18. 'TO HER MAJESTY'S ATTORNEY GENERAL: THE HUMBLE MEMORIAL OF SANDRA STRINGER AND DONNA

¶CARLILE (the mother and sister of Paul Carlile) JOHN AND THERESA GLOVER (the father and mother of Ian Glover)

¶JOAN SINCLAIR (the sister of Michael Kelly) LESLIE AND DOREEN JONES (the father and mother of Richard Jones)

¶PETER AND JOAN TOOTLE (the father and mother of Peter Tootle) JAMES STEPHEN AND ANNE WILLIAMS (the father and mother of Kevin Williams)', 15 April 1992, AGO000000070001, p11 and p23. 19. Memorandum from SJ Wooler to the Attorney General, 31 July 1992, AGO000000140001, pp11-12 and p23. 20. Letter from SJ Wooler to Malcolm J Greggs, 18 August 1992, SYP000096240001, p426. 21. 'First Affidavit S H PIMLOTT Sworn On behalf of Respondent Case No.C0/1009/92 IN THE HIGH COURT OF JUSTICE

¶QUEENS BENCH DIVISION CROWN OFFICE LIST IN THE MATTER OF AN APPLICATION FOR JUDICIAL REVIEW

¶BETWEEN:- REGINA – and – HER MAJESTY'S CORONER FOR SOUTH YORKSHIRE Ex parte STRINGER and

¶OTHERS', SCC000002510001, p102.

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¶2.10.68 In his subsequent affidavit for the Judicial Review Dr Popper reaffirmed his earlier position.22 The ambulance arriving on the pitch was the 3.15pm marker 'because on the overwhelming pathological evidence available to me, by that time permanent irrecoverable damage would have already occurred … my decision was based mainly upon the expert pathological medical evidence'.

¶2.10.69 The South Yorkshire Metropolitan Ambulance Service (SYMAS) Chief Ambulance Officer claimed in his affidavit for the Judicial Review that the 'response of the ambulance service' had been 'rapid', prioritising the most 'seriously injured victims'.23 He stated that there was no evidence that 'shortcomings' in the emergency response 'played any part at all in the causation of any of the deaths' or that 'lives could have been saved by more prompt medical attention'. The emergency response has been considered in full in Chapter 4.

¶2.10.70 As detailed in Chapter 5, opinions from Dr Iain West, a consultant forensic pathologist at Guy's Hospital, and from Dr James Burns, a forensic pathologist, contested the 'pathological evidence' on which Dr Popper based his conclusions.

¶2.10.71 Dr West stated that it was not possible to establish how long consciousness would have been sustained after crushing and that a victim 'could well have survived for a considerable period, well beyond 3.15pm'.24 Dr Burns concurred, noting that 'it is by no means certain that even in a severe case of traumatic asphyxia, death necessarily ensues three or four minutes after the compression begins'.25 The issue was whether 'severe compression' had been sustained. This evidence was at odds with the opinions of the original pathologists who had specified periods of 10 to 20 seconds between receiving crush injuries and losing consciousness and three to four minutes between loss of consciousness and death.

¶2.10.72 To the bereaved families the original pathologists' views appeared questionable because there were well-publicised examples of survivors who had lost consciousness yet recovered. It seemed likely to them that there was a continuum from those who recovered quickly after a short period of unconsciousness and those who recovered within days to the cases of two young men who remained in a persistent vegetative state, kept alive by tube feeding.

¶2.10.73 Dr West and Dr Burns had only a small number of post mortem records with which to work. With the benefit of access to the records of all who died at Hillsborough, it is clear that there is ample additional evidence to support the families' views, and that they were correct to challenge the opinions expressed by the original pathologists (see also Chapter 5).

¶2.10.74 On 5 November 1993, on hearing the arguments from all sides in the Judicial Review, the High Court dismissed the challenge. Lord Justice McCowan could 'see no fault in the coroner in this matter'. He had 'made a full inquiry'. In questioning the purpose of fresh inquests he saw 'no evidence' to suggest criticism of the emergency services, noting that 'in any event it would be irrelevant if all six were brain dead by 3.15 pm'.

'IN THE MATTER of AN APPLICATION FOR JUDICIAL REVIEW BETWEEN: REGINA – and – HER MAJESTY'S

¶CORONER FOR SOUTH YORKSHIRE Ex parte STRINGER AND OTHERS AFFIDAVIT OF STEFAN LEOPOLD

¶POPPER', 10 September 1993, SYC000001280001, p14. 23. 'IN THE MATTER OF AN APPLICATION FOR A JUDICIAL REVIEW BETWEEN: REGINA HER MAJESTY'S CORONER

¶FOR SOUTH YORKSHIRE EX PARTE STRINGER AND OTHERS AFFIDAVIT of Albert Page', September 1993 [date unspecified], SCC000000350001, pp39-47. 24. Report of Dr Iain West, Department of Forensic Medicine Guy's Hospital,²⁰²⁰ April 1989, HOM000016460001, pp1-5. August 1992, SYC000001280001, p69. 25. Dr Burns, quoted in Parliament by Sir Malcolm Thornton, 26 October, 1989, AGO000000480001, p55.

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¶2.10.75 While noting the bereaved families''deep instinct to know the circumstances in which their relatives died' he concluded that 'this was not a case in which it will be right to order a fresh inquest'.26 His ruling accepted the medical opinion of the pathologists, supported the Coroner in his interpretation of that opinion and confirmed the appropriateness of the 3.15pm cut-off.

¶The continuing controversy 2.10.76 In December 1996, following the screening of Jimmy McGovern's Hillsborough, Sue McDougall of the Operational Policing Policy Unit at the Home Office wrote to the Home Secretary, Michael Howard. She noted that a significant issue had been raised by the drama-documentary: 'the suggestion that some of the victims were still alive at 3.30 pm ... The coroner is reported in the press to have said that he thinks he might have been mistaken insisting on the 3.15 deadline'.27 This had 'increased the demands for a fresh inquest'. 2.10.77 Paul Pugh, also at the Unit, wrote to the Chief Constable of SYP, Richard Wells, informing him of renewed calls for a further public inquiry.28 He stated that the Home Secretary would need to be convinced that a further inquiry would be in the public interest and was 'particularly anxious to establish whether any new evidence has emerged'. 2.10.78 While the Home Secretary did not have the authority to reopen inquests, 'the relatives have expressed continuing anger that the Coroner imposed a 3.15pm cut off point after which he would not take any evidence'. CC Wells replied that according to the 'professional view' of the SYP officers involved with the earlier inquiries and investigations there was no new evidence but the Force would be 'content to have this view challenged'.29 2.10.79 Several weeks later CC Wells wrote again to the Unit's Police Policy Directorate.30 He emphasised that there was no new evidence and commented that issues raised in the drama-documentary had been 'aired' at the Taylor Inquiry and the inquests. Regarding the 3.15pm cut-off, the pathologists' evidence alongside the Coroner's observations 'led him [Dr Popper] to believe that 3.15pm cut-off was appropriate'. 2.10.80 On 10 March 1997 a Home Office meeting considered the implications of material submitted by the Hillsborough Family Support Group (HFSG) calling for a new inquiry.31 Prior to the meeting, however, there had been 'no examination of the material supplied' and it was 'unclear' whether 'it had any real significance'. 2.10.81 Within days the Attorney General received advice regarding the HFSG submission.32 It noted evidence from Dr Ed Walker about the emergency response and its implications for the 3.15pm cut-off. The claim was that Dr Walker's evidence undermined the Coroner's decision. 2.10.82 The advice rejected the claim, noting that the cut-off point had been 'found to be fully justifiable by the Divisional Court'. Consequently, there was no justification for the Attorney General to review the decision. Further, it was considered 'significant' that the HFSG barrister had 'not advised a further application'. 26. 'To the Solicitor General, Application under Section 13 of the Coroners Act 1988', 13 March 1996,

¶AGO000000480001, p7. 27. Memorandum from Sue McDougall (Operational Policing Policy Unit) to Home Secretary, 19 December 1996,

¶HOM000034110001, p2. 28. Letter from Mr Paul Pugh (OPPU) to Richard Wells, Chief Constable, South Yorkshire Police,²⁰²⁰ April 1989, HOM000016460001, pp1-5. December 1996,

¶AGO000000520001, pp1-3. 29. From CC Wells to Mr Paul Pugh, Home Office OPPU,²⁰²⁰ April 1989, HOM000016460001, pp1-5. December 1996, SYP000131860001, p339. 30. Letter from CC Wells to OPPU, 3 February 1997, SYP000131860001, p320. 31. Note of a meeting at the Home Office, 10 March 1997, AGO000000530001, p4. 32. Memorandum from SJ Wooler to the Attorney General, 13 March 1997, AGO000000530001, p3.

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¶2.10.83 Months later the HFSG submission continued to resonate within the Attorney General's office. Dame Barbara Mills, then Director of Public Prosecutions (DPP), wrote to the Attorney General presenting the background to the case and detailing previous judgments.33 She noted that the HFSG had 'continued to press for more and more inquiries into the cause of the disaster'. 2.10.84 Its 'new evidence' centred on video-tape footage, a statement and an affidavit from Sheffield Wednesday Football Club's design and maintenance engineer responsible for CCTV coverage and from Dr Walker who had attempted resuscitation at the Northern General Hospital. In assessing the video material and the engineer's evidence Dame Barbara considered that 'his criticisms come nowhere near the standard of proof required for criminal liability'. 2.10.85 Regarding Dr Walker's evidence she stated that there was 'no evidence ... that anyone with serious crush injuries could have survived' given that '[i]rrevocable brain damage will ensue within four to six minutes of the crushing'. She concluded that 'there is no new evidence as alleged by the HFSG and their legal representatives, and therefore no grounds for reopening the police investigation into the Hillsborough disaster'.

¶The Stuart-Smith Scrutiny 2.10.86 Two months later the recently elected Labour Government's Home Secretary, Jack Straw, noted that the 'alleged new evidence and allegations made in the Granada television programme' had been examined at the Home Office, and also by the Attorney General and the DPP.34 These considerations had found 'no evidence to justify a new public enquiry, a re-opening of the inquest, or the prosecution of individuals'. 2.10.87 However, he was 'certain that public concern will not be allayed by a reassurance from the Home Office that there is no new evidence' (emphasis in original). Consequently he proposed 'an independent examination of the alleged new evidence by a senior legal figure – a respected judge ... or perhaps a senior Counsel ... sufficiently senior and respected to command public confidence' (as noted in Part 1, this became the 'scrutiny' of 'new evidence' conducted by Lord Justice Stuart-Smith). 2.10.88 A handwritten comment on a document, from the Prime Minister's Private Secretary for Home Affairs to Liz Lloyd of the Number 10 Policy Unit, questioned Mr Straw's proposal: 'Liz, doesn't this strike you as a silly precedent?' Ms Lloyd wrote to the Prime Minister, Tony Blair, disclosing Mr Straw's position and the rationale behind the Scrutiny proposal: 'JS does not believe there is sufficient new evidence for a) a new inquiry, b) reopening the inquest or c) prosecution of individuals. However, he believes that this is not publicly acceptable unless it comes from an independent source'.35 2.10.89 A handwritten note from the Private Secretary added that it was not necessary 'to intervene on this, but we should watch for JS setting up too many inquiries of this kind'. An additional note, apparently written by the Prime Minister, asked 'Why? What is the point?'. 2.10.90 Ms Lloyd wrote to Mr Blair two weeks later referring to his scepticism concerning the need to 'look anew' at Hillsborough.36 She stated that Mr Straw considered the Scrutiny necessary because 'he and others had given assurance before the election that the new 33. Letter from Dame Barbara Mills to John Morris QC MP, Attorney General,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 1997, AGO000000570001, pp4-6. 34. Letter from Jack Straw Home Secretary to John Morris QC MP, Attorney General, 5 June 1997, COO000001360001, pp1-2. 35. Memorandum from Liz Lloyd, Number 10 Policy Unit, to Prime Minister, Tony Blair,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note June 1997, COO000001200001, p1. 36. Memorandum from Liz Lloyd, Number 10 Policy Unit, to Prime Minister, Tony Blair, 26 June 1997, COO000001350001, evidence would be examined'. An added comment from Mr Blair's Private Secretary noted: 'I understand your caution, but the Home Secretary is really too far into this (and was before the election) to pull back now'.

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¶2.10.91 Within SYP the Stuart-Smith Scrutiny was considered to be a result of 'pressure from bereaved relatives and others who allege that hitherto unseen video recordings have been unearthed and that there is new evidence to suggest that victims were dying after 3.15 pm'.37 The record of a discussion between Assistant Chief Constable Ian Daines, Superintendent Roger Greenwood and the SYP solicitor dismissed 'concern over the video evidence' as 'hysterical linking of the knowledge that there were two video tapes which were lost or went missing'.

¶2.10.92 The meeting also dismissed 'new' medical evidence, noting that 'it should be perfectly possible to show that there are no inconsistencies between what the Coroner found, the basic factual information that LJ Taylor [sic] and what Dr Walker now recollects in the light of the drama/documentary'.

¶2.10.93 There was a suggestion, however, that the medical evidence was 'a slightly more grey area partly because ... there are other contributory factors in each victim's case' while the 'causative background must be very similar'. The discussion concluded that the 'only area for further investigation, if it be due, will be the extended period from 3.15pm onwards when the terraces were still being cleared and/or treatment and resuscitation was being given as best they could'. Thus 'medical evidence of the scene at the time will be significant'.

¶2.10.94 A further letter noted that the 'final stage in all this is the method and which way we propose to adopt for informing Lord Justice Stuart-Smith of the absence of any new evidence and/or the submission of any new expert evidence in the grey "causative" area which we have identified'.38

¶2.10.95 Keen to challenge the classification of 'new evidence', the SYP legal representatives considered that, as the video evidence and a statement from Dr Walker had been available to all previous Inquiries, 'on a very simple view ... there is no new evidence'. What followed was a series of exchanges challenging Dr Walker's veracity.

¶2.10.96 ACC Daines also considered Dr Walker's claim that he had not been approached by the police to offer evidence.39 Further, Dr Walker alleged that some of those who died had lived beyond 3.15pm. ACC Daines noted a conversation with Dr Walker in which he 'could not recall whether or not he had made a statement'. Told by ACC Daines that the officers had 'witnessed his signature on the statement', Dr Walker responded 'that his memory may be flawed'.

¶2.10.97 The SYP held records of a statement by Dr Walker made three months after the disaster and witnessed by two police officers. The solicitors planned to rely on the pathologists' evidence, dismissing Dr Walker as an unreliable witness: 'In view of the eminence of these people (especially Alan Usher) and the shilly-shallying of Dr Walker, I do not think we need to pursue further medical opinion'.

Letter from Mr Nicholas Owston, Winkworth and Pemberton Solicitors, to Mr Alan Walker, Force Solicitor, 29 July

¶1997, SYP000096270001, p54. 38. Letter from Mr Nicholas Owston, Winkworth and Pemberton Solicitors, to Mr Alan Walker, Force Solicitor, 5 August 39. Letter from ACC Ian Daines, South Yorkshire Police, to Mr Nicholas Owston, Winkworth and Pemberton Solicitors,

¶6 August 1997, SYP000096270001, p64.

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¶2.10.98 Inevitably, the 3.15pm cut-off was a central issue in LJ Stuart-Smith's Scrutiny. At a meeting with Trevor Hicks of the HFSG and barrister Alun Jones QC, the well-publicised case of Eddie Spearritt was discussed.40 Mr Spearritt, along with his son Adam, lost consciousness in pen 4. His whereabouts between that moment and 5pm, when he was first treated at the Northern General Hospital, were and remain unknown. Admitted to intensive care, he recovered.41

¶2.10.99 Mr Spearritt's survival raised doubts about the imposition of the 3.15pm cut-off in terms of the quality of care and potential for survival beyond that time. It was Mr Jones' concern, raised at the Scrutiny, that the flawed logic of the 3.15pm cut-off was 'once you are unconscious, you have had it'.42

¶2.10.100 Given Mr Spearritt's case, he proposed that death was not 'inevitable' but that there were some who died who might have survived. Mr Jones stated that the jury was unaware of the survival of people who had been admitted to intensive care because they 'were not given evidence about what happened to these people after 3.15'.

¶2.10.101 The 3.15pm cut-off was raised by a number of families in their individual meetings with LJ Stuart-Smith and he wrote to Dr Popper noting that his decision continued to be criticised.43 While LJ Stuart-Smith was familiar with the reasons for Dr Popper's decision and its support by the Divisional Court, he stated that it was 'now suggested that the Jury were unaware … that some who died did so after 3.15' and 'that some of those who suffered severe crushing injuries, and were unconscious, recovered'.

¶2.10.102 LJ Stuart-Smith found these suggestions surprising as it was 'clear' that the jury knew about Lee Nicol and Adam Spearritt, both of whom died after 3.15pm. Further, Mr Spearritt had given evidence at the generic hearing and James Wardrope had given evidence regarding cases admitted to intensive care.

¶2.10.103 LJ Stuart-Smith asked Dr Popper if he was 'right in thinking that the legal representatives were not under any misapprehension' on this issue. Dr Popper was under 'no illusion that anybody who died had not suffered the injury from which he died after 315 … that they may have breathed or had a heart beat say at 320 or 330 or 400 was neither here nor there'.44

¶2.10.104 He later wrote to the Scrutiny team to state that this comment sounded 'rather callous' and he 'would not wish to give offence' – he was simply establishing that what 'mattered was the time when the damage was done and not how long after there continued to be signs of life'.45 Dr Popper informed LJ Stuart-Smith that he had 'taken quite a bit of trouble' to inform legal representatives and the families of the logic of the 3.15pm cut-off.46

¶2.10.105 He argued that the position adopted by legal representatives concerning 'investigating the medical attention and care' was based on a 'misconception of what an inquest can do'. While the Taylor Inquiry could address the 'overall matter', including 'medical intervention', this was not the role of inquests.

The Hillsborough Scrutiny conducted by Lord Justice Stuart-Smith, 30 September 1997, HOM000039080001, pp1133, e.g. p122. 41. Full details of the case are in Scraton, P 2009 Hillsborough: The Truth Edinburgh: Mainstream. 42. The Hillsborough Scrutiny conducted by Lord Justice Stuart-Smith, 30 September 1997, HOM000039080001, p96. 43. Letter from Lord Justice Stuart-Smith to Dr Popper, 28 October 1997, SPP000000570001, pp1-2. 44. The Hillsborough Scrutiny, evidence of Dr SL Popper,¹⁷¹⁷ December 1997, HOM000030920001, p1. November 1997, SPP000001180001, p12. 45. Letter from Dr SL Popper to Mr CF Bone, Hillsborough Scrutiny,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. November 1997, SPP000000500001, pp1-2. 46. The Hillsborough Scrutiny, evidence of Dr SL Popper,¹⁷¹⁷ December 1997, HOM000030920001, p1. November 1997, SPP000001180001, p13.

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¶2.10.106 Dr Popper stated that he was 'not saying that the medical people couldn't have been called sooner; that more could not have been done … it is quite possible that better quality care could have been achieved'. The inquests' purpose, however, was to establish the cause of death 'of these poor, unfortunate people' and he did not 'think it was medical care; it was crushing'.

¶2.10.107 At the time of Dr Popper's interview with LJ Stuart-Smith his successor, Christopher Dorries, contacted one of the pathologists, Dr David Slater.47 He was unsure whether Dr Slater had been contacted by LJ Stuart-Smith but suggested that given 'everything that has gone before' he might 'wish to take the opportunity to have your views heard', particularly Dr Slater's 'reservations ... about the 3.15 pm cut-off time'.

¶2.10.108 Dr Popper had 'made it plain' to Mr Dorries that the issue 'did not arise until well after the interim inquests, at which you [Dr Slater] gave evidence, had been completed'. Mr Dorries suggested the possible 'inference made by various people' was that Dr Slater had been 'pressured into making the pathology fit the time [3.15pm]'.

¶2.10.109 Subsequently, Dr Slater wrote to LJ Stuart-Smith on the suggestion of a 'third party'.48 He stated that he had complained to the Broadcasting Standards Commission regarding his portrayal in the Hillsborough drama-documentary (a complaint that was upheld) but at the time the Commission was awaiting the Scrutiny's outcome.

¶2.10.110 He noted the allegations that the pathologists had been pressurised 'to make their evidence fit the 3.15pm cut-off time'. Dr Slater stated that he had no involvement in establishing a cut-off time and had made no 'specific comment about the timing of death' or any 'comment to HM Coroner about this prior to giving oral evidence'.

¶2.10.111 In fact, he had been 'somewhat surprised by the artificial concept of a 3.15pm cut-off time and the exclusion of evidence following that time' although 'appreciative of the legal reasoning behind it'. Further, he understood the 'criticisms of the relatives with regard to this point'.

¶2.10.112 In December 1997 LJ Stuart-Smith interviewed Tim King, the HFSG barrister at the generic stage of the inquests.49 Mr King confirmed that the families' legal representatives were aware that people died after 3.15pm and noted that the Coroner's ruling had been given with the jury absent. He stated that he had 'told the families over and over again that challenging the Coroner's 3.15 cut-off point would mean getting expert medical evidence that there were people whose fatal injuries were inflicted after 3.15'.

¶2.10.113 He considered that there 'was no such evidence' and 'he did not know of any novus actus interveniens after 3.15'. The jury was aware that not all who were crushed had died. Mr King was unaware that 'Mr Fraser [the families' solicitor] had agreed to the 3.15 cut-off point' or whether, 'as now alleged', the Coroner 'misled families into believing that the questions of where and when people died would be looked at again during the main inquests'. Mr King stated that his 'efforts' had been 'directed to creating an overall picture of what happened and not to establishing the precise circumstances in which particular individuals died'.

Letter from CP Dorries HM Coroner to Dr DN Slater, 26 November 1997, SPP000000140001, p1. 48. Letter from Dr DN Slater, Rotherham Hospital NHS Trust, to Lord Justice Stuart-Smith,⁴⁴ March 1988, SYP000096970001, p600. December 1997, 49. Note of Hillsborough Scrutiny meeting, 8 December 1997, HOM000039460001.

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¶2.10.114 In January 1998 Paul Pugh from the Operational Policing Policy Unit at the Home Office wrote to Stephen Wooler in the Attorney General's Office Legal Secretariat to give 'advance warning' of LJ Stuart-Smith's report.50 It was his understanding that LJ Stuart- Smith would conclude that the inquests were 'properly conducted, and that the submissions he has received about medical evidence do not call into question the decision of the Coroner in relation to the 3.15pm cut-off point'.

¶2.10.115 The following month Mr Pugh wrote to the Home Secretary recommending that he accept the 'main conclusions' of LJ Stuart-Smith's report and 'as far as possible draw a line under the Hillsborough disaster'.51 He advised that 'to hold out the hope of further inquiries or investigation' would be a 'disservice' to families 'although some of them will not see matters like that'. For them, he continued, the report would be 'another betrayal and we can expect them to be very critical of the report, the judge, the scrutiny process and you'.

¶2.10.116 Concerning the 3.15pm cut-off, LJ Stuart-Smith's report concluded that the 'arguments' presented to the Scrutiny 'show a complete misunderstanding of the coroner's reasons for determining that point' and none of the evidence put to the Scrutiny 'provides any reason to question that decision'.

¶2.10.117 On 18 February MJ Pyne of the Operational Policing Policy Unit provided advice to Home Office minister Alun Michael suggesting the 'line to take' in response to questions raised by LJ Stuart-Smith's report.52

¶2.10.118 It stated that the 3.15pm cut-off had been 'widely misrepresented', that the Coroner 'ruled ... he considered all those who died had received the injuries from which they died by 3.15' and had not suggested that 'all those who died did so before 3.15 or that the medical evidence was to this effect'. Mr Pyne's memorandum advised that the imposition of the 'cut-off point' was concerned only with 'how, by what means, the deceased came to their deaths'.

¶2.10.119 This position was followed up in a further undated, unattributed briefing.53 It noted that the jury had heard evidence about those who died after admission to hospital and of those who had been resuscitated. The evidence of death beyond 3.15pm 'would not therefore effect [sic] the inquest'. The briefing also noted that in 1993 the issue had been examined thoroughly in the Divisional Court establishing 'no other cause of death' and the decision to impose a 'cut-off point' had been 'considered and reasonable'.

¶The Scrutiny's findings 2.10.120 LJ Stuart-Smith published his findings in February 1998.54 He noted that the Coroner's ruling on the 3.15 cut-off 'had been subjected to a good deal of criticism'. While the Divisional Court had upheld the Coroner's ruling, Counsel for the HFSG had submitted that 'fresh evidence discovered since 1993' undermined that Judgment.

Letter from Paul Pugh, Police Policy Directorate to Stephen Wooler, Legal Secretariat to the Law Officers, 7 January

¶1998, AGO000000860001, pp1-2. 51. Memorandum from Paul Pugh to Jack Straw, Home Secretary, 6 February 1998, HOM000032470001, pp1-2. 52. Memorandum from MJ Pyne, Operational Policing Unit, Home Office to Mr Alun Michael, 18 February 1998,

¶HOM000041940001, pp1-2. 53. 'HILLSBOROUGH Q & A BRIEFING FOR THE STATEMENT' [undated post-Scrutiny, 1998], HOM000041580001, p13. 54. Stuart-Smith, Rt Hon LJ 1998 Scrutiny of Evidence Relating to the Hillsborough Football Stadium Disaster Cm 3878

¶London: The Stationery Office.

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¶2.10.121 LJ Stuart-Smith, however, concluded that 'the Coroner's reasoning' had 'been widely misunderstood and misinterpreted'. The actual time of death and medical intervention, he stated, were irrelevant, rendering it inappropriate to enquire 'into the response of the emergency services or consider in any given case whether had it been quicker, differently organised, or with other facilities a person who died might have been saved'.

¶2.10.122 He considered the medical evidence unequivocal – all who died had suffered 'crush or traumatic asphyxia as a result of being crushed in pens'. There had been no break in the chain of causation between receiving the injuries that led to asphyxiation, and death. The fatal injuries had been inflicted by 3.15pm 'at the latest' although people lived beyond that point, 'running to hours or to days'.

¶2.10.123 Further, the 'pathological evidence ... was that once the chest of the victim was fixed so that respiration could not take place, irreversible brain damage would occur after between four and six minutes'. Finally, the Coroner had to keep the inquests 'within reasonable bounds', necessitating the 3.15pm cut-off.

¶2.10.124 LJ Stuart-Smith considered it consistent with the evidence that the fatalities were 'those people whose chests were in a state of permanent fixation as a result of the crush for four to six minutes, so that they could not breathe at all for that time, whose condition was irreversible'.

¶2.10.125 Reflecting the Divisional Court Judgment, he believed it acceptable not to enquire 'into whether lives could have been saved by calling the emergency services sooner or providing better emergency care for the injured'. Such 'questions were not relevant to the inquiry into how – ie by what means – the deceased had come to their deaths'.

¶2.10.126 LJ Stuart-Smith dismissed the relevance of evidence about those who lived beyond 3.15pm and died later, considering it 'less arguable that such new evidence affords grounds for quashing the verdicts of accidental death at the inquest'. All who died 'came to their deaths' through 'traumatic or crush asphyxia' as a consequence of 'dangerous overcrowding' in the pens but not 'because first-aid or medical attention failed to resuscitate them'.

¶2.10.127 LJ Stuart-Smith stated that the Coroner and the families' legal representatives were aware that 'not all those who died did so before 3.15' and 'not all those who were unconscious as a result of the crushing died'. He concurred with the Divisional Court's opinion that it 'was a matter for the Coroner's discretion at what point he chose to confine the inquiry' and that the decision was 'reasonable and sustainable'.

¶2.10.128 He concluded that 'it is quite impossible on the basis of the evidence and submissions now advanced to impugn the verdict of accidental death or suggest that the Divisional Court should again be invited judicially to review that verdict'.

¶Kevin Williams 2.10.129 The most highly publicised case regarding the effectiveness of the emergency response, and the treatment received in the minutes following the rescue from the pens, was the death of Kevin Williams. As the documents demonstrate, this was also a case that created considerable concern within the Attorney General's office.

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¶2.10.130 Much of the controversy surrounding the case is in the public domain and centres on inconsistencies between the pathology evidence presented at the mini-inquest and statements by those who attempted resuscitation on the pitch. The former established the cause of death as asphyxia with death occurring within minutes of the crushing. The latter concerns evidence from an off-duty Merseyside Police officer, Police Constable Derek Bruder, that Kevin convulsed during attempted resuscitation and evidence from a Special Constable, Deborah Martin, that a considerable time later he opened his eyes and said the word 'Mum'.

¶2.10.131 Public concern about the case increased when the police officer, PC Bruder, stated that a year after the disaster he was visited at home by a WMP investigating officer, Inspector Robert Sawers, 'who asked him to "reconsider" his statement', particularly his assertion that Kevin convulsed and had a pulse.55

¶2.10.132 While the WMP officer was with PC Bruder he claimed the Coroner rang 'and tried to persuade him [PC Bruder] that the facts of his statement were incorrect'. In December 1991, asked if he would make a further statement, 'Bruder replied that he would be prepared to stand up in Court and state that Kevin was convulsing, that there was a pulse, and that there was vomit in his mouth'. When he attended Kevin 'there was a pulse and if that means he was alive then he was alive'.

¶2.10.133 An internal memorandum written in 1992 by Stephen Wooler in the Attorney General's Office stated that while the pathologist, Dr Slater 'did not deal very fully with the suggestion of convulsion (because he was not asked to)', his view was 'that the extent of the irreversible brain damage caused by the asphixia [sic] ... would have totally prohibited any form of communication'.56 Further, Kevin had suffered 'four fractures of the two bones in the voice box and therefore the deceased could have uttered nothing whatsoever'.

¶2.10.134 Mr Wooler noted that as a consequence of the family's concern the Coroner had both police officers re-interviewed. He also stated that 'when asked to go into detail' PC Bruder 'was less firm and said that, having had further first aid training since the incident, he would no longer use the word "convulsion" but describe what he saw as "twitching"'.

¶2.10.135 The witness statements were dismissed as mistaken: that Kevin had 'twitched' rather than convulsed and air had passed from his body giving the appearance of speaking a word. 'Sadly', concluded Mr Wooler, 'the family are convinced that their son was alive for some time after he was removed from the stand at Hillsborough and that some form of "cover up" is afoot'.

¶Memorial to the Attorney General, 1992 2.10.136 In the Memorial presented to the Attorney General the case was made that the evidence summaries presented by a WMP officer at the mini-inquest into Kevin's death established that according to the officers attending him on the pitch he was alive.57 While 55. Meeting between Anne Williams and PC Derek Bruder, 15 December 1991 [In file of evidence: Judicial Review forwarded to SYP by Malcolm Gregg solicitors on 28 April 1993], SYP000096240001, pp330-332. There is some ambiguity in the documentation as to whether the phone call referred to in paragraph 2.10.132 was in fact from the

¶Coroner (Dr Popper) or from Dr Slater, the pathologist. In paragraph 2.10.150 below, Dr Slater suggests that it was he

¶– and not Dr Popper – who spoke to PC Bruder. 56. Memorandum from SJ Wooler to the Attorney General, 6 February 1992, pp1-4.