Firefighters did not respond to the Manchester attack for two hours because they believed a gunman could be on the loose, a report has found.
Lord Kerslake, the former head of the civil service, praised “individual acts of bravery and selflessness” by the emergency services and members of the public following the bombing on 22 May last year but said communication failures delayed vital parts of the response.
Isis supporter Salman Abedi detonated his device in the foyer of Manchester Arena as thousands of young Ariana Grande fans poured out of a concert, killing 22 people and injuring more than 100.
Police were on the scene one minute later and declared a major incident at 10.39pm, just eight minutes after the explosion.
Firefighters stationed nearby heard the blast themselves and prepared for mobilisation, but initial fears of an “active shooter” meant they did not arrive at the scene for two hours despite having first-aid skills and terror-attack training.
“The effect of this was that a valuable resource was not available to assist on the scene, particularly with the movement of those who were injured from the foyer” amid a shortage of stretchers, Lord Kerslake concluded.
“The fire service was effectively ‘outside the loop’, having no presence at the rendezvous point established by the police, little awareness of what was happening at the arena and only a very limited and belated presence at Strategic Gold Command.”
Lord Kerslake said firefighters interviewed during the review felt they had left Manchester down but said “they did not, but their procedures, communications and operational culture most certainly did ... it is incredible”.
He said firefighters stationed near Manchester Arena “could see that something was happening and wanted to go forward, but were prevented from doing so” and could not deploy themselves.
There were only three paramedics in the foyer at the time, triaging patients to be taken to a designated casualty clearing station for treatment alongside British Transport Police officers, security guards, staff from Manchester Victoria station and members of the public.
All injured people were evacuated from the blast site within just over an hour of the explosion, but Lord Kerslake said the presence of firefighters “would clearly have been valuable”.
The impact of the delay will be examined by the coroner in ongoing inquests into the 22 victims’ deaths, while a separate criminal investigation continues.
A previous review by the former Independent Reviewer of Terrorism Legislation found that MI5 might have been able to prevent the attack, having dismissed two pieces of intelligence on Abedi that were “highly relevant” to his plans.
He had already been put under active investigation twice – once over his contact with another subject of interest in 2014, when he was considered a “low residual risk”, and again in October 2015 because of indirect contact with an Isis figure in Libya – and was not questioned when he returned to Britain from the country four days before the bombing.
The North West Fire Control initially received reports of a potential gunman from the ambulance service, but despite police confirming that wounds were caused by shrapnel rather than bullets a national liaison officer did not receive the information.
Suspecting a potential marauding terrorist shooting attack like those seen in Paris, he ordered firefighters to assemble at a station two miles from the arena according to procedures creating a 500m safety exclusion zone.
If all emergency services had followed the same guidance, only armed police wearing body armour would have been allowed to enter Manchester Arena’s foyer, but others used “situational awareness” to go in.
The national inter-agency liaison officer tried to speak to the police force duty officer to clarify what was happening but could not get through to him on the phone, the report said.
It called for the fire service to reflect on “poor communication, poor procedures and issues of operational culture which caused its failure to respond properly”.
Greater Manchester Fire and Rescue Service’s interim chief fire officer Dawn Docx apologised “unreservedly”, adding: “Firefighters were desperate on the night to help and they were let down by some of their senior colleagues.”
She said no disciplinary action was planned, following the retirement of former fire chief Peter O’Reilly, and the service was “working to make sure this never happens again”.
The report also revealed that an emergency phone system provided by Vodafone “completely failed”, causing added distress to families frantically seeking information on their loved ones.
Investigators said a restricted, local telephone service was not up and running until 3am, almost five hours after the bombing, leaving relatives to start desperate searches of local hospitals.
Vodafone has apologised and worked with the Home Office on measures to prevent similar issues occurring again, including a back-up system, testing and monitoring.
The review found that the horror was compounded by the actions of some members of the media, with relatives saying they were hounded and shown a lack of respect with behaviour the review called “utterly unacceptable”.
The Kerslake Arena Review was established by Andy Burnham, the Mayor of Greater Manchester, to examine the emergency response to the deadliest terror attack in Britain since the 7/7 bombings.
“By looking honestly at what happened, we can improve the way we protect the public, and begin to provide the families who lost loved ones and those injured, physically and mentally, with the answers to questions they have no doubt been asking ever since,” he said, announcing a wide-ranging review of Manchester’s fire and rescue service.
Lord Kerslake said the views of victims’ families and survivors had been “front and centre” in the review process.
“The Manchester Arena attack was devastating for many thousands of people,” he added.
“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.
“The benefits of collaborative working and planning for emergencies were demonstrated to the full. And there were hundreds, if not thousands, of individual acts of bravery and selflessness.
“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.”
The report said the huge pressures on police charged with leading the response caused communication issues with other agencies, calling for new joint operating principles for responding to a terrorist attack to be drawn up nationally.
Mr Burnham backed the calls for a review of existing guidelines updated after the Paris, Sousse and Mumbai attacks, calling them “right on paper but wrong in practice”.
The report praised preparations and training undergone by the emergency services, the “good judgement” exercised at key points, such as meaning that police and paramedics were allowed to enter Manchester Arena despite safety fears.
The review found that actions by individuals and organisations on the night “demonstrated enormous bravery and compassion” and the civic response was “exceptional”, while support was provided by family liaison officers and bereavement nurses.
Chief Constable Ian Hopkins, of Greater Manchester Police, said officers had worked to save lives while being aware there may be a further attack.
“It was an immense and unprecedented situation that faced us and I am proud of the way the officers and staff of GMP responded that night and in the days, weeks and months that have followed,” he added.
“In the face of danger they ran into the arena as others were running away, they experienced things that no-one should have to experience.”
He said the criminal investigation into the attack was ongoing, with counter-terror officers working through more than 12,000 pieces of evidence and 2,000 statements.
British authorities have been seeking the extradition of Hashem Abedi, the bomber’s brother, from Libya for questioning but the efforts have been frustrating by the armed militia holding him and the chaos of the country’s ongoing civil war.
Join our commenting forum
Join thought-provoking conversations, follow other Independent readers and see their replies