Appendix 3: Research process and method

¶In terms of the broader context and immediate circumstances in which they occur and their short-term and longer-term aftermath, disasters involving multiple deaths and injuries are complex events impacting on the bereaved, survivors, rescuers, their families and their communities. To understand that complexity, in terms of causation and investigation, it has been suggested that disasters and their consequences should be considered as a sequence of distinct but inter-related 'phases'.

¶A three-part medical analogy is often used: 'incubation' phase; 'acute' or 'crisis' phase; 'recovery' phase. 'Incubation' considers the build-up during which the potential for disaster grows and develops, often hidden from view yet inevitable once certain circumstances coincide. The 'acute' or 'crisis' phase occurs as that potential, often quickly and irretrievably, becomes reality. The 'recovery' phase extends from rescue through to resignation.

¶While it is helpful to consider the progression of a disaster, its context and its aftermath as self-contained time periods, these periods cannot be precisely delimited, since human actions and reactions, involving the dynamics of personal, group and organisational responses, are not straightforward. Identifying phases that encompass a definable timespan, nevertheless, helps in analysing, planning for and responding to disasters.

¶Previous research into the context and consequences of the Hillsborough disaster considered eight phases: the historical context; the immediate context; the immediate circumstances; the 'moment'; rescue and evacuation; the immediate aftermath; the short-term aftermath; the long-term aftermath. This enabled an analytical approach to the key factors that contributed to the disaster, to what happened on the day and in the immediate aftermath, and to the investigations and inquiries that followed. As a framework this approach was adopted by the Panel in its analysis of the disclosed documents and other material and is reflected in the structure of the Report.

¶Terms of reference and scope Within its terms of reference (see Appendix 1) the Panel was obliged to write a report demonstrating 'how the information disclosed adds to public understanding of the tragedy and its aftermath'. To achieve that end the Panel negotiated access to documents held by a diverse range of organisations and individuals (see Appendix 2).

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¶The scope of material sought and disclosed covered: the decade prior to the disaster, focusing on the condition of the stadium and the arrangements for crowd safety and crowd management; the circumstances leading up to the FA Cup Semi-Final being held at Hillsborough in 1989; the 'moment' of the disaster; the immediate aftermath; the investigations and inquiries that followed.

¶Once accessed, the documents and other material were catalogued and processed within the digital archive. While hard copies remained in key sites (The National Archive; the Sheffield Archives; the Liverpool Record Office) or with their rightful owners, the digital archive provides a single, coherent repository of all disclosed documents.

¶The cataloguing process was time-consuming because many of the documents provided by the contributing organisations or individuals had not previously been catalogued or filed.

¶Research process Within the first months of the Panel's work it became apparent that the sheer volume of documents would require a fully developed programme of research to provide an analytical review on which the Panel's Report could be based.

¶The research team was Dr Janet Clark, Dr Jo Doody, Dr Shaun McDaid and Ms Gemma Ní Chaoimh. Appointed by the Panel, the team was managed by Panel member Professor Phil Scraton and based at the School of Law, Queen's University Belfast. Other Panel members also contributed significantly to the research process in accord with their specialist knowledge and professional expertise. The team was supported by members of the Panel's secretariat.

¶Research methodology As stated above, a priority for the Panel's work was to show how the disclosed documents contribute to public understanding of the disaster. It was important, therefore, to review 'what was known' in the public domain, from previous investigations, inquiries and research into and publications about the disaster. This review forms Part 1 of the Report.

¶Part 2 is concerned with 'what the disclosed documents add to public understanding', reflecting the context, circumstances and consequences of the disaster and its investigation. It also responds to the questions asked and issues raised by bereaved families in consultation with the Panel.

¶Having established the key focuses for the research, the Panel accessed, digitised and researched the documents accordingly. This involved a methodical content analysis of all documents and other material disclosed to the Panel. The documents, therefore, provided the foundation for the extensive, cross-referenced data that then formed the detail of the Report.

¶The Panel read all the disclosed documents in unredacted form. Redaction of documents, or their removal from public access, has been agreed by the Panel only in exceptional circumstances (see Appendix 2). The main reason for redaction or non-disclosure is privacy relating to personal information, particularly medical records. Names of junior members of staff within organisations have also been redacted.

¶Extensive primary data was drawn from the documents, then further analysed and cross-referenced to present a detailed narrative within each chapter. Inevitably the chapters also rely on documents and material already in the public domain in order to provide a coherent, analytical narrative.

¶Regarding the circumstances and immediate aftermath of the disaster, cross-referencing of content was developed chronologically to construct a comprehensive sequence of events, reflecting the exchange of information between organisations prior to and after the disaster. This included detailed consideration of the decisions taken by relevant organisations regarding crowd management, crowd safety and structural modifications within the stadium throughout the 1980s.

¶The Panel also focused on issues concerning rescue and the emergency response. In examining the emergency response to the disaster, the Panel's approach was consistent with the analysis of disclosed documents as conducted for other chapters. Cross-referencing of a wide variety of sources in chronological order constructed a comprehensive sequence of events as the disaster unfolded. This enabled eye-witness accounts to be located in context.

¶Occasionally, timings of events in statements or other documents conflict with timings derived from radio transcripts. In these instances the transcripts, which are timed verbatim records of every telephone call and radio transmission, were considered definitive.

¶Disclosure and access to documents The initial phase of the research was conducted on hard-copy original or photocopied documents held in Sheffield or at the Home Office. The next phase of the content analysis was conducted by accessing the digitised versions of documents held on a secure site.

¶While all documents disclosed to the Panel are not referenced specifically in the Report, each document has been reviewed and analysed as part of the research process. The Panel is aware that some documents include personal opinions of individuals, and statements about individuals, where those concerned have not had the oppportunity to respond to comments or criticism. In reading the disclosed documents it is important to be sensitive to this situation.

¶Medical evidence The assessment of the evidence on causation of death, central to the preliminary hearings or mini-inquests, was based primarily on the records of the post mortem examinations carried out on the deceased. These records are personal medical records, and as such have been treated as confidential by the Panel.

¶Because of the significance of this evidence and the concerns raised by bereaved families, the Panel's medically qualified member scrutinised the records, summarising their content in aggregate. This scrutiny revealed features previously the subject of comment in individual cases but that had not been assessed. The Panel received the helpful advice of a highly experienced and senior professor of forensic pathology.

¶The disclosed post mortem reports revealed a broad pattern of evidence of prolonged survival in a substantial proportion of the deceased (see Chapter 5). The outcome for those alive but unconscious due to partial asphyxiation was dependent on what happened to them during this period, including the prompt availability of properly equipped first-aid personnel and correct positioning.

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¶The material disclosed to the Panel included the schedule of original data that had been used for an analysis which resulted in a claim that there was a link between later arrival in the ground and a raised blood alcohol level amongst the deceased. Initially, the Panel replicated the original analysis. Prompted by the results it carried out further analysis of the original data, the results of which are described in detail in Chapter 5.

¶Factual accuracy checking A process of factual accuracy checking was conducted with South Yorkshire Police, the South Yorkshire West District Coroner, Yorkshire Ambulance Service and Sheffield City Council as the main contributing organisations. Each organisation was provided with sections of text showing extracts from the documents it provided to ensure that the text was a factually accurate representation.

¶The contributing organisations met with Panel members to discuss the text, but were not given hard copy or online access outside the meetings. In keeping with the principle of 'families first', under which the bereaved families are the first to access the Panel's Report, the contributing organisations were not provided with the Panel's interpretations of the documents.

¶Where appropriate, and based only on factual accuracy rather than interpretation, modifications were made to the text. Objections raised that were considered as matters of interpretation were discounted. The Panel is grateful to the main contributing organisations for their participation in this process.