the City Room blast zone 17 minutes after the bomb detonated at 10.31pm.
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Giving evidence in May, he said he believed the area was safe to operate in and he 'persistently' asked for ambulance staff to attend.
Mark Dexter, then a GMP Chief Inspector, 'self-deployed' and assumed the role of ground-assigned tactical firearms commander.
Both officers were praised by three policing experts appointed by the inquiry to compile independent report.
They said Insp Smith 'did very well under the circumstances', but needed further support with issues outside the City Room and Chief Insp Dexter - now a Superintendent - stepped into a 'command void' to the benefit of the response and worked 'extremely hard to ensure an effective response that night'.
But the inquiry heard that Supt Arif Nawaz, the force's 'silver' commander, went to force HQ and not to the scene, as opposed to official guidance.
It was his job to get a 'tactical grip on the situation, and he 'failed to do so', said former senior Metropolitan Police detective and counter-terrorism commander Scott Wilson, one of the three experts.
On Supt Nawaz's deployment to force HQ, Mr Wilson said he 'doesn't feel that was the correct thing at all'.
"He should have taken himself to that scene and took tactical command," he said.
"Nothing happened in that control room by 11.47pm. He'd been notified very quickly, within the first 10 minutes...but if he had got to that scene by 11pm, he could have made a huge difference. By going to the scene he would have set up a rendezvous point [for the emergency services].
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"He would have been the person at the scene who gets a grip of the situation, and that's what we didn't really have.
"You just needed someone of rank there to get a grip of the situation."
By 11.15pm, Mr Wilson said then Assistant Chief Constable Debbie Ford, GMP's gold commander on the night, knew she had a 'Chief Constable, a Deputy Chief Constable, two Assistant Chief Constables, two Chief Superintendents and at least five Superintendents all heading to headquarters'.
"But it didn't occur to anyone to send one of them to the scene to get a grip of the situation," he said before going on to call it 'staggering'.
"That was going to be 11 senior officers all going into a headquarters unit and yet at the scene, we have got Inspector Smith in the City Room having to cope himself and Chief Inspector Dexter...trying to cope with the risk part and all the consequence management, yet you have 11 senior officers sitting at headquarters.
"That cannot be acceptable."
Paul Greaney QC, counsel for the inquiry, said Mrs Ford has previously told the inquiry that up to 11.47pm, more than an hour after the explosion, nothing that happened in 'silver or gold command' made 'any difference on the ground'.
Richard Horwell QC, for GMP, said there was nothing in any national guidance requiring a 'silver commander' to go to a scene.
He said Mrs Ford was 'rightly' worried about further attacks and was 'doing her best to look after the safety of Manchester'.
The QC went on to suggest the 'whole point of getting everyone to force HQ' and setting up silver and gold control rooms was because they 'didn't know what was around the corner'.
"They didn't know what was to happen... get silver and gold command set up as best as she was able to meet that threat if it arose," he added.
Mr Wilson accepted Mrs Ford didn't know there was no continuing threat, but said he found it 'quite staggering' that 11 senior officers went to HQ, leaving the two at the scene.
"I just find it quite staggering from an experience point of view," he said.
"I find it staggering that you had all that command at HQ yet no one thought one of those five or six Superintendents...and it should have been Supt Nawaz. He's on duty, he could have been there in 10 minutes. I cannot understand it."
The inquiry heard key messages from the scene were not shared with the other emergency services by British Transport Police.
There was no effective communication between the force and the other services, Mr Greaney added - which the experts called a 'significant failure'.
Mr Greaney said the experts also found 'significant failures of BTP command on the night, particularly at bronze and silver level'.
But expert Ian Dickinson said: "The officers on the ground conducted themselves in such a way that they supported the needs of the injured and the survivors, but that was in spite of operational tactical command rather than being enabled by it."
The suicide bombing by terrorist Salman Abedi on May 22, 2017, claimed 22 lives and left 940 others hurt.
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