Firefighters did not arrive at Manchester Arena until two hours after the suicide bombing, only one paramedic entered the blast scene in the first 40 minutes, and Greater Manchester Police (GMP) did not declare a major incident until the following day, the inquiry into the terror attack has heard.
The inquiry, which began last September, moved on Monday to examining Chapter 10, the emergency response to the attack, based at Victoria Station in central Manchester.
Suicide bomber Salman Abedi, 22, exploded his rucksack bomb at 10.31pm on May 22 2017, in the City Room or foyer of the Arena, killing 22 bystanders and injuring hundreds more among the 14,000 crowd leaving an Ariana Grande show.
Paul Greaney QC, counsel to the inquiry, opening the next phase, said: “We will explore whether the emergency response really worked that night and, if it did not, whether that failure made any contribution to the extent of the dreadful loss of life that occurred.”
But Mr Greaney said it “did not take long” for concerns to emerge about how the 999 services responded.
Audio recordings showed that at 11.02pm a Pc Hill, an officer in the City Room, was recorded saying: “We need paramedics like f****** yesterday!”
Mr Greaney said six North West Ambulance Service (NWAS) paramedics were at Victoria Station within 30 minutes of the blast, and within 40 minutes “at least” eight ambulances had arrived and three off-duty doctors were also present.
But only one NWAS paramedic had actually entered the City Room and only one injured person was taken out on a makeshift stretcher in the first 40 minutes.
“Why that is so is plainly something that will need to be closely examined during the evidence in Chapter 10,” Mr Greaney said.
Also, an NWAS Hazardous Area Response Team, with specialist equipment and training, only arrived 43 minutes after the explosion.
Blast victim John Atkinson, 28, who later died, was evacuated from the City Room on a display board 45 minutes after the explosion.
He was then moved to an area near a station entrance where he remained for a further 24 minutes before chest compressions were commenced at 23.47pm and he was then taken away in an ambulance.
The final casualty was evacuated from the City Room an hour and 20 minutes after the explosion on a makeshift stretcher made from cardboard and a crowd barrier.
Firefighters mustered at a fire station three miles from the Arena and did not attend the scene until two hours and six minutes after the attack – even though some crews had heard the bomb go off.
Receiving reports of gunshot injuries and an active gunman, Inspector Dale Sexton, the force duty officer at GMP HQ, declared Operation Plato, believing an armed terrorist was on the loose as part of the bomb attack.
It meant Greater Manchester Fire and Rescue Service (GMFRS) kept its firefighters away from the area, as dictated by national guidance in such a scenario.
Mr Greaney said the declaration of Operation Plato along with why GMFRS did not attend promptly and why paramedics did not attend the City Room “in significant numbers” are two important questions to explore.
Both British Transport Police and NWAS declared a major incident, triggering more resources and a pre-planned response, within half an hour of the explosion, with GMP only doing the same at around 1am on May 23, two-and-a-half hours after the blast.
Experts have “significant concerns about co-operation and co-ordination between different emergency service agencies,” with an “absence” of command, which had a “profound effect”, the hearing was told.
“That failure was, in the opinion of the experts, of command, not individual responders,” Mr Greaney said.
The hearing continues.