IT CONTAINS DETAIL ABOUT THE NATURE OF THE INJURIES
SUSTAINED BY THOSE WHO DIED AND THEIR CAUSE OF DEATH
Introduction
My investigation into the Attack began as twenty‑two inquests. As I set out in my Preface to Volume 1, it became necessary to continue that investigation as a statutory public inquiry. This Part has been drafted with the duties of a Coroner in mind.
The purpose of this Part is to provide a summary of the evidence about what happened to each of those who died. For each individual, I heard detailed evidence about the circumstances of their death during a period of the Inquiry’s oral evidence hearings concerned exclusively with each of those who died.
The summary of that evidence within this Part is intentionally short. Its focus is on the most relevant information about the circumstances in which they were killed. It is not necessary, and would be distressing, to repeat every aspect of the evidence heard. The transcripts of the evidence, which provide far greater detail, are available on the Inquiry’s website.1 I have noted in this Part where some of the evidence has not been published on the Inquiry’s website due to its graphic and distressing nature. This includes post‑mortem reports.
I have summarised the position in relation to each person who died separately. I made exceptions for this in the case of two couples. For each of those who died, I set out where that person was in the period immediately after detonation, what care they received, when they were confirmed as dead and their cause of death. I confirm in the case of every person who died that they were unlawfully killed.
This is the information that, as a Coroner, I would have included in the record of inquest for each person.
The evidence set out in this Part is distressing. It sets out the tragic circumstances in which each person died. It is important to remember, as the Inquiry heard during the commemorative pen portrait evidence, that each of those who died is “not a number, each of them is not just one of the 22 who died: each was an individual, each was unique, each loss of life is a separate tragedy”.2
Investigation
All of those who died were the subject of a post‑mortem examination. These examinations were carried out by a team of forensic pathologists, led by Dr Philip Lumb.3 The post‑mortem examinations were assisted by a radiology team led by Colonel Dr Iain Gibb, who was supported by Lieutenant Colonel Dr Mark Ballard and Commander Dr David Gay.4
Extensive work was undertaken by Operation Manteline, the Greater Manchester Police (GMP) team who assisted my investigation. This included many hundreds of hours spent analysing the footage from 90 CCTV cameras, from 52 body‑worn video cameras and from mobile phones. From that work, timelines were produced to show, as far as possible, what happened to each person who died and the individuals who interacted with them.
An important part of my investigation has been whether a different or better emergency response may have led to the survival of any of those who died. I have been assisted in this part of my investigation by experts. These experts and their qualifications are set out in Appendix 12. Such has been the complexity of some of the issues that have arisen that it has been necessary to call upon more than one expert in certain disciplines.
First, I instructed the Blast Wave Panel of Experts to consider the relevant evidence. The Panel are a multi‑disciplinary team based at Imperial College London and the Defence Science and Technology Laboratory. The Panel have considerable expertise in blast injury. The Panel comprised Professor Anthony Bull, Colonel Professor Peter Mahoney, Colonel Professor Jonathan Clasper, Lieutenant Colonel Ballard and Alan Hepper. The purpose of their review was to consider whether any of those who died may have been able to survive their injuries with different or better care.
Second, in relation to two of those who died, the complexity of the evidence surrounding their deaths led me to instruct further experts. In the case of John Atkinson, I instructed cardiology expert Surgeon Commander Dr Paul Rees. In the case of Saffie‑Rose Roussos, I instructed consultants in pre‑hospital care and emergency medicine, Lieutenant Colonel Dr Claire Park, Dr Gareth Davies and Mr Aswinkumar Vasireddy, and consultant radiologist Dr Richard Wellings.
Third, I instructed forensic pathologists Professor Jack Crane and Dr Lumb to review the post‑mortem evidence in the light of all the medical and scientific evidence. That included a review of relevant video footage. In relation to John Atkinson’s post‑mortem, Dr Naomi Carter, who carried it out, was invited to review her findings following receipt of Surgeon Commander Rees’s report.
Survivability
The Blast Wave Panel of Experts were instructed to assess the available evidence and provide their conclusions on whether each of those who died may have survived, if they had received different medical care. The Panel defined the term “unsurvivable” as “injuries so severe that even if the most comprehensive and advanced medical treatment [available in 2017] was initiated immediately after injury, survival was still deemed impossible”.5 I shall adopt this definition.
In the case of twenty of the twenty‑two people who died, the Panel concluded that all of the evidence supports the conclusion that their injuries were unsurvivable. I accept this evidence. I record this fact in relation to each of those to whom it applies when I address the circumstances of their death.
The evidence was less conclusive in the cases of John Atkinson and Saffie‑Rose Roussos. For this reason, it required more detailed analysis, which I will provide at paragraphs 18.154 to 18.234.