By David Young-
A public inquiry has concluded that two of the 22 people who lost their lives on the night of May 22, 2017, at the hands of terrorist Salman Abedi could have been saved if they had received life-saving care in time, and if the police had responded on time.
Sir John Saunders, the inquiry chairman, found there were “very significant” failings by the police, “very substantial problems” with the ambulance service response, and a “risk averse” approach from the fire service.
Most damningly, Saunders said a “substantial failure by Greater Manchester Police at every level of armed command” helped lead to the death of John Atkinson, 28.
Armed police arrived quickly on the scene and by 10.50pm, 19 minutes after Abedi’s bomb exploded, had established the foyer, or City Room, outside the venue was safe.
Under normal circumstances, this should have been formally declared by the police and communicated to the ambulance and fire services to allow an influx of specialist paramedic and rescue teams.
“That should have saved John Atkinson’s life,” the report concluded.
Instead, it took 47 minutes to rescue the gravely injured Mr Atkinson and he suffered a cardiac arrest after being left at a casualty-clearing station outside the adjacent Manchester Victoria station
Failures in planning, coordination and the response across various emergency services contributed to the avoidable death of John Atkinson, a carer for adults with autism, said the chair of the inquiry, Sir John Saunders.
Atkinson, 28, emerged conscious from the blast on 22 May 2017 but died after waiting an hour and 16 minutes for medical treatment for his severe leg injuries and having a heart attack.
A series of miscommunications and poor decisions meant only three paramedics entered the arena’s foyer that night to help the 91 people lying seriously injured. None treated Atkinson, the inquiry found. The fire service did not show up until more than two hours after the blast, denying survivors further first aid expertise.
“Had [Atkinson] received the treatment and care he should have, it is highly likely he would have survived,” said Saunders, a retired high court judge.
He said there was a “remote possibility” that eight-year-old Saffie‐Rose Roussos could have been saved if the rescue operation had been conducted differently. She drifted in and out of consciousness for 26 minutes but no tourniquets or leg splints were applied to her injuries.
Saunders found “failures to prepare”, “inadequacies in training” and that “the performance of the emergency services was far below the standard it should have been”. But he concluded that none of the bomber Salman Abedi’s other 20 victims could have survived their injuries, regardless of the treatment they received.
In a report, he said the response fell “far below” what was expected.
Mr Atkinson’s family said it was clear he “could and should have survived”.
Inadequate
Delivering the second of three reports into what happened on the night, Sir John said everyone involved in the emergency response “no doubt thought they were doing their best, [but] in some cases . . . their best was not good enough”.
He said “significant aspects” of the emergency response “went wrong”, adding: “This should not have happened.”
“Some of what went wrong had serious and, in the case of John Atkinson, fatal consequences for those directly affected by the explosion,” he said.
The inquiry has heard that Ron Blake, a member of the public in the foyer, used his wife’s belt as a tourniquet on Mr Atkinson’s leg as he lay bleeding in agony on the floor for up to 50 minutes, during which time he told a police officer: “I’m gonna die.”
The 28-year-old was then carried on a makeshift stretcher to a casualty clearing area where he later suffered a cardiac arrest – one hour and 16 minutes after the blast.
Sir John said it was “likely that inadequacies in the emergency response prevented” Mr Atkinson’s survival.
Clear Beyond Doubt
Speaking after the publication of the report, Mr Atkinson’s family said it was now “clear beyond any doubt” that on the night of the bombing he had been “totally failed at every stage”
“It is crystal clear that due to those failings, John died from injuries that he could and should have survived,” they said.
“As we know from witnesses, John kept asking if he was going to die.
“John must have known that he was dying and the pain that causes us is too great to put into words.
“This should simply never have been allowed to happen.”
They added that an apology they had received from North West Ambulance Service meant “nothing unless they act rapidly on this report to ensure that no family ever has to go through this horrific experience again”.
“Talk is cheap and actions speak louder than words,” they said, adding: “We will be watching to see what happens
Sir John said he could not rule out the possibility that both Saffie-Rose Roussos and John Atkinson could have survived
Considering the other evidence he heard, Sir John also said he could not rule out the possibility that the youngest victim of the attack, eight-year-old Saffie-Rose Roussos, could have been saved with better treatment.
He said while it was “highly unlikely” she could have lived, he could not say that she had “absolutely no chance of survival if the most comprehensive and advanced medical treatment had been initiated immediately after injury”.
He added that the inquiry had found the other 20 victims suffered injuries that they could not have survived and he was “sure that inadequacies in the response did not fail to prevent their deaths”.
His report also said two of the most senior Greater Manchester Police commanders on the night “made no effective contribution to the emergency response” and highlighted that the force duty officer, who was responsible for initial command, was overwhelmed and overburdened.
Human Cost
The human cost of the failed emergency response was potentially two lives. John Atkinson, 28, and Saffie-Rose Rousses, 8.
Mr Atkinson, the inquiry concluded, “would probably have survived if the emergency response was better”.
He had been approximately six metres from the explosion and suffered 47 external injuries, mainly to his legs.
A member of the public applied a tourniquet to Mr Atkinson’s legs to stem the bleeding, but it was 47 minutes until he was carried from the City Room.
He arrived at the casualty-clearing area 52 minutes after the explosion and remained there for a further 24 minutes until he suffered a cardiac arrest.
The report found that if a proper tourniquet was applied to Mr Atkinson by a paramedic at an earlier stage, he probably would have survived.
It said: “In his opening remarks at the beginning of the oral evidence hearings, Counsel to the Inquiry explained that I would examine whether there were any inadequacies in the emergency response. I have found that there were.
“He went on to say that, if those inadequacies, or any one of them, led to the loss of even a single life, that would be entirely unacceptable.
“They did. John Atkinson would probably have survived had it not been for inadequacies in the emergency response.”8For Saffie-Rose, the situation was less clear cut. She had suffered 69 external injuries and remained in the City Room for 26 minutes, drifting in and out of consciousness.
She eventually arrived at the Royal Manchester Children’s Hospital around 52 minutes after the explosion. She was declared dead at 11.40pm.
No Up To Date Plan
The police did not have an up-to-date plan of the Manchester Arena complex and so did not know where everything was. The BTP gold commander on the night of the attack was based in the south of England and also did not know the geography of the arena.
There were serious issues for emergency services trying to contact GMP’s force duty officer (FDO), Insp Dale Sexton, because his mobile number was the same one used by journalists seeking information on the atrocity.
Sexton made a “significant mistake” in not swiftly declaring a major incident. His error was not rectified until nearly 1pm the following day
.Instead, Sexton declared Operation Plato, the emergency services’ designation for the response to an attack by a marauding terrorist with a firearm. (Although there turned out to be no armed terrorists within the arena or wider area, Saunders concluded that this was a reasonable decision because there had been some reports of gunshots.)
Another senior GMP officer – temporary superintendent Arif Nawaz – was deemed “not competent” by the inquiry after he admitting pretending to know what Operation Plato was that night, when he really had “no idea”