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The Metro Mayor for Greater Manchester says there should be no scapegoating after a report by Lord Bob Kerslake found failings with aspects of the response to the Manchester Arena Bombing.
The investigation found that the fire service was left "outside of the loop" of the police and ambulance emergency response and 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, despite the nearest station being half a mile away.
"Strategic oversights" by police commanders led to confusion with other 999 services over whether an "active shooter" was on the loose and poor communications between Greater Manchester Police and Greater Manchester Fire and Rescue Service meant the "valuable" assistance of fire crews was delayed by two hours and six minutes after the bombing, which left twenty two dead and scores injured.
The 226-page report by Lord Bob Kerslake was commissioned by Andy Burnham, and concluded the emergency response was "overwhelmingly positive."
But Lord Kerslake described the failure by fire chiefs as "extraordinary" and "incredible."
The then £155,000-a-year chief fire officer, Peter O'Reilly, has now retired, keeping his pension with no action taken against him.
Andy Burnham said no one individual should bear all the responsibility for failures and no one should be "scapegoated".
He announced that a "root and branch" review of the policies, leadership and culture of GMFRS is now under way.
The panel of experts who authored the report state they are not able to say whether earlier arrival of the fire service would have "affected any casualty's survivability."
Suicide bomber Salman Abedi detonated his home-made device at 10.31pm on May 22 last year, in the foyer of Manchester Arena as 14,000 people streamed out at the end of an Ariana Grande concert.
The police duty inspector in the Greater Manchester Police 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 that other agencies were aware.
The Fire Service and the North West Ambulance Service were only informed an hour and a half later and by then Operation Plato was effectively put on "stand by" as it emerged the attack was from a single suicide bomber and not the prelude to further armed attacks.
Armed police and 12 ambulances were on the scene within 20 minutes but there was a shortage of stretchers to ferry the injured from the foyer to a casualty area on the station concourse.
The senior fire officer on duty, a National Inter-Agency Liaison Officer, came to believe an "active shooter" scenario was still in play and stuck to rules which dictate keeping emergency responders 500 metres away from any suspected "hot" zone of danger from a potential armed terrorist.
The fire service was "brought to the point of paralysis" to the "immense frustration on the firefighters faces."
Instead of rushing to the scene to help, fire crews and a Special Response Team, trained to deal with terrorist incidents, rendezvoused at fire station outside the city centre.
It was "fortuitous" the NWAS were not informed - otherwise they may have pulled out their paramedics and instead they stayed and "lives were saved" the report said.
And while a joint Strategic Co-ordinating group of emergency response services and others gathered at GMP HQ in east Manchester, GMFRS chief fire officer Mr O'Reilly focused his senior officers at their own HQ in Salford, which played a "key role" in delaying the response further.
My 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 22 May 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.
The public recognised what we achieved in responding to the attack and ensuring all the other later events could go ahead and we are eternally grateful for their support.
Lord Kerslake and the review team had a difficult job to do in reviewing the response in those first few days. There was so much we did in responding including dealing with the threat, managing the situation, supporting those affected and that includes many concerned people in our communities, armed patrols on the streets of Manchester, identifying those who had lost their lives and supporting their families and I could go on. Capturing the scale of the largest event GMP has ever had to deal with and the worst terror attack since the London bombings of 2005 was an almost impossible task.
This was a complex situation that required a huge response from GMP with the support of officers from across the UK and significant numbers of officers from the national counter terrorism policing network. The investigation is still underway and is working through more than 12,000 exhibits and has taken to date 2,000 statements.
We have detailed plans in place to respond to major incidents and terror attacks. These provide a framework to support decision making in the response to an incident but at the end of the day we have to deal with the situation that faces us. On 22 May 2017 we had a terror attack, many casualties and the possibilities of further attacks. Officers who were in control 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.
On 22 May 2017 we faced a huge challenge and when faced with an unprecedented situation everyone in GMP did their best to help all those affected.
The Government Minister responsible for victims of terrorism has acknowledged that there is a need for improvement after the report by Lord Bob Kerslake into the response to the Manchester Arena Bomb highlighted some failings.
We continue to stand with the people of Manchester as they recover and rebuild following the horrendous arena attack last year. Our thoughts remain with those who were injured and with the families and friends of those who lost their lives.
This comprehensive report rightly draws on the experiences of those most affected by the horrific attack in Manchester last May to reach its conclusions.
While Lord Kerslake acknowledges there were parts of the response that worked, the report shows a need for improvement in some areas. All agencies involved in the response should take time to consider the recommendations.
The report carried out by Lord Bob Kerslake into the emergency response to the Manchester Arena bombing has found that the fire service was kept 'out of the loop' resulting in a two hour delay arriving on scene.
The investigation says poor communication and poor procedures were to blame.
The report, which has been delivered in Manchester, outlines a series of failures that brought the Fire Service to the "point of paralysis."
A police and ambulance staff responded speedily to the scene, firefighters were held at a station less than a mile form the Arena for two hours.
The investigation found that strategic oversights by the police left the Fire Service unable to take part in the response to the Bomb Attack for two hours because they couldn't get through on the phone.
Police wrongly declared an active shooter situation but it was an hour and a half passed before the Ambulance and Fire Service were told that.
Failures at Vodafone meant there was no emergency helpline for concerned relatives leading to some of them searching hospitals for their missing loved ones
British Transport Police were praised for their quick response - they were on the scene within 30 seconds.
The report also says it hopes the mistakes made that evening will "never happen again
As a result of a failure of one of our systems, Greater Manchester Police was not able to issue an 0800 incident response number in the immediate aftermath of the Manchester Arena Attack. This was clearly unacceptable and we sincerely apologise for the distress caused to those affected by this terrible attack.
We have been running the National Mutual Aid Telephony service for the Home Office since 2009. It provides an 0800 number and call handling solution for police forces during a major incident, and has been successfully deployed on numerous occasions. However, any failure is unacceptable and we have since undertaken a major upgrade of the system in question and it is being tested on a daily basis.