Reports that Matter

The Report of the Hillsborough Independent Panel

Front matter

Section 1 of 9

Hillsborough The Report of the Hillsborough Independent Panel September 2012

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The Report of the Hillsborough Independent Panel

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Contents

  • Foreword — 1

  • Report summary — 3

  • Part 1: Hillsborough: 'what was known' — 27

  • Part 2: Hillsborough: 'what is added to public understanding' — 59

  • Chapter 1. 1981–1989: unheeded warnings, the seeds of disaster — 61

  • Chapter 2. The 'moment' of 1989 — 87

  • Chapter 3. Custom, practice, roles, responsibilities — 103

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

  • Chapter 5. Medical evidence: the testimony of the dead — 159

  • Chapter 6. Parallel investigations — 181

  • Chapter 7. Civil litigation — 227

Chapter 8. The Coroner's inquiry: from the immediate aftermath to the

  • preliminary hearings — 255

  • Chapter 9. The generic hearing, Judicial Review and continuing controversies — 271

  • Chapter 10. The 3.15pm cut-off — 291

  • Chapter 11. Review and alteration of statements — 315

Chapter 12. Behind the headlines: the origins, promotion and reproduction of

  • unsubstantiated allegations — 341

  • Part 3: The Permanent Archive for the Hillsborough Disaster — 369

  • Appendix 1. Hillsborough Independent Panel terms of reference — 377

  • Appendix 2. Disclosure process — 381

  • Appendix 3. Research process and method — 387

  • Appendix 4. Retained tissue following post mortem examination — 391

  • Appendix 5. Freedom of information and Parliamentary debate — 393

Contents

Foreword

The fourth-century philosopher, Lactantius, wrote:

The whole point of justice consists precisely in our providing for others through humanity what we provide for our own family through affection. The disclosed documents show that multiple factors were responsible for the deaths of the 96 victims of the Hillsborough tragedy and that the fans were not the cause of the disaster. The disclosed documents show that the bereaved families met a series of obstacles in their search for justice.

The Hillsborough Independent Panel, in accepting its terms of reference from the Home Secretary, acknowledges the legitimacy of the search for justice by the bereaved families and survivors of Hillsborough through the disclosure of documents relating to the disaster and its aftermath.

The Panel was asked to consult with the Hillsborough families. We decided to meet with the three established groups on the very first day that we met as a Panel. Our meetings with the groups that day were the foundation of the Panel's work in the intervening two and a half years. In that period, we have made contact with at least one member of each of the families bereaved by Hillsborough. This includes a number of families who are not affiliated to any of the established groups. We should like to pay tribute to the individual families and to the representative groups. Their comments have informed the work of the Panel. But, more than that, the Panel has been impressed constantly by the determination of the families and survivors and by their dignity in their search for justice. This came to the fore when, in 2009, the Hillsborough Family Support Group met the Home Secretary, who then took the decision to appoint the Hillsborough Independent Panel.

The Panel has overseen full public disclosure of information relating to Hillsborough. The new Hillsborough website makes this information available publicly. Most of it is now being published for the first time.

The Panel was also asked to illustrate how the information disclosed adds to public understanding of the tragedy and its aftermath. The Panel does so through this Report, firstly by providing an overview of what was previously known and then by explaining, in 12 chapters, how the disclosed information changes public understanding.

When the Panel began its work in February 2010, it could not and did not know whether the information it would reveal would add to public understanding and change that

  • Foreword — 1
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understanding. Over the intervening months, we have discovered that the information disclosed will add significantly to public understanding.

The Panel was also asked to consult with statutory agencies in securing maximum possible disclosure of the documents. The Panel is grateful for the cooperation of over 80 organisations who made available their own records, and especially to South Yorkshire Police who set an example for the process of disclosure.

When over 30,000 came to Anfield for the 20th Anniversary of Hillsborough, it showed that the wound of grief was still sore because so many questions were yet unanswered. These disclosed documents address many of those questions. The Panel, which was set up deliberately and distinctly from an inquiry, produces this Report without any presumption of where it will lead. But it does so in the profound hope that greater transparency will bring to the families and to the wider public a greater understanding of the tragedy and its aftermath. For it is only with this transparency that the families and survivors, who have behaved with such dignity, can with some sense of truth and justice cherish the memory of their 96 loved ones.

The Right Reverend James Jones, Bishop of Liverpool

September 2012

Report summary

On 15 April 1989 over 50,000 men, women and children travelled by train, coach and car to Hillsborough Stadium, home of Sheffield Wednesday Football Club, to watch an FA Cup Semi-Final between Liverpool and Nottingham Forest. It was a sunny, warm, spring day and one of the high points of the English football season.

Hillsborough was a neutral venue, like so many stadia of its time a mix of seated areas and modified standing terraces. As the match started, amid the roar of the crowd it became apparent that in the central area of the Leppings Lane terrace, already visibly overcrowded before kick-off, Liverpool fans were in considerable distress.

In fact, the small area in which the crush occurred comprised two pens. Fans had entered down a tunnel under the West Stand into the central pens 3 and 4. Each pen was segregated by lateral fences and a high, overhanging fence between the terrace and the perimeter track around the pitch. There was a small locked gate at the front of each pen.

The crush became unbearable and fans collapsed underfoot. To the front of pen 3 a safety barrier broke, creating a pile of people struggling for breath. Despite CCTV cameras transmitting images of distress in the crowd to the Ground Control Room and to the Police Control Box, and the presence of officers on duty on the perimeter track, it was a while before the seriousness of what was happening was realised and rescue attempts were made.

As the match was stopped and fans were pulled from the terrace through the narrow gates onto the pitch, the enormity of the tragedy became evident. Fans tore down advertising hoardings and used them to carry the dead and dying the full length of the pitch to the stadium gymnasium.

Ninety-six women, men and children died as a consequence of the crush, while hundreds more were injured and thousands traumatised. In the immediate aftermath there was a rush to judgement concerning the cause of the disaster and culpability. In a climate of allegation and counter-allegation, the Government appointed Lord Justice Taylor to lead a judicial inquiry.

What followed, over an 11-year period, were various different modes and levels of scrutiny, including LJ Taylor's Interim and Final Reports, civil litigation, criminal and disciplinary investigations, the inquests into the deaths of the victims, judicial reviews, a judicial scrutiny

  • Report summary — 3
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of new evidence conducted by Lord Justice Stuart-Smith, and the private prosecution of the two most senior police officers in command on the day.

Despite this range of inquiry and investigation, many bereaved families and survivors considered that the true context, circumstances and aftermath of Hillsborough had not been adequately made public. They were also profoundly concerned that following unsubstantiated allegations made by senior police officers and politicians and reported widely in the press, it had become widely assumed that Liverpool fans' behaviour had contributed to, if not caused, the disaster.

In 2009, at the 20th anniversary of the disaster, Andy Burnham, Secretary of State for Culture, Media and Sport, announced the Government's intention to effectively waive the 30-year rule withholding public records to enable disclosure of all documents relating to the disaster.

In July 2009 the Hillsborough Family Support Group, supported by a group of Merseyside MPs, presented to the Home Secretary a case for disclosure based on increasing public awareness of the circumstances of the disaster and the appropriateness of the investigations and inquiries that followed.

The Home Secretary met with representatives of the Hillsborough Family Support Group and in January 2010 the Hillsborough Independent Panel, chaired by James Jones, Bishop of Liverpool, was appointed.

The remit of the Hillsborough Independent Panel The remit of the Hillsborough Independent Panel as set out in its terms of reference was to:

• oversee full public disclosure of relevant government and local information within the limited constraints set out in the Panel's disclosure protocol

• consult with the Hillsborough families to ensure that the views of those most affected by the tragedy are taken into account

• manage the process of public disclosure, ensuring that it takes place initially to the

Hillsborough families and other involved parties, in an agreed manner and within a reasonable timescale, before information is made more widely available

• in line with established practice, work with the Keeper of Public Records in preparing options for establishing an archive of Hillsborough documentation, including a catalogue of all central Governmental and local public agency information and a commentary on any information withheld for the benefit of the families or on legal or other grounds

• produce a report explaining the work of the panel. The panel's report will also illustrate how the information disclosed adds to public understanding of the tragedy and its aftermath.

The structure of the Panel's Report The Hillsborough Independent Panel's Report is in three parts. The first part provides an overview of 'what was known', what was already in the public domain, at the time of the Hillsborough Panel's inaugural meeting in February 2010. The second part is a detailed account, in 12 substantial chapters, of what the disclosed documents and other material 'adds to public understanding' of the context, circumstances and aftermath of the disaster.

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The third part provides the Panel's review of options for establishing and maintaining an archive of the documents made available by over 80 contributing organisations in hard copy, many of which have been digitised and are now available online. Finally, the Report includes a set of appendices: the Panel's full terms of reference; how the Panel has consulted with bereaved families and their representatives and how it responded to well-publicised events during its work; the process of disclosure; and the research methodology adopted in analysing the documents.

The Report summary: scope and content In accessing and researching the mass of documents and other material disclosed by organisations and individuals, the Panel was guided in its work by its regular consultation with, and the priorities of, Hillsborough families and their representatives.

Part 2 of the Report comprises 12 chapters that respond to the bereaved families' priorities in establishing the scope of the Panel's research into the documents. They also demonstrate the depth of the research conducted and the profound issues raised by this unique process of disclosure.

In analysing the disclosed documents it has been necessary within the 12 chapters to include contextual material already in the public domain. What follows summarises each of the detailed 12 chapters, providing an overview of how the documents disclosed to the Panel add to public understanding.

Brief background Hillsborough Stadium, home of Sheffield Wednesday Football Club (SWFC), was opened in 1899. Like many such city stadia it was located in a built-up residential area no longer suited to modern transport or the access necessary for 54,000 spectators on big match days.

The stadium underwent significant structural modification in preparation for staging the 1966 World Cup. Both ends of the stadium, the Spion Kop and the Leppings Lane terrace (beneath the West Stand), were standing terraces.

Hillsborough was hired regularly by the Football Association (FA) to host FA Cup semi-finals, the most prestigious knock-out tournament in English soccer. These matches usually drew capacity crowds. Both teams' supporters, travelling to Sheffield, were unfamiliar with the city, with access to Hillsborough and with the layout of the stadium.

In 1981 before the FA Cup Semi-Final between Tottenham Hotspur and Wolverhampton Wanderers there was serious congestion at the Leppings Lane turnstiles and crushing on the confined outer concourse. This led directly to severe compression on the Leppings Lane terrace and injuries to fans. Hillsborough was not used again for an FA Cup semi-final until 1987, and then again in 1988.

Chapter 1. 1981–1989: unheeded warnings, the seeds of disaster Based on documents disclosed to the Panel, this chapter assesses the impact of the 1981 crush on crowd safety at Hillsborough. It considers the decisions taken between 1981 and 1989 by SWFC, its safety consultants, the local authority (Sheffield City Council) and the

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South Yorkshire Police (SYP) regarding modifications to the Leppings Lane terrace and their consequences for the safe management of the crowd.

It is evident from the documents disclosed to the Panel that the safety of the crowd admitted to the terrace was compromised at every level: access to the turnstiles from the public highway; the condition and adequacy of the turnstiles; the management of the crowd by SYP and the SWFC stewards; alterations to the terrace, particularly the construction of pens; the condition and placement of crush barriers; access to the central pens via a tunnel descending at a 1 in 6 gradient; emergency egress from the pens via small gates in the perimeter fence; and lack of precise monitoring of crowd capacity within the pens.

These deficiencies were well known and further overcrowding problems at the turnstiles in 1987 and on the terrace in 1988 were additional indications of the inherent dangers to crowd safety. The risks were known and the crush in 1989 was foreseeable.

  1. In 1981 before the FA Cup Semi-Final between Tottenham Hotspur and

Wolverhampton Wanderers there was serious congestion at the Leppings Lane turnstiles and crushing on the confined outer concourse. It resulted in the opening of exit Gate C to relieve the crush. The disclosed documents indicate that entry into the stadium was managed by South Yorkshire Police (SYP) officers on duty and

Sheffield Wednesday Football Club (SWFC) stewards.

  1. What followed was a serious crush on the terraces in which many people were injured and fatalities narrowly avoided. At that time lateral fences did not divide the Leppings Lane terrace into pens, and fans were able to move sideways along the full length of the terrace; others escaped onto the perimeter track through the narrow gates in the perimeter fence.

  2. The disclosed documents show that police officers located on the inner concourse, between the turnstiles and the rear of the terrace, restricted access to the central tunnel under the West Stand, diverting fans to the side access points to the terrace, thus relieving pressure at the centre. Crowd density figures available to the Panel demonstrate that the maximum capacity for the terrace was significantly exceeded.

  3. The disclosed documents demonstrate that, following the 1981 incident, there was a breakdown in the relationship between SWFC and SYP. SWFC refused to accept the seriousness of the incident and held SYP responsible for the mismanagement of the crowd. SYP considered that the maximum capacity for the Leppings Lane terrace, set at 10,100, was too high, a view strongly contested by SWFC.

  4. On the recommendation of SYP the construction of lateral fences in 1981 created three pens, with movement between pens limited to a small gate at the head of each lateral fence. According to SYP these gates were used to manage segregation at league matches but were not 'stewarded' by the police.

  5. From the earliest safety assessments made by safety engineers commissioned in

1978 by SWFC, it was apparent that the stadium failed to meet minimum standards under the Safety of Sports Grounds Act 1975 and established in the Guide to Safety at Sports Grounds (known as the 'Green Guide'), 1976. Documents released to the

Panel confirm that the local Advisory Group for Safety at Sports Grounds carried out inadequate and poorly recorded inspections. There is clear evidence that

SWFC's primary consideration was cost and, to an extent, this was shared by its primary safety consultants, Eastwood & Partners.

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  1. Following the near tragedy in 1981, Hillsborough was not used for FA Cup semifinals until 1987. During this period the Leppings Lane terrace underwent a series of significant modifications and alterations, none of which led to a revised safety certificate. The introduction of further lateral fences created two central pens accessed via the tunnel beneath the West Stand. Recommendations to feed fans directly from designated turnstiles into each pen, thus monitoring precisely the distribution of fans between the pens, were not acted on because of anticipated costs to SWFC.

  2. Consequently, the turnstile counters were rendered irrelevant. Although they provided a check on the overall numbers entering the terrace, there was no information regarding crowd distribution between pens, each of which had an established maximum capacity.

  3. It is evident from the disclosed documents that SYP were preoccupied with crowd management, segregation and regulation to prevent potential disorder.

SWFC's primary concern was to limit costs. The Fire Service, however, raised concerns about provision for emergency evacuation of the terraces. As the only means of escaping forwards was onto the pitch, concern was raised specifically about the width of the perimeter fence gates which was well below the standard recommended by the Green Guide. The gradient of the tunnel under the West

Stand leading down onto the terrace also significantly breached the Green Guide's recommendation.

  1. While modifications were made inside the stadium, the issue of congested access to the turnstiles outside the stadium remained unresolved. As Lord Justice Taylor's

Interim Report noted, of the stadium's 54,000 capacity, over 24,000 fans were channelled through 23 turnstiles feeding the North Stand, the West Stand and the

Leppings Lane terrace.

  1. Following alterations, the safety of the existing maximum capacity for the Leppings

Lane terrace was questioned repeatedly yet the decision was taken by the Club and the safety engineers not to revise the figure.

  1. From the documents disclosed to the Panel, key issues – positioning of safety barriers, elevation of the tunnel, adequacy of the perimeter fence gates – were not discussed or recorded at the annual safety inspections. Following the delayed kickoff at the 1987 FA Cup Semi-Final and the crushing at the 1988 FA Cup Semi-Final, it is evident that debriefings held by all parties were inadequate. Crucial information arising from these events was not shared within SYP, nor was it exchanged between

SYP and other agencies. There is no record provided by SWFC of debriefings held between Club stewards and their managers. The Club denied knowledge of any crowd-related concerns arising from the 1987 or 1988 FA Cup Semi-Finals.

Chapter 2. The 'moment' of 1989 The challenges and responsibilities of policing and managing capacity crowds at Hillsborough were evident following the events of 1981 and the subsequent difficult relations between SYP and SWFC. In this context, the decision by SYP senior management to replace an experienced match commander just 21 days before the match is without explanation in the disclosed documents.

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The documents disclosed to the Panel, however, reveal that the flaws in responding to the emerging crisis on the day were rooted in institutional tension within and between organisations. This was reflected in: a policing and stewarding mindset predominantly concerned with crowd disorder; the failure to realise the consequences of opening exit gates to relieve congestion at the turnstiles; the failure to manage the crowd's entry and allocation between the pens; the failure to anticipate the consequences within the central pens of not sealing the tunnel; the delay in realising that the crisis in the central pens was a consequence of overcrowding rather than crowd disorder.

  1. The SYP decision to replace the experienced match commander, Chief

Superintendent Brian Mole, and appoint Chief Superintendent David Duckenfield who had minimal experience of policing at Hillsborough, just weeks before an FA

Cup semi-final, has been previously criticised. None of the documents disclosed to the Panel indicated the rationale behind this decision.

  1. A planning meeting attended by both senior officers was held less than a month before the match. The documents disclosed to the Panel give no explanation for the non-attendance of the South Yorkshire Metropolitan Ambulance Service and the

Fire Service at this meeting.

  1. Chief Superintendent Duckenfield held a briefing for senior officers on the day before the match. At that meeting he emphasised the importance of crowd safety.

Briefings held by other senior officers, however, focused on potential crowd disorder, alcohol consumption, ticketless fans and the difficulties of managing

Liverpool supporters. From the documents disclosed to the Panel, it is apparent that the collective policing mindset prioritised crowd control over crowd safety.

  1. This mindset, directed particularly towards Liverpool fans, was clearly evident in

SYP's submission to the Taylor Inquiry.

  1. As previously known, the SYP 1989 Operational Order was derived, with a few alterations, from the 1988 Order and gave no indication of the crowd management problems experienced in 1988.

  2. The SYP Operational Order concentrated primarily on the control and regulation of the crowd with no appropriate reference to crowd safety, crushing or evacuation of the stands/terraces.

  3. From the documents disclosed to the Panel, the management roles and responsibilities of senior SYP officers were unclear, particularly the lines of communication, decision-making and information exchange between those responsible for policing outside the stadium and the ground commander inside the stadium.

  4. There was clear evidence in the build-up to the match, both inside and outside the stadium, that turnstiles serving the Leppings Lane terrace could not process the required number of fans in time for the kick-off. Yet the growing danger was ignored. When the request to delay the kick-off eventually was made, it was considered too late as the teams were on the pitch.

  5. For a considerable period inside the Police Control Box it was clear from the near view of the central pens below, and the CCTV coverage of the turnstiles and pens, that serious problems of overcrowding were occurring at the turnstiles and in the pens. Senior police officers' decision-making was hampered by poor communications, a malfunctioning radio system and the design of the Control Box.

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  1. Superintendent Roger Marshall was responsible for policing outside the stadium at the Leppings Lane end. As the crush at the turnstiles became severe he requested the opening of exit gates to allow fans into the stadium and relieve crowd pressure.

He had no knowledge of the uneven distribution of fans on the Leppings Lane terrace. Similarly, the ground commander inside the stadium, Chief Superintendent

Roger Greenwood, had no knowledge of the extreme situation developing outside the stadium.

  1. The overview of both sites was the Control Box, with CCTV monitors and a near view of the central pens. Chief Superintendent Duckenfield acceded to

Superintendent Marshall's request and authorised the opening of Gate C. Despite a clear view from the Control Box and CCTV monitors, neither Chief Superintendent

Duckenfield nor his assistant, the experienced Superintendent Bernard Murray, anticipated the impact on the already packed central pens of fans descending the tunnel directly opposite Gate C. 24. On opening Gate C there was no instruction given to the SYP officers inside the stadium to manage the flow and direction of the incoming crowd.

  1. From the documents provided to the Panel it is clear that the crush at the Leppings

Lane turnstiles outside the stadium was not caused by fans arriving 'late' for the kick-off. The turnstiles were inadequate to process the crowd safely, and the rate of entry insufficient to prevent a dangerous build-up of people outside the ground.

Chapter 3. Custom, practice, roles, responsibilities The spectators at an FA Cup semi-final do not comprise the large, mostly local, home-based crowd with limited away support usual at regular league matches. Rather, there are two sets of fans, approximately equal in number and unfamiliar with the stadium. The supporters allocated to the Leppings Lane end, in this case Liverpool, were allocated the entire terrace and the West Stand above it. This intensified the problems of access that were already inbuilt into the restricted approaches, inadequate provision of turnstiles and subdivision of the terrace into separate pens. Over preceding years, police custom and practice had evolved in response to crowd management issues unique to FA Cup semi-finals, particularly filtering access to the concourse through ticket-checking on the approaches, directing incoming spectators away from the central pens when they were estimated to be near capacity, and closing the tunnel when capacity was estimated to have been reached. None of these practices appear to have been recorded and none formed part of the Operational Order or the police briefings before the 1989 Semi-Final. Throughout the 1980s there was considerable ambiguity about SYP's and SWFC's crowd management responsibilities within the stadium. The management of the crowd was viewed exclusively through a lens of potential crowd disorder, and this ambiguity was not resolved despite problems at previous semi-finals. SWFC and SYP were unprepared for the disaster that unfolded on the terraces on 15 April 1989.

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  1. Based on the established policy of maintaining segregation of fans within the stadium and its approaches, particularly at FA Cup semi-finals, the documents disclosed to the Panel demonstrate that SYP determined the allocation of the stadium's stands and terraces to each club's fans. The tickets allocated to

Nottingham Forest fans significantly exceeded those allocated to Liverpool fans, an issue raised by Liverpool Football Club and the Football Association.

  1. The confined outer concourse area serving the Leppings Lane turnstiles accommodated the entire Liverpool crowd, heading towards three discrete areas within the stadium (North Stand; West Stand; Leppings Lane terrace). It was a well-documented bottleneck and at matches with capacity attendance presented a predictable and foreseeable risk of crushing and injury.

  2. From statements provided to the Panel, at previous FA Cup semi-finals SYP managed congestion in the outer concourse area and its approaches by filtering the crowd and checking tickets on the roads leading to the ground. This did not happen in 1989. The former SYP match commander, Chief Superintendent Brian Mole, denied that filtering the crowd's approach to the turnstiles had been previously adopted as police practice.

  3. SYP proposed that preventing ticketless fans from approaching the turnstiles was not possible because no offence had been committed. This was contested and criticised by Counsel to the Taylor Inquiry.

  4. In their 1989 statements some SYP officers referred to crushing in the outer concourse area at the 1988 FA Cup Semi-Final. They were asked by the SYP solicitors, Hammond Suddards, to reconsider and qualify their statements.

  5. Concerning the distribution of the crowd on the standing terraces inside the stadium, Chief Superintendent Mole stated that officers on the perimeter track and in the Control Box estimated when full capacity of each pen was reached 'based on experience'.

  6. SYP officers with extensive experience of policing Hillsborough, including Chief

Superintendent Mole, stated that the fans' distribution between the Leppings Lane terrace pens was based on an informal practice that allowed fans to 'find their own level'. In the aftermath of the 1989 disaster, SYP claimed that 'find their own level' was a flawed practice 'devised' by the safety engineers and SWFC.

  1. From the SYP statements disclosed to the Panel it is evident that SWFC stewards and SYP officers with experience of managing the crowd on the Leppings Lane terrace had adopted the practice of redirecting fans to side pens when the central pens were estimated to be full. At semi-final matches in 1987 and in 1988 the gates at the entrance to the tunnel opposite the turnstiles and leading into the central pens were closed temporarily by police officers who redirected fans to the side pens. In 1988 many fans in the central pens experienced crushing and minor injuries. Neither the gate closures nor the crushing were recorded in debriefing notes.

  2. Although an established practice, the use of the tunnel entrance gates as a means of regulating access to the central pens was not included in the Operational Order for capacity crowd matches.

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  1. The disclosed documents reveal persistent ambiguity throughout the 1980s about

SYP's and SWFC's responsibilities for crowd management. The SYP position, exemplified by Chief Superintendent Mole's statements, was that while safety was a concern for SYP the 'prevention of hooliganism' and 'public disorder' was the main priority. The custom and practice that had evolved within SYP for packing the pens was concerned primarily with controlling the crowd.

  1. In the view of Chief Superintendent Mole's successor, Chief Superintendent David

Duckenfield, crowd distribution between the Leppings Lane terrace pens was the responsibility of SWFC stewards but police officers, particularly those on the perimeter track, were expected to react to overcrowding in the pens.

  1. In its post-disaster assessment the West Midlands Police investigators concluded that the failure to anticipate that unregulated entry of fans through exit Gate C and down the tunnel would lead to a sustained crush in already full central pens had a

'direct bearing on the disaster'.

  1. SYP officers with experience of the inner concourse and terrace access stated that previously they had controlled access to the tunnel once the central pens appeared to be full, particularly in 1988. The disclosed documents reveal that this information was deleted from some officers' statements. Several officers declined a further invitation by SYP solicitors to reconsider their statements regarding SYP responsibility for monitoring the pens.

  2. Senior SYP officers denied knowledge of tunnel closures at previous semi-finals, particularly 1988. They placed responsibility for that information not being given at debriefings on the officers responsible for the closures. Yet SYP officers responsible for closing the tunnel access in 1988 claimed that they had acted under instructions from senior officers.

  3. Whatever their personal knowledge of the 1988 tunnel closure, both Chief

Superintendent Mole and Chief Superintendent Duckenfield admitted their awareness of the practice of occasionally restricting access to the tunnel to prevent overcrowding in the central pens.

Chapter 4. Emergency response and aftermath: 'routinely requested to attend' The immediate aftermath of a major disaster is by its nature chaotic, and presents unique challenges to first responders. To implement effective rescue and recovery, it is important that the disaster is recognised and the major incident plan activated by all emergency services. The disclosed documents reveal important flaws at each stage. Not only was there delay in recognising that there were mass casualties, the major incident plan was not correctly activated and only limited parts were then put into effect. As a result, rescue and recovery efforts were affected by lack of leadership, coordination, prioritisation of casualties and equipment. The emergency response to the Hillsborough disaster has not previously been fully examined, because of the assumption that the outcome for those who died was irretrievably fixed long before they could have been helped.

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  1. Disclosed documents show that police officers, particularly senior officers, interpreted crowd unrest in the Leppings Lane terrace central pens as a sign of potential disorder, and consequently were slow to realise that spectators were being crushed, injured and killed.

  2. Ambulance control room transcripts show that Ambulance Service officers, present specifically to respond to a major incident rather than have any crowd control brief, were slower than police to identify and realise the severity of the crush despite being close to the central pens.