The litany of errors in the emergency services’ response to the Manchester Arena attack has been widely detailed this week, from a senior police officer who failed to pass on crucial information, to a key fire officer who spent an hour driving in from his home, and a specialised paramedic unit that took 44 minutes to arrive from Stockport.

The only paramedic to turn up in that three quarters of an hour – because he had ‘self-deployed’ – was supposed to triage patients but forgot his triage cards and never went back to his vehicle to get them.

A ‘risk averse’ senior fire officer set off a chain of events that led to a two hour and six minute delay in their arrival to the arena, despite knowing they might be needed to extract patients.

The overall response was ‘far below the standard it should have been’ and that was partly because ‘no one really thought it could happen to them,’ Sir John Saunders, the inquiry chairman said.

And that had real effects – John Atkinson, 28, from Bury, a care worker for adults with autism was ‘likely to have survived’. Saffie-Rose Roussos, eight, the youngest victim, who had spent the evening dancing and laughing with her mother and older sister, had a ‘remote’ chance of surviving.

But there was more.

‘One of the most emotional and upsetting parts of the inquiry was listening to the evidence of people in the City Room,’ Sir John wrote, referring to the foyer where the bomb went off and there were 38 badly injured survivors, lying on the blood-stained floor.

The brave police officers, station staff and members of the public who had rushed into the foyer to help, heard the sirens of the ambulances outside and expected to see paramedics arriving imminently. There was ‘despair’ when they failed to turn up.

‘The injured were desperate for help, not realising that decisions that had been made meant they would not see paramedics in the City Room in the numbers hoped for and expected,’ Sir John said.

‘No one wanted the injured and dying to suffer more than they needed. Everyone involved in the emergency no doubt thought that they were doing their best. In some cases, their best was not good enough.’

It took 36 minutes to begin evacuating the City room of casualties, on makeshift stretchers, improvised from advertising hoardings and heavy crowd control barriers, and another 35 minutes to complete it.

Even then it was a truly extraordinary four hours and 19 minutes before all of the casualties were sent to hospital. One of the last to be taken had two broken legs and spent a month in hospital.

The report – the second of three into the attack – was the result of 12 months of hearings, covering every possible stage of the emergency response and the training for it – including how similar problems occurred after the 7/7 attacks, 12 years earlier, and how exercise Winchester Accord, a year earlier, showed they had not been solved.

Following the report’s publication there were apologies from the emergency services, although some members of the victims’ families felt they could have come sooner.

At the end, there are 149 separate recommendations on how to improve matters and Sir John intends to follow them up – requiring statements from named individuals followed by hearings next summer.

The inquiry chairman made a particular point to name, and work out how to solve, the ‘care gap’ – an indeterminate period of time, during which the police and public become the ‘first responders’ as they waited for paramedics to turn up.

Those that filled the gap were the heroes of the Manchester Arena attack – Ronald Blake, who used his wife’s belt as a tourniquet to try and save John Atkinson; Darron Coster, a former soldier, who used a handbag strap on another patient; Paul Reid, a poster seller, who stayed with Saffie-Rose Roussos and urged her ‘come on princess’; Sgt Kam Hare, who led his men up the stairs into the City room, not knowing what they would find, telling them: ‘Keep together, follow me in a line. Stay calm guys, stay calm.’

These, and others, ignored the government advice to ‘run, hide, tell’ and went straight into the scene of the attack to give whatever help they could.

‘That night they represented the very best of our society,’ Sir John said.

In his assessment of the care gap, Sir John identified a problem called ‘zoning’.

At the moment, the emergency services create hot, warm and cold zones, and will only work in a cold zone. They wait for specialist colleagues to go into a ‘warm zone’ and refuse to go to a ‘hot zone’ because terrorists may still be on the loose.

Even when they get to patients, they go through a lengthy two-stage triage process to decide which patients need evacuating before they repeat the process and only then give medical assistance.

The key thing that fell apart in Manchester on the night of May 22, 2017 was that the operational ‘bronze’ commanders did not speak to each other during the ‘critical period’ of the response, so no one agreed on the zones, the chairman said.

However, there remains an outstanding problem – even if they had met up, they might not have agreed on what to do.

The problem, noted by the chairman, is that paramedics and unarmed police officers ‘have different views as to the degree of risk that it is acceptable to take.’

The inquiry chairman has urged the emergency services to consider new ideas and has offered some solutions, suggesting a new class of action-style doctors, who are embedded with police firearms response teams and go into the hot zone with armed officers to extract patients at speed.

That is how they do it in France, using a team known as RAID, who managed the extraction at the Bataclan music venue.

Where there is no firearms team, as there may be in some parts of the country, it will still fall to the public to fill that gap.

Sir John said techniques such as applying tourniquets and dressings and keeping open airways, should be taught as part of the national curriculum.

Employers should be compelled to train up certain categories of employees under the Health and Safety at Work Act.

The Home Office should work out how to provide Public Access Trauma Kits (PACT) ‘in all locations in which they are most likely to be needed’.

‘I emphasise that everything that can reasonably be done to educate the general population in first responder interventions should be done,’ the chairman said.

However, Greater Manchester Police has called the use of the zones, known as Operation Plato, a ‘blunt instrument’ that could have ‘impeded rather than improved the response’ in Manchester.

Richard Horwell KC, for GMP, said the use of zones is ‘draconian and inflexible’ and ‘potentially compromised the safety of casualties’.

There was an admirable attention to detail paid by Sir John and his talented team, led by Paul Greaney KC, but there remains a question – is there any point in ‘zoning’ in the first place?

It is an esoteric exercise carried out at moments when everything is moving incredibly fast.

We know that the victims of attacks need help quickly if they are to survive catastrophic injuries – there is a ‘platinum’ ten minutes and a ‘golden’ hour, in which intervention can make a difference. Thereafter it becomes significantly less effective.

We also know that providing that help does not come without risks – but the risks are almost impossible to quantify.

There are no statistics for the number of plots involving secondary bombs or the average distance from the first device – they could be yards away or miles away. We can never know many attackers there may be in the case of a marauding attack and whether they are likely to be running in straight lines or circles – so we can’t predict where they are heading.

Multiple reports can often encourage responders to think there may be multiple terrorists on the loose when, thankfully, that is rare.

The very act of designating – and transmitting to all personnel – some well-defined zone is time-consuming and may well become pointless in minutes if not seconds.

A level of realism is called for, dealing with what you see in front of you, listening to your colleagues, trusting them to keep you safe – less process and procedure, rather than more.

No emergency responder should have to take unnecessary risks, but there is not a no-risk option when there has been a terrorist attack or a major incident.

For the Manchester heroes, there was no such thing as a ‘hot zone.’ People needed help and they responded.

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