A member of the fire service calling for updates and waiting for the instruction to proceed to the scene on the night.
Only three paramedics entered the scene in the first hour due to an “unduly cautious” approach taken by an ambulance commander, after police failed to relay that armed officers had concluded the area was likely safe after just 19 minutes.
The inquiry report found that John Atkinson, 28, and Saffie-Rose Roussos, 8, may have survived if they had been given the appropriate care in time.
Mr Atkinson was six metres from the blast and suffered serious injuries to his legs when the bomb detonated at 10.31pm.
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