A victim of the Manchester Arena bombing would likely have survived had it not been for the inadequate emergency response, an inquiry has found.
John Atkinson's injuries were "survivable" but he did not receive the "treatment and care he should have", said Sir John Saunders, chairman of the Manchester Arena Inquiry.
Mr Atkinson, a 28-year-old healthcare worker, was one of 22 innocent people who lost their lives following the suicide bombing at the end of an Ariana Grande concert in May 2017.
A report examining the emergency response to the attack found that "significant aspects... went wrong" and "the performance of the emergency services was far below the standard" it should have been.
"Some of what went wrong had serious and, in the case of John Atkinson, fatal consequences for those directly affected by the explosion," Sir John said.
The inquiry has heard that firefighters did not arrive at Manchester Arena until two hours after the bombing; only one paramedic entered the blast scene in the first 40 minutes, and Greater Manchester Police (GMP) did not declare a major incident for more than two hours.
The father of the youngest victim - eight-year-old Saffie-Rose Roussos - described the emergency response as "shameful" and "inadequate", with some experts telling the inquiry she could have survived had the response been different.
However Sir John concluded that "there was only a remote possibility that she could have survived with different treatment and care".
"On the evidence that I have accepted, what happened to Saffie-Rose Roussos represents a terrible burden of injury," he said.
"It is highly likely that her death was inevitable even if the most comprehensive and advanced medical treatment had been initiated immediately after injury."
Emergency response 'prevented victim's survival'
In the second of three reports into the Manchester Arena bombing, Sir John found that 20 of the 22 people who died in the attack suffered injuries that were "unsurvivable".
However in the case of Mr Atkinson, the retired High Court judge said that had the victim "received the treatment and care he should have, it is likely that he would have survived".
"It is likely that inadequacies in the emergency response prevented his survival," Sir John added.
Mr Atkinson, a fitness fanatic whose family described him as their "heart and soul", had received tickets to the Ariana Grande concert as a Christmas present and went with a friend.
He was standing just six metres away from Salman Abedi when the bomber detonated his device at about 10.30pm on 22 May 2017, causing severe injuries to Mr Atkinson's legs.
The inquiry heard Mr Atkinson, from Bury, Greater Manchester, lost a significant amount of blood as he laid in agony on the foyer floor for 47 minutes before he was carried downstairs by police on a makeshift stretcher to a casualty clearing area at Victoria station.
More than 20 minutes passed - as ambulances queued outside - before he went into cardiac arrest at 11.47pm and was finally rushed to Manchester Royal Infirmary at midnight, where he was pronounced dead about 25 minutes later.
A member of the public, Ronald Blake, held an improvised tourniquet on Mr Atkinson's right leg for up to an hour before paramedics reached him.
Only three paramedics entered the area known as the City Room, where the bomb went off, on the night - two of them just a few minutes before Mr Atkinson was evacuated.
He was not triaged, assessed or assisted by North West Ambulance Service (NWAS) personnel during his time in the foyer.
'John was totally failed at every stage'
In his report, Sir John said he accepted the conclusion of experts that Mr Atkinson "would have survived if given prompt and expert medical treatment".
He concluded that medical tourniquets should have been applied to Mr Atkinson's legs and dressings applied to his wounds earlier.
The inquiry chairman said "responsibility for that failure" rested with the arena's operator SMG and the management of Emergency Training UK, which was contracted to provide healthcare at the venue.
He added that more paramedics should have been in the City Room earlier and they would likely have "identified the need for urgent treatment and evacuation" of Mr Atkinson.
"That did not occur," Sir John said. "Responsibility for that failure rests with NWAS.
"Such treatment would, I am satisfied, have enabled John Atkinson to arrive at hospital prior to having a cardiac arrest and would probably have saved his life."
Sir John also said that Mr Atkinson should have been moved from the City Room promptly and if firefighters had been at the scene at the time, the victim would have been "prioritised for evacuation".
He also pointed out that if more ambulances had been at the scene shortly after 11pm, Mr Atkinson would have received treatment and he would have been taken to hospital sooner.
"Either way, he would have reached hospital before having a cardiac arrest and is likely to have survived," Sir John said.
"John Atkinson would probably have survived had it not been for inadequacies in the emergency response."
In a statement following the report, Mr Atkinson's family said: "It is now clear beyond any doubt that on the night of the bombing John was totally failed at every stage.
"It is crystal clear that due to those failings, John died from injuries that he could and should have survived.
"He was left, dying, without his dignity, on the floor when it should have been obvious to medics that he needed to get straight to hospital."
Referring to evidence heard during the inquiry that Mr Atkinson told a police officer: "I'm gonna die," while he was lying on the floor, his family said: "John must have known that he was dying and the pain that causes us is too great to put into words. This should simply never have been allowed to happen."
'Mistakes' made by emergency services
In his report, Sir John said "significant aspects of the emergency response on 22 May 2017 went wrong" and "this should not have happened".
The inquiry chairman said he had "no doubt that lives were saved by the emergency response", but added: "Looked at overall, and objectively, the performance of the emergency services was far below the standard it should have been."
He said GMP "did not lead the response" the way it should have; Greater Manchester Fire and Rescue Service (GMFRS) "failed to turn up at the scene at a time when they could provide the greatest assistance"; and NWAS "failed to send sufficient paramedics" into the City Room and "did not use available stretchers to remove casualties in a safe way".
The inquiry heard that police officers, arena staff and members of the public were forced to carry injured people using advertising hoardings, crowd barriers and tables due to the lack of stretchers, which Sir John said was "a painful and unsafe way of moving the injured".
He added that "one of the most emotional and upsetting parts of the inquiry" was hearing of the "despair" of those injured, who could hear ambulance sirens outside but saw few paramedics arrive.
Among the failures identified in the report:
• Inspector Dale Sexton, the force duty officer at GMP's headquarters, became "overburdened" and made a "significant mistake" in failing to declare a major incident in the early stages of the emergency response. GMP only declared a major incident close to 1am - two and a half hours after the bomb went off
• After inaccurate reports of gunshots, Insp Sexton declared Operation Plato - the emergency response to an attack by a marauding terrorist with a gun - but failed to communicate this to other emergency services
• GMFRS station manager Andrew Berry sent firefighters to Philips Park fire station, three miles away from the scene, meaning some firefighters were driving away from the incident and past ambulances travelling in the opposite direction
• Inspector Benjamin Dawson, from British Transport Police (BTP), declared a major incident around 10 minutes after the attack but did not tell GMP or GMFRS
• There was "substantial confusion" over the location of a rendezvous point for emergency services, with each service choosing their own
• NWAS declared a major incident about 15 minutes after the attack but this was not shared with any other emergency service.
Sir John said "there was the failure of anyone in a senior position in GMFRS to take a grip of the situation during the critical period of the response".
He acknowledged he had "criticised a large number of people" who he considered had "made mistakes on the night", adding that "some of those criticisms may seem harsh, particularly given the situation that those individuals were faced with".
"They were trying to do their best," he added. "I do understand the enormous pressures that they were acting under.
"They had to do many things in a short time and it may not be surprising that things went wrong. I am not unsympathetic to them.
"But I need to identify mistakes where they have been made because otherwise there is no prospect of preventing them in the future."
'Simply not good enough'
In a joint news conference after the report, GMP, BTP, GMFRS and NWAS apologised for their response to the Manchester Arena bombing.
GMP chief constable Stephen Watson said the force's "failings were significant" on the night of the attack.
"We failed to plan effectively and the execution of that which was planned was simply not good enough," he said.
"Our actions were substantially inadequate and fell short of what the public have every right to expect, and for this, I apologise unreservedly."
Among a series of recommendations, Sir John said that "in the event that public funding cuts are in the future considered necessary by the government, the Home Office should consider whether some funding arrangement for police services different from that applied in the post-2010 period is necessary".
Responding to the report, Prime Minister Rishi Sunak said he was committed to "learn from the lessons" of the inquiry.
"Nothing will ease the pain of the families of those killed during the cowardly terrorist attack at Manchester Arena," he tweeted.
"It is my solemn commitment to the victims, survivors and their loved ones that we will learn from the lessons of this inquiry."
Sir John's first report on security issues at the arena venue was issued last June and highlighted a string of "missed opportunities" to identify Abedi as a threat before he walked across the City Room foyer and detonated his shrapnel-laden device.
The third and final report will focus on the radicalisation of Abedi and what the intelligence services and counter-terrorism police knew, and if they could have prevented the attack. It will be published at a later date.