A fire chief has made a public apology for firefighters being delayed two hours before joining in the response to the Manchester Arena terror attack.
Dawn Docx, the interim chief fire officer of Greater Manchester Fire and Rescue Service (GMFRS) said she apologised unreservedly for the failures in the previous leadership of the service at the time of last May's outrage.
"It is clear that our response fell far short of what the people of Greater Manchester can expect," she told a press conference following the publication of a report by Lord Bob Kerslake into the emergency response to the attack.
"I apologise unreservedly for that," Ms Docx said.
"There were clearly failures in leadership and poor decisions made.
"As a result firefighers themselves, desperate on the night to attend the incident, were let down by some of their senior colleagues."
The fire service was left "outside of the loop" of the police and ambulance emergency response and firefighters, some who heard the bomb go off, and trained in first-aid and terror scenarios with specialist equipment, did not get permission to go to the scene, despite the nearest station being half a mile away.
"Strategic oversights" by police commanders led to confusion with other 999 services over whether an "active shooter" was on the loose and poor communications between Greater Manchester Police (GMP) and Greater Manchester Fire and Rescue Service (GMFRS) meant the "valuable" assistance of fire crews was delayed by two hours and six minutes after the bombing, which left 22 dead and scores injured.
The 226-page report by Lord Bob Kerslake was commissioned by Andy Burnham, the Mayor of Greater Manchester, and concluded the emergency response was "overwhelmingly positive."
But Lord Kerslake described the failure by fire chiefs as "extraordinary" and "incredible."
The then £155,000-a-year chief fire officer, Peter O'Reilly, has now retired, keeping his pension with no action taken against him.
Ms Docx added: "We are very much a learning organisation. We are not seeking to go down a discipline route."
Andy Burnham said no one individual should bear all the responsibility for failures and no one should be "scapegoated".
He announced that a "root and branch" review of the policies, leadership and culture of GMFRS is now under way.
The panel of experts who authored the report state they are not able to say whether earlier arrival of the fire service would have "affected any casualty's survivability."
Suicide bomber Salman Abedi detonated his home-made device at 10.31pm on May 22 last year, in the foyer of Manchester Arena as 14,000 people streamed out at the end of an Ariana Grande concert.
The police duty inspector in the Greater Manchester Police (GMP) force control room declared Operation Plato, a pre-arranged plan when it is suspected a marauding armed terrorist may be on the loose - and assumed wrongly that other agencies were aware.
GMFRS and the North West Ambulance Service (NWAS) were only informed an hour and a half later and by then Operation Plato was effectively put on "stand by" as it emerged the attack was from a single suicide bomber and not the prelude to further armed attacks.
Armed police and 12 ambulances were on the scene within 20 minutes but there was a shortage of stretchers to ferry the injured from the foyer to a casualty area on the station concourse.
The senior fire officer on duty, a National Inter-Agency Liaison Officer, came to believe an "active shooter" scenario was still in play and stuck to rules which dictate keeping emergency responders 500 metres away from any suspected "hot" zone of danger from a potential armed terrorist.
The fire service was "brought to the point of paralysis" to the "immense frustration on the firefighters faces."
Instead of rushing to the scene to help, fire crews and a Special Response Team, trained to deal with terrorist incidents, rendezvoused at fire station outside the city centre.
It was "fortuitous" the NWAS were not informed - otherwise they may have pulled out their paramedics and instead they stayed and "lives were saved" the report said.
And while a joint Strategic Co-ordinating group of emergency response services and others gathered at GMP HQ in east Manchester, GMFRS chief fire officer Mr O'Reilly focused his senior officers at their own HQ in Salford, which played a "key role" in delaying the response further.