Chapter 4: Emergency response and aftermath: 'routinely requested to attend'

Chapter 4: Emergency response and aftermath: 'routinely requested to attend'

¶What was already known 2.4.1 As spectators became crushed by the growing pressure within the central pens, they began to suffer serious consequences, principally from the severe restriction of their ability to breathe. Without recognition of their predicament, release from the intolerable pressure and urgent immediate care, they were in mortal peril. 2.4.2 As discussed in Part 1, the initial police response was conditioned by their focus on potential crowd disorder, and initially spectators were unable to convey what was happening. Their attempts to escape by climbing fences, particularly the perimeter fence, were misinterpreted as an attempted pitch invasion, and police reinforcements were summoned. 2.4.3 When the reality and severity of the disaster was realised, the other emergency services were notified. Police officers eventually opened the perimeter gates and began to drag injured spectators through the small openings, while others were pulled over the fences. 2.4.4 Less injured spectators managed to tear holes in the perimeter fencing to allow escape, and some exited through the tunnel at the rear when pressure lessened. Others climbed over the lateral fences or were pulled up into the stand above the terrace. When the Fire Service eventually arrived with cutting equipment that could have speeded evacuation, the pens had emptied. 2.4.5 As spectators emerged or were dragged onto the pitch, it was clear that many were injured, unconscious or close to death. Amid scenes of chaos, some police officers began to resuscitate casualties, quickly aided by the less injured spectators, some of the few ambulance staff and the St John Ambulance personnel present. 2.4.6 The South Yorkshire Metropolitan Ambulance Service (SYMAS) despatched ambulances, mostly via Penistone Road North to the area close to the gymnasium at the base of the North Stand. This was diagonally across the full length of the pitch, and as word spread spectators tore down advertising hoardings as makeshift stretchers to carry the injured. 2.4.7 Inevitably, given the growing realisation of the seriousness of the disaster, some fans were desperate at what they perceived as a slow rescue response, venting their anger at officials. A few Liverpool fans, goaded by Nottingham Forest fans on the packed terrace

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• Chapter 4 Emergency response and aftermath: 'routinely requested to attend' — 131

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¶at the opposite, Spion Kop, end who were unaware of the disaster, ran towards them, and a police cordon was established across the pitch to prevent their progress.

¶2.4.8 For a prolonged period, the number of casualties and their serious nature overwhelmed those involved in the initial rescue, whether spectators or officials. Many of those pulled from the pens were beyond help. Criticism of the effectiveness and efficiency of the emergency response began almost immediately after the event.

¶2.4.9 Subsequently, the Taylor Inquiry referred to failings of communication and coordination. Based largely on medical evidence that those who died had suffered traumatic asphyxia resulting irreversibly in death within a few minutes, the Taylor Interim Report considered that the emergency response could not have aided them in time, and the Coroner imposed a 3.15pm cut-off on the resumed inquests, excluding almost all evidence on the response.

¶2.4.10 As established in Chapter 5, the premise that for all who died death was inevitable after a few minutes was flawed.

¶Context 2.4.11 A major disaster involving multiple fatalities and injuries presents a very different set of circumstances to those that occur in the routine practice of the emergency services, and it is important to understand that both the challenges and the response required are accordingly different. Several aspects must be taken into account.

¶2.4.12 First, the nature of a major disaster is outside the experience of those present or initially responding, making it difficult to assess what is happening and how best to react.

¶2.4.13 Second, the scale of casualties is overwhelming, causing shock and distress to witnesses and to members of the emergency services. The immediate impact and realisation hampers judgement and the capability to make decisions and take appropriate action.

¶2.4.14 Third, the action required, at least initially, runs counter to the instincts and everyday experience of staff, who must suppress the urge to devote their attention to caring for the nearest injured casualty, focusing instead on assessing the situation, calling for necessary assistance, and establishing those in most need of immediate treatment.

¶2.4.15 Fourth, the reaction of bystanders, particularly if they are friends and relatives, driven by the desperate desire to help, understandably is often irrational, sometimes unhelpful and occasionally hostile, further impeding the ability of responders to take appropriate action.

¶Emergency services training 2.4.16 Emergency services plan for major disasters, train staff in their respective roles, and carry out exercises to test and improve the response. Training programmes should be designed to emphasise the particular difficulties facing responders.

¶2.4.17 However, because of the pressing needs of the day-to-day service, training and testing are often theoretical, 'table top' exercises. Even when simulations are conducted – and more recently attention has been paid to making these as realistic as possible – it is doubtful that emergency planning can prevent the initial, human reaction of paralysing shock among those involved in the initial response.

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¶2.4.18 The first moments of a major disaster are inevitably characterised by chaos, with responders unable to act coherently. It is important that this immediate phase is limited and coordinated efforts are established as quickly as possible to mount an appropriate response in accordance with emergency plans, training, and staff roles and responsibilities. Effective leadership is crucial in promoting purposive action, bringing cohesion, responding to novel circumstances and supporting staff who are enduring emotional and physical exhaustion.

¶2.4.19 Eye-witness accounts of the immediate aftermath of the Hillsborough disaster confirm that all the above challenges were present. The response at Hillsborough, therefore, should be considered within this context.

¶Recognition of the disaster 2.4.20 The first essential requirement was that emergency services recognise what had happened with sufficient clarity to mount an appropriate response. It is clear from the documents disclosed to the Panel that there was significant delay before anyone present in an official capacity recognised that they were witnessing the throes of disaster.

¶2.4.21 Eye-witness accounts confirm that a major factor in this delay was the predisposition of police officers and others to view crowd unrest or perturbation as a sign of actual or impending hooliganism.

¶2.4.22 Even before the match kicked off, spectators in the central pens protested that they were being crushed intolerably, shouting to the police officers on the perimeter to recognise what was happening and open the small gates in the perimeter fence. They were ignored or told to be quiet.

¶What happened after 3pm 2.4.23 Lack of recognition of the seriousness of the crush continued as pressure worsened after 3pm. As spectators began to climb the perimeter fence, police attempted to push them back into the pens, misinterpreting their desperate efforts to escape as a pitch invasion, despite the short distance separating them from people already being fatally crushed.

¶2.4.24 Inevitably, spectators within the pens became frustrated at the inability of police officers only yards away to understand and react to their predicament. Many spectators not yet incapacitated by the crush watched others losing consciousness, and some understandably became angry at the failure of officials to respond appropriately, further reinforcing the police view that this was a disturbance due to bad behaviour.

¶2.4.25 Although the Match Commander and his colleagues in the Police Control Box were more distant from the central pens, they were well placed to view the crush, with or without video surveillance equipment. They misinterpreted the visual evidence available, first failing to appreciate that the central pens had become seriously overcrowded and then wrongly attributing the signs of unrest and distress to aggressive behaviour and an attempted pitch invasion.

¶Ambulance Service presence at Hillsborough 2.4.26 That the police were unduly concerned with crowd misbehaviour must be seen within the context of the time and the undeniably poor relationship between the police and football fans.

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¶2.4.27 Yet it is clear from the documentary evidence that recognition of the nature of the disaster was delayed, and the occurrence of serious injuries and fatalities remained unrecognised at 3.06pm when the match was stopped.

¶2.4.28 However, ambulance officers were present in the stadium specifically in case of a possible disaster, with no remit for crowd control and therefore no reason to be distracted by it. Under an arrangement set up by SYMAS following the fire at Bradford's Valley Parade ground, from 1986 two senior ambulance officers had routinely attended football matches at Hillsborough in case of a major incident.

¶2.4.29 Their duties included direct liaison from the ground, enabling early assessment and notification of any developing incident. Two stand tickets were provided to SYMAS by Sheffield Wednesday Football Club (SWFC) for league games, but they were not provided for FA Cup games. Nevertheless, Station Officer Paul Eason and Station Officer Patrick Higgins attended with an ambulance and based themselves at pitch level as they were obliged to in the absence of tickets. They were accompanied by two ambulance crew personnel.

¶Initial SYMAS misinterpretation of the situation 2.4.30 At 3.03pm, the SYMAS officers became aware of crowd unrest on the Leppings Lane terrace, and two minutes later SO Eason went to investigate, accompanied by one of the junior staff. SO Higgins reported to Ambulance Control that there was possible crowd trouble with probable minor injuries but not needing transportation.1

¶2.4.31 SO Eason saw what he believed to be a scuffle on the terrace, with some overspill of spectators onto the pitch, while those still in the pens were becoming agitated. His attention was drawn to an injured spectator on the pitch side of the perimeter fence immediately behind the goal, who was found to have a leg fracture.2

¶2.4.32 The match was stopped at 3.06pm because at least some police officers in the vicinity of the perimeter fence had realised the seriousness of the unfolding disaster. SO Eason and the junior SYMAS officer, however, withdrew to their original position because 'people were getting angry and frustrated and they tended to take out their anger and frustration on those in uniform by hitting out and aiming kicks'.

¶2.4.33 He failed to appreciate that spectators' frustration had arisen because of their inability to persuade those in uniform of the severity of what was happening. He continued to believe that what he had witnessed through the perimeter fence was a consequence of fighting on the terraces. It is unlikely that the state of mind of those within the pens, where many were struggling to breathe and remain conscious, was helped by the sight of ambulance personnel withdrawing from the area.

¶2.4.34 Subsequently all four SYMAS staff returned to the Leppings Lane terrace with equipment to treat the individual with a fractured leg bone, and found that the situation had worsened in the intervening two or three minutes. SO Eason stated: 'It was increasingly obvious there were a lot more angry and a lot more injured spectators. [We] were thumped and subjected to verbal abuse. [Two junior ambulance staff] applied a splint to the youth's leg. The situation was becoming increasingly ugly'.

1. Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001. 2. Statement of Station Officer Paul Eason, 5 May 1989, YAS000001490001, pp4-6.

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¶2.4.35 At this point, approximately 3.11pm, seriously injured spectators were being pulled from the central pens and the first resuscitation efforts were initiated by spectators and police. The SYMAS officers still failed to appreciate the extent of the situation at this stage. In response to a request for information by Ambulance Control, timed at 3.11pm, SO Higgins reported 50 to 100 people on the pitch with 'quite a lot that's been squashed forward, probably just winded'.3

¶2.4.36 There is a manuscript addition to SO Eason's statement at this point that 'we realised that there were fatalities and serious injuries', but this later addition is not credible in the light of SO Higgins's observation that the injured were 'probably just winded', or SO Eason's next comment that '[he] wanted now to bring the other vehicle from Middlewood to Leppings Lane as a precaution'.4 The origin of this manuscript addition is unknown.

¶2.4.37 At 3.13pm SO Higgins, who had previously been approached by a police officer asking for help in responding to casualties and possible fatalities, reported possible fatalities to Ambulance Control. The response was that 'as many mobiles as we can' would be diverted to the ground.5

¶SYMAS recognition of disaster 2.4.38 Although the transmission from SO Higgins was not a definitive report on the situation, and did not refer to a major incident, it is clear that over the course of the next five minutes SO Eason and he did realise that numerous spectators had suffered serious crush injuries.

¶2.4.39 SO Eason attempted to make contact with Ambulance Control using his pocket- phone radio, but it would not function in the pitch area. By now, spectators including doctors and nurses and the two junior ambulance staff were attempting to resuscitate numerous casualties on the pitch in front of the Leppings Lane terrace.

¶2.4.40 SO Eason returned to the ambulance vehicle and radioed Ambulance Control, 'I'd like to declare it as a major incident'.6 He did not describe the nature of the incident or advise on the most appropriate response, but estimated that between 30 and 50 were injured.

¶2.4.41 The call was timed at 3.21pm, 15 minutes after the match had been stopped. Even bearing in mind all the difficulties inherent in the initial stages of a disaster identified above, the evident effect on the ambulance staff and their prolonged misinterpretation of why spectators were frustrated, this delay was regrettable, raising significant questions about the professional judgement of senior ambulance staff whose role was to identify and respond to a major incident. Only a few minutes of this delay could be attributed to the undoubted difficulties that affected radio communications.

¶Initial response 2.4.42 By this time, however, a police officer had been despatched to pitch level to investigate and he reported to the Police Control Box that a disaster was in progress, with serious casualties. In accordance with major incident planning, the appropriate action should have commenced immediately, beginning with the declaration of a major incident by

3. Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, p34. 4. Statement of Station Officer Paul Eason, 5 May 1989, YAS000001490001, p6.

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¶the Control Box to the South Yorkshire Police (SYP) Force Control Room. This would have triggered a cascade of immediate responses from all emergency services, including the ambulance and fire services as well as other agencies.

¶2.4.43 Communications from the Police Control Box inside the stadium confirm that the Match Commander and his colleagues considered the problem was exclusively one of crowd behaviour. There were calls for dog handlers at 3.04pm and two minutes later for Operation Support, to bring all available police assets to Hillsborough.

¶2.4.44 Also at 3.06pm, Force Control initiated the first call to Ambulance Control about casualties, although it was couched as precautionary: 'We've got um an incident at leppings lane um end on the um Sheffield Wednesday Football Ground. We may need a few ambulances its just to advise you at this stage ... a lot of pushing and shoving and there might have been quite a few injuries ... Its just sort of er advise you at the moment'.7

¶2.4.45 As this exchange was in progress, Ground Control asked Force Control for a 'fleet of ambulances to Hillsborough' in line with the report from pitch level, and this was passed to Ambulance Control as part of the same call, shortly before 3.08pm. The message was incorrectly formulated, however, and prompted an unhelpful exchange:

¶'We are requesting a fleet of ambulances'

¶'Fleet of ambulances[?]'

¶'All ambulances that are available to Hillsborough please' …

¶'Okay we will instigate an initial response and we'll assess it from there okay'

¶'All, All ambulances you've got available I understand'

¶'Well we can't do that I will send you our initial response and we'll assess. We've got officers on the scene'.8

¶2.4.46 Ground Control should have asked Force Control to implement the major disaster plan, which would have resulted in the information being cascaded appropriately, including to SYMAS, and acted upon.

¶2.4.47 The call from Force Control for a 'fleet of ambulances' met with an appropriate request for more information from Ambulance Control and the decision that, unless further information could be given, the Ambulance Service would need to investigate before determining the appropriate response.

¶2.4.48 Had Ambulance Control diverted all available vehicles in the absence of a major incident being declared, as they were asked to do, they would have faced justifiable censure if they had been unable to respond to a seriously ill or injured person elsewhere for lack of a vehicle. SYMAS Control, therefore, correctly indicated that it would instigate an initial response and further assess what was required.

¶2.4.49 Deputy Chief Ambulance Officer Alan Hopkins was in Ambulance Control when this call was received. He asked for SO Higgins to be contacted in the stadium for further information. SO Higgins had just requested that the standby ambulance be sent to the gymnasium entrance but, as established above, at 3.08pm in the prevailing chaotic situation he and SO Eason had not realised the seriousness of what was happening.

7. Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, p244 (text as transcribed).

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¶2.4.50 In reply to the request for information SO Higgins suggested only that ambulances should be sent to the gymnasium entrance and not the Leppings Lane entrance, in accordance with the SYMAS plan for an incident at Hillsborough. DCAO Hopkins had already decided to investigate and left Ambulance Control at 3.08pm.

¶2.4.51 He was on the road at 3.14pm and arrived at the stadium at 3.23pm. By this time the initial response had already taken shape, partly prompted by DCAO Hopkins at 3.17pm on his way to the ground. That response was to send as many ambulances as possible. 2.4.52 Although sending ambulances to the gymnasium entrance was integral to the major incident plan, it would have been only one element had the plan been activated. DCAO Hopkins did not provide any further information to Ambulance Control until 3.31pm when he requested the major incident vehicle.

¶Continued incomplete communication 2.4.53 Meanwhile, at 3.13pm Force Control contacted the South Yorkshire Fire Service Control Room to request a vehicle with cutting equipment. This was intended to cut access points in the perimeter fencing which was severely restricting rescue efforts. A police officer described fans trapped in the pens 'dying due to lack of oxygen and it was frustrating to see them being unable to do anything in time to save them ... delay in being able to get to them and being unable to tear down the fence was most definitely a contributory factor which led to the unnecessary death of people'.9 2.4.54 As with the call to SYMAS, the request to the Fire Service was incorrectly formulated and did not include any reference to activating the major incident plan: 'Can we have cutting equipment please to Hillsborough straight away'.10 2.4.55 A conversation characterised by multiple misunderstandings ensued. The Fire Service Control Room correctly asked for further details, needing to prioritise the request against the need to respond to other incidents. The Fire Service responded and its personnel added to resuscitation efforts, and a police vehicle with cutting equipment attended later after a key-holder for the store room had been found. By this time, however, the central pens had already been evacuated using the restricted access provided by single gates or through the tunnel at the rear of the pens. 2.4.56 By 3.20pm, police staff in Ground Control and Force Control and Ambulance Control staff had begun to adopt the description 'major incident' in various radio and telephone communications. Yet the documents confirm that no-one at these locations activated the major incident procedure, not even in response to SO Eason's 3.21pm call.11 Documents disclosed to the Panel show that significant elements of the SYMAS major incident plan were never implemented, including notification of the major receiving hospitals and the deployment of an emergency response team, or were implemented much too late to be of use, such as the deployment of site medical teams. The analysis of the Panel is that it is difficult to conceive that the major incident plan could have been activated by the senior officer in Ambulance Control without implementing crucial and potentially effective elements such as these, which might have made a difference. 2.4.57 In the heat of the moment, it appears that no senior officer thought to verify that the major incident procedure had been implemented. The only locations that did fully implement

9. Statement of Detective Constable Malcolm Turner, 9 May 1989, SYP000008960001, p17. 10. Transcript of call from police to Fire Service Control, SFR000000610001, p9.

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¶their part of the major incident process were the Northern General Hospital (NGH) and the Royal Hallamshire Hospital (RHH). 2.4.58 The NGH implementation was on the initiative of the duty Nursing Officer, acting in conjunction with Charge Nurse Ian Batty in Accident & Emergency (A&E), who had been notified by an ambulance crew member of radio traffic mentioning 'trouble inside the ground at Hillsborough'.12 2.4.59 The RHH implementation followed the arrival of Mr Alan Crosby, Consultant in A&E, at approximately 3.30pm. 'I told him [a Charge Nurse in A&E] we may as well work on the assumption that this was a major disaster and I asked one of the clerical staff to notify the switchboard that I was declaring a Major Disaster'.13

¶Failure to enact the major incident procedure 2.4.60 In a report compiled for the Taylor Inquiry, West Midlands Police (WMP) confirmed that the duty to activate the major incident plan lay with the SYP Control Box, which had responsibility for crowd safety as well as crowd control. As noted previously, police officers in the Control Box initially viewed the problem as a crowd disturbance and activated 'Operation Support', primarily designed as a contingency plan to deal with incidents of spontaneous disorder. At approximately 3.07pm, however, there was a 'move away from the Operation Support procedures and into the major incident plan'.14

¶2.4.61 Despite the repeated requests for a 'fleet of ambulances' that confirm that officers in the Control Box were well aware of multiple serious casualties, the report confirmed that the major incident procedure was not activated:

¶Under the Major Incident Plan, the code word CATASTROPHE should be used by the police to prefix initial messages to the fire and ambulance services in order to alert them that a major incident may have occurred and that the police are implementing their major incident plan. Because of the way this incident developed and because no officer at the scene identified the extent of the disaster early enough the code word

¶CATASTROPHE was not used. This is confirmed by the extended incident log and tape transcripts which do show the time the other emergency services were routinely requested to attend.

¶2.4.62 Regardless of the use of the code word, it is clear from the Control Room tape transcripts disclosed to the Panel that at no stage was the communication from Force Control adequate to trigger the cascade of information to other emergency services and activation of their own major incident procedures.

¶Consequences of failure to activate the major incident plan fully 2.4.63 The absence of complete activation of the major incident plan had significant consequences for the emergency response within the stadium. The SYMAS plan provided for specified senior officers to attend and adopt their designated roles, including Incident Officer, Control Officer, Casualty Clearing Point Officer and Emergency Support Team Officer.

12. Statement of Charge Nurse Batty, SYP000096380001, p89. 13. Statement of Mr Alan Crosby, JWR000000250001, p67. 14. Report of WMP to the Taylor Inquiry on Emergency Planning Procedures, HOM000002580001, p3.

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¶2.4.64 There is some evidence that the first two roles were nominally covered by SO Eason and SO Higgins, at least until DCAO Hopkins arrived, but their roles were not understood by – or indeed visible to – others. The remaining two roles were not covered. There is no evidence from witnesses of appropriate coordination of the process. According to the major incident plan, the Casualty Clearing Point Officer should have taken the central role in triaging casualties – deciding who were priorities for resuscitation and transport to hospital because their condition was critical, and who were not priorities either because they were not seriously injured or because they were beyond help.

¶2.4.65 There is evidence that some ambulance staff attempted to identify those most in need of help in their immediate vicinity before attempting resuscitation or transporting casualties, but there was no attempt to set up the systematic triage urgently needed and expected within the plan, particularly in front of the pens.

¶2.4.66 Under the provisions of the major incident plan, the Emergency Support Team Officer should have mustered an emergency support team or foot team, including such extended-trained staff (paramedics) as were available, to attend and provide 'effective on site patient treatment and care' and evacuate casualties to the casualty clearing point.15

¶2.4.67 In their absence, crews from the first vehicles to arrive attempted to meet the demands of this role, but they lacked direction and leadership, and in some cases left ambulances locked and unattended, hindering access for other vehicles.

¶2.4.68 Further, had a major incident been declared to the hospitals, a site medical officer and team could have been deployed in the first instance with resuscitation and other equipment. In the event attempts were made later to request medical teams from NGH, RHH and Barnsley District General Hospital.

¶2.4.69 An NGH team arrived at approximately 3.50pm and brought much-needed equipment into the gymnasium. By then, however, the opportunity to resuscitate many of the most severely injured had passed, and the team returned to the hospital.

¶2.4.70 When an ambulance arrived to collect the Barnsley medical team the A&E department was unaware of the request but provided a team at short notice. On its arrival at Hillsborough, the Barnsley team was turned away as it was no longer required. There is no record that a call requesting a medical team from RHH was received.

¶2.4.71 The Fire Service would also have been alerted to attend had an appropriate declaration of a major incident been made. It could have provided heavy cutting equipment when needed to free spectators still trapped in the central pens. Fire officers arrived after many spectators had been laboriously extricated through narrow perimeter gates and others had exited after fencing had been torn down in desperation by fans.

¶SYMAS view of delayed recognition of the disaster 2.4.72 SYMAS considered that SYP should have recognised the severity of the incident sooner and activated the major incident plan. Its representations to the Taylor Inquiry concluded that lives could have been saved:

¶SYMAS' submission is that there is evidence to indicate that supporters were being crushed to death by 1459 hours and that this was evident to anyone whose mind was not conditioned by the need to contain supporters within the central pens.

15. SYMAS Evidence to Instructing Solicitors – Major Incident Plan February 1985, YAS000002360001, p50.

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¶It is SYMAS submission that the persons who were in a position to, and should have recognised the plight of persons in pens 3 and 4, are the police officers in the control box, and those stationed along the perimeter track in front of pens 3 and 4.16

¶2.4.73 This submission omits any reference to the two SYMAS senior officers who during this time were alongside police officers on the perimeter track in front of pens 3 and 4 failing to recognise and respond to the plight of those within the pens.

¶2.4.74 The disclosed documents show that the SYMAS officers were slower than the police officers alongside them to realise the situation. Their misinterpretation of the unfolding disaster, together with the subsequent inadequate communication, was a significant missed opportunity to limit the consequences of the initial police failure.

¶Rescue and resuscitation 2.4.75 In the absence of a coordinated immediate response, many at the scene reacted individually to the best of their ability. Inevitably, in the circumstances, their reactions varied greatly. Some spectators and police acted promptly and without self-regard to evacuate people from the pens and to begin first aid. Understandably others were overwhelmed. Some police officers appeared bewildered and failed to act purposively. A few fans were angered by the lack of understanding of their situation by officials. They acted with hostility. 2.4.76 Such diversity of reaction has to be understood in the context of witnessing a devastating incident at close quarters. It should not detract from the dedicated interventions of those fans, police officers and ambulance crew who responded spontaneously to the welfare of the trapped and injured.

¶Scale of the disaster becomes apparent 2.4.77 It rapidly became apparent to rescuers that a number of those evacuated from the pens were unconscious, some with no breathing or pulse. Fans and police attempted resuscitation, usually including chest compression (external cardiac massage) and mouth-to-mouth resuscitation. 2.4.78 In many cases, the injured person's mouth and throat were clogged with regurgitated stomach contents, making mouth-to-mouth resuscitation difficult as well as unpleasant. As the scale and seriousness of the disaster became apparent doctors and nurses among the spectators converged from all parts of the stadium. They took over resuscitation of the casualties they first encountered. Some realised they could spread their experience and skills more widely by delegating resuscitation to willing volunteers, directing and coaching their efforts. 2.4.79 When ambulances began to arrive outside the gymnasium in response to the call from Ambulance Control, staff left their vehicles and went to the Leppings Lane end of the ground on foot, running almost the full length of the pitch. Once there, some added to the resuscitation attempts and others removed those who were injured to the gymnasium which was the casualty clearing point designated in the Hillsborough incident plan. The first ambulance vehicle arrived at 3.17pm.17 2.4.80 Only a few stretchers were available, and fans placed casualties on advertising hoardings torn from around the pitch. They ran towards the gymnasium. At least two

16. Letter to the Taylor Inquiry from Dibb Lupton Broomhead (Solicitors) – Ambulance Service submission,

¶HOM000018310001, pp21-22. 17. Statement of Station Officer Paul Eason, YAS000001490001, p8.

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¶doctors, present as spectators, realised that without systematic prioritisation of casualties (triage) scarce ambulance and first-aid resources would be wasted on those not requiring urgent treatment or others who were already beyond help. 2.4.81 In the absence of any visible coordination by police or ambulance services, these doctors attempted to establish triage. One told 'the police who could be despatched by ambulance next and who could wait. The officers were mostly very good. They took my instructions and acted on them immediately'.18 Another met with less success:

¶I saw a Police Officer with a flat cap. I presumed he was of higher rank and I said to him that I was a senior surgeon. I asked him to give me a Police Officer and we would go around all the casualties and I would tell him who needed urgent treatment and who could be left until later. He did not reply and turned away to talk to someone else.

¶I then went to try and help where I could.19

¶2.4.82 Other doctors and nurses offered help. Some were directed to the gymnasium, but initially found only those not critically injured and those already dead. Some went back to the pitch to find those who required skilled assistance. Their accounts, made in contemporaneous statements, remain illuminating, not least because their professional experience gave them a framework against which to appraise what was happening.

¶2.4.83 The consistent features that emerge from their accounts are: first, the lack of an organised response for a prolonged period; second, the efforts of spectators to provide resuscitation and ferry casualties; third, the lack of equipment for first aid and resuscitation; and fourth, the lack of leadership provided by senior emergency services officers.

¶Whilst some police officers were quick to help extricate spectators from the central pens and to begin resuscitation, others were not: I was going from person to person doing the best that I could. The police were looking at me, some of then [sic] just idly standing by. They looked at me as [if] I was crazy. It was as if they were shell shocked.

¶Unfortunately the St John's [sic] Ambulance assistants were quite clearly out of their depth.20

¶I would like to confirm that there was no emergency procedure being enacted by the police. There appeared to be no organisation or triage and finally it was only volunteers from the crowd who set this up. In two cases that I dealt with I feel the lack of airway devices probably contributed to their deaths.21

¶I saw brave young fans trying to save lives hopelessly. I saw brave lads organise themselves to make makeshift stretchers to carry the dead. I saw some police desperately trying to save lives. I also saw some police standing idly – not knowing what was happening or making any attempt to find out.22

¶The supporters were now impatient and angry at the slowness of the response to the emergencies. There appeared to be only one or two stretchers on the pitch and one ambulance was making its way around from the far corner … I then tried to find somebody in charge to tell me who to report to. I asked several officers but none of them knew … By this stage I realised that there was no organised response and I

18. Statement of Dr John Ashton, Medical Practitioner and Senior Lecturer, Liverpool, 19 April 1989, SYP000096240001, p28. 19. Statement of Tim Cooke, Professor of Surgery, Glasgow, SYP000065110001, p5. 20. Statement of State Enrolled Nurse, Liverpool, SYP000085960001, p6. 21. Statement of Tim Cooke, Professor of Surgery, Glasgow, SYP000065110001, p9. 22. Statement of Dr Glyn Phillips, Medical Practitioner, 15 May 1989, SYP000096240001, p21.

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¶was angry ... I came to the view that somebody needed to take an overview of the situation and began to go around all the casualties to appraise them.23

¶2.4.84 A GP in another part of the ground went to the police room beneath the North Stand with two colleagues to offer help:

¶When we got to the open area beneath the North Stand there was a scene of utter confusion with bodies everywhere, we at that time did not realise so many people were dead, we split up with the intention of giving immediate medical aid to the injured, it was immediately obvious that many of the people had been dead for some time and I feel we wasted valuable time looking for injured people, there was a complete lack of medical equipment available to us, neither did there appear to be anyone co-ordinating the situation.24

¶2.4.85 This judgement was shared by others:

¶Observing from the outside it appears to have taken far too long for the authorities to decide that it was not a security problem and that the fans genuinely needed help. Working with and alongside individual police officers in the immediate disaster area, I have tremendous praise and admiration for their efforts. Overall at the scene, however, there appeared to be a lack of co-ordination and genuine leadership.

¶For an extremely long time we were without any form of medical equipment of any description. I still cannot understand why the local Health Authority's Major Medical

¶Disaster Team was not called upon.25

¶When the match was stopped there was a lack of organisation, co-ordination & leadership from any party and the lack of first aid equipment made the whole thing chaotic ... There was [sic] no plans for a major medical problem.26

¶2.4.86 After the pressure lessened in the central pens it was possible to exit through the tunnel under the West Stand, and some of the injured were removed via that route. In some cases they were given first aid and taken to hospital by ambulance.

¶2.4.87 As with those brought onto the pitch, some were already beyond help when they were carried through the tunnel, and they were laid against a fence in the concourse to await medical confirmation of death. This appears to have given rise to the rumour that some spectators were trampled in the tunnel. This view was mistaken.

¶The gymnasium 2.4.88 The gymnasium, situated beneath the North Stand, was the designated casualty reception area in the Hillsborough incident plan. Ambulances were directed there by Ambulance Control and, after some initial confusion, by police officers around the ground.

¶2.4.89 Those who were injured, dying or dead were taken to the gymnasium in increasing numbers. If coordination and leadership were to be established anywhere, the primary site should have been the gymnasium, but the disorganisation on the pitch also prevailed there.

23. Statement of Dr John Ashton, Medical Practitioner and Senior Lecturer, Liverpool, 19 April 1989, SYP000096240001, pp26-27. 24. Statement of Dr Arthur Crawford, General Practitioner, SYP000084660001, p5. 25. Statement of Mr FJ Eccleston, Nurse Manager, SYP000096240001, p39. 26. Statement of Registered General Nurse, Southport, SYP000081300001, p6.

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¶There did not appear to be anyone in authority in charge of events inside the gym.

¶I felt as though I was chasing my tail, I would ask one person something and then someone else, but no one in charge ... The area inside was chaos. I went to attend the injured there was no equipment. It was annoying as there was not even any water.

¶Someone gave me a coke can full of water and a sponge, this was a godsend. There was [sic] no supplies of a medical nature inside the gym. No oxygen even.27

¶2.4.90 Detective Superintendent Graham McKay, who had responsibility for CID activity at Hillsborough, arrived at the gymnasium shortly after 3.15pm. He met Chief Inspector David Beal, who told him that the gymnasium would be the temporary mortuary: 'One half of the gymnasium had been set up as a dining area and there was a temporary partition down the centre of the gymnasium. It was this area that was cleared'.28 Spectators and police officers arrived at the gymnasium in large numbers, carrying casualties:

¶Brought in with the dead were the injured and these were directed to the far end of the gymnasium at the other side of the partition. The dead were arriving in such numbers that it was impossible to try to establish whether, in fact, they were dead, but I have to say that everybody I saw bore what I recognise to be classic signs of asphyxia and I am satisfied that every body I saw and directed into the area designated as a temporary mortuary was, in fact, dead ... Officers and civilians were attempting to resusciate [sic] some of the victims and I saw least [sic] two such groups attempting to revive, what were quite obviously to me, dead bodies.

¶2.4.91 It is feasible that these casualties were beyond help, but in the absence of skilled systematic triage such an assertion cannot be sustained with confidence. At the request of the police the bodies in the temporary mortuary area were subsequently examined by various doctors among those present, at which stage they were confirmed dead.

¶2.4.92 Meanwhile, clearly struggling to cope with such daunting scenes, D/Supt McKay's focus remained on the deceased, although he was able to observe that 'injured people were arriving and being directed to the far end of the hall and the scene was one of increasing confusion'.

¶Lack of leadership 2.4.93 The lack of leadership and coordination within the gymnasium was evident to those ambulance staff waiting outside with their vehicles. At 3.49pm, a Sheffield ambulance ('S102') that had been on site since at least 3.31pm transmitted: '102 we're still round at the first aid and the gym which is mortuary come [sic] hospital still not seen an officer or any ...'

¶2.4.94 Ambulance Control responded: 'Control Rg they are despatched and (….) senior officers at the scene but where they'll be at this time I cannot tell you I will try to establish that ...' '102 It's just that this is where all the patients are coming to and the mortuary is there is just no co [sic] nothing happening yet'.29

¶2.4.95 Ambulance Control then tried unsuccessfully to contact either DCAO Hopkins or SO Eason, and subsequently any duty officer at the ground. Finally it requested any vehicle to locate any duty officer who should contact control.

27. Statement of Staff Nurse, Liverpool, SYP000086360001, p6. 28. Witness Statement of Detective Superintendent Graham McKay, South Yorkshire Police, SYP000008020001, pp13-16. 29. Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, pp97-99.

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¶2.4.96 Meanwhile, at 3.51pm S102 again radioed Ambulance Control: 'S102 Is it possible to get an officer to the gym. Then we can perhaps start getting something organised'. It is instructive that as late as 3.51pm it was still considered necessary to 'start getting something organised' in the casualty reception area designated in the Hillsborough incident plan.

¶2.4.97 From 3.23pm the senior SYMAS officer on site was DCAO Hopkins. He went to the designated rendezvous point at the gymnasium entrance, but found no-one there. He then went onto the pitch and saw many injured people on the pitch beyond the police cordon that had remained in place. He stated: 'I could not get involved with the injured, my responsibility was to get resources there immediately to deal with the situation'.30 As senior officer on site, he was also responsible for leading and coordinating the ambulance response.

¶2.4.98 Sometime after 3.30pm, DCAO Hopkins 'entered the gymnasium door and it was pandemonium, there were police officers and already some bodies laid on the advertising boards'. His statement continued:

¶There were casualties everywhere and bodies laid on the floor. I turned around and went back to where the ambulances could back in ... Station Officer Higgins reported to me, he said 'it is caos' [sic] … I stopped at the top of the ramp and was then approached by Leading Ambulanceman [name redacted], I sent him into the gymnasium to attend to the injured getting them ready to transport.

¶2.4.99 It is clear from his account that DCAO Hopkins was aware of the lack of leadership and coordination evident in the gymnasium and on the pitch. However, he appears to have considered that his priorities lay elsewhere, principally directing arriving ambulances. Evidently he was unable to find, or spare, an officer more senior than a Leading Ambulanceman to coordinate activity in the gymnasium, the designated casualty reception point.

¶Failure to deploy available paramedics 2.4.100 This ambulance crew member was a trained paramedic, one of only a few present at the site. Therefore he was able to provide some essential equipment and skills in the gymnasium, but no others were present in the area: 'As far as I am aware I was the only para-medic deployed in the Casualty Clearing Area'.31 In 1989 the programme to train a significant proportion of ambulance crew as paramedics and establish one on every emergency vehicle was still at an early stage. SYMAS had no more than 33 extended-trained ambulance crew and ten had only recently qualified.32

¶2.4.101 It is clear from the documents disclosed to the Panel, however, that opportunities were missed to deploy paramedics to Hillsborough in the early stages of the disaster. One paramedic had volunteered for duty on hearing of the disaster, but was assigned to transporting people with minor injuries.

¶2.4.102 Another extended-trained (paramedic) ambulance crew member was at NGH shortly before 3.10pm, and heard radio traffic about Hillsborough: 'At this stage I was able to transmit my message that I was "Green" at Northern General Casualty'.33 He was despatched, however, to deal with a leg injury elsewhere: 'This patient was treated and

30. Typed recollection of Deputy Chief Ambulance Officer Alan Hopkins, YAS000000920001, pp2-5. 31. Typed recollection of Leading Ambulanceman [Name redacted], YAS000000710001, p2. 32. Statement of Chief Ambulance Officer Albert Page, YAS000001940001, p7. 33. Typed recollection of Extended Trained Ambulanceman [Name redacted], YAS000001110001, p2.

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¶transported back to the Northern General Hospital and I called green as soon as possible. I was then told by Control to "stand by", this I did and after a period of approximately ten minutes, I called Control to remind them of my position and state and I was then told to return to base'. This was a missed opportunity.

¶Continued lack of effective arrangements in the gymnasium 2.4.103 Shortly before DCAO Hopkins entered the gymnasium, Dr Nicholas Kearsley, a Sheffield GP who had been a spectator among Nottingham Forest fans in the Spion Kop end of the stadium, arrived to offer assistance, having been directed by a police officer. He stated: 'As I entered [the gymnasium], the first section contained several dead bodies, I do not know how many; in the other section I saw some seriously injured people who were mainly lying on their backs, which is not the position that they should have been in'.34

¶2.4.104 The bodies should have been placed in the recovery position because when an unconscious person is laid on their back, lacking muscle tone and protective reflexes, the lower jaw is liable to flop back, obstructing breathing.

¶2.4.105 As discussed in Chapter 5, an appreciable number of casualties removed from the pens may have been alive at this point, deeply unconscious but still breathing, and extremely vulnerable to the additional asphyxia that may have resulted from inappropriate positioning. While seriously injured people were still in need of attention in the gymnasium, police officers were busy recording the effects of the deceased, as directed by D/Supt McKay.

¶2.4.106 A Liverpool nurse who had helped injured spectators in front of the Leppings Lane end subsequently went to the gymnasium to assist with resuscitation efforts and 'saw people counting money amongst all this mayhem'.35 She 'went over and asked for a pair of scissors and they just looked at me as if I was mad. I was so concerned and annoyed that I tipped over the table with all the money on it ... All the time it did not appear that the ambulancemen did not [sic] know the order of priorities and they were asking me who they should take next to the hospital'.

¶2.4.107 That there was a lack of leadership and coordination on the pitch in the minutes after the disaster must be considered within the context of the immediate aftermath of an overwhelming occurrence. Given the circumstances, nor should it be surprising that unconscious people were placed on their backs on the pitch and on advertising hoardings during the first few minutes, as was confirmed by photographic and video evidence. Clearly, they would have benefited from the presence of appropriate staff with sufficient authority to direct the desperate and well-intentioned efforts of those who were aiding them.

¶2.4.108 The gymnasium was, however, the designated casualty reception area, as recognised in the Hillsborough incident plan and as referred to by senior ambulance staff. It is more difficult to understand that the same lack of leadership, coordination and systematic triage could still be evident there more than 45 minutes after casualties began to be removed from the central pens.

34. Statement of Dr Nicholas Kearsley, General Practitioner, SYP000086910001, p6. 35. Statement of State Enrolled Nurse, Liverpool, SYP000085960001, p6.

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¶Ambulance Service rejoinder 2.4.109 Adverse comments on the emergency response made by two of the doctors present later appeared in the media. In response, the SYMAS submission to the Taylor Inquiry included a long section refuting many of the criticisms. Under the heading 'FACTS' the submission claimed that 'SYMAS personnel operated triage', followed by reference to four individual ambulance crew statements.36

¶2.4.110 These individual statements refer to instances of ambulance crew trying to pick out the most injured people near them, and in one case moving two people beyond help out of an ambulance; referring to this as 'triage' entirely misses the point that these were the ad hoc attempts of ambulance crews in the absence of senior direction, when what was required was a systematic assessment of the injured, put in place at an early stage and operated by a senior ambulance officer or medical team member.

¶2.4.111 Referring to criticisms concerning lack of equipment, the submission notes that 'all SYMAS frontline ambulances carry ... resuscitators and have a static supply of oxygen on board ... all SYMAS frontline vehicles carry a selection of airways and a large number were inserted ... no drips – wrong – infusion equipment is carried by paramedics, and requires special training, however there is no evidence that any casualty was prejudiced by the lack of infusion equipment'.

¶2.4.112 Further: 'This equipment [on front-line ambulances] is intended for use by SYMAS personnel and not by third parties ... much of the equipment has to be kept with the ambulance for use on the journey to hospital ... the primary purpose of the ambulance is to give immediate treatment to casualties and convey them to hospital ... any criticism of lack of equipment on SYMAS vehicles is ill-informed'.

¶2.4.113 Again, this response misses the point: the equipment was no use on the ambulance vehicle when critical early resuscitation was taking place some distance away on the pitch, behind the Leppings Lane end and in the gymnasium. Some ambulance crew did take equipment when they left their vehicle, but there was no systematic direction to do so, not all did, and none initially had been given any information about the situation inside the stadium.

¶2.4.114 The Chief Ambulance Officer's defence of the lack of deployment of paramedics on the day is noteworthy: 'Four paramedics attended the ground and three others were on duty. There was no point in deluging the ground with paramedics because it is difficult for them to put their extended training into practice in crowds. In any event, by 1620 there was no need for them'.37

¶2.4.115 The idea that crowds may have rendered paramedics ineffectual is difficult to understand given that in 1988 he had written to Sheffield Wednesday Football Club:

¶Do you provide the best standards of Ambulance Care for the large number of

¶Employees and Members of the Public whilst they are on your premises? ...

¶There are, however, areas where the level of care which we [SYMAS] can provide, of necessity, exceed [sic] those which can be provided by the Voluntary Societies.

36. Letter to the Taylor Inquiry from Dibb Lupton Broomhead (Solicitors) – Ambulance Service submission,

¶HOM000018310001, pp11-15. 37. Statement of Chief Ambulance Officer Albert Page, YAS000001940001, p25.

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¶These include Advanced Ambulance Aid ... Intravenous Infusion, Cardiac Monitoring,

¶Defibrillation and the Administration of Drugs.38

¶Other views of the emergency response 2.4.116 The attempt to portray criticisms as the views of an ill-informed small minority of doctors is not supported by the collected statements of doctors and nurses present at Hillsborough as the disaster unfolded. The only evident support came from one dissenting voice, a Sheffield doctor who went onto the pitch to assist with resuscitation:

¶Because of the scale of the tragedy, I don't believe that with all the necessary medical equipment being available it would have made much difference. Basically it seemed to me that by the time they had got people out of the pens and onto the pitch they were already dead. I didn't see anyone successfully resuscitated.39

¶2.4.117 This was not the experience of the majority of doctors and nurses on the day. Most who commented on the emergency services response – and many did – made the same points:

¶There seemed to be no co-ordinated plans for a major disaster. Either by the football ground and all the emergency services [sic]. I would accept that initially there was a need for Police Officers across the half way line, but these officers should have been redeployed very rapidly. There was a lack of medical equipment most noticably [sic]

¶Airways. I only came across one while I was on the pitch helping the injured … There was a lack of communication between the police.40

¶As a general observation I feel that there was a lack of co-ordination to get the injured to hospital in priority order and an apparent lack of any major disaster contingency plans at the ground.41

¶I feel there was no overall organisation of the incident after the match was stopped.42

¶... the total lack of organisation or equipment after disaster struck.43

¶It is difficult to know how many lives might have been saved if the emergency response had been more effective, but in my opinion on this occasion it was woefully inadequate.44

¶I still cannot understand why the local Health Authority's Major Medical Disaster Team was not called upon … It is impossible to accurately estimate the difference this would have made in saving life.45

¶2.4.118 This is clearly not a maverick view from a disaffected minority but the considered opinion of the majority of professionals present from the outset.

38. Letter from SYMAS to SWFC, April 1988, YAS000002360001, p126. All the named activities would require extended trained (paramedic) ambulance staff. 39. Statement of Dr Alexander Loch, Medical Practitioner, SYP000087960001, p7. 40. Statement of Tim Cooke, Professor of Surgery, Glasgow, SYP000065110001, p5. 41. Statement of Dr Peter Marsh, Casualty Officer, London, SYP000086990001, p8. 42. Statement of Dr Caroline Altoft, General Practitioner, SYP000081700001, p7. 43. Statement of Dr Glyn Phillips, Medical Practitioner, SYP000096240001, p20. 44. Statement of Dr John Ashton, Medical Practitioner and Senior Lecturer, Liverpool, 19 April 1989, SYP000096240001, p30. 45. Statement of Mr FJ Eccleston, Nurse Manager, SYP000096240001, p39.

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¶Communication problems 2.4.119 It is clear from the Control Room transcripts and from statements that the Ambulance Service response was hampered by significant communications difficulties, which affected both the use of hand-held radios within the ground and the emergency response channel (ERC).

¶2.4.120 The following examples illustrate the difficulties, but it must be noted that there were also numerous attempts made to contact Ambulance Service vehicles and senior officers that either were never received or could not be answered, and many instances of garbled transmissions and calls cutting across others, impeding understanding:

¶15.25 S209 I can't get through on ERC have you informed N Gen we are en route it is a child and it is an arrest [cardiac arrest].46

¶15.31 TA6 Great difficulties getting through on channel 1 [ERC] … to the incident room we require the Major Incident vehicle here …47

¶15.36 504 I'm sort of unable to get you on ERC …48

¶16.27 TA1 [CAO Page] to TA2 [DCAO Hopkins] Allan we've had no communication whatsoever from the ground???? Just this minute had information from …49

¶At one stage I offered to be a runner because there appeared to be no communication system between officers at the ground as the radios were not working.50

¶2.4.121 After the disaster, CAO Page identified three problems with communications:

1. The handsets did not always work properly because of the stands at the ground ...

2. The sheer weight of radio traffic caused some difficulties. Most ambulances were

told to use the emergency reserve channel but one or two used other channels in order to reduce the pressure on ERC.

3. There was interference on the emergency reserve channel. This problem has subsequently been resolved.51

The problems with the radio transmission has [sic] only caused us minor difficulties. They did not result in the operation being handled any differently.52

¶2.4.122 It is clear from the transcripts and statements that the final two sentences were highly optimistic.

¶Transportation and subsequent treatment of casualties 2.4.123 Viewed as an exercise in ensuring that all available ambulances were sent to Hillsborough as quickly as possible, then removing the injured to hospital as soon 46. Ambulance Control Room Tape Transcripts, SYP000014030001, p42. 47. Ambulance Control Room Tape Transcripts, SYP000014030001, p45. 48. Ambulance Control Room Tape Transcripts, SYP000014030001, p48. 49. Ambulance Control Room Tape Transcripts, SYP000014030001, p82. 50. Statement of Anthony Edwards, SYMAS Ambulanceman, YAS000001500001, p7. 51. SYMAS subsequently made extensive efforts to track the source of this interference, which may have resulted from interference from a neighbouring service, but this was disputed. 52. Statement of Chief Ambulance Officer Albert Page, YAS000001940001, pp27-28.

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¶as possible, the records confirm that ambulance control staff and crew acted with commendable efficiency and promptness. That there was potentially so much more to the emergency response to a major disaster with large numbers of seriously injured people in urgent need of resuscitation was a different issue.

¶2.4.124 Concerns have been raised regarding the lack of ambulance vehicles driven onto the pitch. SYMAS correctly followed the Hillsborough incident plan, which identified the area behind the gymnasium as the ambulance loading point. In the event a SYMAS vehicle did enter the pitch area because DCAO Hopkins thought that a visible ambulance presence would help to allay crowd concern, in addition to the St John Ambulance vehicle that was on the pitch at 3.15pm. There are, however, sound operational reasons for avoiding taking vehicles into confined areas where they may easily become blocked in, causing significant disruption to the evacuation of casualties.

¶2.4.125 In the circumstances that occurred, the Hillsborough plan should have been implemented as part of a major incident procedure, with properly equipped resuscitation and immediate care where it was needed and prioritised evacuation via the casualty reception point in the gymnasium. These objectives were not achieved because of the failure to implement the major incident procedure and not because more ambulances were not brought onto the pitch.

¶Evacuation of casualties 2.4.126 Ambulance vehicles were mobilised rapidly from all of the stations nearby, and neighbouring services were asked to provide additional vehicles either to cover SYMAS vehicles attending Hillsborough or directly to the ground.

¶2.4.127 The first ambulance left the ground at 3.21pm, and arrived at the NGH A&E just before 3.30pm.53 By 4.30pm, 88 people had been taken to NGH and 71 to RHH. Three people with minor injuries were also taken to Barnsley District General Hospital.

¶2.4.128 This commendable rapid transport effort was achieved through the deployment of 42 ambulance vehicles, 31 from SYMAS and 11 from other ambulance services including Derbyshire, West Yorkshire and St John Ambulance. Many vehicles made repeat journeys.54

¶Hospital treatment 2.4.129 NGH A&E Consultant Mr James Wardrope was called to the hospital following Charge Nurse Batty's concerns, arriving soon after 3.30pm to find the first three ambulances outside A&E. He 'was met at the door by Charge Nurse Batty who informed me three patients were undergoing resuscitation in the Resuscitation Room which is adjacent to the side entrance'.55

¶2.4.130 Having confirmed that the hospital's major incident procedure had been activated, Mr Wardrope assisted available medical staff resuscitating the first two batches of patients to arrive. Crucially, he then stationed himself so that he could triage all further arriving casualties as they reached the hospital: 'I then returned to the entrance and stayed there until about 5.00 pm, to triage patients as they arrived, and also to triage Doctors so that they could be assigned to appropriate duties'.

53. Statement of [Name redacted] South Yorkshire Leading Ambulanceman, YAS000001540001, p3. 55. Statement of Mr James Wardrope, SYP000096370001, pp208-209.

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¶2.4.131 On arrival patients were assessed and assigned to one of three categories: those in need of urgent treatment and therefore a priority for available staff; those not seriously injured and therefore able to wait for treatment; and those beyond help, for whom attempted resuscitation should be abandoned to enable staff to concentrate their efforts where they could be of most use.

¶2.4.132 Mr Wardrope's counterpart at RHH, Mr Alan Crosby, arrived at its A&E department. The hospital had had no information from the police or the Ambulance Service, but he told the Charge Nurse there that 'we may as well work on the assumption that this was a major disaster and I asked one of the clerical staff to notify the switchboard that I was declaring a Major Disaster'.56

¶2.4.133 Some of the injured began arriving at RHH, more after 4.11pm, when Ambulance Control notified vehicles that capacity at NGH was then stretched. Four casualties at NGH and one at RHH were immediately determined to be dead on arrival, and a further seven were found to be beyond help at NGH and resuscitation was discontinued in A&E. 2.4.134 A total of 81 people were admitted to hospital, 56 from NGH A&E and 25 from RHH A&E. A further 69 people were discharged after treatment for less severe injuries, 21 from NGH and 45 from RHH, as well as the three taken to Barnsley District General Hospital.

¶2.4.135 Those in the most serious condition on admission to hospital had suffered asphyxiation, shortage of oxygen caused by the pressure within the pens severely restricting their ability to breathe. Two of those admitted to NGH were still receiving active resuscitation (chest compression and assisted respiration) on arrival, and although they were stabilised and admitted to an intensive care unit, both subsequently died. Sixteen others showed signs that severe shortage of oxygen had affected their body systems, particularly the brain, and they required intensive treatment.

¶Subsequent treatment of the injured 2.4.136 Most hospital major disaster plans anticipate that the heaviest workload will fall on surgery, orthopaedics, anaesthetics and intensive care in the immediate aftermath, and make special provisions to contact specialists in these areas to bring them to the hospital urgently; the Sheffield hospitals' plans were no exception.

¶2.4.137 The Hillsborough disaster was different in that those admitted who were most at risk did not require surgery but specialist treatment of cerebral hypoxia and cerebral oedema (brain effects of lack of oxygen) from a general physician or neurologist, who were not part of the major disaster plan. However, Dr Frank Ryan, a Sheffield general physician with particular experience of neurology, had seen television coverage from Hillsborough at around 3.20pm to 3.25pm.

¶2.4.138 After contacting the NGH switchboard, Dr Ryan decided to go to the hospital. Although he diverted briefly to the ground itself on hearing a radio request for doctors to attend, he decided he would be more useful at the hospital, arriving between 4.05pm and 4.10pm.

¶2.4.139 Having cleared Ward 60, the receiving ward adjacent to A&E, of non-urgent patients, Dr Ryan assessed the condition of the most serious Hillsborough casualties:

56. Statement of Mr Alan Crosby, JWR000000250001, p67.

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¶Within ten or fifteen minutes, a total of 13/14 patients appeared to exhibit a very similar syndrome. They were either unconscious already or were partly conscious, appearing confused and bewildered ... All of them went on to develop status epilepticus.57 This, under the circumstances, was life threatening. I moved from patient to patient, organizing their treatments ... It was my opinion that every patient who was fitting58 had cerebral oedema59 and they should all be ventilated60 and receive intensive care.61

¶2.4.140 Working with other senior staff, particularly anaesthetists, he arranged for the necessary equipment to be brought to the area: 'Every patient who was regarded as at risk was put onto a ventilator, being transferred subsequently to either Intensive Care, Post- Operative Cardiac Intensive Care, or transferred to the Intensive Care Unit at the Royal Hallamshire Hospital'.

¶2.4.141 Twenty people were admitted to either NGH or RHH with severe cerebral hypoxia (shortage of oxygen affecting the brain), plus the two people who died within 48 hours. All 20 survived the initial period, although six showed signs of permanent neurological damage, one of whom died in March 1993 having been in a persistent vegetative state. The remaining 14 recovered fully.

¶2.4.142 Subsequent hospital major disaster plans have recognised the wisdom of including general physicians amongst those called in to deal with the immediate consequences.

¶2.4.143 Other injuries were treated amongst those admitted, including pneumothorax (air around the outside of the lung potentially affecting breathing), severe laryngeal oedema (fluid swelling of the voice box), right heart strain (probably caused by obstruction of the venous return to the heart) and pericardial effusion (fluid around the heart). Other conditions included many soft-tissue injuries and some fractures to the skull, ribs, forearm bones, wrist and ankle. These patients made a full recovery.

¶Pressure on Northern General Hospital facilities 2.4.144 It is clear that facilities at NGH, which bore the brunt of admitting and treating the most severely injured, were stretched by the influx of casualties. Additional space was used to provide treatment areas and extra ventilators were obtained from elsewhere in the hospital.

¶2.4.145 Sometime before 4pm, Mr Wardrope became concerned about the pressure on the NGH resuscitation facilities. He stated: 'I realised the Resuscitation Room was becoming very full as almost all the first lot of casualties required resuscitation and I therefore sent one of the SHOs [Senior House Officers], Mr Duncan, to telephone SYMAS Control and request casualties be taken to the Royal Hallamshire Hospital'.62

¶2.4.146 This was conveyed at 4.11pm to all vehicles attending the incident on the ERC: 'Control all mobiles all mobiles CAS to be conveyed to RHH I say again RHH is your CAS conveyance point NGEN is full repeat full at this time'.63

57. Continuous convulsions, in this case due to shortage of oxygen affecting the brain. 58. Having convulsions. 59. Swelling of the brain, in this case due to shortage of oxygen. 60. Have a mechanical device take over their breathing. 61. Personal statement of Dr Frank Ryan, FPR000000110001, pp2-3. 62. Statement of Mr James Wardrope, SYP000096370001, p210.

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¶2.4.147 Because of the communication problems afflicting the ERC it is not clear how many vehicles were able to pick up the transmission and divert to RHH, but it appears that for a while more ambulances went to RHH.

¶2.4.148 Consequently the pressure on NGH resuscitation facilities declined: 'After 4.00pm the situation became more controlled and less serious injuries were arriving in the Department'.64 However, it is evident from the documentation that the two hospitals had sufficient capacity between them and, overall, the hospital major disaster procedures functioned without significant problems.

¶Relatives, friends and the bereaved 2.4.149 By 4.30pm the last of the injured had been taken to hospital and the remaining uninjured fans were leaving the stadium. By this time all were aware that a tragedy had occurred, with many dead and injured. The disaster had also been viewed by millions via television and transmitted world-wide by radio broadcast. At the stadium hundreds of fans were desperate to find information about friends and relatives, and to contact their relatives and friends to let them know they had survived. Thousands of relatives, friends and colleagues at home were fraught with anxiety.

¶2.4.150 In 1989 communication depended on telephone land lines and these were in short supply. Rapidly they became overloaded. Many relatives and friends set off from Liverpool and other destinations to travel to Sheffield in their quest for information, while those already in the city headed for the hospitals and police stations.

¶2.4.151 In the gymnasium, freed from the chaos of dealing with multiple casualties, proceedings began to be coordinated more efficiently. Detective Chief Superintendent Terence Addis arrived from Police HQ and, having been informed by D/Supt McKay of the temporary mortuary in the gymnasium, he took control of the police operation there.

¶2.4.152 He liaised with DCAO Hopkins. There were 82 bodies in an area partitioned by sheets hung from netting. Det C/Supt Addis stated:

¶I ascertained that an instruction had been given for one Police Officer to stay with each body and that officers had been despatched to the Northern General Hospital and the Royal Hallamshire Hospital in order to set up casualty bureau liaison units, obtain details of deaths and casualties and deal with relatives and other enquiries at those locations ... I also ascertained that the casualty bureau at Ecclesfield Training

¶Centre was being implemented.65

¶2.4.153 The initial plan was that the deceased would be transported to the hospital mortuaries and the Medico-Legal Centre. Thus NGH, RHH and Barnsley District General Hospital were placed on standby. At approximately 5.00pm, however, Det C/Supt Addis was informed that the Coroner 'had instructed that bodies should not be removed from the temporary mortuary until such time as they had been photographed in situ and their identities confirmed'.

¶2.4.154 He 'then gave instructions for relatives and friends of the deceased, who had congregated outside the temporary mortuary, to be transported to Hammerton Road Police

64. Statement of Mr James Wardrope, SYP000096370001, p211. 65. Witness Statement of Detective Chief Superintendent Terence Addis, South Yorkshire Police, SYP000081480001, pp4-5.

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¶Station where suitable accommodation could be found for them pending arrangements for identification purposes'.

¶2.4.155 At 6.45pm, the Coroner arrived at the stadium, with the senior pathologist from the Medico-Legal Centre (Professor Alan Usher) and two other pathologists. There they met Det C/Supt Addis and agreed the identification procedure. All bodies were to remain in the gymnasium, along with 12 that were to be returned from NGH or RHH.

¶2.4.156 It was decided that a Polaroid photograph would be taken of each of the deceased. Relatives and close friends would then be shown into an entrance area adjoining the gymnasium, where the photographs would be displayed on screens. On recognition, the corresponding body would be brought to the viewing area at the entrance to the gymnasium to confirm identification.

¶2.4.157 The Coroner considered that the use of Polaroid photographs was a solution to overcoming the limitations of the temporary mortuary: 'It was agreed that all the unidentified dead could be photographed with poloroid [sic] cameras and that their photographs would be appropriately numbered and displayed on a board, for viewing by relatives, so that they could pick out their own deceased and not have the trauma of having to walk between the bodies, looking for their loved one'.66

¶2.4.158 Preparations for this identification process were not completed and approved by the Coroner until 9.15pm. During this time, friends and relatives had arrived in considerable numbers to search for their missing loved ones and needed somewhere to wait.

¶2.4.159 D/Supt McKay had left the gymnasium shortly after Det C/Supt Addis's arrival and returned to Hammerton Road Police Station: 'On arrival at Hammerton Road I found the place under virtual siege. Liverpool supporters were wanting to make urgent enquiries, many were standing around not knowing what to do and someone had put out a call for all off-duty social workers to report to Hammerton Road and there were many social workers'.67

¶2.4.160 Members of the clergy also arrived at Hammerton Road offering help, including the local vicar and the Archdeacon of Sheffield who subsequently gave an account of his experiences to a symposium organised by the Regional Health Authority:

¶The police were not yet organised, but asked us if there was anywhere immediately adjacent which could be used as a Relatives Reception Centre. The vicar suggested the boys' club opposite the Police Station, which we opened up. It was one of those youth centres that had been ravaged by years of aggressive wear; one accessible telephone, poor toilets, not enough chairs and tables, a large hall and a number of other rooms off narrow stairways. More chairs had to be fetched, but there was no way of making the drab surroundings any more welcoming. Social Services had also arrived and their senior officer and I recognised that it was up to us to try and induce some order out of the impending chaos.68

¶2.4.161 The impending chaos was, in part, a consequence of an influx of people offering help:

66. File of papers relating to the procedures of the Resumed Inquest and Post Mortems, part 1, SYC000001360001, p242. 67. Witness Statement of Detective Superintendent Graham McKay, South Yorkshire Police, SYP000008020001, p18.

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¶Our first major problem was a broadcast appeal for helpers – social workers and others to come to the boys club. At the same time as the first enquiring friends and relatives were arriving, hordes of volunteers arrived, social workers, psychiatrists, probation officers, bereavement counsellors and people of good-will. Clergy were also beginning to become over-abundant. Looking after those in need, giving them space and support, was in danger of becoming secondary to managing the log-jam of helpers ... The local clergy found that their access to telephones at local vicarages was an asset, and took people there to ring relatives. A psychiatric team took over one room to do work with the bereaved, but were frustrated for lack of clients. What the uncertain enquirer wanted was a quiet supportive relationship that asked nothing of them.69

¶Treatment of the bereaved 2.4.162 Lack of information also contributed to the impending chaos. At Hammerton Road Police Station, D/Supt McKay was informed that 'all numbers to the Casualty Bureau had already gone out over the radio, jamming all of the lines, and as a result there was to be no police contact by telephone with the Bureau for many hours'.70

¶2.4.163 Faced with an interminable wait in the dour surroundings of the Boys' Club, and unable to discover what was being planned, some relatives went to the hospitals, adding to the throngs already occupying the staff canteens at NGH and RHH. Eventually, those waiting were informed that all bodies were held at the gymnasium, and identification would begin there at 9.30pm. The process of transporting relatives and friends from the Boys' Club to the gymnasium began.

¶2.4.164 At the gymnasium, initially they queued outside. Later they were accommodated elsewhere in the gymnasium. Some faced long waits periodically punctuated by clearly audible cries of distress from those viewing the bodies of their loved ones and, for the first time, experiencing the certain knowledge of their loss. 2.4.165 Many of the bereaved wished to hold or touch their loved ones. Some were granted their wish, albeit briefly, but many were refused. They were told that the body was the property of the Coroner. 2.4.166 They were then taken quickly to another area of the gymnasium to be questioned by police officers, envisaged by the Coroner as merely confirming the identification: 'As soon as this identification had been positively done the officer responsible for that body would accompany the identifier and take a written statement from them, giving the identification'.71 2.4.167 As communicated by Det C/Supt Addis, this simple confirmation became something more: 'If a positive identification ensured [sic], then the Police Officer would accompany the person identifying the body to a nearby area where they would be joined by a detective and details of identification, medical background of the deceased, where possible, and the details of the [sic] surrounding the death, if known, would be obtained in statement form'.72

69. Report of Hillsborough Symposium, 19 July 1990, JWR000000250001, p196. 70. Witness Statement of Detective Superintendent Graham McKay, South Yorkshire Police, SYP000008020001, p19. 71. File of papers relating to the procedures of the Resumed Inquest and Post Mortems, part 1, SYC000001360001, p243. 72. Witness Statement of Detective Chief Superintendent Terence Addis, South Yorkshire Police, SYP000081480001, p6.

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¶2.4.168 The reality experienced by many relatives and friends, however, exceeded both of these versions. Questioning often focused on the habits and behaviour of the deceased, particularly their drinking patterns and whether they had consumed alcohol on the way to the match. As mentioned in Part 1, the bereaved considered the process intrusive and lacking sympathy, but the more significant context eventually became clear. 2.4.169 As bodies were identified, they were transported to the Medico-Legal Centre. Some relatives had difficulty recognising their loved ones from the photographs. The Polaroid prints were poor quality. In some cases faces were swollen as a result of the intense pressure in the pens. 2.4.170 After an agonisingly long night, the decision was taken to transfer 20 bodies that remained unidentified at the gymnasium to the Medico-Legal Centre. All were transported by 5.30am on the Sunday. The process of identification continued at the Medico-Legal Centre. Although purpose-designed to accommodate up to 100 bodies in the event of a major disaster, the Centre lacked the facilities to receive large numbers of friends and relatives. 2.4.171 A glass window separated mourners from their loved ones and this proved to be a serious and painful barrier for relatives.73 Relatives visiting the Medico-Legal Centre faced a prolonged period of uncertainty, hoping that their loved one was not among the dead but was elsewhere, possibly in hospital: 'People who had been desperately seeking survivors at the hospitals were arriving to find their worst fears confirmed. Hopes dashed were sometimes the most difficult to handle'.74 2.4.172 It is clear from the documentation that many of those in positions of responsibility attempted to help the bereaved despite the makeshift arrangements and unsatisfactory surroundings. Yet it is also clear that sympathy and understanding were not universal. The processing and questioning of relatives and friends in the immediate aftermath were regularly perceived as crass and insensitive. This added significantly to their distress.

¶2.4.173 The use of the gymnasium as a temporary mortuary and the display of Polaroid photographs were, and remain, issues of concern for bereaved families, as was the decision taken at this time to test alcohol levels in the deceased.

¶2.4.174 While it appears that no contemporaneous notes exist to explain these decisions, Dr Stefan Popper, the South Yorkshire West District Coroner, subsequently addressed the issues.75 Answering criticisms regarding the appropriateness of the temporary mortuary he stated that 'having that gymnasium there was exceedingly fortunate ... I personally do not have any criticism with that'. The gymnasium was used because 'we wanted everyone in one place ... I take responsibility ... for that'.

¶2.4.175 In fact, the return of bodies to the gymnasium from the hospitals enabled relatives to view a full set of photographs and avoided giving false hope by displaying an incomplete set. Dr Popper also rejected criticism of the decision to use and display Polaroid photographs for identification. This had been 'done on my authorisation'. Responding to why blood alcohol samples had been taken and recorded, he was equally adamant: 'The answer is because I authorised it'.

75. Inquest Transcript, 18 April 1990, day 1 am, SYC000109270001, pp30-31.

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¶
• Disclosed documents show that police officers, particularly senior officers, interpreted crowd unrest in the Leppings Lane terrace central pens as a sign of potential disorder, and consequently were slow to realise that spectators were being crushed, injured and killed.
• Ambulance control room transcripts show that Ambulance Service officers, present specifically to respond to a major incident rather than have any crowd control brief, were slower than police to identify and realise the severity of the crush despite being close to the central pens.
• Neither SYP nor the South Yorkshire Metropolitan Ambulance Service (SYMAS) fully activated the major incident procedure. Communications between all emergency services were imprecise and inappropriately worded, leading to delay, misunderstanding and a failure to deploy officers to take control and coordinate the emergency response.
• Only the two major Sheffield hospitals correctly activated their major incident procedures, relying on staff judgement and information received from an ambulance crew member about radio traffic he had overheard.
• Lack of correct activation of the major incident procedure significantly constrained effective and appropriate response. Senior ambulance officers were not deployed to specified command and control roles and an emergency foot team with essential medical equipment was not mustered. Site medical teams were not called until it was too late for them to be used to effect.
• The disclosed documents show clear and repeated evidence of failures in leadership and emergency response coordination. While this is understandable in the immediate moments of an overwhelming disaster, it was a situation that persisted for at least 45 minutes after injured spectators were released from the pens.
• Despite lack of direction, many junior ambulance staff and police officers attempted to resuscitate casualties and transfer them to the designated casualty reception point in the gymnasium. They were aided by the efforts of many fans, some of whom were injured. Doctors and nurses among the fans made a contribution to resuscitation.
• There was no systematic assessment of priorities for treatment or removal to hospital (triage). Individuals including ambulance staff and two doctors among the crowd attempted to compensate for the lack of an appropriate system, with varying results.
• There was a lack of basic necessary equipment where it was most needed, including airways, suction and swabs. While this equipment was provided on front-line ambulances, it remained in vehicles outside the stadium as crews were unaware of what was required on the pitch.
• The absence of leadership, coordination, systematic triage and basic equipment was also evident in the gymnasium, the designated casualty reception point. Statements and ambulance control transcripts reveal that opportunities for senior officers to exercise control were missed for almost an hour, and conditions remained chaotic.
• Doctors and nurses attending the match as spectators were uniquely placed to weigh the emergency services' response against their professional experience. Their documented accounts confirm that a large majority were critical of the lack of leadership, coordination, triage and equipment.

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¶
• SYMAS responded vigorously to any criticism expressed publicly. Its attempts to portray criticism as the views of ill-informed and impulsive doctors caught up in the emotions of the disaster are revealed as factually incorrect. Although given wide credence, the SYMAS responses were misleading.
• Control room transcripts show that radio communication problems clearly hindered SYMAS's response more than the Service was prepared to admit, but the lack of appropriate activation of the major incident procedure was more significant.
• Viewed entirely as an operation to deploy ambulances to the stadium, and to transport casualties as quickly as possible to hospital, the SYMAS response was rapid and efficient. Yet this ignores a significant component of the response to a major disaster set out in the SYMAS major incident plan: the provision of appropriate assessment, prioritisation and treatment on site.
• Disclosed records show that both main Sheffield hospitals provided prompt and effective treatment for survivors taken there, aided by the activation of their major incident procedures. This was enhanced significantly by the spontaneous attendance of a general physician at the Northern General Hospital who was well placed to manage the effects on the brain of shortage of oxygen, the principal cause of life-threatening injury.
• The gymnasium at the ground was used as a temporary mortuary pending identification of the bodies. Neither that environment nor the preliminary identification process using Polaroid photographs were ideal, and were constrained by available facilities. It appears from the Coroner's notes that the identification process was intended to ease distress, but it was poorly executed. No reason is given for the decision to use the gymnasium.
• Large numbers of friends and relatives remained for a prolonged period in poor surroundings in the Boys' Club opposite the divisional police station while the identification process was established. They had minimal information, if any, due in part to the casualty bureau telephone lines being swamped and to limited access to public telephones.
• Immediately following identification, the intrusive questioning of bereaved relatives about the social and drinking habits of their loved ones was perceived as insensitive and irrelevant, and added to their distress.
• Previously, the emergency services' response has been considered in the context of the Taylor Inquiry and the inquests. Medical evidence to both maintained that all who died were irreversibly and fatally injured in the initial crush, and no response could have changed the outcome. As shown in Chapter 5, the disclosed documents demonstrate that this evidence was flawed and some, partially asphyxiated, survived for a significant period.
• It is not possible to establish whether a more effective emergency response would have saved the life of any one individual who died. Given the evidence disclosed to the Panel of more prolonged survival of some people with partial asphyxiation, however, a swifter, more appropriate, better focused and properly equipped response had the potential to save more lives.