Manchester attack victim might have lived but for ‘inadequate’ response, inquiry finds

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One of the 22 people killed in the Manchester Arena bombing would probably have survived had there not been “inadequacies” in the emergency response, while others faced an “interminable” wait for treatment, an inquiry into the atrocity has concluded.

Failures in planning, coordination and the response across various emergency services contributed to the avoidable death of John Atkinson, a carer for adults with autism, said the chair of the inquiry, Sir John Saunders.

Atkinson, 28, emerged conscious from the blast on 22 May 2017 but died after waiting an hour and 16 minutes for medical treatment for his severe leg injuries and having a heart attack.

A series of miscommunications and poor decisions meant only three paramedics entered the arena’s foyer that night to help the 91 people lying seriously injured. None treated Atkinson, the inquiry found. The fire service did not show up until more than two hours after the blast, denying survivors further first aid expertise.

“Had [Atkinson] received the treatment and care he should have, it is highly likely he would have survived,” said Saunders, a retired high court judge.

He said there was a “remote possibility” that eight-year-old Saffie-Rose Roussos could have been saved if the rescue operation had been conducted differently. She drifted in and out of consciousness for 26 minutes but no tourniquets or leg splints were applied to her injuries.

Saunders found “failures to prepare”, “inadequacies in training” and that “the performance of the emergency services was far below the standard it should have been”. But he concluded that none of the bomber Salman Abedi’s other 20 victims could have survived their injuries, regardless of the treatment they received.

While he hailed the heroism of many of those who disregarded their personal safety to help the injured – particularly members of the public whom he described as representing “the very best in society” – Saunders found serious failings in the preparedness of Greater Manchester police (GMP), British Transport Police (BTP) and ambulance and fire services for such an attack.

“The evidence I have heard revealed that a great deal went wrong in the emergency response to the attack on 22 May 2017,” he concluded. “At a command level, things went badly wrong,” he said, heavily criticising poor communication between senior officers at the emergency services.

Other findings include:

The police did not have an up-to-date plan of the Manchester Arena complex and so did not know where everything was.

The BTP gold commander on the night of the attack was based in the south of England and also did not know the geography of the arena.

There were serious issues for emergency services trying to contact GMP’s force duty officer (FDO), Insp Dale Sexton, because his mobile number was the same one used by journalists seeking information on the atrocity.

Sexton made a “significant mistake” in not swiftly declaring a major incident. His error was not rectified until nearly 1pm the following day.

Instead, Sexton declared Operation Plato, the emergency services’ designation for the response to an attack by a marauding terrorist with a firearm. (Although there turned out to be no armed terrorists within the arena or wider area, Saunders concluded that this was a reasonable decision because there had been some reports of gunshots.)

Another senior GMP officer – temporary superintendent Arif Nawaz – was deemed “not competent” by the inquiry after he admitting pretending to know what Operation Plato was that night, when he really had “no idea”.

Meanwhile, no one from Greater Manchester fire and rescue service (GMFRS) arrived until two hours and seven minutes after the bomb was detonated at 22.31pm, after senior officers wrongly thought there had been a marauding terror attack to which they were not qualified to attend. Saunders judged the delay to be “serious and unacceptable”.

He concluded: “All firefighters were trained in rescue and first aid. The addition of the rescue capability of GMFRS would have resulted in the safer and faster extraction of the severely injured from the City Room to a location where they could receive clinical care.”

It was not until 2.50am on 23 May that the final casualty left the casualty clearing station at the arena for hospital. “To those who experienced it, this period of time will have seemed interminable. It must not happen again,” wrote Saunders.

Some preparations were hampered by budget cuts, particularly at GMP, the inquiry heard. Saunders said he had no doubt that austerity cuts imposed by Conservative-led governments from 2010 “had a damaging impact upon GMP’s planning for all emergencies”, including this one.

From 2010-11 to 2017-18, GMP’s income fell by more than 23% and the number of its officers fell by 25%. This principally affected GMP’s planning department and firearms and policy compliance units, Saunders found.

He made a recommendation that “the Home Office consider the different arrangements for funding police services if a similar programme of budgetary cuts and austerity occurs in the future”.

Volume two of the Manchester Arena inquiry also said it was not until 11.47pm, an hour and 20 minutes after the bombing, that an explosives detection dog arrived at the scene to determine that there were no secondary devices.

Owing to the “unacceptable failure” of the ambulance service to make stretchers available to those in the City Room, where Abedi had detonated his bomb, advertising boards, security barriers and tables were used to carry people out of the arena.

One of those was Atkinson, described by his sister Laura as “the most thoughtful, loving, caring”man she had known. After the detonation, it was 45 minutes before he was carried out by police officers on an advertising board. It broke and he was transferred painfully to a metal barrier.

A further 45 minutes passed before he was seen by paramedics, the inquiry heard. He was taken to Manchester Royal Infirmary but declared dead at 0.24am after multiple cardiac arrests.

Saunders concluded: “By no means all the mistakes that were made on 22 May 2017 were inevitable. There had been failures to prepare. There had been inadequacies in training. Well-established principles had not been ingrained in practice.

“Why was that? Partly it was because, despite the fact that the threat of a terrorist attack was at a very high level on 22nd May 2017, no one really thought it could happen to them. This was the case even though such a high-profile concert in a very large arena might obviously attract the attention of a terrorist intent on killing and injuring as many people as possible. Maybe it is also because, fortunately, this sort of tragic event is rare.

“Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been.”