The inquests

Preliminary hearings

¶1.165 Given the potential for prosecutions with the Taylor Inquiry in process, the Hillsborough inquests were opened and adjourned immediately after the disaster. As stated above, the WMP investigation serviced not only the DPP and LJ Taylor but also the Coroner; the police investigators eventually were deputed as coroner's officers.

¶1.166 Following publication of LJ Taylor's Interim Report in August 1989, the bereaved were concerned about the slow progress of the criminal investigation and the delayed inquests. They were eager to establish the precise circumstances in which their loved ones died and why the Coroner had considered it necessary to record blood alcohol levels of all who died. The bereaved and survivors considered allegations of drunkenness had been compounded by the decision to take and publish blood alcohol levels, impugning the reputation of those who died.

¶1.167 In July 1989, the Hillsborough Steering Committee informed families that the Coroner was contemplating holding a generic inquest 'covering the general facts and matters which gave rise to the deaths immediately followed by 95 individual Inquests [at that time the death toll had not reached 96] dealing with the situation of each of the deceased'.

¶1.168 The generic element would 'set the scene', exploring the circumstances of the disaster. Before a jury it would hear expert and general evidence. Following the generic element there would be individual hearings with each family.

¶1.169 After further exchanges with the Steering Committee, the Coroner decided to hold limited, preliminary inquests before a decision was reached on the criminal prosecution. Having taken advice from a range of sources, including the DPP, the Coroner met Doug Fraser, the Steering Committee solicitor representing the families.

¶1.170 On 6 March 1990, the Coroner called a pre-inquest review meeting attended by Mervyn Jones, the WMP Assistant Chief Constable heading the Coroner's investigation, together with solicitors representing other 'interested parties'. ACC Jones informed the meeting that the DPP had yet to receive all the information necessary to rule on prosecution. Following discussions with the DPP, the Coroner explained his intention to hold inquests on a limited basis. It reversed his previously intended sequence.

¶1.171 He proposed preliminary hearings with each family to hear the medical evidence on the deceased, blood alcohol levels, where possible the deceased's location before death, and subsequent identification.

¶1.172 The Coroner was 'prepared to take some evidence to meet the legitimate needs of the bereaved' but this would be restricted so as not to interfere with the ongoing criminal investigation. He planned for eight family hearings, or 'mini-inquests', each day hearing medical evidence from pathologists.

¶1.173 This would be followed by relevant evidence specific to the deceased, including witness accounts, summarised and presented to the jury by WMP investigating officers. It was an unprecedented decision as the evidence would not be examined.

¶1.174 On 9 March Mr Fraser wrote to all families' solicitors, stating that it was 'not possible' for 'all the information' to be released because of the possibility of criminal prosecution. The summaries, compiled and presented by the WMP investigating officers, would be 'scrutinized' by senior WMP officers and the Coroner before being released to families ahead of the mini-inquests. This would 'ensure they contain no controversial details and they are as accurate as possible in the circumstances'.

¶1.175 Mr Fraser stated that families would be 'satisfied with the factual information [in the summaries] ... and not want to take any further action'. The preliminary hearings would be 'low key ... an exercise in distributing information to families about precisely how their loved ones died and where, and not an attempt to discover why or who was to blame'.

¶1.176 Their purpose was to provide an 'information dissemination exercise'. The senior pathologist, Professor Alan Usher, would present 'distressing' evidence but 'will hopefully clear up much anxiety and show that many fans simply "went to sleep" without any great discomfort because of lack of oxygen'. This was a curious comment pre-empting the evidence pertinent to each death.

¶1.177 Mr Fraser concluded:

For our part we believe that this move by HM Coroner to impart information to families is to be applauded and we have taken the liberty of making that point in open court and through the Press ... we believe his stated intentions to assist families in any way he can by providing this information are entirely genuine and we trust that those families who you represent will accept this move on his behalf'.

¶1.178 The Coroner wrote to the families' solicitors reiterating the format: 'the intention is to take post-mortem evidence together with a summary of the evidence as it relates to the location of the deceased, the time of death as far as it can be reasonably established and to clear up any minor matters such as the spelling of names'.

¶1.179 Evidence would be presented in a 'non-adversarial' form and would be 'non-controversial'. Early in April 1990, the Coroner wrote to families informing them of the date and time of 'their' mini-inquests. The opening session was set for 18 April at Sheffield Town Hall's Council Chamber, just three days after the first anniversary.

¶1.180 Accompanied by ACC Jones, the Coroner introduced the proceedings, welcoming 'interested parties' and their legal representatives. He repeated the plan agreed at the pre-inquest review meeting. Selected extracts from statements would be used at his discretion. The families' lawyers accepted the format although it limited disclosure of evidence and prevented its examination. Expert witnesses gave generic evidence, including a chemical pathologist on blood alcohol levels and the Northern General Hospital's Accident & Emergency consultant on the injuries suffered by the deceased, focusing particularly on asphyxia.

¶1.181 The preliminary hearings then moved to the Coroner's Court at Sheffield's Medico-Legal Centre where each family, accompanied by social workers, attended at a prescribed time. For the first time they were given the WMP's summary of evidence relating to the death of their loved one.

¶1.182 In a public forum, facing the deeply emotional pressure of hearing evidence about the death of their loved one, they had little time to digest the contents and some identified factual errors, causing further distress. Two WMP officers were assigned to each family, some already familiar through previous home visits.

¶1.183 Each family was escorted into court, along with social workers and police officers. The Coroner introduced the process followed by the pathologist's evidence. The recorded blood alcohol level was presented to the court. A WMP officer then read a summary of the evidence. On a map of the stadium another WMP officer showed all recorded sightings of the deceased in photographs and video material.

¶1.184 Families left the court through another door to a small room where they met the pathologist who gave words of reassurance, informally answering questions. Many families had questions they wanted addressed but this had not been possible as the abridged evidence could not be examined. Once the preliminary hearings were completed the inquests were adjourned to await the decision on criminal prosecution.

The generic hearing

¶1.185 On 19 November 1990 the inquests resumed, in generic form, at Sheffield Town Hall. They concluded on 28 March 1991, having heard evidence from 230 witnesses. At the time they were the longest inquests in English legal history. Twelve 'interested parties' were represented, six of which were 'police interests'. Forty-three families each contributed financially to representation by one barrister. A bereaved mother represented her family. In the absence of legal aid, survivors were not represented.

¶1.186 The Coroner announced that the generic proceedings would be extensive but no evidence would be heard relating to events beyond 3.15pm on the day of the disaster. The families' Counsel argued that there had been 'no investigation directed to the global organisation of what happened immediately after they [the dying and injured] were brought off the terraces' and that 'to ignore ... concerns as to the adequacy of the attentions and the rescue efforts after 3.15' amounted to failing to 'investigate what could well have been a major reason for why somebody died and did not survive'.

¶1.187 Having taken legal submissions, the Coroner argued that by 3.15pm 'the real damage was done'. The 'overwhelming medical evidence, the pathological evidence, and that is the crucial one [sic] I am interested in, is the damage that caused the death was due to crushing'. Once the 'chest was fixed so that respiration could no longer take place, the irrevocable brain damage could occur between four and six minutes'.

¶1.188 Thus, 'the latest, when this permanent fixation could have arisen would have been approximately six minutes past, which is when the match stopped'. The Coroner added a further six minutes to accommodate the pathologist's assessment of a six-minute period for irreversible brain damage, taking the time to 3.12pm. He identified a clear 'marker' close to that, the ambulance appearing on the pitch at 3.15pm.

¶1.189 He reasoned that the 3.15pm cut-off was consistent with the medical evidence and 'each individual death' was 'in exactly the same situation'. He concluded 'the fact that the person may survive an injury for a number of minutes or hours or even days, is not the question which I as a Coroner have to consider'. Crushing, he maintained, was the sole cause of death.

¶1.190 The 3.15pm cut-off was the most controversial decision of the generic stage of the inquests. Consequently, those most directly concerned with rescue, evacuation and medical treatment did not give evidence.

¶1.191 The Coroner, in consultation with others 'behind the scenes', selected the witnesses. The 'order' of witnesses was also his decision: licensees and local residents, police officers, senior police officers, survivors and 'experts'. The combined evidence of local residents and police officers provided a strong foundation for the accounts of senior officers responsible for crowd management and control on the day. Senior officers, discredited as witnesses by LJ Taylor, repeated their previous allegations about the behaviour of Liverpool fans.

¶1.192 Much of the senior officers' evidence focused on responsibility for crowd management, foreseeability and communication between officers after Gate C was opened. The Duckenfield–Murray relationship was central to the examination of both men's evidence, focusing on division of responsibilities, the monitoring of the pens, the custom and practice of fans being left to 'find their own level' and the decision to open Gate C and its consequences.

¶1.193 Considerable attention was paid to C/Supt Duckenfield's lack of experience. Following the 'expert' evidence of those associated with Sheffield City Council, SWFC and the Health and Safety Executive, survivors were called to give their personal accounts.

¶1.194 At the conclusion of the evidence, legal submissions were made to the Coroner over two days in the absence of the jury. Most oral submissions were supported in writing. They concerned a possible verdict of unlawful killing and the required standard of proof to demonstrate a failure of a duty which comprised a substantial cause of death.

¶1.195 The families' Counsel focused on the 'logical chain' of events set in motion by C/Supt Duckenfield's decision to open Gate C. It had been, it was proposed, a positive act and the failure to divert was an 'omission'. Taken together they constituted unlawful killing.

¶1.196 The Coroner directed the jury on two possible verdicts: unlawful killing and accidental death. He stated that 'the word "accident" straddles a whole spectrum of events from something over which no-one has control' where 'no-one could be blamed – to a situation where you are in fact satisfied that there has been carelessness, negligence, to a greater or lesser extent and that someone would have to make, for instance, compensation payments in civil litigation'. A verdict of accidental death did not mean that individuals were absolved from 'all and every measure of blame'.

¶1.197 At 12.33pm on 26 March 1991 the jury retired to consider its verdict. Two days later, at 12.08pm, on the 80th day of the generic stage of the hearings, the jury returned. It was a nine to two majority verdict: 'accidental death'.

Judicial Review

¶1.198 On 6 April 1993 six bereaved families were granted leave by the High Court to proceed with an application for a judicial review of the inquest verdicts. Grounds of challenge included: irregularity of proceedings; insufficiency of inquiry; and the emergence of new facts or evidence.

¶1.199 Effectively these were test cases for all who died. The barrister for the six families, Edward Fitzgerald, stated 'whatever else this death was, it was not accidental and it would be some assuagement of feelings if the verdict was struck down'.

¶1.200 In consenting to the judicial review, Mr Justice Macpherson concluded that 'a case can be sensibly argued'. Yet he sounded a cautionary note: 'I don't know what will happen in the end. I don't know how desirable it is that these agonies be prolonged'.

¶1.201 Christopher Dorries, the South Yorkshire West District Coroner who succeeded Dr Stefan Popper, said: 'All that has happened today is that the families have gone along and won the right to a full review. No-one else was in court'.

¶1.202 Nineteen months after the initial submission to the Attorney General, the Judicial Review opened in the Divisional Court before two judges. 'In many respects', argued Alun Jones QC on behalf of the families, the inquests were 'empty'. There had been an 'appearance of bias' towards the police and authorities by the Coroner, particularly in the withholding and suppression of evidence. These claims were strongly contested by the Coroner's barrister.

¶1.203 On 5 November 1993 Lord Justice McCowan rejected the families' submission that the accidental death verdicts were either misleading or in error. Together with Mr Justice Turner he considered that the inquests had been properly conducted and there had been no suppression of important evidence.

¶1.204 LJ McCowan stated, 'I would hold the inquisition was correctly completed and the coroner's direction to the jury as to the manner in which they should approach its completion was impeccable'. J Turner concluded, 'There is nothing to show any lack of fairness or unreasonableness – there was no error'.

¶1.205 LJ McCowan commented on liability and also the 3.15pm cut-off. He asked what would be the purpose of fresh inquests as the police had already been criticised by the Taylor Report. He noted that SYP 'had admitted fault and paid compensation'.

¶1.206 He considered that no criticism could be levelled against the emergency services. Such criticism would be 'irrelevant if all six were brain dead by 3.15pm'. Further 'examination of the last minutes of their lives' would provide no further information, would be 'harrowing' and involve 'large numbers of witnesses ... lasting if not for 96 days, for not far short'.

¶1.207 The families argued that the summarised evidence presented at the mini-inquests and the imposition of the 3.15pm cut-off had combined to deprive them of the opportunity to hear evidence significant to their specific case and have it cross-examined. LJ McCowan acknowledged the 'deep instinct to know the circumstances in which their relatives died' shared by the bereaved.

¶1.208 He accepted that this was 'their motive' but hoped that the families could understand that he had 'to take an objective view and ... consider the interests of all concerned including those of all the witnesses who would have to come along five years later and try to cast their minds back to events they must have been trying to forget'. On this basis, and using his 'discretion', he considered 'this was not a case in which it would be right to order fresh inquests'.

Tony Bland

¶1.209 Having been crushed on the terraces, 18-year-old Tony Bland suffered severe anoxic brain damage. He was admitted to the Northern General Hospital in Sheffield, where he was ventilated. Able to breathe, his condition was consistent with being in a 'vegetative state'. He was transferred to Airedale Hospital, close to his home in Keighley, where he was treated by a team headed by neurologist Dr Jim Howe.

¶1.210 Dr Howe stated that despite excellent nursing, 'there was no improvement'. Mr Bland 'remained unresponsive ... no eye contact and no sign of communication'. After full consultation among the medical teams and the Bland family, Dr Howe decided that treatment should be withdrawn, including nutrition and fluids supplied by tubes direct to Mr Bland's stomach.

¶1.211 A date was agreed for withdrawal. Dr Howe informed the South Yorkshire West District Coroner, Dr Popper, whose response was that he would risk a murder charge should treatment be withdrawn. Dr Popper warned that he 'could not countenance, condone, approve or give consent to any action or inaction which could be, or would be construed as being designed or intended to shorten or terminate the life of this young man'. This applied specifically 'to the withholding of the necessities of life, such as food and drink'.

¶1.212 The Coroner's letter was copied to the WMP Chief Constable, the Yorkshire Regional Health Authority solicitor and Dr Howe's medical defence society. Dr Howe was interviewed by the police and advised that, should treatment be withdrawn, he would be charged with murder. The status quo obtained.

¶1.213 In 1993 the Bland family agreed that a legal application should be made to withdraw treatment. The case was heard in the High Court Family Division. It was concluded that withdrawal of treatment would not be unlawful. The Official Solicitor appealed the ruling and the case was heard in the House of Lords. The initial ruling was upheld and treatment withdrawn. Almost four years after the disaster, on 3 March 1993, Tony Bland died peacefully, his parents with him.