A MAJOR report into the Manchester Arena terror attack is calling for better communication between emergency service control rooms after finding there was a two-hour delay in deploying firefighters.

The fire service was effectively "outside of the loop" of police and ambulance emergency responders so firefighters, some who heard the bomb go off, and trained in first-aid and terror scenarios with specialist equipment, did not get permission to go to the scene until hours after the suicide bombing, despite being stationed half a mile away.

The report is critical, stating that "strategic oversights" by police commanders led to confusion over whether an "active shooter" was on the loose and poor communications between the police and Greater Manchester Fire and Rescue Service meant fire crews only arrived two hours and six minutes after the bombing, which left 22 dead, including Bury schoolgirl Olivia Campbell-Hardy and Radcliffe man John Atkinson, and scores injured.

Fire service apology

The 226-page report by Lord Bob Kerslake was commissioned by Andy Burnham, the mayor of Greater Manchester, to assess the preparedness and emergency response to the attack last year.

Lord Kerslake stated: “There is a lot to be proud of in the response to the attack, both for the city region of Greater Manchester, and for the emergency services.

"There were hundreds, if not thousands, of individual acts of bravery and selflessness.

Police Chief Constable's response

“But it’s also vital to learn the lessons around things that did not go so well. It matters not just for the people of Greater Manchester and beyond who were caught up in the terrible events of that night, but also for places that might be caught up in such an attack in the future.

“I would like to thank all of those who contributed to this report. There was honesty, there was soul-searching, and there was a determination that their insight would benefit others in the future.”

The report makes 50 recommendations but states its panel of experts was not to answer the question of, "would the earlier arrival of GMFRS at the scene have made any difference to the medical outcomes of the injured?"

"This is a question that only the coronial inquests can decide," the report states.

But it says firefighters "would have been much better placed to support and, potentially, to accelerate the evacuation of casualties from the foyer," if they had gone to the scene.

Suicide bomber Salman Abedi detonated his home-made device at 10.31pm on May 22 last year, as 14,000 people streamed out of Manchester Arena at the end of an Ariana Grande concert.

Officers from British Transport Police were on scene one minute later and declared a major incident by 10.39pm.

The police duty inspector in the GMP force control room declared Operation Plato, a pre-arranged plan when it is suspected a marauding armed terrorist may be on the loose, and assumed, wrongly, that other agencies were aware.

But he was praised for taking one of the most crucial "life or death" decisions of the night, a "key use of discretion" to override the rules and allow paramedics and police to continue treating the injured even though they may be in danger of further attacks.

However, Greater Manchester Fire and Rescue Service and the North West Ambulance Service were only informed an hour and a half later and by then Operation Plato was effectively put on "stand by" as it emerged the attack was from a single suicide bomber and not the prelude to further armed attacks.

Armed police and 12 ambulances were on the scene within 20 minutes but a shortage of stretchers hampered ferrying the injured from the foyer to a casualty area on the station concourse.

The senior fire officer on duty, a National Inter-Agency Liaison Officer, stuck to rules which state that emergency responders should be kept 500 metres away from any suspected "hot" zone of danger where a potential armed terrorist may be.

But it was "fortuitous" that the North West Ambulance Service was not informed so that paramedics, who were saving lives, were not pulled out of the area.

The report states that the response of the fire service was "brought to the point of paralysis" as the fire officer could not get through on the phone to the police force duty officer, leading to "immense frustration on the firefighters' faces".

Instead of rushing to the scene to help, fire crews and a Special Response Team, trained to deal with terrorist incidents, rendezvoused at fire station outside the city centre.

And while a joint strategic co-ordinating group of emergency response services and others gathered at Greater Manchester Police headquarters in east Manchester, the fire service chief fire officer, Peter O'Reilly, who has now retired, focused his senior officers at their own headquarters in Salford, playing a "key role" in delaying the response further.

The report says it hopes, in future, that different services control rooms not being able to properly pass critical information between them "will never happen again."

What went well

  • Emergency planning meant people were generally able to act with confidence.
  • Enormous bravery and compassion was demonstrated by individuals and organisations.
  • Good judgement was exercised by key emergency personnel at critical points throughout the evening.
  • The civic response was described as "exceptional".
  • Bereavement nurses and family liaison officers offered vital support and comfort.
  • Removal of those who died at the Arena was treated sensitively.

Areas for improvement

  • Greater Manchester Fire and Rescue Service played no meaningful role in the response for two hours and must address issues of poor communication, poor procedures and operational culture.
  • Failure of a Vodafone telephony system meant there were problems with an effective emergency response line for families, causing considerable distress on the night for people frantically trying to find information about their loved ones.
  • It was unacceptable for families at a vulnerable time to have encountered "intrusive and overbearing" behaviour at the hands of some members of the media.
  • There were issues of communication between the police and other agencies.
  • Support and care for families directly affected by the attack, especially access to mental health services, was not always carried on beyond the immediate aftermath.

Timeline of events on May 22/23 2017

22:31 British Transport Police at Victoria station run to sound of explosion in Arena foyer, arriving one minute later.

22:33 First call to Greater Manchester Police reporting explosion at Arena.

22:42 First paramedic arrives at Victoria station.

22:43 First armed police arrive in the foyer.

22:46 Road closures commence nearby.

22:49 Twelve ambulances at scene.

22:58 Movement of injured from foyer to station concourse as casualty treatment area commences.

00:37 Three fire engines arrive at scene for first time.

02:30 Reception centre at Etihad Stadium opened by Manchester City Council.

02:46 All injured transported from scene.

04:15 Strategic multi-agency meeting at Greater Manchester Police force headquarters; fire chiefs not present.

10:00 Meeting of Mass Fatalities Coordinating Group.

12:00 Police confirm first arrest.

15:35 First victim's body moved to temporary body storage facility on site.

18:00 Vigil in front of Manchester Town Hall.

21:07 Last body removed to temporary facility on site.