Emergency services have admitted communication failures and violations of terror attack protocols in the aftermath of the Manchester Arena bombing.
The response to the 2017 attack, where 22 victims were killed, is being examined by a public inquiry amid questions by bereaved families.
Tuesday’s hearing was told that neither British Transport Police (BTP), which was responsible for the City Room where the bomb was detonated, or national counter-terror police had received any intelligence on Salman Abedi.
After he launched his attack, the North West Ambulance Service (NWAS) admitted that “inter-agency liaison, communication and decision-making” between police, the ambulance service and firefighters was inadequate.
Lisa Roberts QC, on behalf of NWAS, said that when the bomb detonated there were only eight ambulances available to be deployed immediately in the region despite 75 being on duty.
She told the inquiry that the first paramedic entered the City Room 21 minutes later but had to “establish a command and control structure” before treating people.
Ms Roberts said the decision was made to move casualties amid concerns over the structure of the building, a secondary bomb or “active shooter”.
NWAS declared a major incident but did not share its decision with other agencies “as expected”.
One minute later, Greater Manchester Police’s force duty officer (FDO) triggered Operation Plato protocols drawn up for a terror attack by marauding gunmen, then did not tell the ambulance or fire services.
Bereaved relatives and survivors who were injured have criticised delays in the treatment and evacuation of victims, but the inquiry was told that the deviation from protocol may have saved lives.
Richard Horwell QC, representing Greater Manchester Police (GMP), said: “GMP’s emergency service partners were not informed Operation Plato had been declared when they should have been. That was because the FDO made a deliberate decision not to do so.”
He said that chief inspector Dale Sexton believed that following the policy would have caused loss of life by forcing paramedics to pull out of the City Room and “abandon casualties” for their own safety.
“In his words, he took a ‘calculated risk’ to leave vulnerable responders in the City Room in order that they would remain and continue their treatment and evacuation of the casualties,” Mr Howell told the inquiry.
“Although GMP cannot support the withholding of information from the other emergency services, it does understand why the FDO did what he did and one of the possibilities is that his decision may have saved lives.”
Mr Howell admitted that GMP had failed to implement changes after learning lessons from training exercises, such as a simulated terror attack that took place in 2016.
It showed that the FDO was “overstretched and at times it was impossible to contact him”, he said, but the same problems were repeated after the bombing.
He said police could have made greater efforts to bring the fire service, who did not arrive for more than two hours, to the scene and made use of their treatment and evacuation skills.
Mr Horwell added: “GMP accepts its share of the criticism made by both the police experts and Kerslake that the ability of those in the emergency services' control rooms to communicate with each other in the immediate response to the attack was poor.”
But he denied there were any significant issues with the Airwave communications system, or that there was a “command vacuum at the scene”.
Mr Horwell appealed for hindsight to be “excluded” from analysis of GMP’s actions, adding: “The police officers and staff of GMP go to work to protect the people of Manchester, to keep them safe, and it is a matter of the deepest regret that they were not able to do so that night.”
Patrick Gibbs QC, representing BTP, admitted that Abedi had made three visits to Manchester Arena as hostile reconnaissance but had not drawn the suspicion of officers.
He said the force “knew nothing of the plans and preparations for murder” made by Abedi, and had received no intelligence or information about him before the bombing.
But Mr Gibbs admitted that the immediate aftermath saw a significant gap “between guidance and practical reality”, adding: “Communication between the different emergency services was tested beyond breaking point.”
The lawyer said the emergency services’ airwaves became “overwhelmed by volume of traffic and information” and that BTP was unable to contact GMP’s duty officer or connect the forces’ silver commanders.
Mr Gibbs said: “The unanimous experience of every police force in every UK mass murder terror attack to this day has been that inter-agency liaison in the urgency of immediate response throws up communication problems.
“Systems and processes and human reactions which may be workable on paper or in multi-agency training exercises, do not perform in the same way in reaction to the real life devastation of a bomb site with mass casualties … information sharing was far from perfect.”
Matthew Butt QC, representing the Counter-Terrorism Policing Headquarters (CTPHQ), said its counter terrorism security advisors had given advice to Manchester Arena’s operators because it was classed as a “crowded place”.
He said guidance was available to counter threats inside and outside the venue, including “consideration of extending the security perimeter, reporting suspicious behaviour and detecting hostile reconnaissance”.
“CTPHQ did not receive any intelligence on Abedi or his family before the attack,” he added.
The inquiry will continue on Wednesday, when an opening statement will be made on behalf of MI5 over its investigation of Abedi leading up to the bombing.