Video report by ITV News Correspondent Richard Pallot
A major review into the Manchester Arena terror attack has criticised the fire service for their slow response to the suicide bombing, which saw them arrive at the scene more than two hours after the bomb had been detonated.
However, the Kerslake Report states that it cannot conclude if the delay in deploying firefighters to the scene could have saved lives or not.
Salman Abedi killed 22 people and injured more than 100 when he detonated a shrapnel-laden bomb following an Ariana Grande concert at the arena on May 22, 2017.
The report, commissioned to assess the preparedness and emergency response to the attack found that the fire service was effectively "outside of the loop" of police and ambulance emergency responders.
This meant that firefighters, some who heard the bomb go off, and trained in first-aid and terror scenarios with specialist equipment, did not get permission to go to the scene until hours after the suicide bombing, despite being stationed half a mile away.
Greater Manchester Fire and Rescue Service's (GMFRS) average response time is six minutes, yet in the case of the bombing, they arrived two hours and six minutes after the attack.
Due to this, "a valuable resource was not available to assist on the scene, particularly with the movement of those who were injured from the foyer to the Casualty Clearing Station," the 226-page report found.
It continued that "there is not one single reason nor one individual that caused this failure, rather, it was a combination of poor communication and poor procedures".
Aside from the criticism of the fire service's response, the main conclusions from the report are:
"Considerable distress" for the families of those caught up in the attack was caused by the "complete failure" of an emergency response phone line provided by Vodafone, meaning they were unable to find out more information.
The panel said it was "shocked and dismayed" that families were "hounded" by some of the media in the wake of the attack, including "sneaky" attempts to take photos when families were receiving bad news.
There were multiple duties on the Police Gold Commander (the person in charge of GMP's resources at the scene) and the Force Duty Officer on the night of the attack that were extremely wide ranging and testing, meaning some issues of communication between the police and other agencies arose.
Support and care for the families directly affected by the attack was not always carried out beyond the early period, continuing access to mental health services was highlighted.
Despite the many recommendations, the report praised:
Investment in emergency planning meant people were generally able to act with a high degree of confidence.
Actions by individuals and organisations on the night demonstrated enormous "bravery and compassion".
Good judgement was exercised by key emergency personnel at critical points during the evening.
The city's response was exceptional.
Vital support and comfort was provided by family liaison officers and bereavement nurses.
The removal of the deceased from the Arena was treated with care and sensitivity.
The report by Lord Bob Kerslake, the former head of the Civil Service also criticised "strategic oversights" by police commanders which led to confusion over whether an "active shooter" was on the loose.
It stated that the police duty inspector in the Greater Manchester Police (GMP) force control room declared Operation Plato, a pre-arranged plan when it is suspected a marauding armed terrorist may be on the loose - and assumed, wrongly, other agencies were aware.
As a result, GMFRS was not aware until a conversation was heard at 12.15am the next morning.
The report continued that it was "fortuitous" North West Ambulance Service (NWAS) were not informed of Operation Plato - otherwise they may have pulled out their paramedics, but instead they stayed and "lives were saved".
However the duty inspector was praised for taking one of the most crucial "life or death" decisions of the night, a "key use of discretion" to override the rules and allow paramedics and police to continue treating the injured even though they may be in danger of further attacks.
The report, released on Tuesday, makes 50 recommendations but states its panel of experts was not to answer the question of, "would the earlier arrival of GMFRS at the scene have made any difference to the medical outcomes of the injured?
"This is a question that only the coronial inquests can decide," the report said.
Despite the criticisms that the review found, it also highlighted many areas of good practice including prior training and planning for any such major incidents, including a exercise at Manchester's Trafford Centre just months before the attack.
It also praised the actions of the Arena staff, British Transport Police (BTP) and members of the public who showed "enormous bravery and compassion" when they stayed at the scene to help.
The report was commissioned by Andy Burnham, the Mayor of Greater Manchester, to assess the preparedness and emergency response to the attack, and to see what could be learnt from it should any similar event occur in the future.
Following his report's publication, Lord Kerslake said the views of the bereaved,injured, and others affected by the attack were at the "front and centre" of the report's creation, and it was these people who must always be thought of first and foremost in the wake of the attack.
He continued that the attack "was devastating for many thousands of people...
“There is a lot to be proud of in the response to the attack, both for the city region of Greater Manchester, and for the emergency services.
"The benefits of collaborative working and planning for emergencies were demonstrated to the full. And there were hundreds, if not thousands, of individual acts of bravery and selflessness.
“But it’s also vital to learn the lessons around things that did not go so well.
"It matters not just for the people of Greater Manchester and beyond who were caught up in the terrible events of that night, but also for places that might be caught up in such an attack in the future.
“I would like to thank all of those who contributed to this report.
"There was honesty, there was soul-searching, and there was a determination that their insight would benefit others in the future.”
How have those caught up in the attack responded?
Martin Hibbert, the person closest to the bomb who survived said he was "really disappointed" with the report, calling it "offensive" to the survivors and "even more offensive to those who died".
Mr Hibbert added that the report offers "no answers" to anything and simply amounted to"people trying to get out of another situation" and "sweep" the issues "under the carpet".
He added that it "does not come close to the truth", due to "people trying to protect their reputations", who now have "blood on their hands" due to emergency services not entering the arena sooner.
The 41-year-old recalled how "first aiders had to play Roman Emperor, they had to say who lived and who died... All they had were first aid kits and trauma bags" in a scene like "a battlefield from Iraq and Afghanistan".
He added he "pretty much bled to death on the floor" and believed he was going to die.
Mr Hibbert, who was at the arena with his daughter, said he was "not going to put up with" the report's findings and if the "truth isn’t going to come out by proper means I’ll do it myself".
Steve Howe, whose wife Alison was killed in the attack, agreed with Mr Hibbert that the report offered him "no answers", and was instead filled with "nonsense" and "excuses".
Mr Howe also questioned the delay in emergency services entering the arena, saying there were "500 reasons for going in, but three for not".
However, Mr Howe said he did not believe anything could have been done to save his wife, but others could have been helped.
He added that answers were still needed and "somebody has to be held accountable".
How have the emergency services responded?
Chief Constable of GMP, Ian Hopkins said the forces's "thoughts today are with the families of the 22 people who lost their lives and all those who have been physically and psychologically affected.
"The families suffered a terrible loss but have shown great courage and with the first anniversary just eight weeks away this will be a difficult time for them.
"From the moment we received the first call on May 22, 2017, about that barbaric act our actions have always been focused on supporting them.
"In those first few minutes the priority was to save lives while being aware there may be a further attack.
"It was an immense and unprecedented situation that faced us and I am proud of the way the officers and staff of GMP responded that night and in the days, weeks and months that have followed.
"In the face of danger they ran into the Arena as others were running away, they experienced things that no-one should have to experience."
Chief Con Hopkins continued that the investigation into the attack is still underway, working through 12,000 exhibits and 2,000 statements.
He continued that police officers on the night "used their professional knowledge and experience to make sure we did the right thing in those challenging circumstances.
"Learning from such exceptional events is so important.
"This is why we have extensively reviewed and assessed the responses so that learning can be included in future plans.
"These plans will assist not just GMP but the whole police service.
"There were a number of matters that were raised and some improvements have already been made.
"The Kerslake Report will now form part of that learning."
Dawn Docx, Interim Chief Fire Officer said the service "apologised unreservedly" following "failures in leadership and poor decisions made."
She added: "It is clear that our response fell far short of what the people of Greater Manchester can expect...
"As a result firefighers themselves, desperate on the night to attend the incident, were let down by some of their senior colleagues."
Speaking at a press conference after the report's publication, Mr Burnham said no one individual should bear all the responsibility for failures and no one should be "scapegoated".
However, he announced that a "root and branch" review of the policies, leadership and culture of GMFRS is now under way.
How did events unfold in the immediate aftermath of the attack?
Monday, May 22, 2017
10.31pm - BTP at Victoria station run towards the sound of explosion in the Arena foyer, arriving one minute later.
10.33pm - First call to GMP reporting an explosion at the Arena.
10.42pm - The first paramedic arrives at Victoria station.
10.43pm - First armed police arrive in the foyer.
10.46pm -Road closures commence nearby.
10.49pm - Twelve ambulances are now at the scene.
10.58pm - Injured people in the foyer begin to be moved to the station concourse as a casualty treatment area is set up.
Tuesday, May 23, 2017
12.37am -Three fire engines arrive at the scene for the first time.
2.30am - A Reception Centre is opened at the Etihad Stadium by Manchester City Council.
2.46am - All the injured are taken from the scene.
4.15am - Strategic multi-agency meeting at GMP Force Headquarters, but fire chiefs are not present.
10am - Meeting of the Mass Fatalities Coordinating Group.
12pm - Police confirm first arrest.
3.35pm - The first body of a victim is moved to a temporary body storage facility on site.
6pm - A vigil is held in front of Manchester Town Hall.
9.07pm - The last body is removed to a temporary facility on site.