One of the 22 people killed in the Manchester Arena terror attack could have survived if emergency services responded adequately, an inquiry has found.
Volume II of the Manchester Arena inquiry findings found a catalogue of failures by the emergency services on the night of the terror attack. The inquiry's author ruled one of the 22 who were killed, John Atkinson, 28, could have survived, MEN reports.
Sir John Saunders, chairman of the inquiry said: "It is likely that inadequacies in the emergency response prevented his survival."
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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. Still conscious and speaking, Mr Atkinson was moved on a makeshift stretcher to the "casualty clearing station" on the concourse of Victoria railway station.
He repeatedly told people caring for him: "I'm going to die."
He suffered catastrophic blood loss and went into cardiac arrest moments after he was loaded onto a proper stretcher. John finally left the arena in an ambulance two seconds after midnight - an hour and 29 minutes after detonation.
He died later in hospital despite a blood transfusion and attempts to resuscitate him.
In a statement, John Atkinson's family said in response to the report: "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.
"Today, the inquiry has answered our questions about John’s death. It is now clear beyond any doubt that on the night of the bombing John was totally failed at every stage, both by the private medical providers at the Arena – ETUK and the emergency services.
"It is crystal clear that due to those failings, John died from injuries that he could and should have survived. We want to say thank you again to Ronald Blake for all he did that night. However, the medical tourniquets John needed were not made available and the paramedics who could have saved him should have been at the scene much sooner.
"As the report says, responsibility for these failures lies squarely with ETUK, SMG who commissioned ETUK to provide medical services at the Arena and North West Ambulance Service. Finally, had GMFRS arrived at the scene earlier, as they should have done, they could have used their stretchers to get John out of the City Room much sooner and with much less pain.
"He was left, dying, without his dignity, on the floor when it should have been obvious to medics that he needed to get straight to hospital. 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. We welcome Sir John’s promise to monitor the implementation of his recommendations.
"Talk is cheap, and actions speak louder than words. We will be watching to see what happens now. We thank the Chair for his meticulous and fearless report. John will always be in our thoughts and in our hearts."
The report also said it was "highly unlikely" the youngest victim, eight-year-old Tarleton schoolgirl Saffie-Rose Roussos, could have survived. He said: "There was only a remote possibility that she could have survived."
But he added: "In the case of John Atkinson, his injuries were survivable. Had he received the treatment and care he should have, it is likely that he would have survived. It is likely that inadequacies in the emergency response prevented his survival."
Sir John’s long awaited second report into the atrocity comes after his first report, on security around the event, concluded "disruptive intervention" should have been taken against Abedi, who was weighed down by a huge bomb in his backpack, and lives could have been saved as a result.
His second report, in two volumes across 716 pages, praises the bravery of individual officials and members of the public on the ground on the night, but outlines dozens of failures by many commanders in the emergency services to prepare properly for such an event and deal with attack when it happened.
Sir John. said: "Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been."
Nicola Brook, a solicitor from Broudie Jackson Canter who represents five Manchester Arena victims' families, including the family of Saffie-Rose Rousso, 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."
Greater Manchester Police
The Force Duty Officer (FDO) on the night of the attack, Inspector Dale Sexton, had "correctly" launched Operation Plato - the police response to a continuing marauding terror attack - over fears of a second terrorist at large, the report concludes.
It was "vital" he shared this with the other emergency services that night but he "failed to do so", said the report.
The report said: "That failure fundamentally undermined the joint response to the attack. The FDO failed in other important respects. The overall impact of his failures was serious and far-reaching."
But Sir John said Insp Sexton "failed because he was overburdened on the night", adding that GMP "had known for years" that he would become overburdened in the event of such a terror attack.
Greater Manchester Fire and Rescue Service
Sir John also criticised the other emergency services. A commander for Greater Manchester Fire and Rescue Service, David Berry, should have ordered firefighters to be sent to an initial rendezvous point nominated by GMP, said the report.
Mr Berry was "lost" on his way to the scene as he encountered roadworks and he should have co-ordinated the fire service response from home, it said. He "rejected" the rendezvous point nominated by GMP as he thought it was unsafe and instead ordered firefighters to head to Philips Park fire station three miles away from the scene.
Firefighters, who could have helped with the removal of casualties from the blast zone, eventually arrived at the arena two hours after the explosion. The fire service has previously apologised for this, but has blamed "silence" from GMP on the night.
The report said: “In the first quarter of an hour after the attack and thereafter, there was substantial confusion over the location of an RVP. Each emergency service chose its own. In some cases, this was passed on to other agencies. In others, it was not. There should have been a concerted effort to agree a multi-agency RVP where all the emergency services could co-locate.”
North West Ambulance Service
North West Ambulance Service should have scrambled specialist paramedics, trained to deal with terror incidents, sooner according to Sir John. More ambulances should have been sent straight to the scene before 11pm rather than being sent to a rendezvous point away from the city centre.
Only three paramedics were ever dispatched into the blast zone, and one of those was involved in triaging rather than treating casualties. The report said the absence of firefighters at the scene in two key messages to NWAS control room "was not identified".
The NWAS operational commander on the ground, Daniel Smith, was "unduly cautious" due to his lack of "situational awareness", while his evacuation plan was "inadequate". He ought have ensured available stretchers were used instead of the makeshift stretchers fashioned from railings and advertising hoardings, said the report.
A second NWAS commander, Neil Barnes, "should have made a greater contribution" to the emergency response, said the report, which added the management of the "walking wounded" should have been handled better.
Two radio channels were monitored around the clock by GMP in the event of major incidents - but neither was used by the other emergency services on the night of the attack, said the report. Other bodies were also criticised in the report, including British Transport Police, North West Fire Control (which handles 999 calls for the fire service), the arena’s owners SMG and its’ medical services contractor Emergency Services UK.
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