John Atkinson’s injuries were “survivable” but he did not receive the “treatment and care he should have”, said Sir John Saunders, chairman of the Manchester Arena inquest. Mr Atkinson, a 28-year-old healthcare worker, was one of 22 innocent people who lost their lives following the suicide bombing at the end of an Ariana Grande concert in May 2017. A report examining the emergency response to the attack found that “significant aspects … went wrong” and “the performance of the emergency services was well below the standard” it should have been. “Some of what went wrong had serious and, in the case of John Atkinson, fatal consequences for those directly affected by the explosion,” Sir John said. The inquest heard that firefighters did not arrive at Manchester Arena until two hours after the bombing. only one ambulance attended the scene of the explosion in the first 40 minutes and Greater Manchester Police (GMP) did not declare a major incident for more than two hours. The father of the youngest victim – eight-year-old Saffie-Rose Roussos – described the emergency response as “disgraceful” and “inadequate”, with some experts saying the investigation could have survived if the response had been different. Image: Saffie-Rose Roussos was the youngest victim of the attack However, Sir John concluded that “there was only a remote possibility that he would have survived with different treatment and care”. “According to the evidence I have received, what happened to Safi-Rose Roussos represents a terrible burden of injury,” he said. “It is highly likely that her death would have been inevitable even if the most comprehensive and advanced medical treatment had been initiated immediately after the injury.” Emergency response ‘prevented victim’s survival’ In the second of three reports into the Manchester Arena bombing, Sir John found that 20 of the 22 people who died in the attack suffered non-survivable injuries. However, in Mr Atkinson’s case, the retired High Court judge said if the victim had “received the treatment and care he should have, it is likely he would have survived”. Use Chrome browser for more accessible video player 3:11 “He was left to die without his dignity” “It is likely that inadequacies in the emergency response prevented his survival,” Sir John added. Mr Atkinson, a fitness fanatic whose family described him as their “heart and soul”, had received tickets to Ariana Grande’s concert as a Christmas present and went with a friend. He was standing just six meters away from Salman Abedi when the bomber detonated his device at around 10.30pm on 22 May 2017, seriously injuring Mr Atkinson’s legs. Read more: How emergency crews responded to arena bombings Security failures that led to Manchester attack The inquest heard Mr Atkinson, from Bury, Greater Manchester, lost a significant amount of blood as he lay in agony on the floor of the foyer for 47 minutes before being taken under police on a makeshift stretcher to a casualty release area at Victoria station. It was more than 20 minutes – as ambulances queued outside – before he went into cardiac arrest at 11.47pm and was finally rushed to Manchester Royal Infirmary at midnight, where he was pronounced dead around 25 minutes later. A member of the public, Ronald Blake, held a makeshift tourniquet on Mr Atkinson’s right leg for up to an hour before paramedics arrived. Only three ambulances entered the area known as the City Room, where the bomb went off, on the night – two of them just minutes before Mr Atkinson was evacuated. He was not tested, assessed or assisted by North West Ambulance Service (NWAS) staff during his stay in the foyer. “John was a complete failure at every stage” In his report, Sir John said he accepted the experts’ conclusion that Mr Atkinson “would have survived had he been given prompt and specialist medical treatment”. He concluded that medical casts should have been applied to Mr Atkinson’s legs and bandages applied to his wounds sooner. The chairman of the inquiry said “responsibility for this failure” lay with arena operator SMG and the management of Emergency Training UK, which was commissioned to provide healthcare at the venue. He added that more paramedics should have been at the City Room sooner and would probably have “identified the need for urgent treatment and evacuation” of Mr Atkinson. Image: Police at the scene of the bombing on May 22, 2017 “That did not happen,” said Sir John. “The responsibility for this failure lies with NWAS. “Such treatment, I am satisfied, would have enabled John Atkinson to reach hospital before he suffered a cardiac arrest and would probably have saved his life.” Sir John also said Mr Atkinson should have been taken from the City Room straight away and if firefighters had been on the scene at the time, the victim would have had “priority for evacuation”. He also pointed out that if more ambulances had been at the scene shortly after 11pm, Mr Atkinson would have been treated and taken to hospital sooner. “Either way, he would have made it to hospital before he went into cardiac arrest and it’s possible he would have survived,” Sir John said. “John Atkinson would likely have survived if there had not been deficiencies in the emergency response.” Image: The victims of the Manchester Arena bombing In a statement following the report, Mr Atkinson’s family said: “It is now clear beyond any doubt that on the night of the bombing John failed completely at every stage. “It is clear that because of these failures, John died from injuries that he could and should have survived. “He was left dying, without his dignity, on the floor, when it should have been obvious to the doctors that he should have gone straight to hospital.” Referring to evidence heard during the inquest that Mr Atkinson told a police officer: “I’m going to die” as he lay on the floor, his family said: “John must have known he was dying and the pain he was causing us. . It is too great to put into words. This simply should never have been allowed to happen.” “Mistakes” made by emergency services In his report, Sir John said “significant aspects of the emergency response on 22 May 2017 went wrong” and “this should not have happened”. The chairman of the inquiry said he had “no doubt that lives were saved by the emergency response”, but added: “Overall, and objectively, the performance of the emergency services was far below the standard it should have been.” He said GMP “didn’t lead the response” as it should have. Greater Manchester Fire and Rescue Service (GMFRS) “did not attend the scene at the time when they could have provided the most assistance”. and NWAS “failed to send adequate paramedics” to the City Room and “failed to use available stretchers to remove victims in a safe manner”. Use Chrome browser for more accessible video player 4:29 Arena bombing victims ‘disappointed’ The inquest heard that police officers, arena staff and members of the public were forced to carry the injured using hoardings, crowd barriers and tables due to the lack of stretchers, which Sir John said was “a painful and unsafe way of moving the injured. “. He added that “one of the most emotional and upsetting parts of the investigation” was hearing the “desperation” of the injured, who heard ambulance sirens outside but saw few ambulances arrive. Among the failures identified in the report: • Inspector Dale Sexton, the force’s duty officer at GMP headquarters, was “burdened” and made a “significant error” by failing to report a significant incident in the early stages of the emergency response. GMP reported a major incident at around 1am. – two and a half hours after the bomb went off • After inaccurate reports of gunfire, Inspector Sexton declared Operation Platoon – the emergency response to an attack by a terrorist raider with a gun – but failed to communicate it to other emergency services • GMFRS station manager Andrew Berry sent firefighters to Philips Park fire station, three miles away from the scene, meaning some firefighters moved away from the incident and passed ambulances traveling in the opposite direction • Inspector Benjamin Dawson, from British Transport Police (BTP), declared a serious incident about 10 minutes after the attack but did not tell GMP or GMFRS • There has been “substantial confusion” over the location of a rendezvous point for emergency services, with each service choosing its own • NWAS reported a major incident about 15 minutes after the attack, but this was not shared with any other emergency services. Sir John said “there was a failure by anyone senior in GMFRS to understand the situation during the critical period of the response”. He acknowledged that he had “criticized a large number of people” who he felt had “made mistakes on the night”, adding that “some of these criticisms may seem harsh, particularly given the situation these individuals faced”. “They were trying to do their best,” he added. “I understand the enormous pressures they were operating under. “They had to do a lot of things in a short amount of time and it may come as no surprise that things went wrong. I don’t dislike them. “But I have to identify the mistakes where they have been made because otherwise there is no prospect of preventing them in the future.” Read more: Missed chances to end lives of Salman AbediManchester Arena could have been saved – but warning ‘withdrawn’ Image: Salman Abedi was carrying…