One of the 22 people murdered in the Manchester Arena suicide bombing would probably have survived but for inadequacies in the emergency response. 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." 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.
On Thursday, 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 May 22, 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."
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."
Speaking after delivering the inquiry's findings, Sir John said: "Those who have listened to the evidence will not be surprised that I am highly critical of many of the rescue operation. Those criticisms must not overshadow our admiration for the courage of those who went into the City Room without any hesitation to help the dying and the injured."