The operators of the 21,000-capacity Manchester Arena 'took an unacceptable approach' to making sure there was adequate healthcare services at the venue, the newly-published report arising from the public inquiry into the 2017 terror bombing has found.
Sir John Saunders, the inquiry's chairman, heaped criticism on SMG and its contracted medical services provider at the time, Emergency Training UK (ETUK). He said their relationship didn't operate as it should have, adding: "In relation to healthcare, inadequate consideration was given to the welfare of the event-goers."
"Looking at the evidence as a whole, I am satisfied that SMG took an unacceptable approach to ensuring that there were adequate healthcare services at the Arena," said Sir John in the report.
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"SMG failed to carry out basic checks that would have revealed major deficiencies in ETUK's approach. Neither SMG nor ETUK gave adequate thought to how the healthcare services that were in place would cope with an event such as occurred on May 22, 2017. As a result, ETUK was not adequately prepared to respond."
The findings led the chairman to make a series of key recommendations that could now become binding on all concert and event venues to drive up standards and public safety.
He recommended the Department of Health and Social Care consider introducing guidelines to ensure all event healthcare staff are trained in how to use tourniquets and other life-saving techniques for treating blast, bullet and knife wounds. Guidance, added Sir John, should also be officially issued on the first aid equipment event providers are expected to have available.
And he added: "I recommend that the Department of Health and Social Care consider introducing compulsory minimum standards of training for event healthcare staff to ensure that they are familiar with how to assist those injured in a terrorist attack."
Ten years before the blast, which killed 22 people after an Ariana Grande concert, Arena operators SMG contracted out medical and first aid services on concert nights to ETUK. Sir John said, in a damming second report arising from the public inquiry, that an organisation like it 'has an extremely important role to play in keeping the injured alive while the ambulance service get to the scene'.
ETUK, heard the public inquiry, had committed to providing eleven first-aiders, a radio controller, and two 'emergency medical technicians' for a little over £1,000 per event.
In one of a number of key findings, Sir John said the healthcare service provided by ETUK on the night was 'inadequate' and the 'combined skill level' of those on duty was 'too low' - a 'long way short' of official guidelines. He said there was no one on duty with a 'major incident qualification'.
"There was a failure to provide any adequate standard of care by ETUK," said the report.
Sir John said he found it was a result of 'a lack of preparedness and inadequate staff skill level', with responsibility lying with ETUK and its director Ian Parry, who gave evidence at the inquiry. "Taking the evidence as a whole, the healthcare service provided by ETUK on the night was inadequate," said Sir John in the report.
"While the number of staff may have been adequate, they did not have anything like the necessary skill level for a concert of this size. This was for three reasons: first, because SMG's specification of the level that was required was too low; second, because ETUK and Ian Parry provided an even lower mix of skills than SMG thought it was receiving; and third, because the minimum standard Ian Parry and ETUK set for its first aiders was too low."
"This lack of highly skilled staff resulted in a lower standard of care being provided to the injured during the period before North West Ambulance Service could arrive. The timing and number of North West Ambulance Service paramedics entering the City Room [where the explosion took place] meant that the impact of this continued longer than it would have done had more paramedics been committed to the City Room."
Sir John said he wasn't critical of any individual ETUK first aiders, saying they showed courage to enter the City Room, but blamed 'failures by ETUK'.
The report found the contract between SMG and ETUK required information about the training and qualifications of ETUK staff to be provided for every event. "ETUK did not provide this information, " said Sir John. "For reasons that were not satisfactorily explained, SMG did not insist on its provision."
The number of healthcare staff on duty at any given Arena event would normally depend on an 'event-specific risk assessment'. But Sir John said: "No adequate risk assessment was carried out for the Ariana Grande concert on 22nd May 2017."
ETUK's director, Mr Parry, 'did not require a sufficiently high standard of skill from ETUK staff members', said the report, and he hadn't undertaken required refresher training. "It was his, not the staff’s, responsibility to ensure that there was a sufficient skill level across the staff for every event at the Arena," said Sir John.
Not all members of ETUK staff on duty on the night were trained in the use of tourniquets either, found the report. "Neither SMG nor ETUK took an adequate approach to considering how the healthcare service at the Arena would respond to a mass casualty incident," Sir John said.
"A further aspect of SMG’s failure towards ETUK was the lack of any formal review of ETUK's preparedness and performance, whether internally or by obtaining the opinion of anyone independent with relevant expertise.
"If SMG had conducted proper checks on ETUK’s performance, it would have discovered that ETUK was not meeting an adequate standard, particularly in relation to preparedness for a mass casualty incident. This was a significant failure by SMG."
The chairman went on to say that in terms of ETUK, plans in place were not followed and should have been. "In light of all the evidence about the level of training received by ETUK staff, I am satisfied that Ian Parry did not require a sufficiently high standard for those staff members he used at events. This was not the staff members' fault."
The Manchester Evening News has contacted SMG and ETUK for comment.
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