One of the 22 people murdered in the Manchester Arena suicide bombing would probably have survived but for failings in the emergency response, the inquiry chairman said, as he unveiled a scathing analysis of the rescue operation that night.
Professional tourniquets would have saved John Atkinson’s life, inquiry chairman Sir John Saunders said.
Chief Constable for Greater Manchester Police Stephen Watson apologised unreservedly for the response to the bombing, admitting communication between emergency services was poor and that his force’s failings contributed to the loss of life.
Home secretary Suella Braverman said she would carefully consider the report’s recommendations.
Care worker Mr Atkinson, 28, was 6 metres away from the explosion, detonated by Salman Abedi, 22, in the foyer at the end of an Ariana Grande concert on the evening of 22 May 2017.
A member of the public used a belt as a tourniquet on Mr Atkinson’s leg as he lay bleeding in agony on the City Room floor for up to 50 minutes, during which time he told a police officer: “I’m gonna die.”
Only three paramedics entered the room, the report reveals, and none was seen to attend to Mr Atkinson before he was carried on a makeshift stretcher to a casualty clearing area, where he later suffered a cardiac arrest – an hour and 16 minutes after the blast.
Sir John is scathing in his conclusions on the response of the emergency services, making 149 recommendations.
He urged the government to bring in legislation imposing a “protect duty’’ on companies that operate large entertainment venues as soon as possible.
Ms Braverman said: “This report is a devastating reminder of the Manchester Arena attack and the horror of that night when 22 lives were lost, while countless others were changed for ever. I’m thinking of them, the people who loved them, and everyone still affected by this appalling event.
“Without doubt, our emergency services show incredible courage when responding to incidents of this magnitude. It’s right that we reflect and work together to learn from this tragedy.
“I will carefully consider the recommendations made so far to strengthen our response.”
John must have known that he was dying and the pain that causes us is too great to put into words. This should never have been allowed to happen— John Atkinson’s family
Launching his report, Sir John said: “Those who have listened to the evidence will not be surprised that I am highly critical of many 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.”
He said the inquiry heard heartbreaking evidence of the injured who heard rescuers nearby but who failed to arrive to help.
However, he recommended changes to ensure the mistakes were not made again, saying many of the things that went wrong that night had gone wrong before.
Twenty-two people were killed and hundreds were injured in a suicide attack at the end of an Ariana Grande concert on May 22 2017.
“Significant aspects of the emergency response on 22nd May 2017 went wrong. This should not have happened,” Sir John said.
“Some of what went wrong had serious and – in the case of John Atkinson, fatal – consequences for those directly affected by the explosion.”
Mr Atkinson’s family said in response that he was failed at every stage by those who should have cared for him.
“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.
“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.”
They said everyone who knew Mr Atkinson loved being around him and he always put others first.
“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. As the report says, timely medical treatment to stop or slow John’s catastrophic bleeding and get him to hospital would have saved him.”
They said they would be watching to see whether the report recommendations were acted on.
The inquiry chairman said it was highly unlikely the bombing’s youngest victim, eight-year-old Saffie-Rose Roussos, would have survived her injuries with “only a remote possibility she could have survived with different treatment and care.”
Mr Watson, who was not in charge of Greater Manchester Police at the time of the attack, said coordination of the response was inadequate.
“We had failed to plan effectively and the execution of that which had been planned, was simply not good enough. Our actions were substantially inadequate and fell short of what the public had every right to expect,” he said.
“For this I apologise unreservedly.
Our actions were substantially inadequate and fell short of what the public had every right to expect— Stephen Watson, Greater Manchester Police Chief Constable
“Our failure to effect proper command and control of the incident, from the outset, undermined an effective multi-agency response to a dreadful set of circumstances. We did not act upon learning from previous exercises which could have reduced the burden or impact felt on the Force Duty Officer.
“Poor communications, poor planning, inadequate training and shortcomings in strategic leadership all played a part in our failure.”
He added: “Sadly, GMP’s combined failings were significant and contributed to the loss of life.
“To the families and loved ones of those who died, I am truly sorry. It is important that we now take the time to carefully consider every facet to the volume published today and we have a dedicated team already in place for this purpose.”
The report found the initial command of the emergency was taken by Greater Manchester Police’s force duty officer, Inspector Dale Sexton, but he “quickly became overburdened by the number of tasks he had to undertake”.
Sir John said: “This had a direct impact on the effectiveness of the emergency response. It affected who received information, what resources were made available and the decisions of other commanders.”
Following erroneous reports of gunshots, Inspector Sexton declared Operation Plato, a plan for a suspected marauding terrorist, but he “overlooked” telling other emergency services.
“It affected the ability of the emergency services to work together by jointly understanding the risks,” said Sir John.
“In the first quarter of an hour after the attack and thereafter, there was substantial confusion over the location of an RVP (rendezvous point). Each emergency service chose its own.”
Fire crews took more than two hours to even attend the incident after station manager Andy Berry chose to mobilise resources three miles from the arena amid fears over safety.
Sir John said: “The effect... was that the fire appliances at Manchester Central Fire Station drove away from, not towards, the incident. While driving away, the Manchester Central fire appliances drove past ambulances travelling in the opposite direction.”
He said that North West Ambulance Service operational commander Dan Smith made an error in sending ambulances to meet at Manchester Central Fire Station rather than to go directly to the scene.
Mr Smith also wrongly believed non-specialist paramedics should not be deployed into the City Room.
By 10.50pm the room was a “cold zone”, said Sir John, where it was assessed there was no immediate threat to life from an armed terrorist.
A police chief had deemed it “safe enough” for non-specialist emergency responders and the public to be in.
He said: “Not only should this have been the view across the emergency services, based on the available information, but it was in fact correct, as is now known for certain.”
As the post-attack “golden hour” ended, the emergency response had failed to achieve effective evacuation.
Just after midnight there were still 36 casualties waiting to go to hospital, with the last casualty departing at 2.50am.
Sir John said: “To those who experienced it, this period of time will have seemed interminable. It must not happen again.”
The hearings began and ended with a minute’s silence to remember those who died – John Atkinson, 28; Courtney Boyle, 19; Kelly Brewster, 32; Georgina Callander, 18; Olivia Campbell-Hardy, 15; Chloe Rutherford, 17; Liam Curry, 19; Wendy Fawell, 50; Martyn Hett, 29; Megan Hurley, 15; Alison Howe, 44; Nell Jones, 14; Michelle Kiss, 45; Angelika Klis, 39; Marcin Klis, 42; Sorrell Leczkowski, 14; Lisa Lees, 43; Eilidh MacLeod, 14; Elaine McIver, 43; Saffie-Rose Roussos, aged eight; Philip Tron, 32; and Jane Tweddle, 51.
Sir John said the evidence was conclusive there was no possibility that 20 of the 22 victims could have survived the “murderous actions” of Salman Abedi, referred to sparingly by his initials in the 874-page report.
Sir John said: “In the case of John Atkinson, his injuries were survivable. Had he received the care and treatment he should have, it is likely he would have survived. It is likely that inadequacies in the emergency response prevented his survival.”
Mr Atkinson would probably have survived if an “intervention sufficient to slow substantially or stop bleeding” had been undertaken up to 45 minutes after the blast, he said.
Staff at medical provider for the arena ETUK should have been able to apply medical tourniquets to both his legs, along with dressings.
The inquiry heard that only three paramedics entered the City Room foyer, the scene of the explosion, and that crews from Greater Manchester Fire and Rescue Service took more than two hours to even attend the arena.
Sir John’s first report on the tragedy, released last June, which looked at security issues at the arena venue, highlighted a string of “missed opportunities” to identify Abedi as a threat.
