Injured father Martin Hibbert was was not moved from the foyer for almost an hour, and said a blanket was placed over his teenage daughter as if she were dead, although she was alive and survived her injuries.
“There are still no answers [about the wait for treatment],” he told the BBC. “What I get so angry about is if I had lost consciousness or had not managed to stay alive, or to sum up the energy to signal that she was still breathing, my daughter wouldn't be here with us now.
”Somebody made a decision not to allow people to come in. Paramedics that could have dealt with that situation better with the right equipment.”
Ruth Murrell, who was injured alongside her daughter Emily, said “things could have been different”.
“Knowing that has conjured up a real mixture of feelings in us – anger, upset – but at the same time, people who did things
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Kerslake Report into Manchester Arena bomb finds firefighters were held back by bosses for two hours on a night of 'extraordinary heroism'
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The story of the response on the night was overall ‘overwhelmingly positive’ with police, paramedics, arena staff and the council praised for their incredible actions following the horrific events of May 22
BY JENNIFER WILLIAMS 22:23, 27 MAR 2018
Fire crews desperate to help victims of the Manchester Arena bombing were held back by their bosses for two hours amid mistakes that brought the service ‘to the brink of failure’.
While paramedics and armed police were on the scene of last May’s attack within ten minutes, the fire service was in ‘paralysis’, according to Lord Bob Kerslake’s report into the atrocity, published today.
Frustrated crews - many of whom had heard the blast from their city centre post - were instead sent away to a station in Beswick, three miles away, only to later be sent back into town again amid confusion.
Lord Kerslake’s review concludes the actions of then-chief officer Peter O’Reilly ‘played a key role’ in the delays, while concluding ‘poor communication and poor procedures’ within the service were more broadly at fault.
The review also finds that Vodafone, which holds the national Home Office contract for emergency post-disaster hotlines, experienced a ‘catastrophic’ technical failure on the night that meant no fully-functioning phone number could be set up for desperate people in search of information.
Some relatives were forced to drive around hospitals in search of loved ones instead.
His review also criticises Greater Manchester Police for a breakdown in communication with other agencies that saw key officers overloaded with responsibilities and the fire service struggling to get key updates.
Nevertheless the story of the response on the night was overall ‘overwhelmingly positive’, it finds.
The review praises GMP’s duty officer, who made a ‘life or death’ decision to keep first responders at the scene rather than evacuate in the face of a possible further attack.
It paints a picture of extraordinary heroism, including from British Transport Police, rail staff, arena security, paramedics and members of the public, who ran straight into danger despite not yet knowing whether the arena’s foyer was safe to enter.
And it depicts in detail the experiences of victims and families - many of whom spoke directly to the review about the painful hours, days and weeks that followed the atrocity, which claimed the lives of 22 people.
Their experiences include frustrations with delayed mental health treatment and press intrusion, set alongside praise for the way Manchester as a city rallied round in the bomb’s aftermath.
“The people of Manchester did a fantastic job of boosting the morale of those affected,” one relative told the review, “making us feel as though we were not alone.”
The report, set up by Greater Manchester mayor Andy Burnham in the wake of the bomb, seeks to identify both the strengths and weaknesses in how the disaster was tackled.
Here are the key findings on each aspect of the response to the Manchester Arena attack:
The fire service
The fire service liaison officer decided relocating crews from the city centre to Philips Park station was the safest option, in case a marauding terrorist proved to be on the loose(Image: Joel Goodman)
After months of speculation about its role in the attack’s response, Greater Manchester Fire and Rescue service is singled out for stinging criticism in the report.
It finds the service provided ‘no meaningful role in the response to the attack for nearly two hours’, despite usually attending incidents within little over five-and-a-half minutes.
As a result crews and control room staff felt ‘they had let down the people of Greater Manchester and other visitors to the city that night’, it says, adding that ‘a valuable resource was not available to assist on the scene’ because the service was ‘out of the loop’.
Following the bomb’s detonation at 10.31pm, the report finds communication between fire and police was patchy, with the fire service’s designated liaison officer - who lived 22 miles away - struggling to reach the police’s duty officer for key information about the situation on the ground.
As a result, the fire service liaison officer decided relocating crews from the city centre to Philips Park station in Beswick, three miles from the arena, was the safest option, in case a marauding terrorist proved to be on the loose.
However the review found that having failed to get through to GMP command on the phone, for reasons that were ‘obvious’ due to the unfolding situation, he did little else to find out the precise picture.
“The...liaison officer appears to have acted as though he had no other options available to him through which to gain situational awareness himself or for others to get it for him,” it finds.
Greater Manchester’s chief fire officer Peter O’Reilly
“It has been disappointing for the panel to learn that, in this instance, specialist ‘inter-agency liaison’ appeared to count for nothing other than telephoning the GMP force duty officer and when this failed, the whole GMFRS response to the scene was effectively brought to a point of paralysis, which was to last until 00:21hrs when pumps were finally deployed forward.”
Meanwhile then-county fire officer Peter O’Reilly - the most senior officer in the service - ‘played a key role in delaying opportunities’ to coordinate with other services, such as the police, finds the report.
He did not arrive at fire command in Swinton until nearly midnight, having chosen not to go to the joint ‘gold command’ unit set up for all agencies at police HQ, where senior ambulance, health, council and transport officials had all gathered.
Asked why that was the case, he told the panel that his previous experience suggested gold command to be ‘chaos’.
But the review remains unconvinced, finding his reasons ‘insufficient’.
It finds the behaviour of senior officers ‘surprising’ and concludes that, when combined, the lack of their understanding of events on the ground - combined with the failure to deploy crews - demonstrates ‘an organisation brought to the point of failure by a reversion, under pressure, to a state of single-agency thinking’.
“It is the panel’s belief that this was underpinned by the service’s culture,” it adds, later adding that it must review the way it works with other agencies.
The chief fire officer eventually took direct control of deploying crews just as his colleagues - now on the ground - were starting to get a grasp of the situation and were about to order in the brigade’s ‘special response teams’, firefighters trained and equipped to deal with terrorist attacks.
But this was stopped by the chief, who held them back and instead ordered three regular pumps to move to the scene.
“This order caused the special response teams considerable concern,” says the report.
It adds: “The panel believes that the chief fire officer was frustrated that he had not been informed about the incident earlier by North West Fire Control. This led him to believe that he should intervene with tactical decision making at this point.”
When the regular crews finally arrived at the arena, nearly two hours after the blast, they suffered a further delay entering the building itself - because the officer on the ground now had to await the chief officer’s permission for them to go in.
Officials from other blue-light services ‘could see the immense frustration on the firefighters’ faces at their still being restrained from helping the other responders, who were clearly visible to them all treating the casualties within the station building’, it adds.
Crews eventually entered the arena two hours and six minutes after the bomb went off.
The report makes more than a dozen recommendations to the fire service, including around the role of liaison officers and joint working with other agencies.
At the time of writing Mr O’Reilly, who took early retirement last month, had not yet been contacted for comment.
The review however said it could make 'no comment' on whether the presence of fire crews at the scene earlier on the night 'would have affected any casualty's 'survivability', saying it would be a matter for a coroner at inquest.
Inquest hearings have been adjourned until June. But the report said that had fire crews been deployed to rendezvous points 'at the earliest opportunity', the evacuation of casualties 'could have been achieved more efficiently and possibly more rapidly'. The report only focused on the response to the attack in the nine days that followed.
The police
Greater Manchester Police are praised for deploying armed officers to the scene ‘remarkably fast’, with the first arriving within ten minutes.
With little concrete information available in the early stages of the attack about further threats, the force duty officer - the inspector in charge of initially coordinating the response - had to make a judgement call as to whether first responders should stay in the foyer helping casualties.
In the end he made a ‘life or death’ decision to keep them there.
“The force duty officer decided that to tell these responders to evacuate would have been unconscionable,” says the report, adding that it fully supports the decision.
Shortly after the attack GMP were also dealing with the lockdown of Piccadilly Station amid fears of a further atrocity, a suspicious package at North Manchester General Hospital, a possible gunman on the loose at the cathedral and the lockdown of the National Football Museum following an addition security alert.
The report finds that both the force duty officer and gold command - the officer in charge of strategic decisions on the night - were having to juggle too much, however, leaving too much hinging on a couple of individuals.
That led to a ‘shortfall’ in communication with other agencies such as the fire service over whether or not there was a continued terror threat, leading to ‘confusion’ - meaning a ‘critical’ opportunity to share vital information was lost.
It also concludes that police IT systems nationally need updating, since GMP could not electronically track the whereabouts of officers from other forces brought in as part of the immediate emergency response.
But ‘selfless willingness’ of police officers on the ground, along with ambulance staff, British Transport Police, and arena staff, meant the lack of fire service attendance did not throw the situation into chaos, it finds.
The report also heaps praise on GMP’s family liaison officers, the key point of contact for families in the aftermath of the attack.
Described as a ‘vital source of support and comfort to many of the families which went well beyond their formal roles’, the review says it heard many examples of how the officers helped the shocked and bereaved.
“This is just one example of the way in which families were put first by the different agencies involved in responding to the attack,” it says.
The ambulance service
Paramedics outside Manchester Arena(Image: Getty Images Europe)
The first advanced paramedic was inside the arena within 11 minutes - and on learning that the incident was a ‘suicide bomber’, walked straight up the stairs from the concourse and into the foyer, where he started triaging casualties.
In the immediate aftermath two technicians also went into the foyer without bulletproof vests, ‘despite the fact it hadn’t been declared safe’, says the report.
Advertising placards, metal poles and other improvised bits and pieces were then used to carry the wounded out of the arena foyer and onto the concourse.
“At this time, there were no stretchers available, so the responders rapidly improvised by using display boards and metal crowd barriers to carry the injured,” says the report, adding that witnesses were ‘amazed’ at the speed of the teamwork.
Once ambulance crews arrived, the ranking officer on the ground took the ‘pragmatic’ decision to allow the makeshift evacuation to continue into the station, so that casualties could be safely treated by crews on the concourse, away from any potential emerging threat.
While the review finds this was the correct decision, it says many who contributed to the review expressed their concerns.
However it finds the initial decision was based on ‘clear and logical reasoning’ by the advanced paramedic, who felt the foyer was dangerous, while the presence of armed police would mean ‘the process would be made more difficult for ambulance crews to come up and take away the casualties according to priority’.
“The panel understands that this perception of delay was frustrating and disorientating for the injured and other members of the public that were there,” it concludes.
“However, the pause that was introduced by the period of casualty stabilisation in the casualty clearing station actually gave the receiving hospitals the vital time they needed to clear and prepare operating theatres and to assemble operating teams.
“In addition, the casualty clearing station provided a place for essential triage to take place to ensure the best possible onwards care, and provide the means for the most effective utilisation of NWAS resources (ambulance staff) for onward dispersal of patients in the most challenging circumstances.
“Importantly, it ensured that casualties went to the hospital with the most appropriate specialists and facilities to treat their specific injuries.”
Concluding, it suggests key venues should have easy-to-use stretcher equipment that can be used in the aftermath of a major disaster when casualties need to be removed from a scene fast.
“All major transport hubs and public venues should possess and provide immediate access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks,” it says.
Emergency services should also look at making such equipment readily available to staff, it adds.
It also notes the lack of the fire service’s special response crews - who had specific stretchers designed to evacuate from disaster zones fast.
By the time the fire service arrived all casualties had been evacuated, it says, but adds: “It is important here to repeat, however, that the panel can make no comment on whether the presence of GMFRS crews earlier on the night would have affected any casualty’s survivability.”
The British Transport Police, Northern Rail and arena staff
First on the scene, dozens of security and transport workers also bravely rushed into danger.
Four officers from British Transport Police were first to get to the foyer, arriving within 30 seconds.
Praised as being among the ‘unsung heroes’ of the atrocity, the report says BTP took one young casualty to hospital themselves amid concerns for her life.
“The panel was impressed to hear of the way in which these officers immediately started to manage the scene and assist arena staff and members of the public in treating casualties before further assistance arrived,” it says.
Officers then helped with the makeshift stretchering of victims in a ‘seamless’ joint operation with GMP, despite fears that there may be another bomber on the loose.
Rail employees leapt to help, too.
“Immediately on hearing the detonation, fifteen Northern staff ran to the site of the explosion from Victoria train station,” it adds.
“These staff were not medically qualified staff but had received standard first aid at work training.
“Normal working procedure is for staff to evacuate and stay safe but this was not followed on the night. “Once the magnitude of the event was conveyed by the staff in the foyer area to their control room, more staff were sent with additional medical supplies.
“The staff were asked to leave for their own safety by police officers but they refused, choosing to stay with the casualties.”
Despite not knowing whether the foyer was safe, more than a dozen first aiders working from security firm Showsec also joined.
One family member described the arena’s security staff as forming ‘a human wall to stop people going before the smoke’.
The emergency hotline
The report finds a government contract with Vodafone, intended to provide emergency public hotlines in disaster situations, resulted in ‘complete’ and ‘catastrophic failure’.
One of the firm’s servers failed on the night, meaning police were unable to set up the 0800 number they had planned for people seeking information on loved ones.
An 0161 number was eventually installed by 3am, but was unable to handle the volume of calls a specialist hotline would normally case.
“This failure was a cause of significant stress and upset on the night to the families involved, who were seeking to find out more about the situation of their loved ones,” it says.
“A number were reduced to a frantic search around the hospitals of Greater Manchester to find out more.”
The report reveals the human impact of the failure, which it also says staff at the firm - and its sub-contractor Content Guru - had ‘little knowledge’ of the police’s needs through the contract.
Vodafone’s chief executive has since apologised for the failure and promised it will not happen again.
But the review reveals the human impact of such technological failures on those desperately seeking information on May 22 and 23.
“The family called the helpline seven times and were given seven different reference numbers,” according to one account.
“The helpline contacted me the following afternoon to ask if X had been found but offered no other help,” describes another relative.
Vodafone has held the national contract for the service since 2009 and the report recommends the Home Office ‘urgently secure appropriate guarantees from Vodafone that the necessary fall-back and disaster recovery arrangements are in place to address the failures’.
The council and the mayor
The report says the civic response of the city-region 'was by any measure exceptional'(Image: PA)
The report praises the response of Manchester council and the mayor’s office in providing both civic leadership and specific support in the aftermath.
“The civic response of the city-region was by any measure exceptional and demonstrated the enormous strength of the civic leadership and partnership in Greater Manchester.
“The early press conference by the leader of Manchester city council and the Mayor of Greater Manchester, through to the vigil attended by thousands in front of the town hall, stands testament to the determination that Greater Manchester would stay open for business.
“The strength of the civic leadership had a profound impact on how events played out in the subsequent days following the attack.”
Councillors and town hall officers got involved early and everything kicked in smoothly, adds the report.
Council leader Sir Richard Leese told the panel he was clear the Greater Manchester Run should go ahead as usual the following weekend.
“The council leader told the panel of his experience visiting a deserted Paris two weeks after the terrorist attack in that city and his determination that the run should go ahead to provide the message that Manchester was open for business,” says the review.
Families also praised the centre set up by the council at the Etihad in the early hours of the following morning, where people could gather while awaiting news of relatives and loved ones.
“The arrangements at the Etihad were excellent … it couldn’t have been handled better,” said one family member.
“It all clicked together … blankets, chargers, paracetamol … everything you could need,” said another.
The town hall also carefully and ‘sensitively’ removed all the flowers from Albert Square to St Ann’s Square, says the review, which praises its ‘highly effective leadership’, including on the We Love Manchester fundraising campaign.
The press
The Manchester Evening News is praised for responsible reporting and its role in raising millions for the We Love Manchester Fund
Many families reported feeling ‘hounded’ by the media during the hours and days that followed the attack, although the Manchester Evening News is singled out for praise by the report.
The review panel describes itself as ‘shocked and dismayed’ by the level of press intrusion in some cases, with one family member describing how a picture was taken of them receiving news of their bereavement through a window.
“At the hospitals, families attending to look for missing loved ones and visiting the injured described having to force their way through scrums of reporters who ‘wouldn’t take no for an answer’,” says the review.
“One mother, who was herself seriously injured as was her daughter, spoke of the press ringing her on her mobile whilst she was recovering in hospital.
“A member of staff on her ward spoke of a note offering £2,000 for information being included in a tin of biscuits given to the staff.”
Police officers in St Ann's Square(Image: PA)
Another relative describes a reporter ‘ramming a foot in the doorway’ of their home, while the review cites two reported examples of impersonation - one suspected journalist pretending to be a bereavement nurse and the second, a police officer.
The Manchester Evening News is praised for responsible reporting and its role in raising millions for the We Love Manchester Fund.
“The information in the Manchester Evening News was correct but when national press picked it up it would change,” said one family member, while another described their local press as ‘amazing’.
“A number of families spoke in praise of sympathetic reporting by the Manchester Evening News and other papers local to the bereaved,” says the report.
The review makes a number of recommendations in relation to the media, including that the Independent Press Standards Organisation - the press regulator - introduce new guidelines on reporting the aftermath of terror attacks.
The health service
Families interviewed for the review were full of praise for hospitals involved in scrambling to treat victims on the night.
In some cases as doctors and nurses rushed to set up emergency procedures some parties ‘already got to leave of their own volition’ having heard the news.
“The NHS staff were amazing … genuinely cared for and supported … nurses held my hand during flashbacks,” said one concertgoer.
“Medical teams were waiting to assess and treat people as they arrived … medical staff updated us every fifteen minutes on his progress,” added a family member.
But numerous families felt a lack of mental health support was made available, particularly for children and young people.
“Respondents identified services for children and young people as being particularly hard to access, with waiting lists of several months, says the report, citing one example of a young woman who faced an eight-month wait for post traumatic stress disorder counselling.
“The response from schools varied, with some respondents stating that their children had been supported well at school with specialist psychological provision, whilst others described how the school had failed to recognise the child’s trauma.”
The local ‘resilience hub’, which was intended to coordinate their care, comes in for praise - but many people still felt they were waiting too long for support.
“My place of work paid for private counselling sessions,” said one victim.
“I was a mess and did not stop crying for the first three sessions. I have not been in work since the attack. I spend most of my time talking to a war veteran who gives me support.”
The report recommends future emergency planning for major incidents should include proper mental health provision for both children and adults.
Manchester
Manchester emerges from the report as a city that rallied round its grieving and wounded, including through the We Love Manchester fund and One Love concert.
The review itself describes just how quickly the community mobilised, adding: “The day following the attack saw hundreds queuing in Manchester to donate blood.
“Hospitals and police maintaining the cordon received many donations of food from private individuals, community groups and local businesses.”
For bereaved families and victims themselves, the city is described as a source of strength.
“The response from the city of Manchester and its people was incredible,” said one family member interviewed by the panel.
“I loved the community spirit of Manchester, how they all came together in defiance and raised money all from good will,” said another.
The One Love Manchester concert at Old Trafford(Image: PA)
“Whoever we spoke to, we felt as though we were being listened to, that they made sure they had time for us. You could tell that they cared,” said a third.
The report repeatedly highlights the ‘selfless’ acts of Mancunians who rushed to help people in their hour of need, either in the immediate aftermath or the days that followed, including through the vigil on May 23.
“I feel that the vigil, poem and benefit concert showed a lot of support and community spirit, made it seem like people did care about what happened,” said another contributor.
And one parent told how taking their daughter to the One Love gig helped her deal with PTSD symptoms and was ‘one of the most overwhelming and uplifting experiences of my life’, adding: “My daughter now considers Manchester her spiritual home, her favourite place.”