Survivability

Introduction

I find the following people sustained unsurvivable injuries:

• Alison Howe
• Kelly Brewster
• Angelika Klis
• Lisa Lees
• Marcin Klis
• Martyn Hakan Hett
• Chloe Rutherford
• Megan Joanne Hurley
• Liam Curry
• Michelle Kiss
• Courtney Boyle
• Nell Jones
• Eilidh MacLeod
• Olivia Paige Campbell‑Hardy
• Elaine McIver
• Philip Tron
• Georgina Bethany Callander
• Sorrell Leczkowski
• Jane Tweddle
• Wendy Fawell

Once the explosion had occurred, it was inevitable that each would die. I have set out in Parts 13 to 16 in Volume 2‑I details in relation to the treatment and evacuation of some of these individuals on the night of the Attack. Any inadequacies in the emergency response, as set out in Parts 10 to 16 in Volume 2‑I, did not contribute to their deaths.

For John Atkinson and Saffie‑Rose Roussos, there was evidence about the possibility of their survival had the response been different. Due to its complexity, this requires a detailed analysis of the evidence.

Readers may find what follows particularly distressing.

John Atkinson

Post-mortem examination

Dr Carter is a consultant forensic pathologist on the Home Office register. She was one of the team that carried out the post‑mortem examinations of the twenty‑two who died in the Attack.

Dr Carter performed the post‑mortem examination of John Atkinson on 28^th May 2017.¹⁶² In her written report of that examination, Dr Carter listed 47 external injuries. Of those, 16 were to the right leg and foot and 14 to the left leg.¹⁶³

Dr Carter concluded that John Atkinson had sustained very severe leg injuries as the result of penetration by multiple metal objects. These had shredded the musculature, damaged deep leg blood vessels and severely fractured the bones of the leg, particularly on the right side. While John Atkinson had suffered injuries to other parts of his body from penetrating objects, those injuries had not contributed to his death. Dr Carter’s conclusion was that John Atkinson “died principally of the effects of blood loss from his leg wounds”.¹⁶⁴

Surgeon Commander Rees, an expert in cardiology,¹⁶⁵ explained this in further detail during the oral evidence hearings. When a person suffers unchecked blood loss, their body will ultimately go into a state known as ‘hypovolaemic shock‘. This involves the body’s circulation shutting down. Organs then fail, including the heart. In simple terms, blood loss causes hypovolaemic shock which causes cardiac arrest.¹⁶⁶ The view of Dr Carter was that this was the mechanism of John Atkinson’s death.¹⁶⁷ The other experts agreed.¹⁶⁸

There was, however, a complicating factor identified by Dr Carter on her post‑mortem examination. On her internal examination, she noted that John Atkinson had pre‑existing heart disease. One of his coronary arteries contained a blockage and there was also scarring to his heart that had been present for months or years. In medical terms, John Atkinson had a condition known as ‘ischaemic heart disease’. Dr Carter considered that this disease might have been a contributory factor in John Atkinson’s death, either by making his heart more likely to fail in the context of the blood loss from his leg injuries and/ or by reducing the chances of successful resuscitation.¹⁶⁹ Dr Carter was right to identify this as a potential issue.

Reports of the Blast Wave Panel of Experts in John Atkinson’s case

The Blast Wave Panel of Experts carried out an assessment of survivability in the case of each of the twenty‑two killed, including John Atkinson.

In their first report dated 27^th September 2019, the Panel expressed the view that John Atkinson had “potentially survivable” injuries.¹⁷⁰ The Panel used that term to describe injuries which “could prove fatal”, but which they were aware of individuals surviving.¹⁷¹ Their assessment assumed that the right people with the right skills and right equipment would be available immediately after the injury had been sustained.¹⁷²

It follows that, in their first report, the Panel considered that John Atkinson might have survived with prompt and effective treatment. However, the Panel did raise a proviso, namely the potential impact on survivability of John Atkinson’s pre‑existing heart disease, as commented upon by Dr Carter.¹⁷³

After preparing their first report, the Panel were provided with additional material, in particular CCTV footage and footage from the body‑worn video cameras of police officers.¹⁷⁴ In light of that material, they looked again at the issue of survivability and produced a second report dated 30^th March 2020.¹⁷⁵ Of John Atkinson, they said:

“[He] sustained multiple secondary blast injuries with an overall high burden of injury … The PM [post-mortem] photos and medical imaging demonstrate severe leg injuries; these leg injuries were associated with severe compressible bleeding.

The video demonstrates catastrophic and continuing external bleeding; this appears amenable to treatment outside hospital.

Based on the video footage, witness statements, and the above information, we believe, John Atkinson could have potentially survived in this situation with earlier treatment (application of effective bilateral tourniquets).

However, the post-mortem noted a pre-existing cardiac condition that reportedly reduced the chances of survival given the burden of injury. This reduction in chances of survival due to the pre-existing cardiac condition is a matter not within the expertise of the panel.”¹⁷⁶

In a third report dated 24^th March 2021, the Panel clarified that the change of language from “potentially survivable” in the first report to “could have potentially survived” in the second report was deliberate.¹⁷⁷ They explained that it “reflects a strengthening of our opinion that timely medical intervention – the application of effective bilateral tourniquets – could have made a material difference for John Atkinson”.¹⁷⁸

However, the Panel’s opinion as to survivability in John Atkinson’s case continued to have a proviso. Throughout their reporting, the Panel made it plain that their opinion on survivability in his case was contingent upon the significance of his pre‑existing ischaemic heart disease. In that regard, the Panel responsibly drew attention to the fact that the significance of that condition to survivability was outside their combined expertise.¹⁷⁹

The expert cardiological opinion

For that reason, I instructed Surgeon Commander Rees to provide his opinion on the significance of John Atkinson’s pre‑existing heart disease.

Surgeon Commander Rees is an expert in cardiology, general internal medicine and pre‑hospital emergency medicine. He works as a consultant cardiologist within Barts Heart Centre, at St Bartholomew’s Hospital in London, and undertakes regular duties with an air ambulance service. He also has military experience, having undertaken combat deployments including working in a field hospital in Afghanistan, and worked as a consultant leading the Medical Emergency Response Team, often treating those injured in explosions.¹⁸⁰

Surgeon Commander Rees gave evidence to the Inquiry.¹⁸¹ He agreed with Dr Carter that the problems in John Atkinson’s heart and coronary artery found in the post‑mortem examination were not a consequence of the explosion but instead were pre‑existing.¹⁸² John Atkinson had lived with the blockage in his artery for a substantial period prior to 22^nd May 2017, and the scarring to his heart was pre‑existing and likely the result of a heart attack at some point in the past. John Atkinson’s medical records contained no reference to any history of heart problems, let alone to a heart attack. Surgeon Commander Rees found this unsurprising. He explained that cardiology recognises the concept of a silent heart attack in which the patient is wholly unaware that anything untoward has happened. Moreover, even where the patient has symptoms, they may mistake them for something trivial and make no report of them.¹⁸³

Notwithstanding that the problems in John Atkinson’s heart and coronary artery identified on the post‑mortem examination appear not to have caused him any or any significant difficulties in life, Surgeon Commander Rees agreed with Dr Carter that the findings were notable. However, he did not consider that they had made a contribution to John Atkinson’s death.¹⁸⁴ His opinion was in three parts.

First, he did not think that the presence of ischaemic heart disease contributed to John Atkinson’s blood loss.¹⁸⁵

Second, he did not think that the ischaemic heart disease made any material contribution to the cardiac arrest at 23:47.¹⁸⁶ The disease that was identified during the post‑mortem was minor and was not interfering with John Atkinson’s ability to conduct a normal life. He had what Surgeon Commander Rees described as a stable “bystander” disease.¹⁸⁷ Surgeon Commander Rees stated:

“[We] also know from the post-mortem that the area of scarring is very small, so he was left with the vast majority of his heart muscle able to function perfectly normally. What we also know from the post-mortem is that his other major cardiac arteries, his main heart arteries, were entirely normal and free from disease. So, in all likelihood, they were functioning perfectly well. So, in the context of having a very small area of scar, a very small area of narrowing in a relatively unimportant heart artery, I think the relative contribution of ischaemic heart disease here is actually very small, and the primary contributor to his very sad deterioration is the degree of hypovolaemic shock that we outlined earlier. I think that’s by far the most significant contributor to him ending up in a state of cardiac arrest, and I think the role of ischaemic heart disease here is very small or negligible in terms of its overall contribution to deterioration to the point of cardiac arrest.”¹⁸⁸

Third, ischaemic heart disease did not contribute to the inability to resuscitate John Atkinson once he went into cardiac arrest. The deciding factor on resuscitation was John Atkinson’s state of hypovolaemic shock.¹⁸⁹ Surgeon Commander Rees considered that John Atkinson’s survival after the cardiac arrest at 23:47 was “extremely unlikely”.¹⁹⁰ That event marked the “point of no return”.¹⁹¹ Electrical activity detected at about 00:00 on 23^rd May 2017, as John Atkinson was in the ambulance on his way to hospital¹⁹² was likely to have been intermittent and not reflective of a fully functioning heart. In no sense was it a return to the activity of a normal heart.¹⁹³

The evidence of Surgeon Commander Rees was measured, clear and persuasive. I accept his opinion that John Atkinson’s ischaemic heart disease did not make any material contribution to his death. That removes the proviso that the Blast Wave Panel of Experts applied to their own opinion. That is of significance to the issue of survivability in the case of John Atkinson.

Surgeon Commander Rees was clear that his role was to address the cardiological aspects of the case. He recognised that the Blast Wave Panel of Experts were able to draw upon a broader range of expertise. In those circumstances, he considered that he ought to defer to them on the issue of survivability.¹⁹⁴ In my view, he was right to do so.

Survivability

In respect of John Atkinson’s survivability, I heard further evidence from the pathologists and the Blast Wave Panel of Experts. They did not give evidence one after another, as is usual, but instead concurrently in a process sometimes referred to as ‘hot‑tubbing’. I used this approach on a number of occasions during the oral evidence hearings and found it an effective way of getting to the core of the expert issues.

The pathologists who gave evidence were Dr Lumb and Professor Crane. As I explained earlier in this Part, I instructed them to review the post‑mortem evidence for each of the twenty‑two killed in the Attack in light of all of the medical, scientific and available video evidence. Dr Lumb is a consultant forensic pathologist on the Home Office register and led the team that carried out the post‑mortem examinations of those who died in the Attack.¹⁹⁵ Professor Crane was the State Pathologist for Northern Ireland between 1990 and 2014 and is currently Professor of Forensic Medicine at Queen’s University Belfast.¹⁹⁶

Dr Lumb and Professor Crane were clear that Dr Carter’s initial view that John Atkinson’s ischaemic heart disease might have made a contribution to a death that was principally caused by blood loss from leg wounds was entirely reasonable on the basis of what she knew.¹⁹⁷ They were not critical of Dr Carter’s original conclusion and nor am I. Dr Carter highlighted an important issue that undoubtedly required further investigation. However, Dr Lumb and Professor Crane had access to more evidence than Dr Carter, including the opinion of Surgeon Commander Rees.

In light of all of that evidence, Dr Lumb and Professor Crane had no doubt that John Atkinson’s death was caused by the leg injuries he sustained and that the pre‑existing heart disease from which he suffered played no part.¹⁹⁸

I accept that evidence. It means that the issue of survivability becomes focused on whether anything more could have been done to stem the bleeding from John Atkinson’s leg injuries. It was this bleeding that led, ultimately, to his death.

Professor Bull and Colonel Clasper of the Blast Wave Panel of Experts gave evidence on the issue of John Atkinson’s survivability. They set out the views of the Panel as a whole. Professor Bull is a bioengineer. He heads the Department of Bioengineering and the Centre for Blast Injury Studies at Imperial College London. The Centre brings together experts in medicine, engineering and other areas of science to investigate blast injuries.¹⁹⁹ Colonel Clasper is a consultant orthopaedic surgeon with considerable experience of major injuries in both a civilian and military context. He is a Visiting Professor within Professor Bull’s department at Imperial College London and Clinical Lead for the Centre for Blast Injury Studies.²⁰⁰

Colonel Clasper explained how the views of the Blast Wave Panel of Experts on the survivability of John Atkinson had developed. He confirmed that the position of the Panel in light of all of the evidence, including the opinion of Surgeon Commander Rees, was that John Atkinson “could have potentially survived” his injuries.²⁰¹

Colonel Clasper agreed with Surgeon Commander Rees that there was “no coming back from” the cardiac arrest at 23:47.²⁰² He explained the timeline in John Atkinson’s case by reference to the footage the Blast Wave Panel of Experts had seen.²⁰³ A belt had been applied as a tourniquet to John Atkinson’s right leg within five to six minutes of the explosion.²⁰⁴ It was the view of Colonel Clasper that the member of the public who applied this makeshift tourniquet, Ronald Blake, “did brilliantly”.²⁰⁵ Nonetheless, despite the heroic efforts of Ronald Blake, John Atkinson continued to lose blood.²⁰⁶ If additional early steps, in particular the application of bilateral tourniquets by properly qualified first responders, had been taken to stop or slow his blood loss, then that would probably have delayed John Atkinson going into a state of hypovolaemic shock and that, in turn, would probably have delayed the cardiac arrest, or even prevented it altogether.²⁰⁷ Colonel Clasper stated the following in answer to questions:

“Q. If this course had been delayed so that John had reached hospital in a state in which he was not in cardiac arrest, in your view would that have made a difference?

A. Yes.

Q. What difference do you think it would have made?

A. He had other severe injuries, but I think if he’d got to hospital without having had a cardiac arrest, given that the team were prepared for him, I think there’s a high chance he would have survived. I can’t give you an estimate of exactly how high, but I think it’s a high chance.”²⁰⁸

The fact that there was a “high chance” that John Atkinson would have survived if he had reached hospital prior to his cardiac arrest does not mean that that necessarily could have been achieved and does not mean that survival was, on a sensible analysis of what could be achieved, probable. Colonel Clasper was pressed on this important issue.²⁰⁹

In response, he described a “platinum 10 minutes” during which the best prospect of stemming significant bleeding exists.²¹⁰ However, Colonel Clasper was clear that it was not the case that intervention after ten minutes was incapable of making a difference.²¹¹ His evidence, which represented the views of the Blast Wave Panel of Experts as a whole, was clear (with emphasis added):

“Q. … bearing in mind John goes into cardiac arrest … 1 hour and 16 minutes after the explosion and his injuries, bearing in mind that we know he was conscious and able to speak, what is your view about the window during which an intervention would have made a difference to John’s survivability?

A. I think there was a window up to about 40 minutes after the incident.”²¹²

Later, he extended that period up to 45 minutes.²¹³

I accept this evidence of Colonel Clasper. I therefore assess the issue of survivability on the basis that, if an intervention sufficient to slow substantially or stop bleeding had been undertaken before 23:16, that is, up to 45 minutes post‑explosion, John Atkinson would probably have survived. That is because he would have arrived at hospital before his cardiac arrest.

My conclusion is that such an intervention should have occurred in one or both of two ways.

First, medical tourniquets should have been applied to both of John Atkinson’s legs and haemostatic dressings applied to his wounds²¹⁴ well before 23:16. ETUK staff should all have been competent to use such treatments and equipped to do so. They were not or at least not sufficiently. Responsibility for that failure rests with the management of ETUK, namely Ian Parry, and SMG, who should have ensured that the event healthcare provider was competent. More NWAS paramedics should have been in the City Room before 23:16, as I explained in Parts 10 and 14 in Volume 2‑I. If that had occurred, it is likely that they would have identified the need for urgent treatment and/or evacuation of John Atkinson. That did not occur. 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.

Issues also arise about whether the firearms officers and unarmed police officers should have provided such treatment. In future, they should do so, where the circumstances permit. However, for reasons I will address in Part 20, I am not critical of GMP or BTP for the fact that their officers did not do so on the night of the Attack.

Second, John Atkinson should have been evacuated from the City Room promptly. His evacuation in fact started at 23:17²¹⁵ and he did not arrive in the Casualty Clearing Station until 23:24,²¹⁶ following an extraction which, through no fault of those engaged in it, was entirely unsatisfactory. If firefighters had been in the City Room shortly after 22:45, as I have concluded in Parts 10 and 15 in Volume 2‑I ought to have been the case, John Atkinson would have been prioritised for evacuation. If more ambulances had been present at the Victoria Exchange Complex shortly after 23:00, as I have also concluded in Parts 10 and 14 in Volume 2‑I ought to have been the case, John Atkinson would have received treatment and would have been transported to hospital shortly after that time. Either way, he would have reached hospital before having a cardiac arrest and is likely to have survived.

In his opening remarks at the beginning of the oral evidence hearings, Counsel to the Inquiry explained that I would examine whether there were any inadequacies in the emergency response. I have found that there were. He went on to say that, if those inadequacies, or any one of them, led to the loss of even a single life, that would be entirely unacceptable. They did. John Atkinson would probably have survived had it not been for inadequacies in the emergency response.

Saffie-Rose Roussos

I heard expert evidence about the cause of the death of Saffie‑Rose Roussos over the course of three days between 1^st and 3^rd December 2021. There was a significant disagreement between, on the one hand, the members of the Blast Wave Panel of Experts and, on the other hand, some of the additional experts I instructed. The former ultimately considered that there was no possibility that Saffie‑Rose Roussos would have survived whatever treatment she had received. The latter felt that survival was not an impossibility with the best treatment. No one will benefit from a detailed recitation of that evidence, which was harrowing. Instead, I propose to record my conclusions, setting out the reasons for those conclusions in summary form. Even that will inevitably be distressing to read.

Dr Lumb performed the post‑mortem examination on Saffie‑Rose Roussos on 24^th May 2017.²¹⁷ He identified 69 external injuries in addition to internal injuries. The internal injuries involved extensive damage to the musculoskeletal and vascular systems of Saffie‑Rose Roussos, injuries to her lungs and liver, and internal bleeding.²¹⁸ In their work, the Blast Wave Panel of Experts utilised an internationally recognised system called the New Injury Severity Score. They did so by reference to the post‑mortem report of Dr Lumb, the post‑mortem photographs and the results of the computerised tomography (CT) scan that was undertaken, which included a reconstruction. This work ascribed a greater number of injuries to Saffie‑Rose Roussos than Dr Lumb had, not because of any error on his part, but as a result of differences of description. Applying the New Injury Severity Score, the Panel identified that Saffie‑Rose Roussos had suffered a total of 103 injuries that were “scorable”²¹⁹ against that system. They stated: “Graphically, this can be described as equivalent to the energy of more than 15 handgun bullets.”²²⁰

In considering the injuries that were causative of the death of Saffie‑Rose Roussos, or potentially so, the experts focused on three categories of harm: the fractures to her pelvis and legs; the damage to her vascular system; and the damage to her lungs.

Fractures to the pelvis and legs

Saffie‑Rose Roussos sustained extensive fractures to her pelvis and legs.²²¹ These were the consequence of bolts penetrating her body and striking bone and/or bolts penetrating her body and depositing energy into the bone as they passed by.²²² I see no value in describing these injuries further given that all of the experts agreed about the severity of the injuries sustained.²²³ Dr Lumb described the fractures as “extremely severe”.²²⁴ All of these fractures, the experts agreed, will have bled.²²⁵

Vascular injury

The evidence identified four potential areas of significant vascular injury to Saffie‑Rose Roussos: the popliteal arteries (the arteries behind the knees which extend upwards and into the thighs); the vessels in the area of the acetabulum (hip joint) on the left side; and the femoral arteries and associated vascular structures in the left thigh and the right thigh.²²⁶

The experts were agreed that there was vascular injury and consequent bleeding in the popliteal arteries.²²⁷ However, there was a dispute as to the existence of vascular injury and/or its severity in the area of the acetabulum and in the left and right thighs. The members of the Blast Wave Panel of Experts expressed the firm view that such injuries were present and were serious.²²⁸ They supported their opinion by reference to a presentation by Lieutenant Colonel Ballard, a consultant radiologist with considerable military and civilian experience.²²⁹ Dr Wellings, also a consultant radiologist, agreed with the Panel.²³⁰ Conversely, Lieutenant Colonel Park, Dr Davies and Mr Vasireddy, additional experts I instructed, all considered that there was no significant vascular injury in these areas. They did so on the basis that, in their experience, the presence of such injuries would have caused Saffie‑Rose Roussos to die through blood loss much more quickly than in fact occurred.²³¹

On each side of this dispute were experts of high quality, each of whom had considerable relevant experience and each of whom, I have no doubt, was trying to help me to reach the right conclusion. However, both sides cannot be right.

On balance, I preferred the opinion of the Blast Wave Panel of Experts and Dr Wellings about the nature and extent of the vascular injuries. That is for the following two reasons.

First, I will consider the conclusions to be drawn from the CT scans. Computerised tomography (CT) scans combine a series of X‑ray images taken from different angles around the body with computer processing, to create cross‑sectional images of the body. CT scanning is of considerable diagnostic value in living patients. In the context of the Attack, CT scanning assisted the pathologists to identify where bolts had penetrated the body and the structures they had struck.

CT scanning may take a number of different forms.²³² One form is known as contrast CT scanning. This involves the introduction into the body of a dye known as a contrast medium. In a living patient, this is pumped around the veins and arteries of the body by the heart, enabling the vascular system to be seen on the CT scan.²³³ A second form of CT scanning is known as full‑body CT scanning. This does not involve the introduction of a contrast medium. It enables the musculoskeletal system to be seen on the scan but not the vascular system.²³⁴

Dr Lumb and his team carried out full‑body scans of Saffie‑Rose Roussos and the others who died, rather than contrast CT scans. As the radiologists agreed, there were good reasons why this was the correct approach.²³⁵ The process of contrast CT scanning slows the post‑mortem process and creates risks for those carrying it out. At the time, there were no clear indicators that it was necessary to carry out such scanning. In any event, the equipment to enable it to be done was not readily available. Even today, post‑mortem contrast CT scanning is very much the exception and Dr Lumb described it as an area of research in forensic pathology.²³⁶

Although I am not at all critical of the decision to carry out only a full‑body CT scan, the consequence is that the CT scanning of Saffie‑Rose Roussos does not show her vascular system.²³⁷ That means that the scanning alone does not establish definitively whether she had sustained significant vascular damage in the area of her acetabulum and in the left and right thighs.²³⁸

However, the radiologists Lieutenant Colonel Ballard and Dr Wellings considered that the CT scans were of assistance in determining whether vascular damage had occurred in those areas. They pointed out that the scans showed that Saffie‑Rose Roussos had sustained penetrating injuries in each of the relevant areas with consequent fracturing.²³⁹ It was their view that such injuries must have had cavitating effects.²⁴⁰ Such effects are, as Colonel Clasper of the Blast Wave Panel of Experts explained, rarely seen in civilian practice.²⁴¹ They involve a high‑velocity projectile entering the body, transferring energy into the body, tearing and distorting the tissues, and creating a cavity beyond the wound track.²⁴² Lieutenant Colonel Ballard and Dr Wellings explained that these cavitating effects must have caused significant vascular damage to Saffie‑Rose Roussos. In their view, it was not possible for such extensive damage to have been caused to the bone and soft tissue in these areas without the underlying blood vessels also having sustained significant damage.²⁴³

I accept that analysis.

Second, I will consider the conclusions to be drawn from the post‑mortem examination. At the time of that examination, Dr Lumb reported on the vascular injury to the arteries behind the knees of Saffie‑Rose Roussos.²⁴⁴ This was a reference to the popliteal arteries, which the experts agreed were the location of vascular damage. After completing his post‑mortem report, Dr Lumb was asked whether he was able to say whether there had also been vascular damage in the thighs. In response, he explained that the thighs are “richly vascular”.²⁴⁵ He expressed the strong view, based upon what he observed on his examination, that there was significant vascular damage to both thighs, describing such damage as “inevitable” in relation to the left thigh and “almost certain” in relation to the right thigh.²⁴⁶ He described the injuries to Saffie‑Rose Roussos’s legs as “very severe” and capable of causing death on their own.²⁴⁷ Professor Crane agreed that these injuries were sufficient on their own to cause death.²⁴⁸

I accept the evidence of Dr Lumb as to the presence of significant vascular damage in the thighs. It comes from the expert who actually carried out the post‑mortem examination, supported by the opinion of a pathologist of long experience and undoubted expertise.

I gave careful consideration to the views of the experts who expressed the competing opinion that Saffie‑Rose Roussos had sustained no significant vascular damage save behind the knees.²⁴⁹ Their experience is substantial, and their views were expressed with force and conviction. While I accept that they may have had different experience on which to draw, the overwhelming burden of the evidence demonstrated that significant vascular injury causing bleeding was present in each of the areas I have described.

The fact that Saffie‑Rose Roussos did not die sooner through blood loss is explicable by reason of the following factors: she is likely to have bled rapidly in the period just after sustaining her injuries but then more slowly as her blood pressure dropped;²⁵⁰ her blood vessels may not have fully bled immediately or all of the time due to various mechanisms about which the various experts agreed;²⁵¹ Saffie‑Rose Roussos’s age will have made her more resilient;²⁵² and there is real‑world experience of people with serious vascular injury surviving for the same length of time Saffie‑Rose Roussos remained alive.²⁵³

Colonel Clasper of the Blast Wave Panel of Experts gave evidence on this final point.²⁵⁴ As I have set out, he is a consultant orthopaedic surgeon with particular knowledge and experience of injuries caused by explosions. He explained that the experience of the military is that a femoral artery injury does not always cause death swiftly. There is experience within the military of those with Saffie‑Rose Roussos’s burden of injury, including femoral artery injury, surviving for longer than 40 minutes, indeed for over an hour in some cases. Hence, the fact that Saffie‑Rose Roussos survived for a little over one hour does not, in the view of Colonel Clasper, make her “an outlier”.²⁵⁵ I accept his evidence.

For these reasons, I am satisfied that Saffie‑Rose Roussos sustained significant vascular damage not only to the arteries behind her knees, but also in the area of her hip joint and in both thighs. Furthermore, I consider that these injuries were extremely serious.

Injury to the lungs

The experts agreed that Saffie‑Rose Roussos had suffered lung damage as a result of the explosion, significantly worse on the right side than on the left.²⁵⁶

The strong view of the Blast Wave Panel of Experts was that the cause of this lung damage was a condition known as blast lung.²⁵⁷ They explained that an explosion has a number of effects. The first is known as the primary blast.²⁵⁸ This is best described as a shock wave which surges out from the seat of the explosion. The interaction of this shock wave with the human body is capable of causing injury to the air‑containing organs, such as the lungs, airway and bowel. Injury to the lungs is characteristic and, where it occurs, is known as blast lung.²⁵⁹ Such injury involves disruption of the structures of the lung, causing bleeding and a subsequent inflammatory reaction.²⁶⁰ It becomes progressively worse, is very dangerous and may be fatal, in particular where there is otherwise a high burden of injury.²⁶¹

At one stage, I had understood that there was a dispute as to whether the damage to the lungs of Saffie‑Rose Roussos was the result of blast lung. As a result, I asked Professor Crane to consider that issue. He was a consultant forensic pathologist during much of the period of the Troubles in Northern Ireland and therefore has considerable experience of deaths as a result of explosions.²⁶² He examined photographs of the lung tissue of Saffie‑Rose Roussos.²⁶³ He expressed the opinion that she had sustained “severe primary blast lung injury to the right lung”.²⁶⁴ On the left there was also, in his view, blast lung, but not as extensive or serious as on the right.²⁶⁵ Dr Lumb agreed with Professor Crane.²⁶⁶

In light of the clear and unequivocal evidence of the pathologists, Dr Davies, who was on the other side of the survivability debate, realistically accepted that the damage to the right lung was severe and that a significant part of the cause was blast lung.²⁶⁷

On the basis of all the evidence I heard, it is my view that Saffie‑Rose Roussos had severe damage to her right lung and some, but less extensive, damage to her left lung and that the cause of both was blast lung.

Although this fact was established by the evidence, an issue remained about the severity of the consequences of this for the ability of Saffie‑Rose Roussos to survive. In particular, Lieutenant Colonel Park was unconvinced that the lung injury, serious though she accepted it was, had an effect on Saffie‑Rose Roussos’s ability to breathe to the extent that her life was imperilled by it.²⁶⁸ She and Dr Davies attached importance to the footage from the body‑worn video camera of, in particular, Police Constable (PC) Leon McLaughlin.²⁶⁹ They stated that they had been unable to detect in that footage any significant respiratory impairment on the part of Saffie‑Rose Roussos and were of the view that the lung damage did not, therefore, have any significant physiological effect in the period before her death.²⁷⁰

I have viewed the footage. I do not consider that it establishes the point advanced by Lieutenant Colonel Park. Furthermore, the opinion of Lieutenant Colonel Park and Dr Davies is at odds with the evidence of lay witnesses who saw Saffie‑Rose Roussos in the period before she was transported to hospital. That evidence is consistent with Saffie‑Rose Roussos experiencing difficulties breathing.²⁷¹ PC McLaughlin gave evidence that, while Saffie‑Rose Roussos was on the pavement on Trinity Way, her breathing was “quite shallow, quite laboured”.²⁷² Bethany Crook, an off‑duty nurse who was with Saffie‑Rose Roussos for a 14‑minute period²⁷³ prior to her departure for hospital, expressed her concerns about the breathing of Saffie‑Rose Roussos. She explained that there were times when it was very shallow and times when it was “very pronounced and exacerbated … that is an indication to me medically, in my training, that tells me that she’s having difficulties breathing”.²⁷⁴ The lay witness evidence, in my view, was consistent with the effect that blast lung would generally be expected to produce, namely respiratory difficulties.

I consider that the evidence overall demonstrated that the damage to the lungs of Saffie‑Rose Roussos was so severe that it must have significantly compromised her ability to get oxygen to her tissues, which was necessary for her to sustain life. This ability had already been compromised by her blood loss from the injuries to her pelvis and legs and to her vascular system.

Overall burden of injury

In all of the circumstances, I am satisfied that the views of the Blast Wave Panel of Experts about the disputed areas of injury, and about the severity of those injuries, were correct.

It is important to understand, as I explained at the beginning of this section, that these injuries formed just a part of what happened to Saffie‑Rose Roussos. Overall, as all the experts agreed, she suffered an extremely high burden of injury.²⁷⁵ It is also important to recognise that all of those injuries were affecting Saffie‑Rose Roussos at the same time and, as Dr Lumb explained, will therefore have had a compounding effect upon each other.²⁷⁶

Alan Hepper was a member of the Blast Wave Panel of Experts. His background is in engineering. He is a Fellow with the Defence Science and Technology Laboratory, where his main responsibilities are for issues related to human vulnerability, injury assessment and injury modelling. He undertakes research on the effects of weapons, including bombs, on the human body in order to aid improvements in treatment.²⁷⁷

Alan Hepper carried out an assessment of the burden of injury sustained by Saffie‑Rose Roussos, using the New Injury Severity Score system.²⁷⁸ This allocates a score to the three principal injuries suffered by a victim of trauma. These scores are then added together to provide an overall measurement. On the basis of her three principal injuries, the New Injury Severity Score produced a result of 41 in the case of Saffie‑Rose Roussos.²⁷⁹ This is in itself a high score, and those on the database used by Alan Hepper who shared the same score, and had one or more injuries in common with Saffie‑Rose Roussos, had generally, although not invariably, died.²⁸⁰ Alan Hepper emphasised, however, that 41 may not reflect the overall burden of Saffie‑Rose Roussos’s injuries because she had sustained many more than three injuries; he explained that some of those other injuries were very serious in their own right.²⁸¹

Care needs to be taken before drawing conclusions from a statistical tool such as the New Injury Severity Score. However, the Blast Wave Panel of Experts emphasised that they had not used the New Injury Severity Score as the foundation for their opinion about Saffie‑Rose Roussos’s survivability. Instead, once they had formed the view that her injuries were unsurvivable, they used the New Injury Severity Score as a check.²⁸² In my view, that was an appropriate approach and the New Injury Severity Score result was of some, albeit limited, weight in my conclusions.

Survivability

The important question at the end of all of this evidence is whether the injuries sustained by Saffie‑Rose Roussos were ones that she could have survived with different care and treatment.

In their first report, the Blast Wave Panel of Experts expressed the view that the injuries sustained by Saffie‑Rose Roussos were “unlikely to be survivable” with current advanced medical treatment.²⁸³ The Panel explained that the term “unlikely to be survivable” described:

“… individuals whose injuries were so severe that even if that same advanced and comprehensive medical treatment was initiated immediately after injury, we would not expect that person to survive, but at that point we could not say survival was impossible.”²⁸⁴

In their second report, the Panel reviewed their conclusion in relation to Saffie‑Rose Roussos and found that her injuries were “unsurvivable”.²⁸⁵ Colonel Mahoney explained this term:

“[I]t meant that we felt the injuries were so severe that even if the most comprehensive and advanced medical treatment was initiated immediately after injury, we believe that survival was impossible.”²⁸⁶

It follows that the Panel were initially unable to exclude the possibility of survival in the case of Saffie‑Rose Roussos but then six months later felt confident in doing so. This change was naturally of concern to her family and those who represent them and led to the instruction by me of the additional experts to whom I have referred.

The Panel were pressed in evidence on their change in opinion.²⁸⁷ They explained that their first report made clear that it was a preliminary report that was always intended to be subject to any further evidence that was received.²⁸⁸ What had changed between the first and second report was that the Panel had received the footage from the CCTV and body‑worn video cameras, as was recorded in Appendix 1 to that second report.²⁸⁹ That led Colonel Mahoney to conclude that Saffie‑Rose Roussos had become “very sick, very quickly” with respiratory distress that was, he believed, a combination of lung injury and blood loss.²⁹⁰ In turn, that led the Panel to conclude that Saffie‑Rose Roussos had suffered from blast lung, as outlined in paragraphs 18.211 to 18.218, which conclusion I have found to be correct.

It was appropriate that the Blast Wave Panel of Experts were pressed to explain their change in position. However, having heard their evidence, I am clear about what happened. The Panel expressed a preliminary opinion, making plain that they would review that opinion if further evidence was provided. Further evidence was provided of a type regarded by the Panel as significant. That altered the Panel’s opinion and they said so. Not only was their approach understandable, it was also entirely responsible.

That does not mean, however, that the final conclusion of the Blast Wave Panel of Experts that survival was impossible is correct.

Even though I accept that the Blast Wave Panel of Experts were right about the nature and extent of the injuries suffered by Saffie‑Rose Roussos, I do not consider that the evidence enables me to say that she had absolutely no chance of survival if the most comprehensive and advanced medical treatment had been initiated immediately after injury.

Lieutenant Colonel Park, Dr Davies and Mr Vasireddy were experienced and impressive experts. Their evidence about what consultants in pre‑hospital emergency medicine can achieve out of hospital was striking.²⁹¹ The evidence of their experiences means that I cannot exclude the remote possibility that Saffie‑Rose Roussos would have survived, notwithstanding the severity of her injuries, if she had received treatment from an experienced consultant in pre‑hospital emergency medicine immediately, followed by swift evacuation to hospital and expert treatment there.

While I have recognised the dangers involved in seeking to apply statistical data, I noted that within the database utilised by Alan Hepper, one individual who sustained blast lung of a severity comparable to that sustained by Saffie‑Rose Roussos survived, notwithstanding that this person had a total New Injury Severity Score of 66, significantly higher than that given by Alan Hepper to Saffie‑Rose Roussos.²⁹² While I recognise that the score of 41 given to Saffie‑Rose Roussos was described as conservative,²⁹³ this finding seems to me to underscore why I should not conclude that Saffie‑Rose Roussos had no prospect of survival at all. Colonel Mahoney was asked about this example in the database.²⁹⁴ His answer did not persuade me that my analysis is flawed.

I make clear that what I am postulating is a remote possibility of survival. On the evidence that I have accepted, what happened to Saffie‑Rose Roussos represents a terrible burden of injury. It is highly likely that her death was inevitable even if the most comprehensive and advanced medical treatment had been initiated immediately after injury.