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Two police officers ignored briefings and went on a five-mile journey to get a kebab the night of the Manchester Arena bombing, an inquiry heard.
A report into the inquiry into the May 2017 terrorist attack found that suicide bomber Salman Abedi should have been identified as a threat that night by those in charge of security.
In his 196-page report examining security arrangements at the venue where 22 people were murdered and hundreds were injured at the end of an Ariana Grande concert, inquiry chairman Sir John Saunders found there were a number of missed opportunities to prevent or minimise the “devastating impact”.
Sir John said he considered it was likely Abedi would still have detonated his device if confronted “but the loss of life and injury is highly likely to have been less.”
Police officers stand guard at a cordon after being called to the bombing at Manchester Arena on May 23, 2017
Manchester-born Abedi, 22, of Libyan descent, walked across the City Room foyer towards an exit door and detonated his shrapnel-laden device, packed into his bulging rucksack, at 10.31pm on May 22 just as thousands, including many children, left the concert.
Sir John's report highlights how British Transport Police (BTP) went for a kebab and a steward missed the chance to stop the bomber, the Manchester Evening News reports.
There was a 36 minute-long period, as Abedi walked around, where there was no policing presence, Sir John wrote.
The Inquiry had heard that uniformed officers from BTP were tasked to patrol Victoria station, including the City Room of the Arena, but when the bomb was detonated there were none in the foyer despite instructions that one officer should be positioned there at the end of the concert.
Four BTP officers had ignored briefings to stager their breaks during the concert and took "substantially longer" than they should have done, the report stated.
The 22 victims of the Manchester Arena bombing: (top row left to right) off-duty police officer Elaine McIver, 43, Saffie Roussos, 8, Sorrell Leczkowski, 14, Eilidh MacLeod, 14, (second row left to right) Nell Jones, 14, Olivia Campbell, 15, Megan Hurley, 15, Georgina Callander, 18, (third row left to right), Chloe Rutherford,17, Liam Curry, 19, Courtney Boyle, 19, and Philip Tron, 32, (fourth row left to right) John Atkinson, 26, Martyn Hett, 29, Kelly Brewster, 32, Angelika Klis, 39, (fifth row left to right) Marcin Klis, 42, Michelle Kiss, 45, Alison Howe, 45, and Lisa Lees, 43 (fifth row left to right) Wendy Fawell, 50 and Jane Tweddle, 51
Two set off on a five-mile journey to get a kebab, the inquiry heard.
A fifth and more senior officer, a sergeant, should have been there, and Sir John found there was a "lack of clear leadership on the ground" on the part of BTP.
Sir John wrote: "All five officers allocated to the Arena that night failed to follow clear instructions and do what was expected of them in important respects."
Sir John wrote that the officers didn't realise they "needed to be alert to the possibility of a terrorist attack".
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BTP, as an organisation, was "principally responsible for this defect in the officers" attitudes, Sir John added.
The report was critical of arena owners SMG, stewarding company Showsec, and BTP, saying they were "principally responsible for the missed opportunities" to prevent the atrocity.
Abedi carried out hostile reconnaissance shortly after the arena opened its doors that night, and returned to the City Room foyer area, where he would later detonate his homemade bomb.
He hid for almost an hour in a CCTV blind spot on a mezzanine level.
Salman Abedi is seen on CCTV on the night he carried out the Manchester Arena terror attack
Members of the public thought he looked suspicious, and one raised his concerns with a member of Showsec staff, but "no effective action was taken in response".
Abedi, carrying his bomb in a heavy rucksack, walked past two BTP PCSOs and two members of Showsec staff before detonating the device.
The report was critical of the existence of the CCTV blind spot and noted that the CCTV system was not properly monitored.
Hearings at the public inquiry into the circumstances leading up to and surrounding the attack have been ongoing in the city since September last year.
Retired High Court judge Sir John is issuing his findings on a rolling basis, split into three volumes.
A further report will follow on the emergency response and the experience of each of those who died, and finally an analysis of whether the atrocity committed by Abedi, could have been prevented.
In response to the findings, BTP Chief Constable Lucy D’Orsi said: "I would like to reassure everyone that British Transport Police, as you would expect, has been reviewing procedures, operational planning and training since this dreadful attack took place in 2017.
"We continue to work closely with our emergency service colleagues, Greater Manchester Police and other experts to strengthen our multi-agency preparedness for major incidents. We are committed to ensuring our staff are supported and prepared to undertake the roles they are required to do.
“We will never forget that 22 people tragically lost their lives following the truly evil actions of the attacker and many received life changing injuries. They continue to be at the forefront of our thoughts as are their loved ones and all those affected by this dreadful attack.”