The government has done nothing to close a loophole that has left first aid providers at entertainment events unregulated and led to "unsafe treatment, abuse and deaths," the last day of the inquiry was told.

Sir John Saunders was holding the last of a three-day hearing, asking officials to explain whether they have implemented changes following the attack that led to the deaths of 22 people in May 2017.

The hearing was told that the Department of Health had failed to take action to regulate event healthcare providers, despite a request from the regulator four years ago.

ETUK, the first aid provider at the arena, did not have enough staff with the right clinical qualifications on the night of the attack and some staff were not qualified to provide healthcare at events.

They were the first to arrive at the scene of the explosion in Manchester but had not prepared properly for a major incident and on the night the "whole system fell apart," the inquiry was told.

Paul Greaney KC, for the inquiry, said the lack of regulation gave rise to a "risk of injury and death to the public" and "cries out for effective regulation".

He said that a Department of Health statement last month provides "no meaningful assistance in relation to when, if at all, this gap in regulation will be filled".

Sir John wrote in his report in November that he had "little doubt that such serious shortcomings occurred elsewhere at other venues" and added: "I fear that they continue to happen".

He recommended that the Department of Health gave "urgent consideration" to making changes in the law to enable the Care Quality Commission (CQC) to take up regulation.

"Those who provide event healthcare services may be responsible for the lives of very many people," he added.

"There is a strong argument that there should be both civil and criminal consequences, including the possible imposition of custodial sentences."

Read more:
The security failings
Could MI5 have prevented the attack?

The hearing was told that regulating "event medical providers" is the CQC's "number one priority" and they first put proposals to the government in 2019 to remove the current exemption.

However, Emma Reed, director for health protection at the Department of Health, said a "scoping review" was required before they could decide on regulation.

Mr Greaney asked: "Surely we are able to agree, there is a state of affairs in which routinely thousands of people are going to venues for events, and they are at risk of injury and death as a result of a lack of regulation?"

Ms Reed said: "That is absolutely going to be the question that we need to answer. We need to consider exactly what it is that we're wanting to implement."

The inquiry previously went through a series of 12 recommendations for NHS England and heard that only one has been implemented so far.

Stephen Groves, director of resilience for NHS England, told the inquiry they had spent six months trying to find the right personnel for a "task and complete" group.

Sir John said: "I think that it has become apparent that having to give evidence in public about what has been done has focused minds and has ensured that at least some steps have been taken by now,

"It is essential that lessons are learned and the same mistakes are not made again.

"It is much more likely that those mistakes will not be made again if the monitoring process continues."

Sir John called on Home Secretary Suella Braverman to appoint "somebody of sufficient independence and authority to ensure they can make things happen".

He added: "It is important that there are public hearings of some sort, so that the public and the families can be reassured as to what is happening."

Pete Weatherby KC, for the victims' families, called for "accountability" and added: "The families have learned with some dismay that inquiry recommendations are not always considered and actioned swiftly or indeed at all."

He said the three days of hearings were innovative and added: "I hope it will concentrate the minds of policymakers to establish a process in which recommendations can be monitored as a matter of course."

The inquiry, which has heard evidence from 283 witnesses over more than two and a half years, concluded with the reading of the victims' names.