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."
Mr Atkinson's family said it "should simply never have been allowed to happen", adding: "It is crystal clear that due to those failings, John died from injuries that he could and should have survived." 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.
The Arena attack killed 22 people after bomber Salman Abedi, 22, detonated a homemade explosive packed with shrapnel. Among the victims was 14-year-old Eilidh MacLeod, who had travelled to Manchester from Barra in the Outer Hebrides with her mum and a friend.
The "much-loved" middle sister of three was "very family orientated" and loved music which was a big part of her life, having enjoyed success in the World Bagpipe Playing Championships in 2016. Those who know her said they are sure she would have succeeded at whatever she wanted to do in life.
Miss MacLeod was four metres from the explosion and a post-mortem examination showed it was very likely she would have died quickly from multiple injuries, said to be unsurvivable. Her body was covered in clothing and she was pronounced dead at the scene.
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 22nd May 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."
In a statement released after the report's publication, Mr Atkinson's family said: "It is now clear beyond any doubt that on the night of the bombing, John was totally failed at every stage, both by the private medical providers at the Arena - ETUK and the emergency services. It is crystal clear that due to those failings, John died from injuries that he could and should have survived.
"As we know from witnesses, John kept asking if he was going to die. John must have known that he was dying and the pain that causes us is too great to put into words. This should simply never have been allowed to happen."
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." The initial command of the incident was taken by Greater Manchester Police's force duty officer, Inspector Dale Sexton, but he "quickly became overburdened by the number of tasks he had to undertake", the report found.
Sir John said: "This had a direct impact on the effectiveness of the emergency response. It affected who received information, what resources were made available and the decisions of other commanders."
Following erroneous reports of gunshots, Inspector Sexton declared Operation Plato - a pre-arranged plan for a suspected marauding terrorist - but he "overlooked" telling other emergency services. "It affected the ability of the emergency services to work together by jointly understanding the risks," said Sir John.
Sir John also reprimanded fire service bosses for deploying appliances from three miles away and said ambulance chiefs made an "error" in not sending ambulances to meet at Manchester Central Fire Station. He also levelled criticism at those who hesitated to send emergency crews in long after it had been agreed the area was safe from further attack.
As the post-attack "golden hour" ended, the emergency response had failed to achieve effective evacuation. Just after midnight there were still 36 casualties waiting to go to hospital, with the last casualty departing at 02.50am on May 23.
Sir John said: "To those who experienced it, this period of time will have seemed interminable. It must not happen again."
Sir John's first report on security issues at the Arena was issued last June and highlighted a string of "missed opportunities" to identify Abedi as a threat before he walked across the City Room and detonated his shrapnel-laden device.
The third and final report will focus on the radicalisation of Abedi and what the intelligence services and counter-terrorism police knew, and if they could have prevented the attack. It will be published at a later date.
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