Two victims of the Manchester Arena bombing, including an eight-year-old girl, could have survived were it not for serious failings by the emergency services, a report has found.
The public inquiry into the May 2017 atrocity, which left 22 dead, concluded that the response of the police, ambulance service and fire service was “far below the standard it should have been”.
In an excoriating, 916-page report, the chairman Sir John Saunders said “non-existent” communication between the emergency services in the aftermath of the attack meant dozens of the wounded and dying were deprived of treatment for too long.
Only three paramedics entered the scene in the first hour due to an “unduly cautious” approach taken by an ambulance commander, after police failed to relay that armed officers had concluded the area was likely safe after just 19 minutes.
Setting out the detail of his report, Sir John said in a statement at Manchester Hall: “The criticisms that I have made are principally directed at the organisations and there were significant failings by a number of organisations in preparation and training for an emergency such as this and in their actions on the night of the attack.”
He added that he had been in discussion with the Home Office about how best to implement the report’s recommendations.
The inquiry report found that John Atkinson, 28, and Saffie-Rose Roussos, 8, may have survived if they had been given the appropriate care in time.
Mr Atkinson was six metres from the blast and suffered serious injuries to his legs when the bomb detonated at 10.31pm.
‘Entirely unsatisfactory’
It took 47 minutes for him to be taken out of the City Room – the venue’s foyer – on an advertising hoarding, in what Sir John described as an “entirely unsatisfactory” extraction.
He then remained at a casualty-clearing station outside the adjacent Manchester Victoria station for a further 24 minutes, when he suffered a cardiac arrest.
The report concluded: “John Atkinson would probably have survived had it not been for inadequacies in the emergency response.”
Saffie-Rose, pictured below, was much more gravely injured when the bomb detonated five metres from her. It took 26 minutes for her to be carried out of the City Room on an advertising hoarding and 52 minutes to get her to hospital.
Sir John said there was a “remote possibility that she could have been saved if the rescue operation had been conducted differently”.
The significant delays in treatment were widespread. By midnight there were still 36 casualties waiting outside the station to be taken to hospital.
It was not until 2.50am that the final casualty – a man with two broken legs – left the scene.
‘It must not happen again’
The report said: “To those who experienced it, this period of time will have seemed interminable. It must not happen again.”
Sir John identified 12 main failings in the emergency response, including the delays in getting ambulances and paramedics to the scene and the failure of police to keep the other agencies properly informed.
The actions of Greater Manchester Police’s (GMP) “overburdened” duty officer that night, Dale Sexton, were singled out for particular criticism.
The impact of his failures were said to be “serious and far reaching”.
Mr Sexton declared Operation Plato - the agreed operational response to a suspected marauding firearms attack – at 10.47pm, but failed to tell the other agencies.
The report said this “affected the ability of the emergency services to work together by jointly understanding the risks”.
The officer then failed to properly designate which areas of the scene were safe and which were not. However, it had been secured by firearms officers by 10.50pm and there was no obvious sign of a secondary device, leading the inquiry to conclude it should have been declared safe at that point.
‘Unduly cautious’
This led Daniel Smith, the North West Ambulance Service (NWAS) operational commander, to “make unduly cautious decisions about deployment” of paramedics into the area.
Mr Sexton failed to declare a major incident at the outset, something that was done at 12.57am, “long after such a declaration was capable of making a difference to the emergency response during this critical period”.
Summarising his findings, Sir John said the heroism “shown by very many people that night was striking” and he praised 14 specific members of the public over their actions.
He concluded: “Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been. GMP did not lead the response in accordance with the guidance that it had been given or parts of its own plans.
“Greater Manchester Fire and Rescue Service failed to turn up at the scene at a time when they could provide the greatest assistance. North West Ambulance Service (NWAS) failed to send sufficient paramedics into the City Room.
“NWAS did not use available stretchers to remove casualties in a safe way, and did not communicate their intentions sufficiently to those who were in the City Room.”
Sir John made dozens of detailed recommendations on the improvement of training across the emergency services.
GMP ‘apologise unreservedly’
Stephen Watson, the chief constable of GMP, apologised for the failings highlighted in the report.
He told a press conference after the report’s release: “I accept the findings of the chairman, Sir John Saunders. Beyond the selflessness and professionalism of so many of our front-line staff, it is also clear that our coordination of the response to this atrocity was poor.
“We had failed to plan effectively and the execution of that which was planned was simply not good enough. Our actions were substantially inadequate and feel short of what the public have every right to expect and, for this, I apologise unreservedly.”
He added: “Sadly, GMP’s combined failings were significant. To the families and loved ones of those who died, I am truly sorry.”
The police chief insisted that improvements had already been put in place by GMP, including “the wholesale reform of our force control room”.
He continued: “I am already able to confidently state that GMP is now in a fundamentally stronger position than it was in 2017.”
Darren Mochrie, chief executive of the North West Ambulance Service (NWAS), said: “On occasions like this, the word ‘sorry’ might sound hollow.
“Nevertheless ... we apologise wholeheartedly for our failures. They weigh heavily on us individually and as an organisation.”
Lessons of 7/7 went unheeded
Speaking outside of court, Kim Harrison, a solicitor representing 12 of the victims’ families, said: “So many failures happened on that night, it is impossible to list them all here.
“Almost everything that could go wrong did go wrong. It is totally unacceptable that members of the public were left seriously injured and dying in this way for what seems like an eternity.
“What makes this even worse is that so many of the lessons of today’s report could and should have been learned after the 7/7 bombings in 2005. Twelve years after 7/7, the same things went wrong again, at Manchester Arena.
“The complete and utter failure of the Government and the emergency services to learn those lessons and implement them on a national level is totally unacceptable. This must never happen again.”
Pain ‘too great to put into words’
Nicola Brook, a solicitor from Broudie Jackson Canter who represents the families of five victims, including the family of Saffie-Rose, said: “This damning report reveals what the families knew all along – that all the organisations meant to protect their loved ones failed on an enormous and unfathomable scale.
“To compound the families’ pain, they were then forced to listen to denials, excuses and finger-pointing rather than admissions of the terrible mistakes made. So much distress could have been spared had Greater Manchester Police admitted its glaring failures from the start.
“Saffie’s parents Andrew and Lisa have pushed to get answers about what happened to their beautiful daughter over five and a half incredibly traumatic years. After initially believing the blast had killed Saffie instantly, the pain of that loss was compounded by learning that she had lived for over an hour.
“However, it is testament to their strength that they have taken comfort that the daughter they loved so much fought for life until the end. The family is comforted that the chair has made recommendations to help close the care gap that may have made all the difference to Saffie.”
The family of Mr Atkinson said in a statement: “John was our son, brother, uncle and friend. Everyone who knew him loved being around him. He always put others first. As today’s report says, his working life was spent helping those in care and his kindness and generosity were evident for all to see. He lit up our lives, and there is less laughter in the world without him. Since his passing, our lives have been shattered.
“As we know from witnesses, John kept asking if he was going to die. John must have known that he was dying and the pain that causes us is too great to put into words. This should simply never have been allowed to happen.
“The apology from North West Ambulance Service means nothing unless they act rapidly on this report to ensure that no family ever has to go through this horrific experience again.”
