The chairman of a damning report into failings around the Manchester Arena atrocity has praised the heroism of members of the public and individual officers but he insisted: “Many things did go badly wrong.”
As he published a highly critical report which detailed the failings of the emergency services, Sir John Saunders conducted a minute of silence to remember the 22. He said: “We have started with a minute’s silence to remind ourselves, if we needed reminding, that 22 special and much-loved individuals died as a result of the murderous attack by Salman Abedi on 22 nd May 2017.”
His ‘Volume 2’ report blasted a series of failings by the emergency services, concluding one of the 22 who died could have survived with better, more prompt treatment.
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He went on: “Volume 2 of my Report includes a summary of the tributes which we heard at the beginning of the Inquiry for each of those who died. The summary doesn’t do justice to that very moving evidence but I hope it does, to some extent, capture the individual qualities of each of them.
“The majority of Volume 2 of my Report deals with what happened after the explosion during the rescue operation carried out by the emergency services. In the course of the evidence of what happened after the explosion I saw CCTV evidence and video from body-worn cameras of the City Room. That showed clearly the appalling aftermath of the explosion.
“It showed those who had died within seconds of the explosion, it showed victims with appalling injuries. I have considered post mortem evidence and expert evidence which confirmed that those who died did so as a result of injuries caused by a bomb exploding.
“There can be no question on the evidence that those who died, died as a result of the actions of Salman Abedi which caused the severe injuries suffered by many people who attended the concert or were waiting to collect children who had attended.
“Those who have listened to the evidence will not be surprised that I am highly critical of many aspects of the rescue operation. Those criticisms must not overshadow our admiration for the courage of those who went into the City Room without any hesitation to help the dying and the injured. There were members of the public, people working at the Arena on 22 nd May, British Transport Police officers, Greater Manchester Police officers, travel safe officers and paramedics who went into the City Room to help others without regard for their own safety. While their courage should be recognised by me, what is most important at this time is that I identify what went wrong and recommend changes to ensure that the same mistakes are not made again. That is what has guided my approach throughout this Inquiry.
“During the evidence the suggestion was made that the Greater Manchester Fire and Rescue Service in particular and NWAS to a lesser extent were risk averse. While there is a case for saying that some of the decisions made by some commanders were unduly cautious because of concerns they felt about the risks inherent in responding to any major emergency, there was no evidence that individual fire fighters or members of the ambulance service were other than ready and willing to carry out their job of protecting life.
“The evidence of the firefighters was that on the night of the attack they were angry that they had not been in the City Room helping to rescue the injured. I did not find there was evidence to support any suggestion that the commanders making the decisions were risk averse for their own safety. It is one thing to take a risk on your own behalf, it is another to send people under your control into a situation where they might be injured.
“Having said that, many things did go badly wrong and it has been the job of this Inquiry to identify them; work out if possible why they went wrong and make recommendations to try and ensure that they don’t happen again.
“The criticisms that I have made are principally directed at 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.
“I have also criticised some individuals for decisions that they took on the night.Some may think that to criticise individuals who were faced with an extremely difficult situation is harsh but we rely on people in command positions to make the right decisions when faced with a complex emergency. None of them intended to make the wrong decision. Some had not had sufficient instruction or training and others were doing their best to balance the need to help those who were injured with ensuring that people under their command were not put in a position which carried excessive risk.
“It has been my job to identify when and how things went wrong so when incorrect decisions have been made, however understandable, I have had to identify them. I have not looked for scapegoats and everyone who I have criticised has had the opportunity to respond to those criticisms and I have taken their observations into account in my Report to the extent that I accepted them.
“Many of the things that went wrong on 2nd May have gone wrong before either in genuine emergencies or in exercises designed to test out the emergency services’ procedures.
“The best example of this is the failure of JESIP, the Joint Emergency Services Interoperability Programme, on the night of the 22nd May. JESIP was introduced in response to the recommendations of Lady Hallett after the inquests she held into the deaths caused by the 7/7 bombings. It is not an overstatement to say that JESIP almost completely failed on the night of the Arena Attack. JESIP is designed to ensure that any rescue attempt involving more than one of the emergency services is co-ordinated so that all follow the same plan and share information so that well informed decisions can be taken.
“Had JESIP worked on 22 nd May, things could and should have been very different. There would have been a joint assessment of risk taken by all the emergency services and the result of that should have been that there would have been more paramedics in the City Room using their skills to triage and, where necessary, using their life saving skills to assist those who couldn’t wait to be removed from the City Room before they received treatment. Firefighters would have arrived on the scene to use their considerable skills to ensure an organised and safe removal of the injured to the station entrance where they could receive assessment and treatment pending a rapid transfer to hospital.
“Instead, we heard heart breaking evidence of the injured and the rescuers who were in the City Room hearing the sirens of ambulances; knowing paramedics were close by; expecting their imminent arrival only for them not to arrive in the sort of numbers which were needed. Had firefighters got to the City Room as soon as they could have done, they would have removed the injured using proper equipment which would have been safe and quick. Instead, the injured had to be removed on railings and pieces of cardboard which were uncomfortable, unsafe, painful and inevitably this meant that it took longer for each patient to be removed.
“This is not the first time that JESIP has failed both in real emergencies and in exercises. With the help of Core Participants I have set out a number of recommendations to try and ensure that it works in the future.
“Those are only some of a large number of recommendations which I hope will be accepted but more importantly actioned by those who are in a position to make the necessary changes.
“One of the other areas covered in the report is the care gap; that is the inevitable gap between an event, such as this bombing, happening and the arrival of people trained to give expert medical help. To try to reduce that gap what we need to ensure is that there are suitable people on site at places such as the Arena who are able to give emergency lifesaving assistance which may result in people surviving who otherwise would not if they had to wait for the arrival of medical professionals.
“This could be included as part of the Protect Duty but we will need to see what the government proposes. Can I repeat my encouragement to the Government to consider bringing in legislation imposing a Protect Duty on companies that operate large places of entertainment who cater for large audiences like the Arena as soon as possible rather than trying to include that as part of a comprehensive Protect Duty? I am not to be understood to be discouraging a Protect Duty for smaller venues, which I support. I can see no reason why the duty for larger venues should not be completed quickly.
“As I think has been accepted, police officers, firefighters and those who are likely to be first on the scene should also have those necessary lifesaving skills. Finally, but not least important, members of the public who are unlucky enough to find themselves at the aftermath of a disaster and choose to remain and help should have the opportunity to get training to enable them to do something which may save a life. Members of the public made an enormous contribution on the night of the 22 nd but it would have been even greater if they had all had the training to deal with the sort of injuries that they were faced with.
“I have made recommendations on all these topics although implementation in some cases may already be taking place. We also heard evidence about the different systems used in other countries to try and ensure the best possible chance of saving lives.
“Some of those countries use different procedures to try and ensure that the best possible medical assistance is got to the injured quickly and they are removed to hospital as soon as possible. It may not be possible to replicate those systems in this country but we should consider radical alternatives to ensure the best possible outcomes. I have made recommendations designed to ensure that these alternatives are considered and that everything that can reasonably be done to fill the care gap is done.
“We had a hearing quite a long time ago about the steps that I needed to take in order to monitor my recommendations, as I am determined to do. Having carefully considered those submissions we have been in discussion with the Home Office to decide on the best way to achieve this. I believe that in principle it is accepted that there is a strong argument for some of the recommendations to be monitored Agreement has not yet been reached as to the best mechanism for achieving this. I have had a meeting with the Home Secretary to try and bring this matter to a speedy conclusion and that will be followed up by a further meeting.
“I believe that I have reached the correct conclusions about what went wrong. I have had the assistance of many very clever and hardworking people to all of whom I am grateful. I also hope that this inquiry will make a difference and that things that went wrong on 22nd May will never be repeated. This is a hope which is shared by the Home Secretary and I hope that we can work together to achieve that aim. I am confident that all the rescue services are also determined that this should happen.”
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