Chapter 6: Parallel investigations

Chapter 6: Parallel investigations

¶2.6.1 As stated in Part 1, a tragedy on the scale of the Hillsborough disaster witnessed by thousands of people in the stadium, millions on television and recorded in detail by photographs, television and CCTV resulted in immediate recrimination and blame. In a volatile climate of shock, distress and reaction the investigation of, and inquiry into, the causes, context and circumstances of the disaster were initiated.

¶2.6.2 Given the well-publicised focuses on fans' behaviour and the policing of the crowd, South Yorkshire Police (SYP) moved quickly to set up an internal investigation. This was in anticipation of another police force eventually conducting a criminal investigation to provide the Director of Public Prosecutions (DPP) with possible grounds for prosecution. The external investigation extended to potential breaches of police discipline and involvement of the Police Complaints Authority.

¶2.6.3 Further, there was a range of civil litigation including claims for damages involving organisations whose acts or omissions regarding the safety of the stadium might have contributed to the disaster. It was self-evident that in the public interest a judicial inquiry led by a senior judge and supported by appropriate specialists would be established.

¶2.6.4 Finally, as stated previously, multiple deaths in controversial circumstances presented the South Yorkshire West District Coroner with a considerable challenge in gathering information and conducting the inquests before a jury.

¶2.6.5 Based on material disclosed to the Panel, this chapter considers the dynamics of, and relationship between, the investigations as they ran, often in parallel, from the immediate aftermath of the disaster to the conclusion of the final remaining complaint against a police officer in January 1992.

¶2.6.6 Beginning with the early investigations conducted by SYP, it details: the transfer of the investigation to West Midlands Police (WMP); the triple role in servicing the Judicial Inquiry, the criminal/disciplinary investigation and the coronial inquiry; the reports, investigations and responses to the Judicial Inquiry; other reports, including those produced for civil litigation; the outcomes of the criminal investigation; and the disciplinary inquiry.

¶2.6.7 The complex civil litigation issues are examined in Chapter 7 and the role of the Coroner and the inquests are discussed in detail in Chapters 8 to 10. The following

¶
• Chapter 6 Parallel investigations — 181

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¶illustration maps the time span of the various investigations and inquiries demonstrating the extent of overlap within a relatively brief timeline.

¶Figure 8: Timespan of the investigations and inquiries

¶Initial investigations 2.6.8 Soon after 5.00pm on 15 April 1989 the SYP Chief Constable, Peter Wright, spoke by telephone with the Home Secretary, Douglas Hurd. There is no available record of the conversation. As a consequence, however, Sir Richard Barratt, Her Majesty's Chief Inspector of Constabulary, spoke with CC Wright the following morning ahead of a visit to Sheffield by the Prime Minister, Margaret Thatcher, accompanied by Mr Hurd.1

¶2.6.9 Sir Richard noted that CC Wright 'believed that because (a) of the serious criticisms which were being made of police competence and (b) he was anxious that there should be seen to be an independent and objective professional scrutiny of the policing arrangements and actions, it was desirable for inquiries to be undertaken by another force'. This was usual practice.

¶2.6.10 It was 'mutually agreed' that, on behalf of CC Wright, Sir Richard would 'ascertain whether Geoffrey Dear, Chief Constable of West Midlands Police (WMP), was willing to take on the task'. Simultaneously, a decision had been made to establish a judicial inquiry. Accordingly, Lord Justice Peter Taylor had been approached.

¶2.6.11 Subsequently, a Home Office official noted that the 'original intention' was to ask CC Dear to be an 'assessor' for the inquiry but '[d]uring Sunday [16 April] Mr Wright came under increasing pressure to announce a police inquiry by an independent force ... and the

1. Memorandum from Sir Richard Barratt, Her Majesty's Chief Inspector of Constabulary, to Mr Addison, Home Office,

¶12 June 1989, HOM000006720001, pp1-3.

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¶Home Secretary agreed during his visit to Sheffield that Mr Wright should announce that Mr Dear would undertake this inquiry'.2

¶2.6.12 The WMP investigation had a wide brief to 'gather evidence on the planning and operational decisions of the South Yorkshire police' which would 'be made available to Lord Justice Taylor, who will have the help and advice of his police assessor, the Chief Constable of Lancashire [Brian Johnson]'.3 It would also be 'available to the coroner and for the internal purposes of the South Yorkshire police'.

¶South Yorkshire Police: briefing the Prime Minister 2.6.13 At 9.00am on 16 April, CC Wright held a briefing with senior officers to get a 'grasp of the overall picture' of the disaster before meeting the Prime Minister and Home Secretary.4 A position was already forming focusing on the late arrival of fans, ticketless fans and drunkenness.

¶2.6.14 Officers reviewed the chronology of the disaster, drawing comparisons with the crush on the same terrace at the 1981 FA Cup Semi-Final. SYP's role in the allocation of the smaller terrace to the team with the larger following was also discussed.

¶2.6.15 Superintendent Roger Marshall, who had been stationed outside the Leppings Lane turnstiles, reported that at 2.45pm 'there was an enormous press of fans pushing'. In the Police Control Box inside the stadium, Superintendent Bernard Murray had noted on CCTV a 'huge presence' at the turnstiles at 2.30pm but considered that the crowd 'should have got into the ground by 3.00pm' via the turnstiles.

¶2.6.16 The Chief Constable asked about the number of fans outside the ground without tickets because 'it's going to be a major issue'. Supt Marshall estimated '200/250 probably more' while Inspector Paul Hand-Davies, a mounted officer, considered it 'nearer ... 1,000 and that would be typical for Liverpool ... opportunists, they look for opportunities to pinch a ticket, to rob a ticket'.

¶2.6.17 The Chief Constable summarised the opening of the gates, the 'real issue' being the 'timing and the effect of those actions'. He discussed the potential enquiries and the task-in-hand of 'simply gathering all the evidence together instead of pursuing priorities and aspects where the responsibility/blame lies'.

¶2.6.18 Recognising the 'distressing and harrowing' experiences faced by police officers, he noted their 'good job' and what they had 'to deal with'. Their evidence would reflect a 'true impression of what we saw there' but it had to be given 'in a balanced and responsible way'.

¶2.6.19 There would be 'some form of judicial enquiry' but, CC Wright stated, SYP had 'nothing to fear at all in a sense'. They had 'taken decisions ... done things on the basis of what we saw and in what circumstances presented themselves to us ... let's have it as it's been up to now, open, straight forward, no intention to try and blur'.

2. Internal Home Office memorandum, 4 May 1989, HOM000007740001, p1. 3. Home Office file note entitled 'Link Between Taylor Inquiry and West Midlands Police Inquiry', undated,

¶HOM000007610001, p1. 4. Notes of Chief Constable's briefing with operational staff engaged on FA Cup duties, 9.00am 16 April 1989,

¶SYP000096360001, pp19-42.

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¶2.6.20 There should be no 'shedding any responsibility'. He continued: 'If it is that the drunken, marauding fans, and I thought of this last night, contributed to this let somebody else say that'. The police had 'carried our responsibility', doing what had been considered 'essential in order to deal with the situation' with the 'knock-on effect' being 'fate'. It would not 'be right now to be talking about the animalistic behaviour of fans, the level of drink. Whoever is looking at it overall will find that without any problem'.

¶2.6.21 The Chief Constable's initial position, therefore, appeared to accept the senior officers' allegations of the prevalence of drunkenness, ticketlessness and refusal to cooperate while not disclosing such allegations to the media. Within hours of this meeting, supported by officers who attended, he briefed the Prime Minister and the Home Secretary.

¶2.6.22 There appears to be no record of CC Wright's briefing to the Prime Minister and Home Secretary. An early draft of the Home Secretary's Statement to Parliament indicates some of the information Mrs Thatcher received in Sheffield.

¶2.6.23 CC Wright had stated 'that shortly after the start of the match there was a surge of spectators on the Leppings Lane terrace which crushed many at the front against the safety barrier ... account[ing] for most of the fatalities and injuries'.5 The suggestion of a 'surge' echoed comments CC Wright had made in the media.

¶2.6.24 Comments made by Bernard Ingham, the Prime Minister's Press Secretary, in the aftermath of the disaster and some years later provide an indication of the discussion at the meeting. His Westminster lobby briefing of 18 April 1989 records journalists being informed that '[w]hat had happened on Saturday was not the result of obvious hooliganism but was more a matter of safety at sports grounds'.6

¶2.6.25 However, this contrasts markedly with his position several years later when he wrote that during the visit to Sheffield on 16 April he 'learned on the spot' that '[t]here would have been no Hillsborough if a mob, who were clearly tanked up, had not tried to force their way into the ground. To blame the police is a cop-out'.7

5. Drafts of the Home Secretary's statement to the Commons about the Hillsborough disaster, with associated briefing notes, 17 April 1989, CMS000011940001, p6. 6. Lobby briefing, 11am 18 April 1989, ING000000020001, p3. 7. Scraton, P Hillsborough: The Truth Edinburgh: Mainstream Publications, 1999 (1st Edn).

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¶Prime Minister Margaret Thatcher with Press Secretary Bernard Ingham, second right, and others at Hillsborough on the day after the disaster

¶South Yorkshire Police: early days of the investigation 2.6.26 In the immediate aftermath, SYP's Detective Superintendent Graham McKay briefed senior officers that SYP had 'had to start up the investigation and set up the Incident Room, equip it and build the machine as it were, but not start the engine'.8 2.6.27 On 17 April, the emphasis changed. With WMP's arrival imminent, it was necessary for SYP not only to 'build the machine', but to 'pinpoint the information and indicate to the enquiry team where it can be found and the nature of it' before 'the evidence disappears into the sand'. 2.6.28 The adequacy of the Leppings Lane turnstiles was a priority as 'it has been suggested that the reason the turnstiles could not cope was that the Liverpool supporters were getting to the turnstiles and instead of offering tickets were offering money'. 2.6.29 Another focus was 'how many of the three gates were opened, when they were opened, in what sequence they were opened and who authorised them to be opened'. Further, in supporting the Coroner, it was necessary to identify 'whereabouts the bodies have come from'. 2.6.30 SYP officers would not take statements but it was anticipated that SYP's information gathering 'might only last for a few days ... good or bad, warts and all'. The process had to be presented as impartial rather than 'getting our act together before the enquiry team arrives' and 'no-one should add or say anything to indicate to any potential witness that they ought to change their information in any way'.

8. Briefing notes from South Yorkshire Police for briefing held on 17 April 1989, SYP000010190001, pp1-24.

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¶2.6.31 A meeting of senior SYP officers had been held earlier in the day at which CC Wright had stated that 'if we [SYP] leave it to the West Midlands to provide the evidence we might not get the broad scope of events flowing in'.9 SYP would need to be 'the authors of most of the information fed in'.

¶2.6.32 WMP Chief Constable Geoffrey Dear visited Sheffield on 18 April accompanied by Assistant Chief Constable Mervyn Jones.10 ACC Jones returned the next day with three senior officers 'and informed members of the team that the West Midlands Police would be taking over all aspects of the enquiry'.11 The SYP team was 'instructed to not pursue any further enquiries into the incident'.

¶2.6.33 WMP assumed control on 20 April and four days later the outside Force took possession of the evidence collated by SYP.12 A team of officers was established within SYP, headed by Chief Superintendent Donald Denton, to liaise with the WMP investigation.13 A second team of SYP officers led by Chief Superintendent Terry Wain was tasked with gathering evidence for the submission to the Judicial Inquiry.14

¶Submissions to the Taylor Inquiry 2.6.34 Within weeks of the disaster, following the appointment of LJ Taylor, 'Salmon letters', setting out potential allegations against SYP, Sheffield Wednesday Football Club (SWFC) and Sheffield City Council (SCC) were issued by the Assistant Treasury Solicitor.15 In June a Salmon letter was issued to Dr Wilfred Eastwood, the safety engineer retained by SWFC. The letters ensured that recipients were aware of the potential criticism against them arising through the inquiry. Written so soon after the disaster, they indicate the early official appreciation of key issues.

¶2.6.35 The SYP letter noted the following potential criticisms: failure to take adequate steps to control the crush outside the Leppings Lane entrance; failure by officers outside the ground to liaise adequately with those inside and vice versa; failure to properly monitor the state of pens 3 and 4; failure by officers to react appropriately when people began to

9. Note of meeting held on Monday 17 April, SYP000096360001, pp43-51 (quote on p50). 10. Lord Justice Taylor also visited Sheffield on 18 April 1989. A number of organisations disclosed material to the Panel relating to an allegation made by an SYP officer against LJ Taylor and CC Dear in relation to that visit (for example, at

¶SYP000151710001). In view of the officer's junior rank, their name has been withheld from publication.

¶An SYP officer allocated to driving duty that day later alleged overhearing a comment passed from LJ Taylor to CC

¶Dear that, 'I suppose you realise that to give this inquiry any credibility we have to apportion the majority of the blame on the police?' CC Dear was alleged to have replied 'I suppose we do'. The allegation was not reported by the officer until almost exactly a year later, on 12 April 1990, after the officer had discussed the matter with Superintendent

¶Norman Bettison.

¶At the request of SYP, the allegation was considered by the DPP and the Home Office. The DPP, Allan Green, advised that – even assuming the claim were true – no criminal offence had been committed. At the request of SYP, the DPP also took Counsel's advice, which confirmed his view.

¶Officials from the Home Office met with LJ Taylor and Mr Dear to discuss the allegation. LJ Taylor 'immediately rejected' the suggestion, calling it 'nonsense'. Mr Dear could not recall the conversation but 'would have objected' to any suggestion of bias. LJ Taylor, he said, had been 'scrupulously fair … in his pursuit of the truth'.

¶The matter was taken no futher. 11. Note by Chief Superintendent Denton, 31 July 1989, SYP000096900001, p7. 12. One of the issues under investigation at this stage was the theft of two CCTV tapes belonging to Sheffield Wednesday

¶Football Club. Documents relating to the missing tapes – which have not been located – can be found in a report sent from Assistant Chief Constable Stuart Anderson to Mr Peter Metcalf on 11 May 1989 (SYP00016028001), in an 'Action' recording the outcome of the police investigation (SYP000127080001, pp46–47) and in the witness statements of Roger Houldsworth, the SWFC video operator (SYP000007640001), PC Guest (SYP000007660001), a

¶CCTV contractor (SYP000038700001, pp396–397) and Douglas Lock (SYP000007670001). 13. See, for example, extensive papers in SYP000096870001. 14. Chief Superintendent Wain's briefing notes, 26 April 1989, SYP000097200001, pp1-6. 15. Named after Lord Justice Salmon who recommended their use in his 1966 report on Tribunals of Inquiry.

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¶lose their lives; inadequacy of contingency plans to deal with the emergency; and failure to consider deferring the match kick-off.16

¶2.6.36 Potential allegations levelled at SWFC and SCC (the local authority responsible for the ground's safety certificate) and raised in their Salmon letters were also extensive:

¶
• several 'significant failures' in applying the Green Guide on safety (signage, stewarding, emergency planning and structural matters)
• insufficient turnstiles for the Leppings Lane terrace, poor signage and a steep slope in the tunnel feeding the pens
• failure to take steps to ensure the pens did not get overcrowded
• the collapse of a barrier in pen 3 could indicate a lack of strength
• failure to prepare for a capacity crowd and for fans arriving without tickets, and inadequate stewarding
• inadequate access for ambulances or fire engines to the playing area and insufficient provision of first-aid equipment.17

¶2.6.37 In addition to the above, Dr Eastwood's Salmon letter also noted that the 'construction, disposition and height' of crush barriers in the Leppings Lane terrace constituted a 'number of failures to follow the Green Guide'.18 Further, the introduction of radial fences in 1981 and terrace alterations in 1985 reduced capacity. Dr Eastwood had 'failed to take proper account of this in his advice to the Club and in his dealings with the Local Authority'.

¶Written submission from SYP and the 'Wain Report' 2.6.38 Organisations and individuals were invited to present their cases to LJ Taylor in oral evidence and through written submissions. Within SYP a team of five senior officers, led by C/Supt Wain, was involved in an intensive exercise to establish the police case.19 On 26 April an initial trawl of material was discussed by senior SYP officers and their legal advisers.20 This appears to be the foundation to what became the 'Wain Report'.21

¶2.6.39 The record of a meeting held earlier on 26 April demonstrates the wide range of issues under investigation:

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• the history of semi-finals at Hillsborough since 1948
• the differences between the 1988 and 1989 semi-finals
• discussions between the police and the Football Association (FA) at the planning stage of the 1989 match
• timescale and progress of the match and the feasibility of delaying the kick-off
• Lord Justice Popplewell's recommendations after the Bradford fire in 1985.22

16. 'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Hammond Suddards, 9 May 1989,

¶HOM000002700001, pp2-3. 17. 'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Davies, Arnold, Cooper, 9 May 1989,

¶TSO000000260001, pp3-4.

¶'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Keeble Hawsons, 9 May 1989,

¶HOM000002700001, pp4-5. 18. 'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Reynolds, Porter, Chamberlain, 9 May

¶1989, TSO000000260001, pp1-2. 19. Chief Superintendents Mole and Wain and Chief Inspectors Drabble, Brooke and Bettison. 20. Minutes of SYP meeting with Counsel, 26 April 1989, SYP000096360001, pp58-104. 21. The 'Wain Report', undated, SYP000096980001. 22. Minutes of a meeting held to discuss the SYP presentation of evidence to Lord Justice Taylor, 26 April 1989,

¶SYP000097190001, pp1-12.

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¶2.6.40 Addressing the later meeting Deputy Chief Constable Peter Hayes reported 'people' stating 'they had never seen ... so many non-ticket holders arriving, so much alcohol brought to the football match and therefore having to be consumed or disposed of at the turnstiles'.23 Fans were obdurate and at the turnstiles they 'were trying to bribe their way into the match'.

¶2.6.41 SYP Counsel advised it 'may help if we look upon ourselves as "the accused"'. He advised officers to 'cast your net as widely as you can, gather what you think myself or Mr Metcalfe [sic], in our most perverse mood may require of you'. Peter Metcalf, a solicitor representing SYP, suggested 'we don't call this present investigation an inquiry as such, but we look upon it as a gathering of evidence. You should be careful not to use the word inquiry'.

¶2.6.42 The team of SYP officers led by C/Supt Wain, under the direction of DCC Hayes and advised by Mr Metcalf, was tasked to gather evidence of the events on the day.24 Chief Inspector Norman Bettison deputised for C/Supt Wain in the latter's absence and provided an alternative contact for officers' queries.

¶The Wain Report 2.6.43 An early version of the Wain Report was submitted to the Taylor Inquiry on 12 May 1989.25 It contained considerable background material and minimal information about events on the day. This was expanded in C/Supt Wain's final report less than a month later.26 It appears unlikely that the final version was submitted to the Taylor Inquiry.27 Rather, it was intended to inform a written submission by SYP Counsel.

¶2.6.44 The final Wain Report was substantial, supported by 79 appendices of primary evidence. In the section focusing on the day's events it placed significant emphasis on ticketless fans, alcohol and crowd behaviour.28

¶2.6.45 The report stated that initially 'all the people entering the ground at this time were honest, decent ... well dressed and well behaved'. Yet 'towards the 3.00pm kick-off, the atmosphere changed dramatically'. Sections of the crowd were 'the worse for drink and unruly' and 'evidence from officers' statements' established that a 'large crowd of supporters prepared to converge on the turnstile areas ... in possession of packs of alcohol and this is considered to be a contributory factor as to the reason for their late arrival en masse at the turnstiles'.

¶2.6.46 In a section of the report written by himself, Chief Constable Peter Wright rejected criticism of SYP, stating that '[e]very conceivable care and effort' had been made in match planning, replicating previous arrangements that were 'entirely satisfactory'. Yet 'many visiting spectators' used the good weather 'as an opportunity to find local public houses and consume alcohol, to the extent that in so doing their arrival at the stadium was seriously delayed'.

¶2.6.47 This was 'exacerbated by the obvious influx of a large number of Liverpool supporters who did not have a ticket to gain admission, and whose presence seriously aggravated the worsening situation at Leppings Lane'. 23. Minutes of SYP meeting with Counsel, 26 April 1989, SYP000096360001, pp58-104. 24. Message to all divisions, 2 May 1989, SYP000096840001, p282. 25. South Yorkshire Police submission to Lord Justice Taylor, 12 May 1989, HOM000026520001. 26. The 'Wain Report', undated, SYP000096980001. 27. No copies of the final Wain Report have been located outside of the SYP archive. 28. The 'Wain Report', undated, SYP000096980001, quotes from p137, p143, pp212-214.

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¶2.6.48 There were 'substantial police resources', it was claimed, but 'senior officers found themselves suddenly and unexpectedly overwhelmed by several thousand spectators who had converged on the Leppings Lane entrance within a few minutes of the designated time for kick-off, many of whom being the worse for drink embarked upon a determined course of action, the aim of which was to enter Hillsborough Football Stadium at all cost; irrespective of any danger to property or, more importantly, the lives and safety of others'. In this context the decision was taken to open exit gates.

¶Counsel's written submission 2.6.49 SYP Counsel's written submission to the Taylor Inquiry drew on the Wain Report, responding also to evidence at the oral hearings.29 As WMP's investigation was proceeding, it argued that 'it may be unsafe, even if it were considered possible, to come to what might strictly be described as findings of fact'. Further, it could be 'dangerous to attempt anything more than an impression or a general view (which in any event may ultimately be demonstrated to have been mistaken)'. 2.6.50 SYP's Counsel rejected criticisms of the police, claiming that the crush in Leppings Lane was not a consequence of poor planning by the police as it 'was no more reasonable, in the absence of intelligence, to assume that no-one would turn up than it would have been to have assumed that some thousands would present themselves for admission after 2.30pm such that they would have no real prospect of getting in before the kick-off'. 2.6.51 The concentration of fans outside the stadium, stated SYP Counsel, 'occurred quite quickly'. It consisted of those without tickets, 'latecomers' and 'a considerable number of persons who had taken drink'. It had been suggested by 'a number of observers' that it 'appeared' to be an unprecedented 'concerted action'. 2.6.52 It was further claimed that whether by 'design, the effect of alcohol or simple selfish arrogance, it is plain that there was a considerable relentless disregard of the safety and wellbeing of others by some fans'. Consequently SYP Counsel submitted 'that such behaviour and to the extent encountered on that day could not reasonably have been anticipated and, when it occurred, it was not in the circumstances possible to deal with it'. 2.6.53 SYP Counsel's written submission was supplemented by a report from Detective Inspector King who, after the disaster, was assigned to investigate 'the behaviour pattern of Liverpool Football Club Supporters at matches played away from home'.30 His report was provided to WMP. DI King concluded that '[i]t does appear that there is a nucleus of Liverpool supporters (unidentified) who do travel to matches played away from Liverpool without tickets and cause severe problems'. 2.6.54 Consequently, 'rather than soak up Police manpower' police forces considered it preferable 'to allow them into the ground ... rather than them cause havoc in the town their team is playing'. DI King concluded that there was 'no direct evidence to support this' yet 'fans do appear to know this'. 2.6.55 Despite a lack of material evidence, DI King's conclusion supported the SYP suggestion that there had been a possible 'conspiracy' to force entry at Hillsborough. WMP, who investigated the notion of 'conspiracy' at the request of SYP, 'found a total of thirteen persons who describe some kind of pre-determined intention to enter the ground without

29. Submission to Lord Justice Taylor on behalf of South Yorkshire Police, 6 July 1989, HOM000018350001, pp9-40. 30. Report by Detective Inspector King 'Re: Previous Behaviour Liverpool Fans', 6 July 1989, SYP000097880001, pp2-10.

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¶tickets' and 'many other statements identify significant numbers of supporters without tickets'.31 2.6.56 They estimated 'in excess of 2,000' fans had arrived ticketless, but 'we do not believe that there was a major "conspiracy" as such, rather a continuation of a well established practice by many supporters to visit the ground for this particular match and purchase a ticket'. There was a 'sizeable hard-core', WMP found, who will attempt 'to enter the ground by fair means or foul' but it did not constitute 'one large conspiracy'. It was 'opportunism which collectively could be significant'.

¶2.6.57 SYP also requested WMP to investigate a suggestion that the barrier in pen 3 had 'collapsed at a time before the police were obliged to open the gates at Leppings Lane'.32

¶2.6.58 WMP's analysis of the relevant evidence33 led LJ Taylor to conclude that 'whilst the evidence does not permit the time of collapse to be fixed with certainty, it was after 2.52pm'.34 LJ Taylor stated that 'if so catastrophic an event had occurred as early as 2.47pm' as SYP had suggested, it was highly unlikely that 'the police on the track and elsewhere would have taken until nearly 3 o'clock to realise something was seriously wrong'. Had that been the case, it would have exposed the police to 'even graver criticism'.

¶SYP updates on the Taylor Inquiry 2.6.59 As the Taylor Inquiry progressed, SYP officers were provided with updates. On 23 May, SYP Assistant Chief Constable Stuart Anderson circulated a document entitled 'The Hillsborough Inquiry – Update 1'.35 ACC Anderson's update informed officers that the 'purpose of the inquiry' was 'not to apportion blame for the disaster but, rather, to discover some of the multiplicity of causes and make recommendations to try to prevent something similar happening again'.

¶2.6.60 While 'newspapers and television' had 'reported individual and sometimes sensational accounts', they did not 'represent the whole evidence that had been given'. At this point SYP officers had not given evidence. It was due to be 'called from Wednesday 24 May 1989'.

¶2.6.61 The Update noted that while not all SYP officers on duty at Hillsborough would have the opportunity to 'tell his or her story', SYP's Counsel would have the opportunity to call additional witnesses at the Inquiry's conclusion. This opportunity would be used if 'we [SYP] feel that the whole story has not been presented or that the Inquiry has been misled in any way'.

¶2.6.62 A second 'Hillsborough Update', circulated on the same day, focused on the review and alteration of officers' statements. It is discussed further in Chapter 11. A third 'Hillsborough Update' was circulated on 2 June,36 written by the SYP Chief Constable, Peter Wright. SYP officers had 'been giving evidence for eight days' and the Chief Constable sought to reassure junior SYP officers that it was unlikely that they would experience the rigorous cross-examination to which senior officers had been subjected.

31. West Midlands Police report 'Ticketless Supporters', 27 June 1989, SYP000033180001. 32. South Yorkshire Police meeting with Counsel, 26 June 1989, SYP000097990001, p3. 33. Analysis chart of the broken barrier, 8 May 1989, SYP000026000001. 34. Interim Report of the Inquiry into the Hillsborough Stadium disaster 15 April 1989, HOM000038080001, p46. 35. 'The Hillsborough Inquiry – Update I', by ACC Anderson, 23 May 1989, SYP000097520001. 36. 'The Hillsborough Inquiry – Update III' by CC Peter Wright, 2 June 1989, SYP000098070001.

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¶2.6.63 Senior officers, he stated, 'for the most part' could provide 'an overview of the full sequence of events that occurred' or they had taken 'critical decisions during that afternoon'. Consequently, their evidence had 'been scrutinised in great detail and vigorously cross-examined'.

¶2.6.64 CC Wright 'anticipated, however, that future witnesses will not be challenged to the same degree' and 'officers still to give evidence simply had a piece to add to the emerging jigsaw'.

¶2.6.65 He also noted that officers had been called at short notice to give evidence. CC Wright assured officers that the Force would respond supportively: 'As soon as that first indication is given then the relevant officers will be contacted by a member of the South Yorkshire Police Inquiry Liaison Team and furnished with all necessary information and assistance'.

¶2.6.66 Further, he criticised media portrayals of events, particularly sensationalist reporting. Other reports had been positive, particularly a comment in the Sheffield Star which referred to the 'heroic' police work of Superintendent Roger Greenwood. The sentiments in this article, CC Wright stated, were 'precisely those with which I would wish to be associated'.

¶2.6.67 On 30 June CC Wright issued the fourth and final 'Hillsborough Update' announcing that the first phase of the Taylor Inquiry, the hearing of oral evidence, had concluded.37 He praised and thanked officers who had given evidence and those who had not been called.

¶2.6.68 He noted that '[n]either the South Yorkshire Police nor Lord Justice Taylor' had 'any control over the press coverage of the evidence that has been given'. He reassured officers, however, 'that the journalistic "slant" bears little relation to the mountain of facts and claims that have been set before the Inquiry'.

¶2.6.69 LJ Taylor and his assessors would 'sift through that mass of evidence attaching weight to, and dismissing that which they see fit'. CC Wright stated that SYP and their witnesses had adopted a policy of 'openness and helpfulness towards the Inquiry'. The Force had supported fully LJ Taylor's objectives, and had 'not sought to obscure any fact, for fear of embarrassment, that may serve the very worthwhile aims of the Taylor Inquiry'.

¶Sheffield Wednesday Football Club's submission to the Taylor Inquiry 2.6.70 In its written evidence to the Taylor Inquiry, SWFC submitted that while its 'Salmon' letter was 'a perfectly fair document' when it had been written, in 'the light of the evidence which has now been given … it can be seen that many of those criticisms are not justified – at least as against the club'.38

¶2.6.71 The Club submitted that it was 'clearly regrettable in the extreme that the Safety Certificate was allowed to become seriously out of date'. Accepting that parts of the stadium did not comply with the safety certificate and Green Guide, 'no material alterations were ever made which were not requested by a member of the working party [which included the Council, the police and fire service] and/or discussed and agreed with the working party'.

¶2.6.72 It was recognised that all Liverpool fans entering via the Leppings Lane turnstiles 'inevitably' created 'additional strain'. Yet 'the very worst that could realistically have been 37. 'The Hillsborough Inquiry – Update IV' by CC Peter Wright, 30 June 1989, SYP000098080001. 38. Written submission to the Taylor Inquiry from Sheffield Wednesday Football Club, undated, HOM000019260001, pp1-15.

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¶anticipated was that the kick-off might have to be delayed', and this only 'if Liverpool supporters ... ignored in substantial numbers the advice in their own supporters' magazine to arrive early to take account of the fact that the turnstiles would open at 11.30 – which they did'.

¶2.6.73 Concerning the pens, the 'legitimate criticism which has to be faced … is that they needed to be monitored for over-crowding if they were not to become … dangerous'. But the Club 'had confirmed with the senior responsible police officer (Supt. Mole) that the Police were monitoring the pens'. 2.6.74 The pens, the Club claimed, had been constructed to prevent a repeat of the 1981 crush on the terrace 'on the advice of experts, in response to a police suggestion and in accordance with the local authority's permission'. It would be 'unfair to criticise the club' for acting on this advice. 2.6.75 The Club submitted that the 'tragedy occurred because Gate C was opened, without any preparation, and approximately 2,000 people were allowed to enter pens 3 and 4 at a rapid and uncontrolled rate and at a time when those pens were both full'. Other 'subsidiary "causes"' required examination but 'none of them caused this tragedy'.

¶Sheffield City Council's submission to the Taylor Inquiry 2.6.76 The potential criticisms faced by SCC were similar to those levelled against the Club. SCC noted Home Office advice in relation to the Green Guide, emphasising its 'voluntary' status.39 The Guide was 'intended to demonstrate standards of safety to be achieved ... applied reasonably and with a degree of flexibility'. For those stadia already built, in contrast to new developments, 'maximum flexibility had to be maintained'. 2.6.77 According to SCC, this had 'always been the approach taken' and was 'being far from a recipe for disaster'. Yet it was also 'likely to achieve less by way of reasonable safety than is possible'. The Council suggested the abandonment of the Guide's 'flexible' approach. 2.6.78 It was 'quite clear', SCC stated, that in administering the safety certificate the City Council (and the previous County Council) 'relied on experts from the beginning'. There had been '[n]o doubt ... ever expressed to the certificating authority [the Council] that the turnstiles were inadequate or that there were any crowd problems outside the turnstiles', otherwise 'some reaction might have been expected'. 2.6.79 There was 'no evidence' to suggest that SCC had ever considered the capacity of individual pens. This was 'not surprising' as the Green Guide did not require calculations of 'capacity for an area such as a pen'. This would have been 'meaningless', because supporters were free to move between pens with no mechanical means to monitor pen distribution or movement. 2.6.80 SCC claimed that a 'sensible interpretation' of events was 'that death and injury resulted from the sudden influx of large numbers of spectators once the gates were opened, and which were numbers so great that overcrowding and crushing was ever likely to occur'. There had been no 'wrongful act or omission on the part of the certificating authority' but 'shortcomings in the execution of the administrative system'. Yet 'the system as practised was sufficient to achieve reasonable safety'.

39. Final submission from Sheffield City Council to the Taylor Inquiry, 5 July 1989, HOM000018320001, pp5-22.

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¶Eastwood & Partners' submission to the Taylor Inquiry 2.6.81 Dr Eastwood's submission to the Taylor Inquiry provided a detailed overview of his firm's involvement as consulting engineers to the Club, a role they had held since 1978.40 Proposed alterations to the Leppings Lane turnstiles were made by the firm in 1981 and 1985 but not realised.

¶2.6.82 The 1981 proposal had not been considered a 'priority at that time'. It was 'understandable' as the Club was in the Second Division. Attendances were lower and other modifications had been made. In 1985, following the Bradford fire, timber decking in the South Stand was prioritised alongside the repair of rusting steel within the cantilever roof. Yet '[n]either in 1981 nor later in 1985 was it ever suggested to me by the Club or by any other body represented on the working party that a scheme of rearrangement [of Leppings Lane] was required to alleviate any difficulties' of access to and egress from the stadium.

¶Submission to the Taylor Inquiry on behalf of the injured and bereaved 2.6.83 Lawyers for the bereaved, the Hillsborough Steering Committee (HSC), submitted evidence on behalf of the bereaved and injured. It stated that the 'immediate cause of the death was crushing, and the immediate cause of the crushing was over-crowding in pens three and four at the West end of the ground'.41

¶2.6.84 Overcrowding occurred, the HSC claimed, because pens 3 and 4 were already overfull before Gate C was opened. The initial overcrowding in the central pens was a consequence of 'the installation of the radial fences without the installation of separate turnstiles ... the failure even to attempt any other system for controlling the numbers entering the pens ... the failure to observe that the pens actually were overcrowded'.

¶2.6.85 The HSC did 'not submit that Supt. Marshall was wrong' to request opening Gate C, nor did they 'criticise Chief Supt. Duckinfield [sic] for acceding to that request'. It was, however, a 'fundamental and inexcusable blunder' not to order the closure of the tunnel to prevent access to already full pens.

¶2.6.86 The HSC rejected the police case that crushing at the turnstiles 'was unforeseeable due to the late arrival of thousands of Liverpool fans a large proportion of whom were drunk, hooligans or without tickets (or all three)'. The claim failed to 'stand up to scrutiny' although it caused 'deep distress of the injured and bereaved' and 'provide[d] a field day for the sub- editors of our popular press'.

¶2.6.87 In fact, the 'sad, but visually obvious, truth is that the Leppings Lane entrance to the ground has for many years been a potential death trap; that it has not until 1989 fulfilled its lethal potential has been due to generally low crowds, different conditions applying to league matches, only three semi-finals having been played in the last decade and good fortune and good policing having attended the other two'.

¶Counsel to the Inquiry 2.6.88 The concluding remarks made by Andrew Collins QC, Counsel to the Taylor Inquiry, were clear.42 In his 'Final Observations' he submitted that the disaster was 'wholly avoidable' yet inevitable 'so long as nothing was done to control the numbers going into the pens

40. Witness statement of Dr Eastwood, 30 May 1989, HOM000000770001. 41. Submissions on behalf of the injured and bereaved, 10 July 1989, HOM000019220001. 42. 'Final Observations' of Counsel to the Inquiry, Andrew Collins QC, undated, HOM000019230001, quotes from p36.

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¶and to provide a sufficiency of turnstiles and policing to avoid a dangerous build up of fans seeking admission'. Tragedy had been avoided previously by 'luck' that 'ran out on 15th April 1989'. He continued: 'Ignorance, complacency and lack of foresight, not deliberate callousness, led to the disaster'.

¶Responses to written submissions 2.6.89 The disclosed documents illustrate the internal responses of SYP and the FA to the various submissions. The FA considered SYP's submission 'incredibly poor ... bad tacticly [sic] and in substance' while helping 'Sheffield Wednesday's position by being so hopeless'.43

¶2.6.90 The Club's submission 'was pretty good but much too complicated by references to the evidence'. Allegations made against the FA in the submission on behalf of the bereaved and injured were considered 'outrageous' given they had not 'put any of the substantive allegations to the FA witnesses'.44

¶2.6.91 SYP considered that the submission for the bereaved and injured had been 'made with a view to future civil litigation'.45 SYP considered the contents of the Club's submission to be 'frustrating in the extreme', attempting 'to turn the more crucial aspects towards the Police'.46 Dr Eastwood had made 'little' comment about the collapsed barrier.47

¶2.6.92 The SYP submission challenged Dr Eastwood's interpretation of the introduction of lateral fencing to control the filling of the pens. It argued that the 'control exercised in relation to the pens has always been in terms of segregation at league matches' but never at semi-finals. Further, it was 'a question which should properly be directed to the club'.

¶2.6.93 SCC's submission was thought to include 'little … of relevance to the South Yorkshire Police'.48 'There are certainly no criticisms of the police, indeed the submission supports some minor aspects of our case'. Regarding the submission by Counsel to the Inquiry, 'aspects of the submission ... might be a little unpalatable, but in the main, most criticisms of police actions ... cannot easily be dismissed on the basis of the evidence which has been heard'.49 It was a possible 'preview' of LJ Taylor's preliminary findings.

¶Formal reports to the Taylor Inquiry Reports from West Midlands Police 2.6.94 As the Taylor Inquiry progressed, the WMP investigation was ongoing, involving as many as 440 officers.50 Assistant Chief Constable Mervyn Jones managed the investigation on behalf of his Chief Constable, submitting reports to the Taylor Inquiry, via the Treasury Solicitor and Home Office.

43. Note by Freshfields solicitor concerning a consultation with John Dyson QC, Julian Gibson-Watt and Herbert Smith to discuss oral submissions, 13 July 1989, FFA000005360001. 44. The FA had been criticised for not taking a more active role in ensuring the safety of Hillsborough as a venue. 45. SYP comments on the submissions on behalf of the injured and bereaved, 12 July 1989, SYP000098140001, p2. 46. SYP comments on the submission on behalf of SWFC, 14 July 1989, SYP000098200001, p3. 47. SYP comments on the submission on behalf of Dr Eastwood, 13 July 1989, SYP000098160001, p2. 48. SYP comments on the submission on behalf of Sheffield City Council, 11 July 1989, SYP000098120001, p2. 49. SYP comments on the submission on behalf of Treasury Counsel, 13 July 1989, SYP000098180001, p2. 50. Organisational structure of the West Midlands Police Inquiry into the Hillsborough Disaster, 24 April 1989,

¶SYP000006050001.

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¶2.6.95 Reports focused on a range of issues, including traffic delays,51 the particular location where people died,52 a survey of public houses,53 the police radio system,54 weather conditions55 and witness statements.56 LJ Taylor also received expert reviews from the Health and Safety Executive (HSE) and from the two expert 'Assessors' appointed to the Inquiry.

¶Reports from the Health and Safety Executive 2.6.96 In the immediate aftermath of the disaster, before the HSE had begun its work, initial investigations into the condition of Hillsborough Stadium were undertaken by representatives of SCC.57

¶2.6.97 As early as Sunday 16 April, it was evident to Paul Jackson of the SCC Environmental Protection Unit that 'whilst the barriers at Sheffield Wednesday were strong enough, the spacings were not in full compliance with the guide and in particular the gaps between barriers were too great'. This and other deficiencies in the ground's construction were to be further exposed by the HSE.

¶2.6.98 The HSE's extensive investigations were led by Dr CE Nicholson. Detailed early findings were summarised in a report submitted to LJ Taylor which underpinned many of his findings concerning the technical aspects of the disaster.58 Further reports were produced later, informing WMP's subsequent criminal inquiry.

¶2.6.99 The HSE found that 45 per cent of the stadium's total capacity was confined to entering through 28 per cent of turnstiles, all concentrated in a confined concourse at Leppings Lane.59 Seven turnstiles were allocated to the 10,100 Leppings Lane terrace ticket holders: 1,443 people per turnstile.

¶2.6.100 This was, by a considerable margin, the highest ratio for any area of the stadium, 'almost 3.5 times the lowest average' (413 people per turnstile for the South Stand's uncovered seating) and 'approximately 2.9 times the average admission requirement of 500 persons [per] turnstile for the Spion Kop'. The Spion Kop was the only other major standing terrace in the stadium and was allocated to Nottingham Forest fans.

¶2.6.101 The two sets of turnstiles with the next highest ratios of 'people per turnstile' were also located in Leppings Lane. These were the eight turnstiles allocated to the North Stand, at 988 persons per turnstile, and the eight turnstiles providing access to the West Stand, at 744 people per turnstile.

51. Letter and report from ACC Mervyn Jones, West Midlands Police, to Taylor Inquiry regarding delays on motorways between Liverpool and Sheffield, 1 June 1989, HOM000002560001. 52. Letter from West Midlands Police to Taylor Inquiry: Analysis of positioning of deceased in Pens 3-4 Leppings Lane

¶End, 13 June 1989, HOM000028540001. 53. Letter from West Midlands Police to Taylor Inquiry: Survey of Public Houses and Drinking, 21 June 1989,

¶HOM000028640001. 54. Letter from West Midlands Police to Taylor Inquiry: Telecommunications; Statement by Thomas Logan regarding South

¶Yorkshire Police radios, 21 June 1989, HOM000015770001. 55. Letter from West Midlands Police to Taylor Inquiry: Weather conditions 1988/1989, 27 June 1989, HOM000029310001. 56. The full range of witness statements can be found on the Panel's website. 57. Initial considerations of Paul Jackson, 16 April 1989, SYP000096970001, p693. See also five-page summary of action taken by Paul Jackson, 19 April 1989, SYP000096970001, pp688-692, and investigation notes of RM Ford,

¶SYP000096970001, pp659-681. 58. The Hillsborough Incident 15 April 1989: An investigation into various technical aspects prepared for the Court of

¶Inquiry, 13 June 1989, HSE000000060001. 59. The Hillsborough Incident 15th April 1989: A compendium of the technical aspects of the incident investigation by the

¶Health and Safety Executive, 21 December 1989, SYP000038720001, pp178-179.

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¶2.6.102 In total, the 23 turnstiles at the Leppings Lane end of the stadium had to accommodate 24,447 spectators, 'approximately twice that [per turnstile] of the 42 turnstiles in Penistone Road'. In the opinion of the HSE, in accommodating a capacity attendance, 'larger crowds would form in Leppings Lane than in the other entrance areas to the stadium'.

¶2.6.103 The HSE's conclusion was unequivocal: 'the longest delays in admission' would be at the Leppings Lane turnstiles and 'those with tickets for the West [Leppings Lane] terraces would experience the most severe delays'.

¶2.6.104 On the day of the disaster, the HSE calculated that had Gate C not been opened it would have taken until 3.40pm to admit all 10,100 spectators with tickets for the Leppings Lane terrace, 40 minutes after the scheduled kick-off.60

¶2.6.105 The HSE also found that had the central pens, 3 and 4, conformed to the Green Guide, their maximum capacities would have been 1,015 and 1,036 respectively. As they did not conform, their maximum safe capacities should have been 822 (pen 3) and 872 (pen 4). Yet the safety certificate allowed 1,200 (pen 3) and 1,000 (pen 4).

¶2.6.106 The HSE estimated that on the day of the disaster 1,576 people entered pen 3. This was approximately double the maximum safe capacity.61 The HSE found no evidence that this was due to fans without tickets entering the ground. It calculated that the highest number of entrants, either through the turnstiles or Gate C, was 10,124, just 24 over the designated capacity of the Leppings Lane terrace.62

¶2.6.107 According to the HSE's assessment, the spacing of the barriers and gaps between barriers failed to comply with the Green Guide. In addition, many crush barriers were significantly below the Green Guide recommended height (1.02–1.1m). This altered the usable terrace space and should have reduced the calculations of capacity.63

¶2.6.108 The HSE concluded that 'if only those barriers which meet the Green Guide recommendations were used in the calculation of safe capacity, the allowable numbers of persons able to use the central terraces [pens] would drop to 389 and 540'. As above, this contrasts with the stated capacity of the pens at the time of the disaster as 1,200 and 1,000.

¶2.6.109 The HSE assessed barrier 124A, which collapsed in pen 3. It was over 60 years old and heavily corroded, including two visible holes caused by corrosion.64 It was assessed by the HSE as capable of withstanding the pressure created in a pen full to maximum safe capacity65 although the test procedures carried out on this and other barriers by the Club's safety engineers were questioned: 'I query whether the test procedures used, could categorically guarantee the reliability of the barriers. That is whether the tests would pick up all the weaknesses in the barrier'.66

60. The Hillsborough Incident 15 April 1989: An investigation into various technical aspects prepared for the Court of

¶Inquiry, 13 June 1989, HSE000000060001. 61. No estimate was made for pen 4. 62. The Hillsborough Incident 15 April 1989: An investigation into various technical aspects prepared for the Court of

¶Inquiry, 13 June 1989, HSE000000060001. 63. The Hillsborough Incident 15th April 1989: A compendium of the technical aspects of the incident investigation by the

¶Health and Safety Executive, 21 December 1989, SYP000038720001, pp311-312. 64. The Hillsborough Incident 15th April 1989: A compendium of the technical aspects of the incident investigation by the

¶Health and Safety Executive, 21 December 1989, SYP000038720001, p98. 65. Collapse load calculations for barrier 124A, 7 February 1990, HSE000000550001. 66. The Hillsborough Incident 15th April 1989: A compendium of the technical aspects of the incident investigation by the

¶Health and Safety Executive, 21 December 1989, SYP000038720001, p312.

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¶Professor Leonard Maunder, assessor to the Taylor Inquiry 2.6.110 Professor Leonard Maunder of Newcastle University was LJ Taylor's structural assessor. In his report to LJ Taylor he reported 'misgivings over the way in which [Dr Eastwood] and the Club dealt with the definition of capacities in the West Terrace, both as a whole and later when divided into Pens'.67

¶2.6.111 Separating 'control of overcrowding ... from structural considerations' was 'difficult to accept'. In fact, 'Dr Eastwood's perfectly workable plan of 1985 would have provided the structural means, but the Club did not proceed with it'.

¶Chief Constable Brian Johnson, assessor to the Taylor Inquiry 2.6.112 Brian Johnson, Chief Constable of Lancashire, was LJ Taylor's policing assessor. A report located in the Home Office, and which the Panel believes to have been written by CC Johnson, is strongly critical of SYP's policing operation.68 The operation, he stated, had been complacent in adopting the 1988 Operational Order in 'virtually all respects', suggesting 'little attention was given to reviewing the 1988 order and identifying its shortcomings'.

¶2.6.113 At the turnstiles, a strategy for queuing and filtering out non-ticket holders would have been appropriate. While '[e]xcessive numbers of determined supporters arriving late en masse may well have overwhelmed both mounted and foot patrol officers thus deployed', it did 'not mitigate the culpability associated with inadequate planning'. Proper queue formation introduced early on might have 'influence[d] late arrivals to comply and join them'.

¶2.6.114 There had been a 'significant breakdown in the established Police National Intelligence System' regarding Liverpool fans' previous behaviour at a match at Watford on which a report had been written.

¶2.6.115 CC Johnson noted 'apparent confusion' concerning responsibilities of officers in Sector 1 (Sheffield Wednesday Football Stadium) and Sector 2 (Liverpool supporters). The 'blurring of edges' in the area between the turnstiles and perimeter fence was 'a common and previously successful practice'.

¶2.6.116 Actions taken by the Sector Commander outside the turnstiles (Supt Marshall) in increasingly difficult circumstances had potentially serious consequences for the Sector Commander within the stadium (Supt Greenwood) who, in the circumstances, was not informed of the developing dangerous situation. While conjecture, it was possible that, had Supt Greenwood been informed of the situation, he might have instigated effective remedial action inside thus mitigating the impact of the opening of the gates.

¶2.6.117 According to CC Johnson there was 'no doubt that options were available to deflect the influx of spectators entering through Gate C away from the central tunnel towards the relatively empty enclosures to the north and south of the terraced area'. Chief Superintendent David Duckenfield 'did nothing other than watch the situation develop' and this was 'a severe indictment on his fitness to fulfil his role on the day'.

¶2.6.118 Focusing on the assumed 'policy' of allowing fans to 'find their own level', CC Johnson considered 'the planning of this operation' to be 'deficient ... with the failure to deploy officers and/or ensure the placing of stewards to achieve occupancy monitoring

67. Report by Professor Maunder: 'The Hillsborough Inquiry: Structural Aspects', 10 July 1989, HOM000003070001, p3. 68. Assessment of the policing operation for the FA cup semi-final at Hillsborough 15 April 1989, undated but pre-20 July

¶1989, HOM000003100001.

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¶of enclosures, amounting to an abdication of responsibility'. The SYP claim that 'previous experience had not revealed this to be a problem' was 'undermined by the de-brief report into the 1981 incident'. 2.6.119 From the available CCTV evidence CC Johnson did not consider that police officers on the perimeter track ignored the pleas of fans and there was 'much evidence of officers acting on initiative to effect both rescue from the pitch and from the rear'. 2.6.120 The Match Commander, C/Supt Duckenfield, however, was slow to recognise the reality and extent of the crisis in the central pens. Having realised, there was no evidence that he 'exercis[ed] any degree of command, control or indeed co-ordination of the police efforts'. 2.6.121 CC Johnson concluded that it was 'the responsibility of the police to co-ordinate and control the emergency response to a major incident'. C/Supt Duckenfield had 'fail[ed] to co-ordinate this response' and 'the staff in the Police Control Room lacked a professional and competent approach to their duties'.

¶Responses to the Taylor Interim Report The Government response 2.6.122 As discussed in Part 1, the Taylor Interim Report was published on 4 August 1989, concluding that the 'main cause' of the disaster 'was overcrowding' while the 'main reason' was a 'failure of police control'.69 Days before, Douglas Hurd, the Home Secretary, warned a Cabinet meeting that the Interim Report was 'likely to be critical of a number of individuals and agencies involved in the disaster'.70 2.6.123 The Prime Minister, Margaret Thatcher, was briefed that 'senior officers in command were defensive and evasive witnesses', that 'neither their handling of problems of the day nor their account of it in evidence showed the qualities of leadership to be expected of their rank' and that C/Supt Duckenfield's allegation that fans had forced a gate 'was not only untruthful ... it caused grave offence and distress'.71 2.6.124 She was also advised that LJ Taylor did 'not attach any significant blame' to fans' behaviour, the lack of medical equipment, the emergency services, the choice of Hillsborough for the match or the allocation of the Leppings Lane terrace to Liverpool fans. 2.6.125 The Home Secretary advised the Prime Minister that he had discussed the report with 'colleagues most closely involved'.72 LJ Taylor proposed to hold a press conference and Mr Hurd intended to respond via a Home Office statement. 2.6.126 While noting that the report was critical of SCC and SWFC, he stated that: 'the most severe criticism is directed at the South Yorkshire Police; Taylor concludes that the main reason for the disaster was the failure of police control'. 2.6.127 Senior officers, particularly C/Supt Duckenfield, were criticised and 'reference is made to poor operational orders, lack of leadership, and evidence of senior officers given to the Inquiry is described as defensive and evasive'. The 'conduct of individual officers' should be addressed by 'the Chief Constable, and perhaps the Director of Public

69. Interim Report of the Inquiry into the Hillsborough Stadium disaster 15 April 1989, HOM000038080001. 70. Cabinet Committee minute (CC(89)27th), 27 July 1989, COO000000030001. 71. Briefing note to the Prime Minister, 1 August 1989, COO000001160001. 72. Briefing note from Home Secretary Douglas Hurd to the Prime Minister, 2 August 1989, COO000001120001.

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¶Prosecutions and the Police Complaints Authority'. Mr Hurd's statement would 'welcome unreservedly the broad thrust of the report'.

¶2.6.128 A further briefing within the Prime Minister's office noted LJ Taylor's finding that 'Sheffield Wednesday were dilatory and inefficient in exercising their responsibility for safety at the ground' and that 'little or no blame is attached to the Liverpool fans'.73 Criticisms levelled against SYP were 'very damning', with C/Supt Duckenfield 'shown to have behaved in an indecisive fashion'. Further, 'senior officers involved sought to duck all responsibility when giving evidence to the Inquiry', and '[t]heir defensiveness apparently infuriated the Judge'. 2.6.129 The briefing noted that Mr Hurd thought that the Chief Constable 'will have to resign' as the 'enormity of the disaster, and the extent to which the Inquiry blames the police, demand this'. The position 'shared by Lord Justice Taylor' was that the Chief Constable would 'continue to lead his force during the very difficult next few months'. Resignation would be a 'sad end to an otherwise distinguished career'. Civil actions against SYP, brought by the bereaved, were anticipated. 2.6.130 The briefing stated that, leaving CC Wright 'aside', the 'defensive – and at times close to deceitful – behaviour by the senior officers in South Yorkshire sounds depressingly familiar' and '[t]oo many senior policemen seem to lack the capacity or character to perceive and admit faults in their organisation'. 2.6.131 The briefing concluded that the Taylor Report was 'likely to have little direct effect on the passage of the Football Membership Scheme Bill' and that ministers were 'on record as saying that hooliganism did not appear to be the root cause of the disaster at Hillsborough'. 2.6.132 The 'main impact', the briefing continued, 'will be on perceptions of the police ... sap[ping] confidence in the police force, despite the report's praise for the behaviour of individual constables who had to extricate the dead and dying in the first half-hour of the carnage'. 2.6.133 Consequently, 'Liverpool fans – who have caused trouble in the past – will feel vindicated' and '[a]ggressive behaviour by fans towards the police may be encouraged'. While being 'a very sorry episode ... there seems no reason to think that the report's conclusions are wrong'. 2.6.134 A subsequent briefing note requesting agreement to the Home Secretary's proposed statement drew a strong response from the Prime Minister:74

¶What do we mean by 'welcoming the broad thrust of the report'? The broad thrust is devastating criticism of the police. Is that for us to welcome? ... Surely we welcome the thoroughness of the report and its recommendations - M.T. [Margaret Thatcher]. 2.6.135 This change was conveyed to the Home Secretary and adopted in his statement.75 2.6.136 A letter and copy of the report were sent to County Councils, Metropolitan District Councils, London Borough Councils, the Common Council of the City of London, Fire and Civil Defence Authorities, Chief Officers of Police, Chief Fire Officers and Chief Ambulance Officers.76 73. Briefing note to the Prime Minister, 2 August 1989, COO000001130001. 74. Briefing note from Caroline Slocock to the Prime Minister, 2 August 1989, COO000001140001. 75. Letter from No 10 to the Home Office, 3 August 1989, COO000001080001. See also document entitled

¶'HILLSBOROUGH STATEMENT BY THE HOME SECRETARY', COO000001110001. 76. Home Office Circular 68/1989, 4 August 1989, HOM000027830001.

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¶2.6.137 Each was encouraged to implement LJ Taylor's recommendations on ground safety without delay. Copies were sent to all sports organisations and authorities and to 'all 92 football league clubs and the international stadiums in the expectation that they will cooperate fully'.

¶2.6.138 Minutes of a meeting between LJ Taylor and the Home Secretary immediately following the publication of the Interim Report noted LJ Taylor's regret that the report heavily criticised the police. It was unfortunate, but 'that was the way the evidence fell'.77

¶The South Yorkshire Police response 2.6.139 It was widely anticipated that the SYP Chief Constable, Peter Wright, would resign. However, Sir Jack Layden, Chairman of the Police Authority, affirmed that 'the Police Authority fully supported the South Yorkshire Police and had complete confidence in the Chief Constable'.78

¶2.6.140 Days later a briefing note to the Prime Minister stated that the SYP Chief Constable had 'read the report and decided – subject to talking it through tonight with his family – that he will accept the findings of the report unreservedly; accept responsibility for the actions of his police force; and offer his resignation to the Chairman of the Police Authority'.79 While the decision to accept CC Wright's resignation lay with the South Yorkshire Police Authority, it was the Home Secretary's view that:

¶the Chief Constable would not be dissuaded even if the Chairman were to seek to make him change his mind.

¶2.6.141 Expressing sadness that an outstanding officer should end his career in this way, the Home Secretary considered the decision 'very much in character' and not something in which he should intervene. Further, if:

¶Peter Wright does not resign immediately, he would probably be hounded by the tabloid press and forced to do so in undignified circumstances.

¶2.6.142 On 4 August 1989, CC Wright issued a press statement in which he accepted 'full responsibility for police action in connection with this event' and confirmed his offer of resignation as Chief Constable to the South Yorkshire Police Authority.80 The Police Authority sought advice on whether the Home Office would wish to be represented in the process.

¶2.6.143 Following discussion with Her Majesty's Chief Inspector of Constabulary it was agreed that this would not be advisable. Involvement of the Home Office 'would very likely feed speculation either that the Home Secretary was trying to oust the Chief Constable or alternatively (depending which way the decision eventually went) to protect him'.81

¶2.6.144 The local Conservative MP, Irvine Patnick, who maintained a high public profile at the time of the disaster, wrote that SYP had 'taken a "beating" from some quarters and

77. Notes of a meeting between LJ Taylor and the Home Secretary, 4 August 1989, HOM000008570001. 78. Memo from HMCIC to John Chilcot, 1 August 1989, HOM000008380001. 79. Briefing note to the Prime Minister, 3 August 1989, COO000001090001. 80. Press statement issued by Chief Constable Peter Wright, South Yorkshire Police, on 4 August 1989,

¶HOM000008500001. 81. Note for the record by John Chilcot, 8 August 1989, HOM000013120001.

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¶morale at lower rank level is from my information low and I remain convinced that a change of Chief Constable will not boost morale rather the contrary'.82

¶2.6.145 CC Wright's acceptance of responsibility, Mr Patnick stated, was 'a typical gesture by him but surely he is not expected to lead the parade and sweep up after it'. It was a time to 'unite not only behind the Chief Constable and South Yorkshire Police but also the Police Authority'.

¶2.6.146 In contrast, Sheffield Labour MP Martin Flannery considered that CC Wright's resignation should be accepted on the principle that 'if a drastic mistake is made, involving massive loss of life, it is accepted that the person at the helm is responsible'.83 2.6.147 The evidence, Mr Flannery claimed, had demonstrated 'that proper planning for Hillsborough was complacent and neglectful, and for this Mr Wright must take blame'. He considered that the 'tragedy' could have been avoided and that operational planning and practice were deficient, 'and it is therefore incumbent on Mr Wright to resign his post, whatever finding the Police Committee comes to'. The Chief Constable had 'accepted full responsibility' and should be replaced by 'a new officer, untainted by this shameful episode'. 2.6.148 South Yorkshire Police Authority rejected the Chief Constable's resignation.84 The Hillsborough Family Support Group was 'appalled', and wrote to the Home Office for guidance on procedures to appeal.85 Martin Flannery wrote to political colleagues to garner support.86 2.6.149 CC Wright remained in post and on 31 January 1990 he gave formal notice of his intention to retire. He stated that his 'personal resolve' to retire at 60 had been 'overtaken by the tragic events at Hillsborough'.87 The 'proper course of action' had been to await the outcome of LJ Taylor's reports, 'to deal, as I thought appropriate, with what emerged in the findings'.

¶Football Spectators Bill and the Taylor Inquiry 2.6.150 From government papers disclosed to the Panel, the principal concern in Whitehall following the Hillsborough disaster was its potential impact on the Football Spectators Bill. Introduced in Parliament three months before the disaster, the Bill's focus was hooliganism and football-related violence. It proposed the introduction of a National Membership Scheme for football supporters, using electronic ID cards. 2.6.151 Prior to the disaster Sports Minister Colin Moynihan stated that the Bill's 'purpose' was 'to deal with the problems of hooliganism associated with football'.88 Scheme membership would apply to all people attending 'a designated football match in England and Wales' and 'designated matches should be played only on licensed football grounds'.

82. Letter from Irvine Patnick MP to Sir Jack Layden, South Yorkshire Police Authority, 11 August 1989,

¶SPA000000120001, p13. 83. Letter from Martin Flannery MP to Sheffield Star, 12 August 1989, MFL000000020001, p5. 84. Minutes of South Yorkshire Police Authority meeting held on 14 August 1989, SPA000000130001. For Peter Wright's letter of resignation see SPA000000120001, p21. 85. Letter from the Hillsborough Family Support Group (HFSG) to the Home Office, 21 August 1989, HOM000014700001.

¶The HFSG was advised that the decision was for the Authority alone and that the Home Secretary had no power to overrule. See letter to the HFSG, 22 August 1989, HOM000014730001. 86. Letter from Martin Flannery MP to other MPs, 19 September 1989, MFL000000020001, p22. 87. Letter from Peter Wright to Sir Jack Layden, Chairman of South Yorkshire Police Authority, 31 January 1990,

¶SPA000000350001. 88. Letter from Colin Moynihan, Minister for Sport, to Members of Parliament, 12 April 1989, COO000000830001.

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¶2.6.152 It would provide 'an effective and comprehensive procedure to keep hooligans away from football matches', breaking 'the link between violence and football'. Anyone 'convicted of a relevant offence' would be banned from grounds and the courts would have 'powers to impose restriction orders on convicted hooligans to prevent them from travelling to specified matches abroad'. 2.6.153 The impact of Hillsborough on the Parliamentary prospects of the controversial Bill was raised in discussion between the Prime Minister and ministers two days after the disaster.89 The Home Secretary was recorded as stating that 'in the atmosphere of general shock and sorrow after the disaster there was, temporarily, a time when attitudes would be more flexible and the possibilities of securing support from other political parties and the footballing authorities for new steps might be greater than for some time past'.

¶2.6.154 Ministers were agreed that the Home Secretary's imminent statement to Parliament should make clear that 'the Government remained firmly of the view that the future of football remained with an all-membership scheme at designated grounds'.

¶2.6.155 In so doing it drew criticism from the Shadow Home Secretary and Sheffield MP Roy Hattersley, who expressed concern that requiring fans to produce ID cards could result in crowd safety problems similar to those at the Hillsborough turnstiles. Mr Hattersley asked the Home Secretary to 'consider the implications of any policy or legislation that results in concentration of crowds outside grounds immediately before matches'.90

¶2.6.156 Many Conservative MPs shared concerns about the Bill and there was pressure to delay the legislation until LJ Taylor had reported. Immediately after Mr Hurd's statement, the Prime Minister's Principal Private Secretary, Andrew Turnbull, informed her of 'a pessimistic assessment' by the Chief Whip of progressing the Bill in the short term.91

¶2.6.157 However, the Chief Whip believed that 'in two or three weeks time when emotion has subsided and the facts about the behaviour of the crowd have been appreciated, the incident will be seen to stem more from rowdyism than from the police's response'. It was not necessary 'to concede the principle of postponement now'.

¶2.6.158 The Prime Minister also was opposed to a delay, making the case for the Bill during Prime Minister's Questions on 20 April. Her position was summarised by the Conservative Research Department. There had been 'four decades of problems with crowd safety and two decades of hooliganism' and '[n]early 300 people have died – the worst record in the developed world'. Included in the lessons from Hillsborough was 'the need for all-seat accommodation for spectators at major grounds'. The Bill had originated in LJ Popplewell's recommendations after the Bradford stadium fire, more than three years earlier.92

¶2.6.159 On 25 April, the Home Secretary met LJ Taylor 'to gain some initial impressions of the progress of [his] enquiry'.93 LJ Taylor was reported as having been 'distinctly unhelpful'.94 His Interim Report would focus on 'what happened' and it was 'unlikely that he would reach the membership card issue until later'.

89. Letter from Dominic Morris, Private Secretary to the Prime Minister, to Philip Mawer, Home Office, 17 April 1989,

¶COO000001010001. 90. Available at http://hansard.millbanksystems.com/commons/1989/apr/17/hillsborough-stadium-disaster 91. Briefing note from Andrew Turnbull to the Prime Minister, 18 April 1989, COO000000820001. 92. 'FOOTBALL SPECTATORS BILL', a note from the Conservative Research Department, 20 April 1989,

¶COO000000720001. 93. Minutes of meeting between the Home Secretary Douglas Hurd and Lord Justice Taylor: Progress of Hillsborough

¶Stadium Disaster Inquiry, 26 April 1989, HOM000010200001. 94. Briefing to the Prime Minister, 26 April 1989, COO000000710001.

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¶2.6.160 This further complicated the Bill's already fraught Parliamentary progress. The 1988/89 Parliamentary session would end in mid-November, before LJ Taylor's final findings and before he would comment on the Bill's proposed membership scheme. The Prime Minister, however, was recorded as stating that the Government 'should press ahead with the Football Spectators Bill in the present Session'.95

¶2.6.161 The Bill offered the 'only available means of dealing with a situation which could no longer be tolerated; if progress on the implementation of a national membership scheme were in any way delayed, then it would be clear that it was those who had obstructed the passage of the Bill who would be indirectly responsible for any future tragedies which might be associated with football matches'.

¶2.6.162 Mr Moynihan restated the Government's commitment to the Bill.96 It was 'not a time for a light-hearted contribution reflecting on a season of successes in the world of sport'. He catalogued a series of 'appalling incidents' and the 'sense of disillusion and disappointment that our great national sport lacks leadership and direction from its senior administrators'.

¶2.6.163 He called for 'more than the Football Spectators Bill ... more than a boardroom revolution in football ... more than a package of measures to curb hooliganism ... more than Hillsborough', specifying 'a total change in attitude, a new realism and above all courage from everyone involved in the game'.

¶2.6.164 The Bill was amended to prevent its provisions for a national membership scheme being activated until after publication of LJ Taylor's Final Report. It could not be brought into effect without the further consent of Parliament.

¶Lord Justice Taylor's Final Report 2.6.165 LJ Taylor's Final Report focused 'on the needs of crowd control and safety for the future'.97 It was published on 29 January 1990. It criticised heavily the 'complacency' shown by club directors following Hillsborough, stating that LJ Taylor had witnessed repeatedly the same refrain: 'Hillsborough was horrible – but, of course, it couldn't have happened here'.

¶2.6.166 He argued, however, that 'the lack of precautions against overcrowding were not unique' to Hillsborough. It 'should not be regarded as a freak occurrence, incapable of happening elsewhere … Complacency is the enemy of safety'. In addition to overcrowding, 'old grounds, poor facilities, hooliganism, excessive drinking and poor leadership' were causing 'danger or marring football as a spectator sport'.

¶2.6.167 While making numerous recommendations, including the introduction of all-seated stadia for teams in the top two football divisions, he did not support the implementation of the national membership scheme envisaged in the Football Spectators Act.

¶2.6.168 LJ Taylor presented 'the gravest doubts' about whether the technical challenges could be overcome, as failures at stadium turnstiles would have 'very serious' implications for crowd safety. A membership scheme had the potential to 'actually increase trouble outside grounds'. Finally, LJ Taylor was concerned about the impact that policing the scheme would have on wider police operations at football matches.

95. Letter from Andrew Turnbull, Principal Private Secretary to the Prime Minister, to Roger Bright, Department of the

¶Environment, 9 May 1989, COO000000610001, p4. 96. Draft speech for Football Writers' Association dinner, 18 May 1989, COO000000590001, pp5-13. 97. Final Report of Inquiry by Lord Justice Taylor into the Hillsborough Stadium Disaster, HOM000028060001.

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¶2.6.169 Pre-empting publication of LJ Taylor's findings, three options were presented to the Prime Minister:

1. Reject his conclusion and press ahead regardless.

2. Accept his conclusions and drop the membership scheme.

3. Commit to LJ Taylor's alternative strategy but keep the scheme in reserve.98

¶2.6.170 On the third option the Home Secretary considered that it would be 'embarrassing to have to announce the shelving of the scheme, but it should be possible to present the decision in a positive way'.99 As LJ Taylor had concluded that the scheme on hold had 'serious drawbacks', his advice should be accepted while leaving the 'enabling provisions ... on the statute book'.

¶2.6.171 The Prime Minister agreed. In preparation for a statement to Parliament by the Home Secretary and following a meeting on 23 January 1990, she concluded that it had been 'clear that Lord Justice Taylor's report was flawed in a number of respects'.100

¶2.6.172 The intention would be to reveal its 'deficiencies ... in response to questions following the Home Secretary's statement'. Yet 'the Government could not proceed with the National Membership Scheme ... in the face of Lord Justice Taylor's findings'. As an enabling provision, however, 'it should be left on the Statute Book for use at a later date should this seem desirable and be shown to be feasible'.

¶2.6.173 The Home Secretary announced the decision to Parliament on 29 January 1990, alongside the publication of LJ Taylor's Final Report.101 The Shadow Home Secretary, Roy Hattersley MP, responded: 'Whatever language the Home Secretary may use today, the identity card is dead as a result of the report'.

¶Parallel investigations and civil litigation 2.6.174 Chapter 7 details the various civil actions arising from the Hillsborough disaster. The 'contribution hearings' provided the process through which contributions to compensation would be established and paid by various parties to the injured and bereaved.

¶2.6.175 SYP and SWFC commissioned 'expert reports' to assist in the preparation and presentation of their cases to the contribution hearings.102 These reports were produced in August 1990, a year after the publication of LJ Taylor's Interim Report and while potential prosecutions were under consideration.

¶2.6.176 They illustrate how different interpretations of events emerge from similarly experienced 'experts' evaluating the same evidence but from different perspectives and contrasting interests.

98. Briefing note to the Prime Minister, initialled F.E.R.B., 22 January 1990, COO000000300001. 99. Memorandum from the Home Secretary's office to the Prime Minister, 22 January 1990, COO000000270001. 100. Letter from Andrew Turnbull, PPS to the Prime Minister, to Colin Walters, Home Office, 23 January 1990,

¶COO000000260001. 101. House of Commons Hansard, 19 January 1990, COO000000140001. 102. Though prepared in support of the civil hearings, they appear to have had a wider distribution, with copies provided to the Coroner and found in the SYP files relating to disciplinary investigations.

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¶The Phillips Report 2.6.177 SYP commissioned two expert reports: on policing (Phillips) and on structural aspects of the disaster (Burne). The policing report was written by JD Phillips, Deputy Chief Constable of Devon and Cornwall Constabulary.103

¶2.6.178 Until June 1989 he was Secretary of the Association of Chief Police Officers (ACPO) Sub-Committee on Hooliganism in Sporting Events and had presented police evidence to the Taylor and Popplewell Inquiries.104 DCC Phillips' submission to LJ Taylor focused on hooliganism. His report on behalf of SYP was extensive.105 In establishing the cause of the disaster he identified two 'decisive elements'. First was the behaviour of the fans at the Leppings Lane end.

¶2.6.179 While Leppings Lane was known to become congested, the police experience was that fans would usually enter through the turnstiles in time for the kick-off. Such a large crowd, though occasional, was not unusual, and DCC Phillips considered that the Leppings Lane crowd would be considered routine at stadia such as Wembley. 'The critical difference', he proposed, was 'whether or not the crowd is minded to develop a surge and momentum towards the turnstiles perhaps because, as happened in this case, they fear they will not get in in time for the kick off'.

¶2.6.180 He concluded that policing arrangements in Leppings Lane would 'have been sufficient had the crowd been reasonable. They were not' (emphasis in original). In fact, 'crowd behaviour in Leppings Lane was sustained, intense and dangerous', constituting 'the first decisive element in this tragedy'.

¶2.6.181 The second element was an amalgamation of several engineering failures in the stadium's construction, 'in particular the inadequacy of the configuration of the turnstiles and the lack of separation between incoming sections of the crowd'. DCC Phillips emphasised the 1981 SYP request that radial fences within the terraces should extend to the turnstiles, providing each pen with a discrete entrance. This design was agreed but not implemented.

¶2.6.182 DCC Phillips noted that maximum capacities of specific areas of the stadium were not updated despite significant changes to the stadium's layout. He referenced the HSE's finding that the capacities for pens 3 and 4 were 25 per cent above the Green Guide's safety level. Had 'the alterations made in 1981 and 1985 ... been constructed in accordance with the Green Guide and in line with Police and engineers' recommendations then, it is highly probable there would have been no tragedy'.

¶2.6.183 DCC Phillips considered it appropriate that the police were preoccupied with crowd behaviour as they were 'only present because of hooliganism'. Hillsborough was considered a safe stadium, the match was all-ticket, so the police assumed that overcrowding could not occur. Spectators would distribute themselves on the terraces, or 'find their own level'. The failure to recognise that the introduction of radial fences without discrete entrances to the pens undermined the logic of assessing maximum capacities was shared by 'everybody' involved and could not be ascribed solely to police negligence.

103. The 'Phillips Report' by JD Phillips, Deputy Chief Constable of Devon and Cornwall Constabulary, 30 August 1990,

¶SYP000116060001. 104. Association of Chief Police Officers submission to the Taylor Inquiry, June 1989, HOM000009640001. 105. The 'Phillips Report' by JD Phillips, Deputy Chief Constable of Devon and Cornwall Constabulary, 30 August 1990,

¶SYP000116060001.

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¶2.6.184 DCC Phillips considered that the decision to open Gate C and other gates was correct. He disagreed with LJ Taylor that the failure to close the tunnel providing access to the central pens was a serious blunder, but conceded that there was 'some error of judgement' in not accommodating the distribution of the crowd once the gates had been opened.

¶2.6.185 This error, along with failing to recognise the growing overcrowding, was mitigated by officers' lack of experience in managing capacity crowds. DCC Phillips stated: 'Had they been used to capacity crowds they might have recognised, with the view obtainable from the control box, that the density in pens 3 and 4 had become so great that something needed to be done'.

¶The Stalker Report 2.6.186 SWFC commissioned John Stalker, former Deputy Chief Constable of Greater Manchester Police, to provide an 'expert' report focusing on the planning and conduct of the police operation.106 The findings of the Phillips and Stalker reports are markedly different, each clearly reflecting the interests of the commissioning agencies. 2.6.187 A clear example is their contrasting assessments of C/Supt Duckenfield's decision not to delay the kick-off. This was not an issue for DCC Phillips but in Mr Stalker's view 'it should have been obvious that the turnstiles could not accommodate the entry of those still outside the ground before kick-off'. 2.6.188 While this 'was a matter of simple arithmetic ... even without the turnstile flow rates, visual evaluation of the terraces, plus information from Superintendent Marshall's sector and video evidence, made it clear that there were too many arriving, too late, for too few turnstiles'. Consequently, '[i]t would have been a simple and unremarkable police decision to request a delayed kick-off'. 2.6.189 Mr Stalker agreed with the decision to open the gates once the situation at the turnstiles became dangerous and a delayed kick-off had been ruled out. On the failure to close off the tunnel leading to the central pens, however, 'there was ample time to arrange a cordon of police officers and/or temporary barriers across the mouth of the tunnel'. 2.6.190 The decision, the responsibility of C/Supt Duckenfield or Supt Murray, was 'simple and obvious ... and could have been accomplished in about two minutes at the most'. Mr Stalker stated that a 'fundamental tenet of policing is to evaluate the probable effect of any course of operational action, especially where the safety of the public is involved'. As this did not happen at Hillsborough it amounted to 'a serious operational failure given the senior rank of the officers involved'. 2.6.191 Mr Stalker also criticised the informal 'policy' of 'expecting the Leppings Lane terrace crowd "to find its own level"'. In his experience crowds required 'help or direction from officials'. Accepting that this was an all-ticket match, he commented that the police role was 'either to help stewards or personally initiate measures to improve safety and comfort'. It was not unusual for police officers to 'relieve pressure by opening perimeter gates in order to move fans to other areas of the ground'.

¶The Burne Report 2.6.192 SYP commissioned a further report from Noel Burne of Elrond Engineering Ltd.107 Mr Burne criticised Hillsborough's design and maintenance. He reviewed the formally 106. Statement of John Stalker, 20 August 1990, SYP000116060001, p262. 107. Report by Elrond Engineering, undated, SWF000003800001, pp12-14.

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¶agreed capacity of the Leppings Lane terrace and found it to be too high. He noted the lack of subdivision of capacity across the terrace and the deficiencies in managing the flow of spectators. Overcrowding in discrete pens could have been avoided had crowd distribution been appropriately measured, directed by signs and pens closed on reaching the designated capacity. 2.6.193 Mr Burne also criticised the condition of the crush barriers. The HSE had concluded that while collapsed barrier 124A was over 60 years old and heavily corroded, its collapse was caused by gross overcrowding. Mr Burne concluded that the HSE had overestimated the number of fans in pen 3 as 1,576. In contrast and 'on the balance of probability' his estimate was 'nearer' 1,200 – the capacity on the safety certificate. The barrier had failed, therefore, in circumstances which it should have been tested to withstand.

¶The criminal investigation 2.6.194 Within two weeks of the publication of LJ Taylor's Interim Report the Director of Public Prosecutions (DPP) was consulted and the criminal investigation was initiated by the SYP Chief Constable, Peter Wright. He wrote to the WMP Chief Constable, Geoffrey Dear, to request his Force to 'undertake this enquiry together with any police discipline aspects which may emerge'.108

¶2.6.195 Present at the initial planning were WMP Assistant Chief Constable Mervyn Jones and Detective Chief Inspector Nick Foster, Crown Prosecution Service (CPS) officials and Gareth Williams QC, Counsel to the DPP. It was agreed that the main allegation for investigation was likely to be manslaughter.109

¶2.6.196 The criminal investigation proceeded alongside preparation for the Coroner's inquests, building on the WMP investigation for the Taylor Inquiry. On 31 March 1990 the investigation's extensive report was presented to the DPP.110 It focused on the following:

¶
• Ground staff (SWFC officials, stewards, turnstile operators, programme sellers and food vendors).
• Ground characteristics (history of SWFC, layout of stadium and approaches, safety considerations and fencing).

108. Letter from CC Peter Wright to CC Geoffrey Dear, 16 August 1989, CPS000003140001, pp98-99 and letter from Allan

¶Green, Director of Public Prosecutions, to CC Peter Wright, CPS000003140001, p104. 109. Minutes of 'HILLSBOROUGH DISASTER CONFERENCE 30 AUGUST 1989', CPS000003250001, pp3-5. 110. The report to the Director of Public Prosecutions is published on the website across a number of digital files. They are:

¶
• Report to the Director of Public Prosecutions: Master Index, SYP000038660001
• Part 1 – Sheffield Wednesday FC staff: Introduction and statement pages 1-348, SYP000038670001
• Part 1 – Sheffield Wednesday FC staff: Statement pages 349-751, SYP000038680001
• Part 1 – Sheffield Wednesday FC staff: Documents 1-43, SYP000038690001
• Part 2 – History of Sheffield Wednesday FC: Report and statement pages 752-1128, SYP000038700001
• Part 2 – History of Sheffield Wednesday FC: Documents 44-87, SYP000038710001
• Part 2 – History of Sheffield Wednesday FC: Documents 88-108, SYP000038720001
• Part 3 – Visual evidence: Report, statement pages 1129-1144 and documents 109-177, SYP000038730001
• Part 4 – Liverpool supporters: Statement pages 1145-1520, SYP000038740001
• Part 4 – Liverpool supporters: Statement pages 1521-1897, SYP000038750001
• Part 4 – Liverpool supporters: Statement pages 1898-2270, SYP000038760001
• Part 4 – Liverpool supporters: Statement pages 2271-2456, SYP000038770001
• Part 4 – Liverpool supporters: Documents 179-191, SYP000038780001
• Part 5 – South Yorkshire Police: Report and statement pages 2457-2718, SYP000038790001
• Part 5 – South Yorkshire Police: Statement pages 2719-3139, SYP000038800001
• Part 5 – South Yorkshire Police: Statement pages 3140-3480, SYP000038810001
• Part 5 – South Yorkshire Police: Documents 192-207, SYP000038820001
• Part 6 – Medical facilities and emergency response: Report and statement pages 3481-3706, SYP000038830001
• Part 6 – Medical facilities and emergency response: Documents 208-220S and statement pages 1448-1590, SYP000038840001
• Part 7 – Report to the Director of Public Prosecutions, SYP000038850001.

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¶
• Visual evidence (video film and still photographs pictorially describing the disaster).
• Fans' behaviour.
• Police (their observations and actions as presented in non-Criminal Justice Act recollections, documents and other submissions).
• Emergency services (their actions and observations).

¶2.6.197 A further section, presented by DCI Foster and using LJ Taylor's Interim Report as its starting point, described the main causes of the disaster, considering possible legal culpability of the organisations and individuals involved.111 Its conclusions suggested interviews with individuals who might be prosecuted and were described as 'interim'. This report was not revised at a later date.

¶2.6.198 The report addressed difficulties regarding possible prosecutions. Concerning the quality and appropriateness of available evidence, the self-taken 'recollections' from SYP officers were 'very unsatisfactory for a criminal investigation' as they 'lack thoroughness' and 'are not protected by the provisions of the Criminal Justice Act'. More information on the issues surrounding these recollections can be found in Chapter 11.

¶2.6.199 The evidence presented at oral hearings 'was not subject to the rigour of the rules of evidence as they would apply in a criminal law context'. Further, in gathering the recollections and in presenting oral evidence those involved had not been warned about the possibility of self-incrimination.

¶2.6.200 These serious factors associated with information gathering for a public inquiry rather than a criminal prosecution possibly created 'insurmountable difficulties' for 'pursuing a successful prosecution'.

¶2.6.201 Media coverage following LJ Taylor's Interim Report was also an issue: 'if a manslaughter prosecution is pursued against Chief Superintendent Duckenfield it is seriously questionable whether he could receive a fair trial'.

¶2.6.202 The report focused on four potential targets for prosecution:

1. South Yorkshire Police

2. Sheffield Wednesday Football Club and their safety engineers

3. Sheffield City Council

4. Fans.

¶2.6.203 Regarding SYP as a corporate body, while 'recklessness' would rest 'with those individuals charged with the responsibility on the day', it was important to consider corporate responsibility. SYP had been aware of overcrowding since 1981 and 'could be criticised with hindsight' yet 'such criticism does not amount to criminal behaviour'.

¶2.6.204 Turning to SYP officers it was considered that while, with hindsight, Assistant Chief Constable Walter Jackson could be criticised for not taking command of the match given C/Supt Duckenfield's relative lack of experience, this did not amount to a criminal offence.

¶2.6.205 Regarding senior officers C/Supt Duckenfield, Supt Murray, Supt Marshall and Supt Greenwood, interviews would be necessary before deciding on the appropriateness of criminal prosecution.

111. Part 7 – Report to the Director of Public Prosecutions, SYP000038850001.

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¶2.6.206 This course of action extended to two junior officers on the perimeter track who had been accused of failing to recognise the extent of the impending crisis within the pens. However, it was considered 'very difficult to imagine' that their actions 'could be so reckless as to be criminal'.

¶2.6.207 LJ Taylor's criticisms concerning the responsibilities of SWFC and their safety engineers, Eastwoods, were: the layout of the Leppings Lane terrace; lack of fixed capacities for the pens; the location and condition of barriers in pen 3; and the inadequacy of the perimeter gates. The submission noted that '[c]ommon sense would suggest that Eastwood & Partners should have been more thorough by following up safety aspects especially where the capacities were concerned between 1981 and 1986'.

¶2.6.208 Further, the failure to ensure that perimeter gates met Green Guide standards again demonstrated 'the unsatisfactory way in which the Club and Eastwoods chose to ignore a safety issue'. Yet, in conclusion, 'as with the Club, the events left Eastwoods' control once the decision was made to open the gates at 1452 hours'. The submission recommended interviews with key individuals but considered there was insufficient evidence to pursue a corporate manslaughter charge against SWFC or Eastwoods. 2.6.209 Regarding the possible prosecution of Dr Eastwood as an individual, however, the failure to reconsider the capacity of the Leppings Lane terrace after the changes of 1981 and 1985 'may be considered as a serious omission which in itself contributed to the disaster'. Nevertheless, '[w]hether the lack of care was sufficiently reckless to consider Dr Eastwood for Culpable Manslaughter seems unlikely'. The development of the Leppings Lane end and the 'lack of attention to safety' provided possibly 'strong mitigating factors in considering the culpability of South Yorkshire Police and Chief Superintendent Duckenfield'. 2.6.210 The report concluded that 'Sheffield City Council (and their predecessors, South Yorkshire County Council) had not dealt with the Safety Certificate correctly as is required by the 1975 Safety at Sports Grounds Act'. 2.6.211 Further, 'the Council, through its records and its employees, has acted in a careless manner'. Yet this did 'not amount to a reckless disregard for safety'.112 The Council's carelessness 'may have led to the enormity of the disaster', but the decision to open Gate C was not its responsibility, nor could it have been foreseen. 2.6.212 There was insufficient evidence to consider corporate manslaughter and though 'an alternative offence of Culpable Malfeasance may have been committed ... given the remoteness of the amendments to the Safety Certificate to the disaster itself, it would be inappropriate to pursue such a prosecution'. 2.6.213 Finally, there was no evidence available 'to prove that an individual or a group of supporters [were] responsible for a major criminal offence'. The submission recommended that the behaviour of fans required examination: 'The extent to which the effects of alcohol played a part, the late arrival of many thousands of Liverpool supporters and even perhaps their own failure to recognise the distress of fellow supporters in pens 3 and 4 are important issues in this disaster investigation'. 2.6.214 The report accepted that 'the evidence on which Lord Justice Taylor drew his conclusions has not been added to significantly', yet there were 'aspects of this disaster which in the opinion of the Investigating Officer may not have been given sufficient prominence [by LJ Taylor]; for example, the role of supporters'.

112. Continuing quotes from Part 7 – Report to the Director of Public Prosecutions, SYP000038850001. This quote from p149.

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¶2.6.215 While LJ Taylor had dismissed the issues of drunkenness and ticketless fans as contributing factors to the disaster, the report put them back on the agenda while stating clearly that there was no evidence on which to base criminal prosecutions of fans. 2.6.216 The report advised a series of interviews under caution. Some of those under examination declined to be interviewed. Other interviews were held in June and July 1990 and transcripts have been disclosed to the Panel.113 The interviews of police officers served the parallel purpose of informing disciplinary investigations. Transcripts were sent to the DPP on 1 August 1990.114

¶Consideration by the Director of Public Prosecutions 2.6.217 Gareth Williams QC and Peter Birts QC were asked to advise the DPP and the CPS on 'whether there exists sufficient evidence to justify bringing criminal proceedings against any of the organisations or individuals concerned' in the disaster.115 Their Joint Opinion was submitted to the CPS on 6 August 1990.

¶2.6.218 In their Opinion, despite the thoroughness of the criminal investigation, it had not 'significantly added to or contradicted Lord Justice Taylor's findings'. Thus LJ Taylor's analysis of the facts was the starting point. Accordingly, the disaster had 'three separate causative elements'. These were: 'the layout of the ground; the opening of the exit gate; and the build up outside the ground'.

¶2.6.219 The layout of the ground was 'the responsibility of four organisations, and ... individuals acting on their behalf, namely the Club, Eastwood and Partners, the Council and the police'. None had foreseen 'that the progressive alterations made to the ground from about 1977 onwards in the interests of safety and good order would come to constitute, in effect, a death trap for supporters entering pens 3 and 4'.

¶2.6.220 The reason, the Opinion stated, was that it had not been anticipated 'that up to 2000 supporters would be allowed to enter these pens at a time when they were already overcrowded, and when spreading out to the side to absorb the extra numbers would be impossible'.

¶2.6.221 The four organisations 'share[d] some responsibility for the lack of safe maximum capacities, the lack of controlled entry to the pens and the absence of any proper system of monitoring, as they must for the departures from the Green Guide and the inadequacy of the Safety Certificate'.

¶2.6.222 Further, the police 'must take the main responsibility for the policy of letting the fans find their own level', although SWFC also 'share[d] some responsibility'.

¶2.6.223 The crushing in 1981 did 'not add to the potential criminal responsibility of the police and the Club'. Radial fences had been installed after that incident with the intention of improving safety 'and until the disaster it was assumed that this was a correct response'.

113. Transcripts available as follows: Superintendent Marshall at SYP000038880001; Graham Mackrell at

¶SYP000038890001; Superintendent Murray at SYP000038900001; Assistant Chief Constable Jackson at

¶SYP000038910001; Superintendent Greenwood at SYP000038920001; Chief Superintendent Duckenfield at

¶SYP000038930001. 114. Letter from CC Sharp to Michael Kennedy, 1 August 1990, CPS000004820001. 115. Joint Opinion by Gareth Williams QC and Peter Birts QC, 6 August 1990, CPS000003270001, pp77-116.

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¶2.6.224 The decision to open Gate C 'was the responsibility of Mr Duckenfield' and 'in the circumstances' it was correct. Yet 'the failure to give any order to accommodate the influx was a serious error which must in our view be Mr Duckenfield's responsibility and his alone'.

¶2.6.225 The Opinion noted that the tunnel had been 'cordoned off in 1988 by a handful of junior police officers apparently on their own initiative – an action that almost certainly would have averted the disaster a year later' and this constituted 'one of the most unfortunate aspects of the case'.

¶2.6.226 While 'at first sight the operational organisation of the police might seem responsible for failing to incorporate this tactic in its match planning', in Counsel's view 'it was within [C/Supt Duckenfield's] power to accommodate the opening of Gate C, and the blame for not doing so cannot in our view be laid elsewhere'.

¶2.6.227 Further, the Opinion noted that planning for and managing the build-up outside the ground was important given the restrictions on space determined by the geography of Leppings Lane; 'the layout of the turnstiles and their numbers, designation and marking was primarily a matter for the police and the Club'. Sheffield City Council was also responsible for ensuring safe entry into the stadium.

¶2.6.228 Outside the stadium, the Opinion claimed, 'drink and unruliness of the supporters certainly contributed to the pushing from the back and was a factor in making supporters less amenable to police requests to move back'. Further, some 'drunk supporters tried to force themselves in at the turnstiles, causing fighting with other supporters and scuffles with the police trying to prevent their entry'. The Opinion noted that a 'minority contributed to the loss of control of the crowd by police in our view'.

¶2.6.229 Counsel's Joint Opinion concluded: 'Nevertheless, the main factor in this loss of control was a failure of police strategy in not planning properly for the crush likely to be caused by a large concentration of arrivals from 2.30pm onwards, and in failing to stem the flow of supporters or filter them towards the turnstiles from some position outside the perimeter gates'. This had happened in 1988, and the failure in 1989 'was solely a police responsibility', but a collective one which 'cannot be attributed to any individual officer'.

¶2.6.230 Counsel advised on whether the mistakes and failures identified amounted to a criminal offence. The Joint Opinion focused on the offence of manslaughter, and in particular the offence of gross negligence manslaughter: 'manslaughter is committed if the person causing the death intends to do an act, or omits to do an act where there is a duty to do so, being grossly negligent whether death or serious injury results ("gross negligence")'.

¶2.6.231 While accepting ambiguity in the law, 'in the circumstances of Hillsborough' it was correct 'to approach the evidence on the basis that the gross negligence test is sufficient to establish the offence of manslaughter' and this formed the basis for their Joint Opinion. SWFC's 'responsibility for the crushing and deaths' lay 'in its responsibility for ... the layout of the inside of the ground' and the 'layout, number, designation and marking of the turnstiles'. While potentially 'substantial causes of the deaths', they were 'not the sole causes, or even the major causes'. For 'the layout of the ground was the responsibility of ... four organisations and in varying degrees'.

¶2.6.232 As 'a case against each defendant must be given totally separate consideration', Counsel's joint advice was: 'there is no sufficient evidence to support a prima facie case that the Club caused the deaths'. In addition, 'the evidence does not begin to show either recklessness or gross negligence' on the part of SWFC and there was 'no evidence to support a charge of manslaughter against either the Club or any of its officials'.

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¶2.6.233 As consultant engineer to the Club, Dr Eastwood shared responsibility for the layout of the stadium and the operation of the turnstiles. His advice, however, 'formed part only of the sequence of events that led to the structural condition of the ground' and 'by no rational yardstick' could it 'have caused the deaths'.

¶2.6.234 It was Dr Eastwood who had recommended discrete turnstile entrances for each pen 'which might well have led to the insertion of maximum figures ... in compliance with the Safety Certificate'. SWFC had not pursued his recommendations for financial reasons. 2.6.235 The Joint Opinion considered there was 'no evidence that Dr Eastwood caused the deaths'; nor that 'he was either reckless or grossly negligent'. Counsel had 'no hesitation, therefore, in concluding that there is no evidence to support a charge of manslaughter against Dr Eastwood or against Eastwood and Partners'. 2.6.236 Sheffield City Council, not Dr Eastwood, was responsible for 'ensuring compliance with the Green Guide' and for issuing the safety certificate which 'should have been amended to provide for the alterations and for the insertion of maximum figures for the pens'. 2.6.237 The Joint Opinion noted that it did 'not follow that the disaster would not have happened even if the safety certificate had been amended, since compliance depended on the Club and Dr Eastwood'. In Counsel's view, as with SWFC and Dr Eastwood, 'the Council's errors only partly contributed to the ground conditions identified above as causes of the deaths and on any view were too remote to amount to a prima facie case of manslaughter'. There was 'no evidence of recklessness or gross negligence on their part'. 2.6.238 Counsel's Joint Opinion, in line with LJ Taylor, was that the 'main responsibility for the disaster' lay with SYP. They had been partly responsible for the stadium layout and for the turnstiles and were also responsible for initiating an informal 'policy' of allowing spectators to 'find their own level' within and between the terrace pens. This had been 'heavily criticised in the Taylor Report'. 2.6.239 Further, there was 'a serious failure of policing in Leppings Lane, due in part to a failure to follow filtering tactics used effectively in 1988'. 2.6.240 In the Joint Opinion, however, these errors were only 'part of a complex sequence of events, many of which were outside the control of the police'. SWFC, Eastwoods and Sheffield City Council each had greater responsibility for the layout of the stadium and the inadequacy of the safety certificate. While the 'unruly behaviour of a minority of [Liverpool supporters]' was 'no doubt foreseeable', it 'created added difficulties' for the police. 2.6.241 Responsibility for the 'failure to postpone the kick-off and to cordon off the access tunnel' was 'confined to Mr Duckenfield'. Thus Counsel considered it 'inescapable' that 'the police as an organisation cannot be said to have caused the deaths by their strategy and operational errors' (emphasis in original). Consequently there was 'no basis on which to advise a charge of corporate manslaughter'. 2.6.242 LJ Taylor's criticisms of C/Supt Duckenfield for failing to cordon off the access tunnel to the central pens and for his decision not to postpone the kick-off had been 'entirely justified'. As 'operational commander ... he was ultimately responsible for the policing both within and outside the ground'. He had been 'slow to recognise the crushing' and 'the gross imbalance of filling' between the central and outer pens and his

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¶'preoccupation with the possibility of a pitch invasion caused him to delay putting the Major Disaster Plan into operation'. 2.6.243 However, C/Supt Duckenfield 'had under his command officers with considerable experience of policing the match and the ground who also made operational errors or failed to react as they should have done'. In addition, if 'the operational orders or police intelligence was inadequate, as seems likely, it was not the fault of Mr Duckenfield who inherited a ready made match plan compiled by others and tried to follow it'.

¶2.6.244 Though C/Supt Duckenfield declined to be interviewed, in Counsel's Joint Opinion he 'would no doubt argue that none of [his] errors caused the deaths because of the imposition of the many other factors already rehearsed'. Counsel considered that this 'argument would be likely to succeed in relation to many of the criticisms'. 2.6.245 Yet there was 'a case to be made ... that his failure both to postpone the kick-off and to take action to close the tunnel after the opening of gate C was a substantial cause of the deaths, in that it significantly contributed to the crowd pressure which led to the crushing and the collapse of barrier 124A'. 2.6.246 In considering manslaughter, the issue was: 'did [Duckenfield] intend an act which created an obvious and serious risk of causing personal injury, either not giving thought to the possibility of such risk, or having recognised that there was some risk involved, nonetheless go on to take it?' 2.6.247 Mr Duckenfield's 'act' was: 'an omission or omissions to act which contributed to a rapidly developing state of affairs ending in serious risk of injury'. Counsel's view was that this was not 'an obvious risk at the time'. 2.6.248 In fact, the 'complexity of the disaster as now known to those who have analysed it in hindsight demonstrates that there must be grave doubt as to whether the omissions created a risk which was obvious to anyone at the time' (emphasis in original). 2.6.249 Consequently, there was 'insufficient evidence' to charge him with recklessness and no evidence that he had been 'grossly negligent in failing to act'. Thus there was 'no sufficient evidence of any criminal offence having been committed by Mr Duckenfield'. Regarding allegations made against SYP officers other than C/Supt Duckenfield, Counsel concluded that there was no evidence of criminal offences but that there should be consideration of disciplinary proceedings. 2.6.250 Counsel considered that responsibility for the disaster lay with SWFC, Eastwoods, Sheffield City Council and SYP, the greatest proportion with the police. They were satisfied that the evidence did not support the criminal prosecution of any organisation or individual. The disaster was complex, with responsibility shared for many failings. 2.6.251 Counsel's Joint Opinion was accepted by the CPS, apparently without further consideration, and the Head of its Police Complaints Division noted, 'there is insufficient evidence to justify the institution of criminal proceedings against any person for any offence arising out of this terrible disaster'.116 Papers would be 'sent to the Attorney General to inform him of that advice' and, '[s]ubject to the Attorney's views, we propose to advise the Chief Constable of South Yorkshire accordingly'. 2.6.252 The timing of a public announcement took into account 'the anxiety that South Yorkshire Police quite properly express' about the opening fixture of the new season

116. Memorandum from Mr CWP Newell, Director of HQ Casework, CPS, to Mr CJ Cleugh, Head of Police Complaints

¶Division, CPS, 20 August 1990, CPS000003250001, p41.

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¶between Sheffield Wednesday and Liverpool. It was delayed until after the match. A press statement confirming the DPP's decision was published on 30 August 1990.117 2.6.253 The decision was contested by MPs whose constituents included bereaved families. In a letter to Doug Hoyle MP, the Attorney General set out the position.118 It had been established that 'many factors' contributed to the disaster – historical, safety requirements, policing – and 'all combined in differing proportions to produce the disaster'.

¶2.6.254 Criminal liability, stated the Attorney General, was not determined by the 'overall picture' but through 'analysis of the individual conduct of each potential defendant and whether his or her conduct was sufficiently proximate to the disaster to constitute what the law describes as a "substantial operating cause"'.

¶2.6.255 Having explained the legal test for 'manslaughter' the Attorney General noted that the DPP had given 'careful consideration' to 'all those whose conduct could be regarded as having a bearing on the tragedy'. Following 'advice from two very experienced leading counsel' he had concluded 'that the evidence was insufficient for there to be a realistic prospect of securing a conviction of any person for manslaughter or any other criminal offence'.

¶2.6.256 Throughout the Judicial Inquiry SYP had obtained copies of the officers' statements to assist with the preparation of their evidence. On the direction of the CPS, and with the agreement of the Police Complaints Authority (PCA) and the Coroner, this practice ceased during the criminal investigation.119 Following the DPP's decision, with the eventual agreement of the Coroner, the DPP and Investigating Officer Chief Constable Leslie Sharp, all statements and evidence material passed into the possession of SYP.120

¶Complaints and disciplinary investigations 2.6.257 Investigations into complaints made by bereaved families and others against SYP officers were undertaken by WMP investigators in conjunction with the criminal investigation. They informed decisions taken by SYP and the PCA regarding possible disciplinary action against SYP officers. The lead Investigating Officer was Leslie Sharp, Chief Constable of Cumbria Constabulary, who superseded the previous Investigating Officer, CC Dear. The investigations were overseen by the PCA.

¶2.6.258 The complaints against SYP Chief Constable Peter Wright focused on reported comments following an interview with the Sheffield Star headlined 'Coroner will reveal the true story'.121 In the press interview, he referred to 'a very strong feeling of resentment and injustice in the force as a result of Hillsborough'. LJ Taylor's conclusion that fans' drinking had had 'no effect on the events' was 'a little difficult to come to terms with'.

¶2.6.259 At the inquest, he claimed, there would 'be a lot of additional evidence presented to the coroner's inquiry that was not presented at Lord Justice Taylor's inquiry, which may put a different complexion on the end product'.

¶2.6.260 In response, bereaved families complained about the 'distressing innuendo, insinuation and veiled hints that additional evidence, not revealed to Lord Justice Taylor, will

117. Press release: 'THE HILLSBOROUGH FOOTBALL STADIUM DISASTER', 30 August 1990, CPS000004930001, p13. 118. Letter from Attorney General to Douglas Hoyle MP, 29 November 1990, CPS000005010001. 119. Several documents within Crown Prosecution Service file CPS000003250001. 120. File note 'Hillsborough – Legal/Inquest Proceedings – Progress Report' written by DCC Peter Hayes, 18 September

¶1990, SYP000118480001, pp23-24. 121. Sheffield Star, 'Coroner will reveal the true story', 5 February 1990, SYP000123600001, p126.

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¶show alcohol played a major part in the tragedy'.122 They considered CC Wright's comments 'at best a breach of his privileged position and at worst a deliberate attempt to pervert the course of justice' by influencing the forthcoming inquests.123

¶2.6.261 The South Yorkshire Police Authority decided that complaints made against the Chief Constable should be investigated by WMP.124 The Investigating Officer was CC Sharp.125 Statements were taken from the complainants and from the Sheffield Star journalist who had written the story.126 CC Wright provided written evidence127 and a full transcript of the newspaper interview was obtained.128 CC Wright was then formally interviewed.129

¶2.6.262 CC Wright reiterated that evidence not heard by LJ Taylor would be presented at the inquests;130 the 'cause of the barrier collapse in pen three and the specific place where deaths occurred' were 'obvious instances of evidence not yet revealed'. He denied implying 'that the fresh evidence relates to drink', stating that he had 'no knowledge of what specific evidence will emerge'.

¶2.6.263 Given 'all the publicity given to Lord Justice Taylor's Inquiry, all that has been said by many people publicly during and since the Inquiry … the suggestion that my statement would prejudice jurors is quite simply nonsense'.

¶2.6.264 CC Sharp reported on the complaints.131 He considered there had been 'nothing' said by CC Wright 'which suggests the additional evidence would or might relate to drink'. Yet, 'the manner in which the article is presented in The Sheffield Star could be interpreted that way' due to 'selectivity and juxtaposition in respect of the quotes'.

¶2.6.265 There was 'nothing to indicate that Mr WRIGHT was, or intended to be oppressive, abusive or uncivil to anyone, or to influence any juror or proceedings'. In conclusion, CC Sharp found 'all of the complaints to be unsubstantiated' and that 'no disciplinary offences' had been committed. His report and conclusions were accepted by South Yorkshire Police Authority on 27 April.132

¶2.6.266 CC Wright retired, as planned, three days later. He wrote to CC Sharp thanking him for processing the complaints quickly.133 He had 'dreaded the thought that I may have left the Service with them unresolved' but could now leave 'with a clear conscience'.

¶2.6.267 CC Sharp replied with gratitude, stating that the investigation had not been 'a job I relished or enjoyed doing'.134 He continued: 'That is not to say that I did not do it to the best of my ability – I did – but I would much rather have been able to sit with you over a pint, and

122. Letter from Mr Devonside to South Yorkshire Police Authority, 3 March 1990, SYP000123600001, p131. 123. Letter from Mr and Mrs Hicks to South Yorkshire Police Authority, 7 February 1990, SYP000123600001, p129. 124. Letter from South Yorkshire Police Officer to West Midlands Police, 22 March 1990, SYP000123600001, p133. 125. Statement of CC Leslie Sharp, 10 April 1990, SYP000123600001, p106. 126. Statements in document SYP000123600001, pp74-113. 127. Letter from CC Peter Wright to South Yorkshire Police Authority, 23 February 1990, SYP000123600001, p143. 128. Transcript of 'Peter Wright 5.2.90' tape, 5 February 1990, SYP000123600001, p147. 129. Interview with CC Peter Wright, 10 April 1990, SYP000123600001, p180. 130. These quotes are from the letter from CC Peter Wright to South Yorkshire Police Authority, 23 February 1990,

¶SYP000123600001, pp143-144. 131. Complaint against Peter Wright, Investigating Officer's Report, 23 April 1990, SYP000123600001, from p213. Quotes from pages 230, 257 and 258. 132. Minutes of special meeting of South Yorkshire Police Authority, 27 April 1990, SPA000000430001. 133. Letter from CC Peter Wright to CC Leslie Sharp, 30 April 1990, SYP000123600001, p212. 134. Letter from CC Leslie Sharp to Peter Wright, 8 May 1990, SYP000123600001, p211.

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¶yarn about the past, present and future'. Given that '[s]omeone had to do it' he was 'pleased that I was able to complete it in time to let you leave the service in peace'.

¶2.6.268 CC Sharp concluded that the 'balance sheet of service and dedication of Peter Wright will always be heavily in credit. More people than you will ever know, believe that. I, for one, know that to be true'.

¶2.6.269 CC Sharp also investigated complaints made against seven other SYP officers. The PCA confirmed it was content that the various complaints had been 'thoroughly investigated' and CC Sharp's reports had been forwarded to SYP and its Police Authority.135 In each case, CC Sharp presented the allegations, his analysis of the evidence and his recommendations regarding disciplinary action.136

¶2.6.270 The complaints against C/Supt Duckenfield were:

1. Failure 'to acquaint himself with the planning and problems related to the control of the semi-final'.

2. Failure 'to prevent a dangerous build up of supporters outside the Leppings Lane gates'.

3. Failure 'to monitor the crowd numbers packing into pens 3 and 4'.

4. Failure 'to act when it became obvious that pens 3 and 4 were overfull when he had an excellent view point from the police box above the pens'.

5. 'He should not have opened the gates under any circumstances giving unlimited and uncontrolled access into the football ground by supporters'.

6. Failure 'to control the movement of supporters subsequent to the opening of Gate C'.

7. Failure 'to make provision for fans coming through Gate C after he had given the order for the gate to be opened'.

8. Failure 'to respond to the developing tragedy and [that he] was slow to effect a rescue operation'.

9. Failure 'to act when it was obvious that people were in distress'.

10. Deceit and intentionally misleading 'senior police officers and members of the public regarding his command and control of police officers on the day'.

11. Attempting 'to mislead the Assistant Chief Constable at the ground and others, namely, representatives of the Club, the FA, and the fans themselves regarding the origin of the order for gate 'C' to be opened. That is by inferring [sic] supporters had forced open the gate when he had, in fact, given the order to open the gate'.

12. Example statement by the Police Complaints Authority, SPA000000390001. 136. The complaint and discipline report files are available as follows:

¶Chief Superintendent David Duckenfield, South Yorkshire Police, SYP000038960001

¶Assistant Chief Constable Walter Jackson, South Yorkshire Police, SYP000038970001

¶Superintendent Roger Marshall, South Yorkshire Police, SYP000038980001

¶Superintendent Roger Greenwood, South Yorkshire Police, SYP000038990001

¶Superintendent Bernard Murray, South Yorkshire Police, SYP000131490001

¶A South Yorkshire Police Constable, SYP000038940001

¶A South Yorkshire Police Constable, SYP000038950001.

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12. Collusion 'with Mr JACKSON, the Assistant Chief Constable, to mislead the public over the opening of Gate C'.137

¶2.6.271 CC Sharp's analysis reflected the WMP report to the DPP. His advice was that allegations 1, 5, 10, 11 and 12 (above) were 'unsubstantiated' while allegations 2, 3, 4, 6, 7, 8 and 9 were 'identical to those currently under consideration by the Director of Public Prosecutions'.

¶2.6.272 Consequently, should it be decided that there was 'insufficient evidence to prosecute these criminal offences, then the same must be said in respect of the disciplinary offence'.

¶2.6.273 CC Sharp also considered that allegations made against one junior officer were unsubstantiated, while in the remaining six cases (including C/Supt Duckenfield), all complaints would be unsubstantiated if the DPP decided not to prosecute. The DPP announced his decision not to proceed with criminal prosecutions on 30 August 1990. 2.6.274 The SYP decision regarding disciplinary proceedings was not made immediately as 'the Coroner and the Police Complaints Authority are of the view that no discipline decisions should be arrived at in advance of the Inquest findings'.138 2.6.275 Following the conclusion of the inquests, SYP's Assistant Chief Constable Stuart Anderson wrote to the PCA.139 He had decided 'that no disciplinary action is appropriate in respect of any of the complaints'.140 His decision was 'based solely upon the evidence presented to me in the report of the supervised investigation undertaken by Mr Leslie Sharp'. 2.6.276 Brigadier John Pownall replied that the PCA was 'disappointed' with the lack of detail in ACC Anderson's letter and requested 'a more fully reasoned explanation'.141 ACC Anderson responded immediately.142 He explained that it had been his wish that 'the events of that afternoon be looked at externally and quite independently without any suggestion of influence by the management of the force'. The recommendation submitted was 'unbiased' and he 'would not seek to influence the decision of the PCA'. 2.6.277 Brigadier Pownall wrote to ACC Anderson's successor, Assistant Chief Constable Moore, presenting the PCA's position on possible disciplinary action.143 For four officers, the PCA agreed that the evidence did not justify disciplinary proceedings. The complaints against C/Supt Duckenfield and Supt Murray, however, raised 'difficult issues'. 2.6.278 The PCA did not accept that the disciplinary charge of 'neglect of duty' was identical to any possible criminal offence. Even had it been, 'we would not be bound

137. Complaint and discipline report file for Chief Superintendent David Duckenfield, South Yorkshire Police,

¶SYP000038960001. 138. File note 'Hillsborough – Legal/Inquest Proceedings – Progress Report' written by DCC Peter Hayes, 18 September

¶1990, SYP000118480001, p23. 139. ACC Anderson's letter did not cover the complaints made against Assistant Chief Constable Walter Jackson. Though

¶CC Sharp had also concluded that complaints against ACC Jackson were unsubstantiated, this case was dealt with separately. South Yorkshire Police Authority were advised to dismiss the complaints made against ACC Jackson on

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¶(as far as discipline is concerned) by the decision of the Director not to bring criminal prosecutions'. 2.6.279 For the PCA, the Hillsborough disaster 'would not have occurred had sensible and simple steps been taken to secure the safety of spectators in Pens 3 and 4'. The 'responsibility for the safety of those in Pens 3 and 4 and blame for overcrowding in those pens should rest with those in the Police Control Box from which the pens could be observed, the deployment of police manpower could be directed and the decision to open Gate "C" was made with its attendant responsibility for controlling those who entered through it'. 2.6.280 Thus the PCA recommended that disciplinary charges of 'neglect of duty' be brought against C/Supt Duckenfield and Supt Murray, as well as an additional charge of 'discreditable conduct' against C/Supt Duckenfield in line with LJ Taylor's finding that he had misled others into believing that Liverpool supporters had forced entry through Gate C. 2.6.281 In preparing a response to the PCA's recommendations, SYP took advice from CC Sharp and Counsel, Richard Payne. CC Sharp wrote to SYP Deputy Chief Constable Peter Hayes, stating it was 'quite wrong … to pursue disciplinary charges of "neglect of duty", particularly as the Inquest jury brought in a verdict of "Accidental Death"'.144

¶2.6.282 In CC Sharp's opinion, the inquest verdict, together with the DPP's decision not to prosecute, was a 'powerful argument' against disciplinary charges. He advised that 'the problems of proving the disciplinary offences proposed by the PCA are formidable'.

¶2.6.283 On 31 May 1991, Stephen Walker, solicitor for South Yorkshire Police Authority, wrote to Mr Payne, requesting further advice.145 Directing Mr Payne towards relevant parts of the inquest transcripts, Mr Walker noted that 'much of what happened at the inquests helped in no small way to redeem a balance which had hitherto weighed heavily in criticism of the actions of some officers at Hillsborough, not least being Chief Superintendent Duckenfield and Superintendent Murray'.

¶2.6.284 Should Mr Payne advise 'that the PCA's views are supportable disciplinary proceedings will be taken as recommended'. Mr Walker stated that ACC Moore had 'no principle objection to taking disciplinary action' but there was 'clear concern that the PCA's recommendations fly so dramatically in the face of the Investigating Officer's views'.

¶2.6.285 Should Mr Payne consider that disciplinary proceedings were 'not supportable', written opinion would be sought by SYP and submitted to the PCA. Subsequently, Mr Payne advised that, with the exception of LJ Taylor, 'the conclusions of those who have made an independent study of the primary evidence do not attribute blame to any Police Officer'.146 He cited the DPP's decision not to prosecute, the inquest jury's finding of accidental death and CC Sharp's report to the PCA.

¶2.6.286 In conclusion, Mr Payne's view was that disciplinary charges would be 'oppressive and unnecessary and fruitless' with none having a 'realistic chance to succeed'. ACC Moore forwarded Mr Payne's and CC Sharp's submissions to Brigadier Pownall at the PCA.147

144. Letter from CC Sharp, Cumbria Constabulary, to DCC Hayes, South Yorkshire Police, 16 May 1991,

¶SYP000123570001, pp58-63. 145. Letter from Stephen Walker to Richard Payne, 31 May 1991, SYP000123570001, pp37-48. 146. Counsel's advice from Richard Payne, undated, SYP000094930001, pp91-125. 147. Letter from ACC Moore, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 26 July 1991,

¶SYP000123570001, p17.

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¶2.6.287 Brigadier Pownall forcefully rejected both submissions.148 He questioned the propriety of CC Sharp's letter, writing that 'we did not feel it was altogether appropriate for the investigating officer to set out so fully his views on the disciplinary action to be taken'. He also criticised the lack of thoroughness underpinning Mr Payne's opinion, stating that it was 'selective' and had failed to reflect 'some important points'.

¶2.6.288 As SYP had not acted on the PCA's recommendations, the PCA had 'decided in accordance with Section 93(3) of the Police and Criminal Evidence Act 1984 to direct that disciplinary charges be preferred against Chief Superintendent Duckenfield and Superintendent Murray as set out in our letter of 7 May, 1991 and for the reasons explained in that letter'. This placed a legal duty on SYP to bring disciplinary charges.

¶2.6.289 Arrangements for a Tribunal to hear the charges followed.149 Charges were drafted by SYP and forwarded to the PCA for approval.150 Following discussion with ACC Moore, Brigadier Pownall agreed with the draft charges, but 'wondered if counsel should have the opportunity to comment upon them before they were served'.151

¶2.6.290 This caused a significant delay. The South Yorkshire Police Authority solicitor provided initial instructions to Counsel, John Sleightholme,152 who visited the PCA.153 Superintendent Alan Fell at SYP estimated the 'anticipated date for the Tribunal' as 2 July 1992, a nine-month delay.154 Brigadier Pownall 'was concerned about the delay'155 and suggested setting a date for the Tribunal without charges being served.

¶2.6.291 According to ACC Moore, however, this 'would amount to oppressive conduct as Chief Superintendent Duckenfield was sick with stress and had been told not to deal with any issue at all relating to Hillsborough'. ACC Moore stated that Brigadier Pownall 'went on at length as to how the public was fed up with police officers using this method of "getting away with it"'.

¶2.6.292 Ahead of a further conversation between ACC Moore and Brigadier Pownall, Supt Fell wrote to ACC Moore informing him of several problems.156 These centred on the status of evidence gathered by WMP. Statements could not be 'conveniently used' for disciplinary proceedings as many were 'unsigned or undated recollections of answers to questionnaires'.

¶2.6.293 Further, relevant witnesses had 'not been asked for their evidence'. Many statements 'did not contain material that the witnesses gave to the Lord Justice Taylor enquiry and the Inquest'. Without proper statements, charges could not be formulated, witnesses could not be chosen and it was not possible to meet the legal duty to disclose evidence against the accused.

148. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police,

¶SYP000123570001, p9. 149. South Yorkshire Police press release, 12 July 1991, SYP000123580001, p319. 150. Letter from South Yorkshire Police to Brigadier Pownall, Police Complaints Authority, 18 July 1991, with draft charges,

¶SYP000123580001, p301 and pp306-311. 151. Note for file of discussion with Brigadier Pownall, Police Complaints Authority, 22 July 1991, SYP000123580001, p289. 152. Instructions to Counsel, 25 July 1991, SYP000110390001. 153. Counsel's advice, 9 October 1991, SYP000123580001, pp180-188. 154. Memorandum from Superintendent Fell to Chief Superintendent Mole, 5 September 1991, SYP000123580001, p257. 155. Note of telephone conversation between ACC Moore, South Yorkshire Police, and Brigadier Pownall, Police

¶Complaints Authority, 29 August 1991, SYP000123580001, p262. 156. Memorandum from Superintendent Fell to Assistant Chief Constable Moore, 23 September 1991, SYP000123580001, p255.

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¶2.6.294 On 25 September, ACC Moore had a telephone conversation with Brigadier Pownall, apparently recorded verbatim.157 Brigadier Pownall's advice, from the Chairman of the PCA, was that the problems raised by Mr Sleightholme were inconsequential. ACC Moore stated that he had 'the impression' that Brigadier Pownall thought the SYP was 'not doing our job properly' and 'might be trying to delay the matters, which I don't think is fair'.

¶2.6.295 Brigadier Pownall replied that 'the issues are really comparatively simple'. ACC Moore disagreed. Brigadier Pownall, however, stated that he had 'seen this in many cases that we [the PCA] deal with, and you know even much much lesser things than this – it's a sort of tactic. I mean, I don't mean it offensively or rudely, but I can see no other reason'.

¶2.6.296 ACC Moore disclosed that he was in a difficult position given Counsel's advice and suggested that the Chairman of the PCA, Judge Francis Petre, should meet Mr Sleightholme and they could 'talk law together'.

¶2.6.297 Brigadier Pownall then wrote to ACC Moore expressing concern that such a meeting might 'be imposing too great an influence from the Authority [the PCA] on matters which are strictly the responsibility of the South Yorkshire Police'.158 He enclosed a note written by Judge Petre intended to 'provide some helpful guidance'.

¶2.6.298 According to Judge Petre's note, the disciplinary charges were 'simple and easy to understand' and although 'the overall enquiry gave rise to a vast amount of paper-work ... the charges are specified so as to keep the issues within manageable limits'.

¶2.6.299 Mr Sleightholme, however, considered that the note appeared to miss the point. He stated: 'Whilst I am grateful for the Chairman's notes, these do not, with respect to him, represent the problems which presently give cause for concern'.159 Mr Sleightholme was concerned about the status of witness statements.

¶2.6.300 Further, his intention had been to rely on C/Supt Duckenfield's evidence at the inquests, but he 'had not anticipated that he [C/Supt Duckenfield] would have given some answers which were against his interests but were untrue'. Apparently, he 'had "wilted" under cross-examination' and it 'would be entirely wrong to seek to rely on answers we genuinely believe to be untrue'.160

¶2.6.301 Mr Sleightholme required more time to consolidate the charges and prepare the evidence thoroughly. While he wanted to establish a timetable for the Tribunal as soon as possible, it was not 'proper' to do so without agreeing charges.

¶2.6.302 Concern about C/Supt Duckenfield's health was also significant, particularly the impact of serving charges on someone who had been 'off sick for a lengthy period'.

¶2.6.303 A further note from Supt Fell presented the problems.161 The Tribunal could not 'proceed until charges accompanied by supporting statements of evidence have been served on the accused officers'. Yet the evidence did not 'exist in an appropriate form'. It would require a 'team of police officers conversant with the circumstances ... to obtain

157. Note of telephone conversation between ACC Moore, South Yorkshire Police, and Brigadier Pownall, Police

¶Complaints Authority, 25 September 1991, SYP000123580001, p251. 158. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 30 September

¶1991, SYP000123580001, pp219-230. 159. Advice from Counsel, 9 October 1991, SYP000123580001, pp180-188. 160. The evidence considered 'untrue' is not specified. 161. 'Problem preventing progress of the Hillsborough tribunal' by Superintendent Fell, 21 October 1991,

¶SYP000123580001, pp172-179.

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¶such statements'. Given that the PCA had already 'certified ... that it was satisfied with the investigation' setting up a team was 'difficult to countenance'.

¶2.6.304 Supt Fell reiterated the issue concerning officers' recollections, some of which 'were supplemented by further recollections'. He considered that 'some' recollections 'were perhaps influenced by advice as to what was required for the purpose of the Taylor Inquiry and civil litigation'.

¶2.6.305 Other statements, made by non-police witnesses, were also unsigned and witnesses had given additional evidence to LJ Taylor or the inquests, making their statements 'incomplete'. Supt Fell continued: 'Unpalatable though it might prove, the Regulations must be followed and the solution to the problem of obtaining suitable statements appears to be that West Midlands police should complete the investigation under the continuing supervision of the Police Complaints Authority'. Otherwise, 'the Tribunal probably cannot begin its work'.

¶2.6.306 According to Supt Fell, there appeared to be 'no alternative to obtaining appropriate and suitable statements'. Yet there were risks. When it became 'widely realised that there is a need to take further statements to be satisfactory for the purpose of the discipline hearing, questions may be asked whether (as the investigating officer indicated) they were unsatisfactory for the purpose of a criminal prosecution'.

¶2.6.307 Should this be the case, it could be suggested that they were not 'ideally appropriate for making decisions as to criminal culpability'. His conclusion was unambiguous: 'Far fetched though such speculation is, it would be better if it never could surface'.

¶2.6.308 Supt Fell's report was forwarded to the PCA.162 Following a request for more information, a schedule of statements given by the proposed disciplinary witnesses, along with details of whether they had been signed, dated and witnessed, was provided soon after.163

¶2.6.309 Meanwhile, because of C/Supt Duckenfield's continuing ill-health, doubts were raised publicly about the likelihood of disciplinary charges. An open letter from Trevor Hicks of the Hillsborough Family Support Group stated that delays in bringing charges were 'totally unacceptable'.164

¶2.6.310 He wrote that considerable time had passed since the decision on criminal prosecution had been taken, and '[n]othing has, so far, happened – allegedly due to Mr Duckenfield's incapacity on undisclosed sickness grounds'. He noted that it was '90 days since ... Mr Duckenfield commenced sick leave' allowing him 'to apply for early retirement on ill health grounds and the disciplinary matters relating to him would automatically lapse'.

¶2.6.311 SYP Chief Constable Richard Wells replied that he understood 'the [bereaved] families' sense of impatience'. He continued: 'The 96 deaths resulting from the Hillsborough tragedy are constantly on our minds and we share the grief of those bereaved. Strong

162. Letter from ACC Moore, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 24 October 1991,

¶SYP000123580001, p161. 163. Letter from ACC Moore, South Yorkshire Police, to Judge Petre, Police Complaints Authority, 29 October 1991,

¶SYP000123580001, pp124-156. 164. Letter from Trevor Hicks to Chief Constable Richard Wells, South Yorkshire Police, 23 October 1991,

¶SYP000123580001, p167.

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¶feelings like this have still to submit themselves to the processes of the world of legal detail'.165

¶2.6.312 He reassured Mr Hicks that SYP had 'let no grass grow under our feet' and had instructed Counsel to draw up disciplinary charges. It was, however, 'very difficult for anyone to finalise arrangements for the hearing while the details of charges have yet to be agreed between the South Yorkshire Police and the Police Complaints Authority'. C/Supt Duckenfield's illness was a 'further complication'. The assessment of his illness was 'not a matter for police officers, it is a matter of medical advice'. A report from 'a police staff surgeon' was awaited.

¶2.6.313 Soon after, the report was received by SYP and CC Wells issued a statement.166 He had taken 'the decision to retire Chief Superintendent David Duckenfield from the South Yorkshire Police on medical grounds'. The police surgeon's 'unequivocal report left ... no doubt that Mr Duckenfield is too ill to continue service as a police officer'. His medical condition could not be disclosed due to 'the rules of patient and doctor confidentiality'. More generally, however, he was 'described as suffering from severe depression and post traumatic stress disorder'.

¶2.6.314 CC Wells stated that he understood that bereaved families and others would 'be angry at my decision since it rules out Mr Duckenfield's involvement in the planned disciplinary tribunal for which South Yorkshire Police have been preparing for some months'. He continued: 'David Duckenfield has become the symbolic focus of much of the anguish felt by those who were so hurt by the tragedy but I must deal with the man, not the symbol. The fact is, David Duckenfield is now too ill to serve'.

¶2.6.315 The decision had not been taken 'lightly ... more especially in a case of such complexity and public interest'. He concluded: 'The fact that David Duckenfield is so unwell has simplified that decision. There has been enough suffering already and I can only hope that time will help to soften the terrible pain felt by the families of the Hillsborough victims, and will help to heal David Duckenfield as well'.

¶2.6.316 The sole remaining charge was against Supt Murray. Mr Sleightholme accepted 'the charge against Supt Murray has some prospects of success' but he was 'concerned as to whether having regard to all the circumstances that now obtain it is just and fair that Supt Murray should as it were be seen to face the music alone'.167

¶2.6.317 A detailed charge was drafted.168 WMP were approached to take additional evidence.169 SYP, however, requested the PCA to allow proceedings to be dropped.170 Crucially, it was questionable 'whether a fair hearing can occur when such an important witness [C/Supt Duckenfield] is absent' leaving 'the tribunal as a means of casting Mr Murray as scapegoat for the Hillsborough Disaster'.

¶2.6.318 On 13 January 1992, the PCA published its decision.171 Following 'very careful consideration' it had decided that in the wake of C/Supt Duckenfield's retirement 'what

165. Statement by CC Wells, South Yorkshire Police, undated, SYP000123580001, pp163-164. 166. South Yorkshire Police press release, 29 October 1991, SYP000123580001, p123. 167. Advice from Counsel, SYP000123580001, p88. 168. Draft disciplinary charge, 26 November 1991, SYP000123580001, p39. 169. Letter from ACC Roche, West Midlands Police, to ACC Moore, South Yorkshire Police, 20 December 1991,

¶SYP000123580001, p14. 170. Letter from ACC Moore, South Yorkshire Police, to Judge Petre, Police Complaints Authority, 12 December 1991,

¶SYP000123580001, p27. 171. Statement by the Police Complaints Authority, 13 January 1992, SYP000123580001, pp9-13.

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¶is, in effect, a joint allegation of neglect of duty cannot be fairly heard in the absence of the more senior officer'. To continue with disciplinary proceedings would be 'unjust and inappropriate'. Thus SYP were granted leave not to proceed.

¶2.6.319 CC Wells expressed SYP's 'deep and sincere sorrow' towards the bereaved families and noted the impact of the disaster on police officers who 'faced with the tragedy, attempted to deal with the horror of the moment'.172 He recalled 'the sentiments of Dr Hapgood who, at the Memorial Service, said that no disaster was the fault of one organisation or of just one human being, but rather a combination of factors and shared responsibilities'.

¶2.6.320 Consequently, CC Wells had 'never been convinced of the appropriateness of the disciplinary tribunal'. This opinion had been 'strengthened by the Director of Public Prosecution's [sic] decision on criminal matters, by the findings of the independent investigating team, the conclusions of the inquest and advice given by leading counsel'.

¶2.6.321 CC Wells had 'never thought that the police alone should be blamed, although we firmly acknowledged our own responsibilities by the settlement of the civil actions against us'. He concluded by stating that SYP were 'anxious not to forget Hillsborough, but to draw strength from its lessons and to move forward, particularly in the area of ground improvements for crowd safety, which are the real ways in which we can give some meaning to the awful loss of life on that afternoon'.

¶2.6.322 On behalf of the Hillsborough Family Support Group, Mr Hicks criticised the decision as the 'final coat of whitewash'.173

¶Conclusion: what is added to public understanding • Documents disclosed to the Panel by SYP show that on the morning after the disaster senior officers discussed privately the 'animalistic behaviour' of 'drunken marauding fans', but agreed not to make this a public issue in case they were perceived as avoiding responsibility. • No contemporaneous documents have been disclosed concerning the briefing given to the Prime Minister and the Home Secretary by SYP when they visited Sheffield on

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• The SYP submission also noted structural deficiencies within the stadium and its management by SWFC. This line of argument was further developed in advice from a senior police officer from another force commissioned by SYP in support of civil proceedings. In contrast, the SWFC submission specified serious failures in policing in monitoring the pens, processing the crowd and opening Gate C without preparing for the consequences.
• Reports commissioned by SYP and SWFC from two experienced senior police officers reveal how, when confronted with consistent information from two distinct and potentially culpable institutional interests, significantly different conclusions were drawn.
• The submission by Counsel to the Taylor Inquiry focused on the build-up of fans outside the stadium, insufficiency of turnstiles and lack of control of the numbers distributed between the pens.
• An initial investigation into the condition of the Leppings Lane terrace and its approaches was conducted by Sheffield City Council. It found deficiencies in the placement of safety barriers and in the width of the perimeter fence gates.
• In its more detailed investigation, the Health and Safety Executive (HSE) established that the safe maximum capacity of the pens had been set too high and that the crowd density in pen 3, where most of the deaths occurred, was substantially higher than the Green Guide maximum.
• The HSE established not only that the maximum capacity of the terrace and the central pens had been significantly over-calculated, but that alterations to the terrace had not been considered in establishing safe capacity. It concluded that the terrace safety barriers were considerably below the recommended height and that this deficiency should have reduced further the maximum safe capacity.
• The restricted approach to the Leppings Lane end and the comparatively low number of turnstiles resulted in inevitable congestion and delays in entering the stadium at capacity matches. The HSE noted that the number of fans that had to pass through each of the Leppings Lane turnstiles was between 2.9 and 3.5 times higher than at turnstiles serving other parts of the stadium. The calculated rate of admission shows that the crowd could not have completed entering the ground until approximately 40 minutes after the kick-off.
• Many of these issues were also raised in Professor Leonard Maunder's advice as one of the assessors to the Taylor Inquiry. The advice from the police assessor, Chief Constable of Lancashire Brian Johnson, criticised SYP's failure to review the 1988 Police Operational Order to identify 'shortcomings'; poor communications between senior officers; and the consequent failure to divert the crowd away from the tunnel once Gate C had been opened.
• It is evident from the Salmon letters issued to SYP, SWFC, Sheffield City Council and Eastwood & Partners (disclosed to the Panel) that there was an understanding within the Home Office of the central issues of responsibility to be examined by the Taylor Inquiry.
• In documents disclosed to the Panel it is evident that the primary concern of the Government at the time was the potential impact (positive or negative) on the Parliamentary passage of the planned Football Spectators Bill.

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• Following the publication of the Taylor Report, the Prime Minister was briefed that 'the defensive – and at times close to deceitful – behaviour by the senior officers in South Yorkshire sounds depressingly familiar'. The Government did not seek to protect the SYP Chief Constable and it was considered inevitable that he would resign. His resignation, however, was rejected by South Yorkshire Police Authority.
• Access to Cabinet documents reveals that in an exchange about her Government 'welcoming the Report' the Prime Minister, Margaret Thatcher, expressed her concern that the 'broad thrust' of the Taylor Report constituted a 'devastating criticism of the police'.
• In reaching a decision on criminal prosecutions, the Director of Public Prosecutions was advised that responsibility for the disaster lay with SWFC, Eastwood & Partners engineers, Sheffield City Council and SYP. While the most significant proportion of responsibility was attributed to SYP, it was considered that the legal case for manslaughter or any other criminal offence could not be established.
• Disciplinary proceedings against Chief Superintendent David Duckenfield and Superintendent Bernard Murray were brought only following a direction from the Police Complaints Authority (PCA). Responding to legal advice, SYP had decided that disciplinary charges should not be brought. The PCA was concerned that subsequent delays in bringing disciplinary proceedings were 'tactical'. A significant cause of the delay was the impact of the 'review and alteration' of SYP statements and their evidential unreliability.