Martin Hibbert
"Strategic oversights" by police commanders led to confusion with other services over whether an "active shooter" was on the loose and the "valuable" assistance of fire crews was delayed by two hours and six minutes after the bombing, which left 22 dead and scores injured.
The 226-page report by Lord Bob Kerslake was commissioned by Andy Burnham, the mayor of Greater Manchester, to assess the preparedness and emergency response to the attack previous year.
The panel of experts state they are not able to say whether earlier arrival of the fire service would have "affected any casualty's survivability".
THE behaviour of some sections of the media was "unacceptable" after the Manchester attack, said the Kerslake report.
Lone suicide bomber Salman Abedi, 22, detonated his home-made device at 10.31pm on May 22 previous year in the arena foyer as 14,000 people, many of them children, streamed out at the end of an Ariana Grande concert.
According to the report, the first North West Ambulance Service (NWAS) paramedic arrived at 22:42 and was told the incident was a "suicide bomber" by police.
He said there had been hundreds and thousands of acts of individual bravery on the night, adding: "not one single reason or one individual was to blame for the errors, but a most unfortunate combination of poor communications and poor procedures".
However, Lord Kerslake said the company "should also apologise directly to the families" for whom the failure of this "vital" system "made the experience of this truly awful evening even worse".
The company was responsible for emergency post-disaster hotlines, but a "catastrophic" technical failure that night meant no fully functioning number was set up to call by people desperately searching for information on the attack.
The report was not created to criticise firefighters themselves, he said, but to "ensure they are supported" by the "best possible leadership and culture".
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But the report said this was not sufficiently well communicated to other emergency services, including the fire service.
Mr Burnham said no one individual should bear all the responsibility for failures and no one should be "scapegoated".
"We were concerned to identify what might be done to prevent this happening again in any future terrorist event". The then £155,000-a-year chief fire officer, Peter O'Reilly, has retired, with no action taken against him.
As the fire officer could not get through on the phone to the police duty officer the response of the fire service was, "brought to the point of paralysis" added the report.
It said one journalist offered condolences to a child before the child had been officially told about the death of her mother in the attack.
Families felt "hounded" by the media, with reports of a "scrum" of journalists outside hospitals.
Lord Kerslake praised the overall response to the attack but noted that it was "vital to learn the lessons around things that did not go so well", The Daily Mail reported.
Manchester bombing victim Jane Tweddle, who was from Hartlepool.
.Police and ambulance personnel were on the scene "very rapidly" and emergency personnel exercised "sound judgement in an extremely stressful, chaotic and risky environment", the report said.
"A major cause of the problems encountered was the absence of any information being received by the fire service from the police", he said. We recommend that the Independent Press Standards Organisation should review the operation of its Code in light of these experiences and that there is exploration of ways to enhance the skills in media handling for the Family Liaison Officers.
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