Judge slams catalogue of failures by 999 crews after fanatic’s suicide blast at Manchester Arena

As dozens lay bleeding and dying on the floor, the casualties and those tending to them waited desperately for paramedics.

But while the wail of sirens could be heard outside Manchester Arena soon after Islamic State-inspired killer Salman Abedi detonated his rucksack bomb, hopes of quick help were soon dashed.

As the smoke cleared and with no paramedics to be seen for more than 20 minutes, off-duty nurse Bethany Crook felt an overwhelming sense of powerlessness. She told yesterday’s inquiry into the atrocity: ‘Never had I felt so helpless, lost or alone.’ Having left her own 13-year-old daughter with arena staff, she went to help dying casualties including the youngest, Saffie-Rose Roussos, eight, and Georgina Callander, 18. Miss Crook recalled: ‘All I had before me were my two bare hands, no equipment, some skills, my faith and hope that somewhere there were people trying to get to us to help. But this wasn’t the case.

‘No-one was coming and what may have been seconds to you all felt like minutes for me, what were minutes felt like hours, and what were hours felt like an eternity, alone with people and children’s lives literally in my bare hands.’ The inquiry heard how an ‘unduly cautious’ response by North West Ambulance Service meant only one paramedic turned up at the City Room foyer – the scene of the explosion – at 10.53pm, 22 minutes after the blast, followed by two more at 11.15pm.

Others waited at the adjacent Victoria rail station for casualties to be carried downstairs by police, arena staff and the public using ‘anything they could find’ including advertising hoardings, crowd barriers and tables. Inquiry chief Sir John Saunders said: ‘From the start, it ought to have been possible to get medical assistance to the injured in the City Room speedily… that is not what happened.’

The failure to deploy paramedics en-masse stemmed from police declaring a terrorist incident and fears of a ‘marauding gunman’.

But firearms officers had secured the City Room by 10.50pm – before the first paramedic had even entered – and Sir John said it should have been declared a safe ‘cold zone’. That information was not passed on to emergency crews. Firefighters did not attend until two hours and seven minutes after the bomb went off. Sir John said: ‘Everyone involved in the emergency no doubt thought that they were doing their best. In some cases, their best was not good enough.’

The inquiry report found 12 main failings by the emergency services, notably in their failure to communicate with each other – despite a training exercise for a major incident only a year earlier.

‘There were total failures in joint working,’ Sir John said.

Ambulance crew caution

An ‘unduly cautious’ response by the ambulance service led to insufficient numbers of paramedics attending, Sir John found.

He identified delays in deploying ambulances and a failure to send all specially-trained Hazardous Area Response Team paramedics into the City Room. Only two went in, following advance paramedic Patrick Ennis, who had left ‘triage tags’ used to identify the most seriously injured patients in his car and instead wrote notes on his glove. Sir John also highlighted ‘the failure to send non-specialist paramedics into the City Room to assist with triage’ and a failure to bring stretchers to the scene.

Operational commander Daniel Smith ‘never sought or obtained the assessment’ of Mr Ennis – who worked alone for more than 20 minutes – about the safety of the City Room. Although ‘police officers in the City Room were literally shouting out for paramedics to attend’, Sir John said ‘arrangements made by [Mr Smith] were not sufficient to meet needs of the casualties’.

Only seven of the 319 ambulances operating that night were available immediately. They were initially held half a mile away at Manchester Central Fire station, and not deployed to the arena until 11pm.

It took an hour and 11 minutes for the last casualty to be brought to the clearing station at 11.42pm, and until 2.50am for the last patient to be taken to hospital.

Fire crews 2 hours late

Fearing the closest fire station to the arena might not be safe, a ‘critical’ error of judgment meant Greater Manchester Fire and Rescue crews mustered three miles away. That resulted in fire crews arriving two hours late, with fire engines driving ‘away from, not towards, the incident’ – and going ‘past ambulances travelling in the opposite direction’.

The decision to rendezvous elsewhere was made by a senior officer responsible for liaison with other services, Andrew Berry. No actual commander was in place until 11.30pm and Sir John said he had heard from ‘a number of very angry firefighters who were ashamed of the fact that they did not get to join in the rescue.’

Sir John said other emergency crews ‘did not notice’ the absence of firefighters, despite the fact ‘they could have provided very substantial assistance’.

Police overwhelmed

While praising officers for helping casualties at the scene, Sir John was critical of Greater Manchester Police (GMP) commanders.

He said that while Force Duty Officer Inspector Dale Sexton correctly enacted procedures for Operation Plato – dealing with a firearms attack – fire and ambulance personnel were not informed, causing confusion. He also, shockingly, failed to declare a major incident. Even without knowledge that Plato had been enacted, other emergency services remained concerned about armed terrorists or a second bomb.

Insp Sexton, presented with the Queen’s Policing Medal in 2018, then failed tell other emergency services the City Room was safe.

Sir John said he ‘failed because he was overburdened on the night’. A senior officer, Temporary Superintendent Arif Nawaz, was also given the status of silver commander despite lacking knowledge of terrorism procedures, meaning he ‘made no contribution of substance’. Sir John said: ‘Because of his lack of understanding, [he] was not competent to perform the role.’

British Transport Police (BTP) officers were the first emergency services at the bomb scene but commanders made several failures. The force did not pass on information to other blue light services or have a written tactical plan.

Meanwhile, its Gold Commander ‘had not read or received any training’ on major incidents. One of its commanders did not arrive at the scene until 1am. Front-line GMP and BTP officers were ‘inadequately trained’ in first aid.

Arena’s first aid failures

Manchester Arena operator SMG contracted out medical provision at concerts to Emergency Training UK, whose staff were inadequately trained. Director Ian Parry’s qualifications in major incident management and advanced life support had expired six years earlier. Staff were ‘not adequately prepared for a real-world mass casualty incident’ – or even providing tourniquets.

As Manchester bomb victims’ families condemn failings of emergency crews…What on earth has happened to our 999 services?

By Richard Marsden and James Tozer 

Appalling failings by the emergency services left Manchester Arena bomb victims ‘dying without dignity on the floor’, furious families said last night.

A highly critical report into the 2017 suicide attack found one – and possibly two – of the 22 innocent victims could have survived if the authorities had responded properly.

But the conduct of the police, fire and ambulance services fell ‘far below the standard it should have been’, retired High Court judge Sir John Saunders said.

Inquiry chairman Sir John said identical mistakes were made by emergency services to those in the aftermath of the 7/7 terror attacks on the London transport system in 2005, when 52 people died.

The father of the youngest victim of the arena attack, eight-year-old Saffie-Rose Roussos, said last night he could never forgive those who failed to do ‘everything possible’ to save her.

And having heard that quicker medical attention could well have saved the life of 28-year-old John Atkinson, his family said he had been ‘totally failed at every stage’.

Highlighting ‘serious failings’, Sir John said yesterday: ‘There had been failures to prepare. There had been inadequacies in training. Well-established principles had not been ingrained in practice.

‘Why was this? Despite the fact that the threat of a terrorist attack was at a very high level, no one really thought it could happen to them. For those who are critically injured, minutes or seconds can count. None of the emergency services had gripped the response to the attack as they should have.’ The report revealed:

•  A senior fire officer who blocked deployment of crews ‘overestimated the risk’ to their safety – but there was ‘an apparent unwillingness by other senior officers to intervene’;
•  North West Ambulance Service’s response was ‘unduly cautious’;
•  Survivors – some with serious injuries including broken legs – waited for more than four hours to be taken to hospital;
•  As chaos and confusion reigned, communication between the three emergency services was ‘non-existent’.

Greater Manchester’s chief fire officer, Dave Russel, said last night: ‘Our response that night was wholly inadequate and totally ineffective, and that will forever be a matter of deep regret for our service.’

Saffie-Rose, who had been among the thousands attending an Ariana Grande concert on the fateful night in May 2017, had a ‘remote possibility’ of survival ‘with different treatment and care’, Sir John said.

Her father Andrew told Sky News the family ‘believe 100 per cent that if she got that chance, she would have survived’.

The family’s solicitor, Nicola Brook, from Broudie Jackson Canter, said the report revealed failings ‘on an enormous and unfathomable scale’, adding: ‘To finally learn today that Saffie was denied medical care that had the potential to save her life is a devastating blow.’

The inquiry report said care worker Mr Atkinson, who bled to death after waiting 76 minutes for an ambulance, had injuries which should have been ‘survivable’.

Even after he was finally evacuated from the bomb scene, his family said he was ‘left, dying, without his dignity, on the floor’.

‘John must have known that he was dying and the pain that causes us is too great to put into words,’ they added. The family demanded action be taken on Sir John’s 149 recommendations, saying: ‘Talk is cheap, and actions speak louder than words.’

Some of the biggest failings included the deployment of just three paramedics to the arena’s City Room foyer where the bomb went off, and the fire service failing to send crews for more than two hours as commanders believed the scene was not safe.

In fact, Greater Manchester Police firearms officers had secured the City Room where the casualties lay within 19 minutes of the bombing – but commanders did not share the information with other emergency services.

Chief Constable Stephen Watson, who took over Greater Manchester Police last year, said: ‘Poor communications, poor planning, inadequate training and shortcomings in strategic leadership all played a part in our failure.’

Daren Mochrie, who took over as chief executive of North West Ambulance Service in 2019, apologised ‘wholeheartedly’ for its ‘failures’. A dozen specific failures were outlined by the 884-page report, concerning poor communication, the lack of paramedics at the scene and even a failure to deploy basics such as stretchers.

Prime Minister Rishi Sunak said: ‘It is my solemn commitment to the victims, survivors and their loved ones that we will learn from the lessons of this inquiry.’

This was Sir John’s second report into the attack.

His first – published in June last year – focused on security issues.

The third and final report will focus on bomber Salman Abedi’s radicalisation, what the intelligence services and counter-terrorism police knew, and if they could have prevented the attack.