Care worker John Atkinson, 28, was six metres away when the explosion went off in the City Room foyer of the venue at the end of an Ariana Grande concert on the evening of May 22, 2017.
A member of the public used his wife’s belt as a tourniquet on Mr Atkinson’s leg as he lay bleeding in agony on the City Room floor for up to 50 minutes, during which time he told a police officer: “I’m gonna die.”
Mr Atkinson’s family said it “should simply never have been allowed to happen”, adding: “It is crystal clear that due to those failings, John died from injuries that he could and should have survived.”
Only three paramedics entered the City Room on the night and none were seen to attend or assist Mr Atkinson, before he was 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.
Manchester Arena Inquiry chairman Sir John Saunders delivered a scathing report on the response of the emergency services.
He said: “Significant aspects of the emergency response on 22nd May 2017 went wrong. 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.”
In a statement released after the report’s publication, Mr Atkinson’s family said: “It is now clear beyond any doubt that on the night of the bombing, John was totally failed at every stage, both by the private medical providers at the Arena – ETUK and the emergency services.
“It is crystal clear that due to those failings, John died from injuries that he could and should have survived. 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.”
The statement added: “The apology from North West Ambulance Service means 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. We will be watching to see what happens now.”
Chief Fire Officer for Greater Manchester Fire and Rescue Service, Dave Russel, said: “I want to start by wholeheartedly apologising. Our response that night was wholly inadequate and totally ineffective and that will forever be a matter of deep regret for our service.
“We let families and the public down in their hour of need and for that I am truly sorry. I want them to know that I fully accept the inquiry’s criticisms of our service and accept the recommendations in full.
“We were simply too late with our response. I want the public to know this will never happen again.”
Sir John said it was “highly unlikely” the bombing’s youngest victim, eight-year-old Saffie-Rose Roussos , would have survived her injuries with “only a remote possibility she could have survived with different treatment and care.”
The initial command of the incident was taken by Greater Manchester Police’s force duty officer, Inspector Dale Sexton, but he “quickly became overburdened by the number of tasks he had to undertake”, the report found.
Sir John said: “This had a direct impact on the effectiveness of the emergency response. It affected who received information, what resources were made available and the decisions of other commanders.”
Following erroneous reports of gunshots, Inspector Sexton declared Operation Plato – a pre-arranged plan for a suspected marauding terrorist – but he “overlooked” telling other emergency services.
“It affected the ability of the emergency services to work together by jointly understanding the risks,” said Sir John.
“In the first quarter of an hour after the attack and thereafter, there was substantial confusion over the location of an RVP (rendezvous point). Each emergency service chose its own.”
Fire crews took more than two hours to even attend the incident after station manager Andy Berry chose to mobilise resources three miles from the Arena amid fears over safety.
Sir John said: “The effect … was that the fire appliances at Manchester Central Fire Station drove away from, not towards, the incident. While driving away, the Manchester Central fire appliances drove past ambulances travelling in the opposite direction.”
By 10:50pm the City Room was a “cold zone”, said Sir John, where it was assessed there was no immediate threat to life from an armed terrorist. He said that did not mean the City Room was entirely safe, but a police chief had deemed it “safe enough” for non specialist emergency responders and members of the public to be in.
He said: “Not only should this have been the view across the emergency services, based on the available information, but it was in fact correct, as is now known for certain.”
As the post-attack “golden hour” ended, the emergency response had failed to achieve effective evacuation.
Just after midnight there were still 36 casualties waiting to go to hospital, with the last casualty departing at 2:50am on May 23.
Sir John said: “To those who experienced it, this period of time will have seemed interminable. It must not happen again.”
He said the evidence was “conclusive” there was no possibility that 20 of the 22 victims could have survived the “murderous actions” of Salman Abedi, referred to sparingly by his initials in the 874-page report.
Sir John said: “In the case of John Atkinson, his injuries were survivable. Had he received the care and treatment he should have, it is likely he would have survived. It is likely that inadequacies in the emergency response prevented his survival.”
He said Mr Atkinson would probably have survived if an “intervention sufficient to slow substantially or stop bleeding” had been undertaken up to 45 minutes after the blast.
Staff at the Arena owner SMG’s then medical provider ETUK should have been able to apply medical tourniquets to both his legs, along with dressings to his wounds.
More paramedics in the City Room would likely have identified the need for urgent treatment and/or evacuation, he said, while more ambulances at the scene would also have meant quicker care.
Sir John said Mr Atkinson would probably have been also prioritised quicker for evacuation if firefighters had arrived when they should have.
Lawyers for eight-year-old Saffie-Rose Roussos had submitted during the inquiry that her injuries were potentially survivable.
Sir John concluded: “In the case of Saffie-Rose Roussos, it is highly unlikely that she could have survived her injuries. There was only a remote possibility she could have survived with different treatment and care.
“I do not consider that the evidence enables me to say she had absolutely no chance of survival if the most comprehensive and advanced medical treatment had been initiated immediately after injury.”
The third and final report will focus on the radicalisation of Abedi and what the intelligence services and counter-terrorism police knew, and if they could have prevented the attack. It will be published at a later date.