Senior Paramedic and Army Reservist Philip Keogh describes the loss of John Atkinson
The inquiry has heard John Atkinson's death had a profound effect on the paramedic after the care worker had begged him 'not to let him die'.
He was being treated on the 'cold concourse floor' by Philip Keogh, from the North West Ambulance Service who had 'self deployed' to the Arena because of his experience as an army reservist paramedic.
He said he had tried to reassure the 28 year old from Bury when he spoke to him, but he told the inquiry he knew he was gravely ill and his chances of survival were 'extremely slim'.
He said his death was a 'catalyst' and he told those at the scene, 'we have to get patients off the floor, which was ever so cold and on to ambulances'.
Mr Keogh had served in Afghanistan between October 2010 and February 2011 responsible for military and civilian casualties with battlefield injuries and also had experience in dealing with gunshot and shrapnel injuries.
On the day of the Arena attack, he was based in Rochdale in a 'rapid response vehicle' when he got the call to inform him of 'an incident in Manchester' although it wasn't clear exactly what it was at that stage.
He was 25 miles away in Rossendale in Lancashire when he suggested making his way to Manchester. He arrived at 11.10pm.
Mr Keogh said when he arrived he was told by his control room there may be an 'active shooter' at the Arena.
He added that if he had not gone 'people would have had to wait longer for care'.
He said he put dressing, tourniquets and gloves in his pockets and took a medical bag with medicines into the railway station.
The inquiry heard that at this stage some 13 patients have come down from the City Room. He first triaged a female patient near the doors.
He said he placed his equipment bags down and later lost sight of it. The inquiry heard he 'lost' his medical equipment bags.
Mr Keogh said he heard a 'commotion' and was told by NWAS bronze commander Dan Smith to assist John Atkinson who had just been brought down the stairs to the casualty clearing station.
He described the situation as 'ever so confusing, chaotic... it became a very difficult situation to manage due to the sheer numbers of people that were there.'
The paramedic said Mr Atkinson only had his t-shirt on and even that had been partially cut away.
Mr Keogh said he was extremely concerned about hypothermia.
He agreed he was already at risk 'because of the trauma he had sustained', the fact he had not been covered with blankets, and he had been placed in a doorway of the station concourse exposing him more to the cold.
He told the inquiry trauma and blood loss increases with hypothermia and can lead to the 'lethal triad of death'.
The inquiry heard about the five minutes he spent with Mr Atkinson, who was conscious and breathing but 'waxy as hell', 'pale and clammy'.
He compared Mr Atkinson to a model at Madame Tussauds before the make-up was applied which indicates 'massive blood loss'.
"My initial reaction was that he had lost an awful lot of blood," said Mr Keogh.
He noted blood staining on the casualty's legs and fragments of the bomb had penetrated his limbs.
But he said there was no 'catastrophic bleeding' at that stage, and 'makeshift tourniquets', one a belt and the other possibly a t-shirt appeared to be working at that time.
He said he felt John Atkinson needed blood products, and he didn't have that equipment with him, that was in the bag he had lost sight of.
The paramedic accepted he should have requested his patient was given the drug, TXA or could have instructed someone to do it.
But he added the administration of the drugs was not straight-forward and would have to be administered via 'IV access' over a ten minute period, and that he had to consider whether there were any further injuries.
Mr Keogh recalled the patient had told him: 'Don't let me die.'
Paramedic Philip Keogh answering questions by Sophie Cartwright QC, counsel to the inquiry about Philip Atkinson's condition.
He told the inquiry: "The impending sense of doom is a tell-tale sign that this patient is not very well and is poorly and at great risk of dying."
Paramedic Keogh said he tried to get a 'pulse oximeter' on Mr Atkinson's finger but he could get no reading. He said he believed the casualty was 'shutting down'.
The 28-year-old lay in agony in the foyer for 47 minutes before police officers carried him on a makeshift stretcher and placed him on the ground near the station entrance.
It was another 30 mins after John Atkinson was first assessed by paramedic Keogh that he was taken to hospital, where he died.
Mr Keogh said he began chest compressions when he saw Mr Atkinson go into cardiac arrest on the stretcher as he was waiting to be wheeled to an ambulance, which was the 'furthest ambulance' away.
The patient was pushed along Station Approach negotiating their way past an 'awful lot of obstacles', while trying to continue chest compressions. Philip Keogh agrees the delay in taking him to hospital had reduced John's chances of survival.
He said after treating John Atkinson, he realised they needed to get other victims to hospital quicker. “Losing John had a profound effect on me that night..in terms of I want to get people off the floor and get them to be where they need to be.”
We had patients all over the Victoria station floor, a marble type floor, which is ever so cold, and we needed to get them off the floor to provide that level of protection from hypothermia.
Mr Keogh said by then the fire service had arrived and he 'grabbed them' and ordered them to get stretchers from the ambulances into the railway station to get the patients off the floor.
Mr Keogh agreed with John Cooper QC, who represents the family of Mr Atkinson that he 'felt overwhelmed' and 'desperately needed more paramedics there to help you doing the job that you were doing'.
He also agreed casualties including Mr Atkinson were left on the floor 'longer than they needed to be'.
Mr Cooper suggests it was obvious Mr Atkinson had lost a lot of blood.
Mr Keogh agreed although he pointed out the casualty wasn't bleeding at the time he saw him.
He agreed it was possible that this was because, by then, he had 'run out of blood.
Michael Ruffles, a senior paramedic at the time of the attack, arrived at the Arena at 11.21pm and was tending to Mr Atkinson eight minutes later.
He had administered the blood clotting agent TXA in the back of the ambulance. It took a further 30 minutes for the ambulance to take Mr Atkinson to hospital.
The were delays in organising a spinal stretcher and waiting for 'vital' drugs in a medical bag they had 'unfortunately' left on the railway station concourse and treatment was continuing in the ambulance.
John Cooper QC, representing the family of John Atkinson, suggested his removal to hospital could have been quicker and Mr Ruffles agreed.