The family of a man who would probably have survived the Manchester Arena attack had he not been left to bleed to death by the emergency services said he had been “totally failed at every stage”.
On Thursday the inquiry into the atrocity identified failures in the emergency services’ response, which left victims with an “interminable” wait for treatment.
The family of John Atkinson, a care worker who died, said it “should simply never have been allowed to happen”, adding: “It is crystal clear that due to those failings, John died from injuries that he could and should have survived.”
The chiefs of Greater Manchester police (GMP), Greater Manchester fire and rescue service (GMFRS) and North West ambulance service (NWAS) all issued unreserved apologies after the inquiry found that “a great deal went wrong in the emergency response to the attack”, particularly at command level.
Failures in planning, coordination and the response across various emergency services contributed to the avoidable death of Atkinson, a care worker 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 there had been “failures to prepare” and “inadequacies in training” and that “the performance of the emergency services was far below the standard it should have been”.
“Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been,” he said. 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 the emergency 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 British Transport Police 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, 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 1am the following day.
Meanwhile, no one from GMFRS arrived until two hours and seven minutes after the bomb was detonated at 22.31pm, because senior officers wrongly thought there had been a marauding terror attack, which they were not qualified to attend.
Saunders judged the delay to be “serious and unacceptable”, concluding: “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 [the area of the Manchester Arena where the bomb went off] to a location where they could receive clinical care.”
On Thursday, the GMFRS chief fire officer, Dave Russel, apologised for their “wholly inadequate and totally ineffective” response, which he said “will forever be a matter of deep regret for our service”.
Daren Mochrie, the chief executive of NWAS, said its failures “weigh heavily on us as an organisation”, adding: “Whilst our actions were well-intentioned, I apologise wholeheartedly for our failures.”
Stephen Watson, the chief constable of GMP, said the inquiry proved “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. For this I apologise unreservedly.”
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 had been 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.
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”.
On Thursday night, Rishi Sunak tweeted: “Nothing will ease the pain of the families of those killed during the cowardly terrorist attack at Manchester Arena. It is my solemn commitment to the victims, survivors and their loved ones that we will learn from the lessons of this inquiry.”
Owing to the “unacceptable failure” of NWAS to make stretchers available, 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.
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 12.24am after multiple cardiac arrests.
On Thursday his family said: “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.”
They added: “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.”