The fire service was 'outside of the loop' of the police and ambulance response to the terror attack at the Manchester Arena - leading to a two-hour delay - a major report said today.
Firefighters, some who heard the bomb go off and are trained in first-aid and terror scenarios, did not get permission to go to the scene until hours after the suicide bombing, despite the nearest fire station being half a mile away.
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'Strategic oversights' by police commanders led to confusion with other 999 services over whether an 'active shooter' was on the loose and poor communication between Greater Manchester Police and Greater Manchester Fire and Rescue Service 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.
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Sheffield woman Kelly Brewster, 32, from Arbourthorne, died when a bomb was detonated at an Ariana Grande concert on May 22, last year.
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She was at the gig with her sister Claire and niece Hollie, who were both seriously injured.
Claire's jaw was fractured in the blast while Hollie suffered two broken legs.
Today, a report by Lord Bob Kerslake - former Chief Executive of Sheffield City Council - makes 50 recommendations after he was commissioned to assess the preparedness and emergency response to the terror attack.
The report states experts were unable to say whether earlier arrival of the fire service would have 'affected any casualty's survivability'.
"This is a question that only the coronial inquests can decide," the report says.
But it says firefighters 'would have been much better placed to support and, potentially, to accelerate the evacuation of casualties from the foyer.' if they had gone to the scene.
Suicide bomber Salman Abedi detonated a home-made device in the foyer of Manchester Arena as 14,000 people streamed out.
Officers from British Transport Police were on the scene one minute later and declared a major incident.
The duty inspector in the Greater Manchester Police 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.
But he was praised for taking one of the most crucial 'life or death' decisions of the night, a 'key use of discretion' to over-ride the rules and allow paramedics and police already at the scene to continue treating the injured even though they may be in danger of further attacks.
Greater Manchester Fire and Rescue Service was 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 of the attack but there was a shortage of stretchers to ferry the injured from the foyer to a casualty area on the concourse of Manchester Victoria Station, under the arena.
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 danger zone from a potential armed terrorist.
It was 'fortuitous' the ambulance service was not informed - otherwise they may have pulled out their paramedics. Instead they stayed and 'lives were saved,' the report says.
Because the senior fire officer on duty that night could not get through on the phone to the police duty officer, the response of the fire service was 'brought to the point of paralysis' to the 'immense frustration on the firefighters' faces,' the report states.
Instead of rushing to the scene to help, fire crews and a special response team trained to deal with terrorist incidents, gathered at a fire station outside the city centre.
The report says it hopes a scenario of different control rooms not being able to properly pass critical information between them 'will never happen again'.