Lord Kerslake’s report into the attack, in which 22 people died and hundreds were injured, found that Greater Manchester Fire and Rescue Service (GMFRS) did not arrive at the scene of the suicide bombing and played "no meaningful role" in the response to the attack for two hours. It was Britain’s deadliest terrorist attack since the 7/7 bombings in 2005.
Kerslake’s report stated: "There is not one single reason nor one individual that caused this failure. Rather, it was a combination of poor communication and poor procedures."
It continued: "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."
The report found that a Greater Manchester Police (GMP) duty inspector declared Operation Plato – a pre-arranged plan between the emergency services for responding to a suspected marauding armed terrorist – in the immediate aftermath of the attack.
The report continued: "There was not a shared communication across the agencies of the declaration of Operation Plato… nor was there a shared understanding of its implications."
Firefighters held back from responding
Firefighters were based two miles away from the scene and, despite the existence of protocols allowing emergency workers to continue treating the injured during a terrorist attack, a senior fire officer stuck to rules intended to keep them away from danger.
The report said: "In the event, pragmatic judgements were made on the night that ensured that the response remained effective. However, we think that during any future events, it is essential that this communication across the agencies happens and happens early."
The report recommended that the principles of Operation Plato should be reviewed nationally.
Emergency phone line failure
Mobile network operator Vodafone, which provides emergency number services to the Government in the event of a major incident, came in for criticism in the report, which referred to a "complete failure" of the system, for which Vodafone had apologised.
There was also criticism of some elements of the media in their attempts to report on the attack.
The report said: "The Panel was shocked and dismayed by the accounts of the [victims'] families of their experiences with some of the media. They spoke of being 'hounded', of a 'lack of respect', and of 'sneaky' attempts to take photos when families were receiving bad news."
However, the report also said there was much to praise in the response, as it singled out British Transport Police, Arena staff and members of the public for their "enormous bravery and compassion".
The report said: "In the Panel’s view, the story of the response is overwhelmingly positive."
Response to the report from GMFRS and GMP
Dawn Docx, interim chief fire officer at GMFRS, thanked Lord Kerslake and said the Service accepted the findings of his review and was working to implement its reccomendations.
She said: "The 22nd May 2017 was Greater Manchester’s darkest hour and it is clear that our response fell far short of that which the people of Greater Manchester have a right to expect. I apologise unreservedly for that. There were clearly failures in leadership and poor decisions made. As a result firefighters themselves, desperate on the night to attend the incident, were also let down by their senior colleagues."
Docx added: "The fundamental mistake made by the fire service that night was failing to communicate with our partner agencies and that is something at the forefront of our plans to change fundamentally the fire service and its culture."
Ian Hopkins, chief constable of GMP, praised the actions of his officers on the night of the attack and the ensuing investigation.
He said: "Learning from such exceptional events is so important. This is why we have extensively reviewed and assessed the responses so that learning can be included in future plans. These plans will assist not just GMP, but the whole police service. There were a number of matters that were raised and some improvements have already been made. The Kerslake Review will now form part of that learning."
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