Video report by ITV Granada Reports correspondent, Rob Smith.
Victims of the Manchester Arena terror attack were left “waiting in vain” and “desperate for help” which did not come, a damning second report has found.
The “inadequacies” in the emergency response also meant the deaths of at least one of the 22 victims could even have been prevented.
A “lack of communication” between emergency services meant paramedics and fire crews were not deployed and instead both rescuers and those injured were simply left hearing “sirens of the ambulances outside”, the report concluded.
Saffie-Rose Roussos, eight, and John Atkinson, 28, both died after suicide bomber Salman Abedi detonated a device at the end of an Ariana Grande concert in May 2017.
A report into the fatal consequences of the explosion found there was a ‘remote possibility’ the youngest victim could have been saved if the rescue operation had been conducted differently.
It also found Mr Atkinson “would probably have survived” had there not been “inadequacies” in the emergency response and he had been taken to hospital sooner.
Full statement from the Chairman of the Manchester Arena inquiry, John Saunders.
Sir John Saunders, the chairman of the Inquiry, said he had “no doubt that lives were saved by the emergency response” and they were doing their best, but in some cases he said, “their best was not good enough”.
He added the performance of the emergency services was “far below the standard it should have been”.
Sir John Saunders also praised the “heroic acts” carried out by bystanders who ignored risks to their own safety to help the dying and the injured.
Describing the City Room as a “war zone”, he said to enter, or remain there to help those injured “required great courage”.
Twenty-two people died and hundreds were left injured and traumatised when the improvised device exploded on 22 May 2017.
The victims were aged between eight and 51.
In the second of three reports, looking into the response of the emergency services, Sir John Saunders said “a great deal went wrong”, including communication, not learning from previous tragedies and specialist plans being out of date or not known by everyone.
His damning report found Greater Manchester Police (GMP) did not lead the response in accordance with guidance, Greater Manchester Fire and Rescue Service (GMFRS) failed to turn up “when they could provide the greatest assistance”, and North West Ambulance Service (NWAS) failed to send sufficient paramedics into the City Room.
But, he said, while his report criticised individuals he considered “to have made mistakes”, he “understood the enormous pressures they were acting under” and was not surprised things had gone wrong.
However he added, his job was to ensure mistakes were identified to prevent them in the future.
Key findings of the 900-page report
A lack of communication between emergency responders both at a single point on the ground and over radio.
A failure by the Force Duty Officer Dale Sexton to inform other emergency services of his declaration of Operation Plato - the code name for the pre-planned emergency response to a marauding terrorist.
There were delays by North West Ambulance Service (NWAS) in getting ambulances and paramedics to the scene.
There was the failure to get stretchers to the City Room to help evacuate the injured.
There was the failure by Greater Manchester Fire and Rescue Service (GMFRS) to arrive on scene and make the contribution in removing the injured that its officers could have done.
There was the failure of anyone in a senior position in GMFRS to take a grip of the situation during the critical period of the response.
Addressing the response of GMP, NWAS and GMFRS, Sir John Saunders said each had their own risk assessments, which meant all had reached different conclusions.
He said the “different approaches to risk were starkly apparent”, and were reflected by the locations in which each was prepared to operate.
GMP and British Transport Police officers entered the City Room immediately, with many remaining there for some time.
Only three paramedics were present in the room - and entered voluntarily, while the fire service did not until two hours after.
What does the report say about North West Ambulance?
Addressing the failures by NWAS the report found that while paramedics and staff made “an important and positive contribution” to the response there were “very substantial problems”.
A breakdown in communication between the emergency services meant the NWAS Operational Commander, Daniel Smith, was “unduly cautious” when it came to deploying paramedics, wrongly believing there may still be an active-shooter.
Mr Smith also “wrongly believed he was prohibited from sending non-specialist paramedics to the City Room”.
That belief, the report said, meant casualties did not see paramedics “in the numbers hoped for and expected”.
Only one paramedic, Patrick Ennis, was present for the first 44 minutes following the attack. He was then joined by Hazardous Area Response Team (HART) members, Lea Vaughan and Chris Hargreaves.
Sir John Saunders added: “Even with the addition of two HART members, there were too few paramedics in the City Room. Three was simply not enough.”
Had the Operational Commander spoken to services inside the City Room, he “would have known it was safe enough to send them in”, the report concluded.
The report also found NWAS did not use available stretchers to remove casualties in a safe way, and the crowd barriers and tables that were used were “a painful and unsafe way of moving the injured”.
What does the report say about Greater Manchester Police?
Sir John Saunders found GMP did not lead the response as expected, either from their own training or guidance given to them.
This in turn meant the force failed to immediately declare a Major Incident, or inform other emergency services it had enacted Operation Plato - the code name for the pre-planned emergency response to a marauding terrorist.
That failure “fundamentally undermined the joint response to the Attack”, the report said.
GMP Force Duty Officer (FDO) Dale Sexton, who was the main point of contact for all services, quickly became “overburdened by the number of tasks” he had to do, which the report found, “had a direct impact on the effectiveness of the emergency response”.
Inspector Sexton’s failures were “serious and far reaching”, while “others within the GMP command structure did not make the contribution that the public was entitled to expect”, Sir John Saunders said.
FDO Sexton told a previous inquiry he ‘forgot about the other services’ when it came to declaring Operation Plato. But, Sir John Saunders concluded his decision to conceal that information was an oversight, rather than a deliberate one.
Sir John Saunders concluded however officers on the ground showed courage and resourcefulness, with firearms officers arriving quickly and in numbers.
Casualties would also have been helped had unarmed officers received adequate first aid training.
What does the report say about Greater Manchester Fire and Rescue Service?
The report found the fire service failed to “take a grip of the situation”, with the first instincts of Station Manager Andy Berry to move crews away from the scene instead of towards it.
Mr Berry assumed GMFRS was responding to marauding terrorists with firearms, and, when he was unable to get hold of FDO Sexton he continued to assume that was the case.
Sir John Saunders said: “The unavailability of the FDO played a very significant role.
“Even allowing for this, the response of an entire fire and rescue service should not stall just because one person does not answer the telephone.”
The failure by GMFRS to deploy officers meant the injured could not be moved to hospital and given the treatment they needed, Sir John Saunders added.
The service acknowledged it was “risk averse”, but the report concluded a number of the firefighters who gave evidence were not, and instead were “angry” and “ashamed” they did not get to join the rescue, and “desperately wanted to get involved”.
What does the report recommend?
Following the 900-page report, Sir John Saunders made 149 recommendations, including regularly reviewing major incident plans - at least every six months - and the involvement of non-specialists in multi-agency training exercises.
He also said there should be the introduction of regular ‘high-fidelity training’ to give emergency responders “better experience of the stress, pressure and pace of a no-notice attack.”
The report also recommended the overarching emergency service bodies should try to create a culture of attending an incident immediately - rather than being risk averse - unless there is good reason not to.
In total, 291 witnesses and experts have given evidence, 172,000 documents have been examined and today (3 November) the long-awaited report into the emergency response has been published.
Twenty-two people were killed and hundreds were injured when suicide bomber Salman Abedi detonated a device shortly after an Ariana Grande concert on 22 May 2017.
Speaking after the report findings were published, Chief Constable Stephen Watson said he was "truly sorry" for Greater Manchester Police's "failings" on the night of the attack.
He said: "Sadly, GMP’s combined failings were significant and contributed to the loss of life. To the families and loved ones of those who died, I am truly sorry.
"It is important that we now take the time to carefully consider every facet to the volume published today and we have a dedicated team already in place for this purpose.
"But I also want to assure the public that we have not waited for the publication of today’s findings before making a number of substantial and beneficial changes to our operational model."
He continued to say that he was "already able to confidently state that GMP is now in a fundamentally stronger position than it was in 2017, should we be called upon to lead and respond to a similarly challenging event".
Greater Manchester Fire and Rescue Service chief fire officer David Russel said the inquiry report made for "very difficult reading".
He said the service's response on the night of the attack was "wholly inadequate and totally ineffective".
Mr Russel said the service "let the families and the public down in their time of need" and he was "truly sorry" for that.
North West Ambulance Service chief executive Daren Mochrie said its failures "weigh heavily on us as individuals and as an organisation".
He said: “On occasions like this, the word sorry has the risk of sounding hollow.
"Nevertheless, I want to make it clear that while our actions were well-intentioned, we apologise wholeheartedly for our failures.”