Hi Guys, Just finished reading the report. Here is a quote form the report.

3.2.3 Organization of Medical Aid from the second paragraph

According to the conclusion made by the Commission, the excessive number of victims was caused by the negligence of officials responsible for providing medical aid to the injured.




I think this is the same conclusion that I and Robal2pl came to. The Commission was called the "Union of Right Forces" it included medical,counter terror, and eyewitnesses to the rescue attempted.