HILLSBOROUGH

HILLSBOROUGH

¶Figure 4: Layout of the turnstiles at Leppings Lane, April 1989 Original available at SCC000002050001, p56.

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¶2.3.32 Police Constable Alan Ramsden, on duty in 1987, noted a 'sort of semi-sterile area' where crowds were kept 'outside the metal railings and gates to allow myself and other officers to carry out searches'.11 Inspector Clive Calvert described how the police restricted ticketless fans' access to the turnstile area and statements made available to the Panel provide a range of accounts regarding ticket checking and crowd filtering in 1987.12

¶2.3.33 Analysis of CCTV evidence by SYP from the 1988 Semi-Final to 'ascertain if stewards were involved in any control of the crowd in Leppings Lane' concluded that they 'appear to have some physical control of the outer perimeter gates leading to the service road'.13 This was a reference to the narrow service road running between the outer concourse area and the river across the face of exit Gate C. 2.3.34 The stewarded section of the outer perimeter fences was restricted to 'selected persons or vehicles'. It was 'isolated from the A–G concourse area, by use of portable barriers'. The A–G concourse area housed the turnstiles for the Leppings Lane terrace. However, there was 'no evidence of a filtering of fans outside the outer perimeter gates' (on Leppings Lane).

¶2.3.35 In his Interim Report LJ Taylor referred to 'a very large and consistent body of evidence that, on the day [1988], the police in Leppings Lane conducted an efficient filtering exercise designed to keep away those without tickets and control the flow of fans towards the ground'.14 Mr Mackrell affirmed that he had been informed by C/Supt Mole that in 1988 on approaching the stadium fans' tickets were checked by SYP officers.15

¶2.3.36 C/Supt Mole, however, denied there was an SYP policy of filtering fans using barriers although this was contested by other officers.16 He stated they were used only at junctions along Leppings Lane to protect residents' access to their homes.

¶2.3.37 C/Supt Mole claimed that police officers 'were briefed to be aware of the possibility of non ticket holders attending the game and that checks should be made to identify them and turn them away' but 'there were no specific plans to place cordons on Leppings Lane in the form of barriers and I did not give any instructions to that effect'. He denied 'knowledge of any such cordons being introduced' and 'it was not my policy to filter supporters by utilising barriers across the footpath'.

¶2.3.38 In the immediate aftermath of the disaster, SYP suggested that the turnstiles could not cope because 'Liverpool supporters were getting to the turnstiles and instead of offering tickets were offering money. At this stage the crush was such that they could not turn away from these turnstiles'.17 Further, it was suggested that ticketless fans were not prevented from approaching the turnstiles.

¶2.3.39 According to the Treasury Counsel's submission to the Taylor Inquiry, the 'police told the inquiry that there was little they could do, since no offence was committed in being near a ground without a ticket, provided there was no obstruction or breach of the peace'.

11. Officer's Report and witness statement of PC Alan Ramsden, SYP000039140001, pp6-7. 12. Statement of Inspector Calvert, SYP000074110001. 13. South Yorkshire Police 'Summary of 1988 Semi-Final', SYP000098380001, pp2-4. 14. Rt Hon Lord Justice Taylor, The Hillsborough Stadium Disaster, 15 April 1989, Interim Report, Cm 765, August 1989,

¶London: HMSO. 15. WMP interview with Graham Mackrell, 22 June 1990, SYP000038890001, p149. 16. Statement of C/Supt Mole,²⁰²⁰ April 1989, HOM000016460001, pp1-5. June 1989, SYP000123550001, p113. 17. SYP briefing notes,¹⁷¹⁷ December 1997, HOM000030920001, p1. April 1989, SYP000010190001, p8.

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¶2.3.40 This was contested: 'We do not think the police are so powerless. Ticketless fans do cause a problem and, in sufficient numbers, are almost bound to cause an obstruction. It is in our opinion perfectly reasonable for a police officer to ask a fan if he has a ticket and, if he has not, it is lawful to refuse him access to the immediate vicinity of the ground'.18 2.3.41 The significance of managing the crowd in the vicinity of Leppings Lane was also considered. In 1989 there was an attempt by stewards to control the crowd outside the turnstiles using portable barriers. Photographs suggested 'that portable barriers were positioned between turnstiles 10 and 11, extending back towards the perimeter gates' to channel fans to particular turnstiles.19

¶Inside the stadium: filling pens and 'find their own level' 2.3.42 On the terrace the issue of 'packing' pre-dated the 1981 incident. During the debriefing for the 1981 game Superintendent David Chapman described how 'the usual packing problems occurred' as the terrace filled.20 2.3.43 Packing became more significant once lateral fences were introduced and pens were created and sideways movement along the terrace was restricted. Inevitably the even distribution of the crowd between pens was difficult to achieve, especially as there was no way of knowing when a pen had reached its designated maximum safe capacity. 2.3.44 Chapter 6 details the controversy about differing estimates regarding the maximum safe capacity for each pen and the overestimation of the figures provided by the out-of-date safety certificate for the stadium. 2.3.45 In 1988 at least 62 people experienced crushing in the central pens ,21 some sustaining injuries such as bruised ribs.22 One fan described hearing a public announcement to alleviate the crush before the match, raising doubts that senior officers were unaware of the problem of crushing.23 2.3.46 In his 1989 statement Police Constable Stuart Beardshall claimed that in 1988 there had been severe crushing on the outer concourse. On this point the SYP solicitors, Hammond Suddards, sought clarification.24 In a clear illustration of how the SYP solicitors gathered information they note that PC Beardshall 'and one or two others [police officers] mentioned below make comments about the severity of the crushing outside the turnstiles in 1988'. Their statements were 'not particularly helpful to our case, but if they represent factual recollections, then they will probably have to stay in'. The letter continued:

¶I wonder if they could not be qualified in one or more of the following ways:

¶A) A clear comment to the effect that the ingress of mounted Officers eased the problem.

¶B) An indication that the problem was relatively short-lived, e.g. by 2.45p.m. the crush had eased, if that is the case.

¶C) Perhaps an indication that the Officers have watched the 1988 and 1989 videos and that the 1988 situation was clearly not as bad as that in 1989. 18. Final Submission to the Taylor Inquiry on behalf of Treasury Counsel, SYP000098180001, p23. 19. Note from C/Supt Wain to Mr Metcalf, 23 May 1989, SYP000097530001, p4. 20. Minutes of the 1981 debriefing, HOM000026500001, p7. 21. See, for example, Chapter 1, paragraph 2.1.106. 22. HOLMES category record print, SYP000121610001, pp13-14 and SYP000123530001, pp297-341. 23. HOLMES category record print, SYP000123530001, p299. 24. Fax from Hammond Suddards to C/Supt Denton, 12 June 1989, SYP000096870001, pp71-72.

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¶2.3.47 In his evidence to the Taylor Inquiry, C/Supt Mole stated that knowing when a pen had reached capacity was 'purely a visible perception based upon experience'.25 A statement by another officer, Police Constable Maxwell Groome, confirmed C/Supt Mole's approach, saying, 'In previous years Chief Superintendent Mole would walk around the perimeter track asking officers how things were going, and obviously noting the ground capacity'.26

¶2.3.48 Remarkably, given the crushing and injuries recorded in the central pens in 1988, C/Supt Mole considered it was not his experience that if fans were left to their own devices overcrowding in the pens would result. He stated there had been 'occasions when it possibly is in excess because, as I say, I have no way of knowing exactly; it is an estimate from experience as to how many are in there'.27

¶2.3.49 C/Supt Mole continued, 'my experience has been that they [the crowd] have found their own level. The level was found in 1987; it was found in 1988 and at other large League matches that level has been found'. The level of crowd distribution between pens was 'monitored and if a difficulty is seen then I would take what action is necessary through the Chief Steward or through my Officers to relieve that problem'.

¶2.3.50 According to Superintendent John Freeman, the 'policy' of 'find their own level' was used for capacity matches. At semi-final matches, 'knowing it was going to be a capacity crowd' the procedure 'was to allow the pens at the Leppings Lane end – on that occasion [1987] for Leeds fans – to fill up all at the same time, with no restrictions on entry'.28 As pens filled, police officers were expected to ensure that fans 'moved to the front and centres within each area'. Invariably, 'at any large capacity game ... the centre pen filled first'.

¶2.3.51 The situation at regular league games was different as, once through the turnstiles, away fans were directed to specific pens. A small crowd, for example, 'would be accommodated in either the centre pen, or the one directly under the Police Control Box, depending on the expected size of the visitors [sic] contingent'.

¶2.3.52 When away fans 'exceeded expectations then a further pen, adjacent to whichever pens were then open, would be opened to accommodate them, but the unused pens were kept closed'. At a capacity match, however, 'all pens would be opened as a matter of course'.

¶2.3.53 Inspector Harry White, who had considerable experience of policing the Leppings Lane terrace, confirmed Supt Freeman's recollection:

¶With regards to distributing the supporters, my normal way, depending on the anticipated numbers, would be to fill the centre two enclosures first and if necessary the enclosures nearer to the South Stand next.

¶I would do this by placing barriers across the building line of the West Stand at its ends giving access to Pens 1 and 2 and at the other end leading to Pens 6 and 7.

¶These barriers would be manned by a Police Officer who would direct supporters to whichever direction they were supposed to go. At the same time, I would have Police

¶Officers on the gates at the rear of the enclosures on the radial fences, they would have these gates closed and bolted but not locked and they were there for evacuation purposes.

25. Transcript of C/Supt Mole's evidence to the Taylor Inquiry, day 7,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. May 1989, SWF000001320001, p72. 26. Officer's Report of PC Maxwell Groome, South Yorkshire Police, SYP000119280001, p5. 27. Transcript of C/Supt Mole's evidence to the Taylor Inquiry, day 7,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. May 1989, SWF000001320001, p72. 28. Statement of Superintendent John Freeman, SYP000096840001, pp511-512.

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¶When the central enclosures were full, I would close the blue gates leading from the concourse onto the tunnel, to show the incoming fans that the central enclosures were full. These gates would be manned by a Police Officer, who would then re-direct the incoming fans. These gates could not be kept closed for more than a few minutes, and in any case whilst they were closed they were always manned by a Police

¶Officer.29 2.3.54 Supt Chapman also described police direction of the spectators in the pens:

¶Leppings Lane end of the ground was, during my era, separated into terraced enclosures by the installation of radial fences. At this time the Leppings Lane end of the ground was used by both home and visiting supporters, and the separate enclosures were used for the purpose of segregation and thus the prevention of public disorder amongst the fans.

¶The policy adopted by the police at league matches was to marshal the opposing fans to their respective enclosures. The allocation of enclosures at the Leppings

¶Lane end of the ground was predetermined according to the nature and number of visiting supporters. For example, if there were a number of supporters that could be accommodated in a single enclosure then they would be allotted and directed towards one of the outer pens, the centre pens would be left empty as a sterile area and the other outer pen would be designated for home supporters (this was the era before the centre pen was split further into two separate enclosures).

¶In carrying out this policy, police officers would be deployed to the turnstile area and to the concourse between the turnstiles and the stand at Leppings Lane, to separate and keep apart the opposing factions of supporters. The fans would be directed by police and stewards into their respective enclosures. A further contingent of police officers would be deployed to the sterile area between the two sets of supporters to maintain order. This contingent would be issued with a key to the gates in the radial fence so they could gain access to either of the populated enclosures to deal with disorder. There would be neither police officers nor stewards on the terraces with the supporters as a matter of course.30 2.3.55 According to Chief Inspector Robert Creaser, at the 1987 Semi-Final the pens were filled 'progressively'.31 The central pens filled first. Once it was estimated that they were full, police officers were positioned at the rear of the pens alongside the narrow radial fence gates which were closed. 2.3.56 The remaining pens were filled and once they were approximately three-quarters full the officers withdrew having reopened the lateral fence gates to allow fans to 'find their own level'. During this time the doors at the head of the tunnel into the central pens were closed and reopened when most of the crowd had been admitted and the lateral pens were approaching capacity. 2.3.57 CI Creaser stated that in his debrief he did not reflect on his management of the crowd as he was following custom and practice at that time which was to fill the pens individually and progressively. He told the Taylor Inquiry that he considered it to be an unsuccessful procedure as fans often wanted 'to leave those pens once they got in … when they want to use the facilities'.

29. Statement of retired police Inspector Harry White, SYP000095080001, pp597-599. 30. Statement of Supt David Chapman, HOM000018350001, pp4-8. 31. CI Creaser's evidence to the Taylor Inquiry, HOM000025950001, pp49-52.

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¶2.3.58 In 1987 Supt Freeman was in the Police Control Box. He was replaced by Superintendent Bernard Murray in 1988 and 1989. CI Creaser's evidence noted a policy change when Supt Murray was appointed. Sergeant Michael Goddard, however, disagreed with CI Creaser's recollection stating that the policy in 1987 and 1988 was consistent: find their own level.32 The precise meaning of the term 'find their own level' was ambiguous. It was used in the context of filling the pens progressively and also filling all the pens at the same time.

¶2.3.59 According to Insp White, prior to the 1989 Semi-Final, 'Superintendent Murray had observed me filling the pens as I have described [pen by pen], and he told me that I was not to do it in this way and that the gates of the rear of the terraces in the radial fences were to remain open bolted against the wall and that the fans would find their own level on the terraces'.33

¶2.3.60 On the day of the 1989 match, CI Creaser visited Supt Murray in the Control Box to enquire how the pens should be filled. He was informed that the fans should find their own level.34 In evidence to the inquests CI Creaser stated that this was 'a tried and trusted method which was found acceptable the previous year and there was an agreement that that was the action which would be taken'.35

¶2.3.61 Fans 'would walk on to the terraces and obviously if it was noted there was a problem with compaction at a particular area, then some action would be taken, but there would be no restrictions on the fans'. Despite the injuries sustained by many fans in 1988, there was no reappraisal of the strategy for filling the pens prior to the 1989 match.

¶Flaws in 'find their own level' 2.3.62 As an assumed policy, 'find your own level' was flawed. According to John Stalker's Report for SWFC, it was 'hard to fully understand what many police officers meant when expecting the Leppings Lane terrace crowd to "find its own level". Crowds just don't do that without help or direction from officials'.36

¶2.3.63 In pursuing disciplinary action against Chief Superintendent David Duckenfield, the Police Complaints Authority (PCA) drafted charges which argued that 'even a cursory glance would have made it clear that such a policy ['find your own level'] was unworkable'.37 John Stalker argued that, as a policy, it failed to consider that 'those who arrive early and obtain better positions will not move in order to accommodate the comfort of late comers'.38 It assumed that if fans considered a pen was full and uncomfortable they could move to the side pens.

32. PS Goddard's evidence to the Taylor Inquiry, HOM000026040001, p340. 33. Statement of retired police Inspector Harry White, SYP000095080001, pp597-599. 34. Sergeant Michael Goddard, who was responsible for the control of radio messages in the Police Control Box, confirmed in his evidence to the Taylor Inquiry that he heard this conversation between Supt Murray and CI

¶Creaser. See HOM000026040001, pp14-15. It is also confirmed in PS Goddard's statement dated 31 May 1989,

¶SYP000038790001, p170. Others in the Control Box included PC Trevor Bichard. His statement dated 5 May 1989 is available at SYP000038790001, pp179-189. PC Michael Ryan worked in the Control Box with responsibility for the Tannoy or public address system and three telephones. His statement dated 5 May 1989 is available at

¶SYP000038790001, pp190-197. 35. CI Creaser's evidence to the Coroner, SYP000110390001, p423. 36. Statement of John Stalker, former Deputy Chief Constable of Greater Manchester,²⁰²⁰ April 1989, HOM000016460001, pp1-5. August 1990,

¶SYP000116060001, p275. 37. PCA, draft disciplinary charges, 30 September 1991, SYP000094930001, p24. 38. Statement of John Stalker, former Deputy Chief Constable of Greater Manchester,²⁰²⁰ April 1989, HOM000016460001, pp1-5. August 1990,

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¶2.3.64 Yet 'it was impossible to move sideways beyond the limits of the radial fences and outside help was essential in redistribution of supporters from one pen to another'. Police Constable Peter Smith described how in his experience fans 'find their own level' by climbing over the lateral fences between pens.39 The system also failed to consider the rate of evacuation in an emergency.

¶2.3.65 At the contribution hearings SYP argued that the system of 'find your own level' had been 'devised and approved here by Dr. Eastwood and in that capacity representing the Club'.40 It was stated by SYP Counsel that 'the Police wrongly tried to make a system work which was a bad system'.

¶2.3.66 They 'should never have used or attempted to use any judgement as to whether a pen was full or not merely by visual impression' and the disaster had made 'it quite plain that the system is hopelessly ineffective'.

¶2.3.67 The SYP position was that they had not 'deliberately overlook[ed] the crowding in the pens' nor did they 'shut their eyes to it'. They had seen how many people were in the pens and 'did not think that it was unsafe'. They reacted when 'they realised that people were being hurt' and 'responded when the situation became dangerous, simply because what they were doing was operating a system which had been devised for them by others'.

¶Responsibility for 'packing' the pens 2.3.68 The documents disclosed to the Panel demonstrate that in 1981, months after the severe crushing at the Semi-Final, ambiguity remained about the division of responsibility between SYP officers and Club stewards in managing the crowd on the terraces. SYP considered that 'Club Stewards at Hillsborough often do less than they should and are at times not aware of our function and operation and our respective roles'.41

¶2.3.69 An internal SYP memorandum entitled 'SWFC Ground Education of Club Stewards' attempted to clarify roles and responsibilities. It stated that the responsibility for the terraces lay with Club stewards and their training was organised by the police: 'We should stress to the stewards that the admission of spectators and the packing of those spectators at the bigger games on to the terracing is primarily their function and not a police one'. SWFC supported the SYP position.

¶2.3.70 Although this appears to be a clear delineation of tasks, the experience and recollections of those policing and attending the match show that they were not clear to the police, the stewards or the spectators.

¶2.3.71 Supt Chapman, in a statement within the SYP submission to the Taylor Inquiry, described the SYP interpretation of the roles of police and stewards:

¶The whole basis of my deployment of police officers at the West End and Leppings

¶Lane Terraces, was intended to deal with the segregation of opposing fans and prevent disorder. This in no way absolved the stewards from undertaking their duties in respect of the safety of spectators and there was never any agreement, formal or informal that the police would accept these stewarding responsibilities.42

39. WMP report to the Director of Public Prosecutions summarising the evidence of PC Smith given to the Taylor Inquiry,

¶SYP000038850001, p92. 40. Transcript of proceedings in the contribution hearings, SYP000098630001, pp14-19. 41. Internal SYP memo from C/Supt Herold to A/Supt Smith and Insp Calvert, 18 August 1981, SYP000047780001, p36. 42. Statement of Supt Chapman, HOM000018350001, pp4-8.

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¶2.3.72 According to Supt Chapman this was the procedure in place when Douglas Lock replaced him in the role in June 1982. He maintained that contrary to Mr Lock's evidence to the Taylor Inquiry he had not participated with him in planning crowd management for any match at Hillsborough:

¶I refute, absolutely, his understanding of the role of the police in 'stewarding' the Leppings Lane end of the ground. In particular, he claims that he was simply continuing practices that pertained which I was responsible for policing Hillsborough.

¶This is certainly not true, the role of officers, whilst under my command, was one of ensuring segregation and preventing disorder. There was never any agreement that the stewards had no role to play at the Leppings Lane End.

¶2.3.73 C/Supt Mole's version of events was that fans entered the pens and found their own level. He maintained that the police were not responsible for packing the pens. Yet a 1986 letter from Mr Richard Chester, then Club Secretary, to C/Supt Mole indicated that at league matches C/Supt Mole occasionally did manage the crowd including packing the terraces for safety.

¶2.3.74 Referring to a West Ham United league fixture on 12 March 1986, Mr Chester stated he would 'be obliged if you could arrange that there will be no future repeat of the situation, concerning your officers, relating to the closure of the elevated standing area [on] Leppings Lane and the apparent uncooperative attitude of the camera man using the T.V. gantry'.43

¶2.3.75 C/Supt Mole's reply to Mr Chester referred to confusion regarding the use of the elevated standing area on Leppings Lane (north-west end of the terrace) for regular league matches. The 'ground commander' had seen 'fit not to open it initially, but subsequently, on my instructions, did so'.44

¶2.3.76 He continued: 'I can only add that it is not my intention to regularly close the elevated standing area and that as agreed in the past, either I or John Freeman would discuss the position prior to a match and if there was such an intention then you would be informed accordingly'.

¶2.3.77 There was also reference to television cameramen objecting to the presence of police officers in their area. C/Supt Mole responded: 'I am sure you will agree that public safety is of greater importance than the media coverage and if we are jointly to achieve our objectives of ensuring the safety of the public at such splendid sporting events then the need for preventative measures such as the attendance of my Scenes of Crime Officers is essential'. In a private meeting between SYP officers and Counsel on 26 April 1989, C/Supt Mole confirmed that it was the responsibility of the police to note when enclosures were full.45

¶2.3.78 C/Supt Mole made an additional statement in preparation for the contribution hearings in which he attempted to clarify what he considered was 'a great deal of misunderstanding' about the reasons for monitoring the pens: 'the purpose of having separate pens is to ensure crowd segregation and improve police access for public order'.46

43. Letter from RH Chester, SWFC Secretary, to C/Supt Mole,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. March 1986, SYP000028310001, p25. 44. Letter from C/Supt Mole to RH Chester, SWFC Secretary, 26 March 1986, SYP000028310001, p26. 45. Discussion with Counsel, 26 April 1989, SYP000096360001, p84. 46. Additional statement of C/Supt Mole for contribution hearings, 5 May 1989, SYP000116400001, pp2-3.

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¶2.3.79 To achieve segregation he considered it necessary 'that the gates at the rear of the radial fences should be locked shut because otherwise spectators would have direct access from one pen to another'. Yet he stated that it was 'recognised that if those gates were locked shut then there had to be an assessment of the numbers being allowed into the pen because the fans were not in a position to "find their own level"'. 2.3.80 According to C/Supt Mole, locking the gates at the rear of the lateral fences was limited to league matches but for semi-finals, when the entire terrace was allocated to one club, 'all the gates between the pens would be locked open and no visual assessment of numbers would take place'. 2.3.81 C/Supt Mole concluded, 'I therefore think it misguided of people to criticise the police for having prevention of hooliganism and prevention of public disorder as by far in a way their main priority in attending a football match. Of course police officers have to be concerned with safety but that is not the reason for their attendance'. This was a clear statement of priority from the SYP officer with the most extensive experience of policing Hillsborough.

¶Crowd distribution: the Club's responsibility 2.3.82 C/Supt Duckenfield was in no doubt that crowd distribution within and between the pens was the Club's responsibility. He informed the Taylor Inquiry that 'the club and ourselves [SYP] accept our individual responsibilities and as far as I am concerned it is clearly defined. My understanding is ... crowd management, filling of pens and monitoring of pens is a Club responsibility and not that of the Police Service'.47 2.3.83 Yet he stated that should the pens reach 'overfilling and it becomes apparent to me that they are overfilling and difficulties are likely to occur, then I shall take some action'. It was the responsibility of the 20 officers on the perimeter track to react 'if the filling of the pens gets to the point of overcrowding'. A further six officers monitored the West Stand above the Leppings Lane terrace. 2.3.84 In his evidence to the Taylor Inquiry CI Creaser stated that the police watched the pens to ensure fans' safety. Regarding what C/Supt Mole described as 'visual assessment' CI Creaser commented that from his 'experience at policing that end of the ground [Leppings Lane], the Officers at that location get a feel for it. There might be, for example, a fan who leaves the terrace from the tunnel and said [sic] "Look it is packed out in there, you want to stop any more going in". That sort of thing'.48 As previously discussed, the pens within the Leppings Lane terrace were directly beneath, and in full view of, the main Police Control Box. 2.3.85 Inspector Steven Sewell considered it was 'the Club's responsibility for the actual packing of people' yet 'there are no stewards allocated to that terrace'.49 The SYP-approved document 'Instructions for match day staff', however, made no reference to Club stewards' responsibility for packing the terraces. This clearly contradicted the 1981 SYP memorandum mentioned above regarding Club stewards' responsibilities. 2.3.86 Insp Sewell explained that officers gained experience of appropriate responses because of their established routine at matches. Yet an analysis of allocated duties showed that none of the officers in Serials 14 and 15, allocated to the Leppings Lane terrace in 1989, although experienced at league matches, was positioned there in 1988.50

47. C/Supt Duckenfield's evidence to the Taylor Inquiry, SYP000123550001, pp231-233. 48. CI Creaser's evidence to the Taylor Inquiry, HOM000025950001, p4. 49. Inspector Sewell's evidence to the Taylor Inquiry, SYP000123550001, p6. 50. Inspector Sewell's evidence to the Taylor Inquiry, SYP000123550001, pp16-17.

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¶2.3.87 At league matches the Operational Order stated that '[o]ccupancy of pens by away fans will be given at briefing'51 yet there was no equivalent statement within the semi-final Operational Order. It was evident that the system that had evolved for packing the pens was geared to crowd control and not to safety or preventing overcrowding.

¶SWFC view of crowd management responsibility 2.3.88 While SYP considered that responsibility lay with SWFC, the Club disagreed. In a WMP interview for the criminal investigation, Club Secretary Mr Mackrell considered that police officers had a crowd management role. They 'had got the close circuit television, the Police Control Box is right above the area where it took place. You know, I would regard that as being the prime Police responsibility ... to monitor that situation'.52 No written agreement existed allocating duties and responsibilities to stewards and police. 2.3.89 According to the SWFC Security Officer and former SYP officer Douglas Lock, there was a formal agreement that the police would assume the duties of the stewards. Chief Superintendent R Herold, however, refuted this claim, noting that it was 'certainly not the case that there has ever been any agreement, oral or in writing, (formal or informal), which in any way alters the duties of the steward and those of the police officers in acting as agents of the club'.53 2.3.90 C/Supt Herold insisted that SYP did not assume the responsibility of stewards while admitting that police officers acted as a 'longstop' to alleviate the 'inadequacies, the age and often the incompetence of the stewards in the interest of public safety'. Police officers were available to assume the duties of stewards should trouble arise but did not seek to assume the role of stewards. 2.3.91 The SWFC document 'Instructions for Match Day Staff' provided some details about the role and behaviour of stewards.54 Advising gatemen and turnstile operators it stated that 'All exit gates must be manned at all times. If any gate is left unmanned at all, the entire staff covering the gate will be instantly dismissed.' It noted that a coded message would be announced over the public address system regarding emergency evacuation. 2.3.92 Club staff were warned against 'becom[ing] involved with crowd misbehaviour' as this was 'a matter for the police – AND THE POLICE ONLY' (emphasis in original). At the head of an SWFC document entitled 'Instruction to stewards', an unattributed handwritten note read 'not a word about terraces or packing supporters'.55 2.3.93 The SYP submission to the Taylor Inquiry criticised the Club's understanding of the role and responsibility of the stewards. Quoting the Popplewell Report, SYP noted 'it has somehow been assumed by the Clubs that the responsibility for control of what goes on inside the ground has passed from them to the Police'.56 2.3.94 The SYP submission stated that Mr Lock's evidence to the Taylor Inquiry indicated 'the existence of some agreement to some such effect', but this was 'refuted by the police'. It concluded that the police 'were not intending to fulfil nor had any arrangement been made that they should perform any stewarding role'.

51. Inspector Sewell's evidence to the Taylor Inquiry, SYP000123550001, p30. 52. WMP interview with Graham Mackrell, 22 June 1990, SYP000038890001, p166. 53. Statement of C/Supt Herold, 10 July 1989, SYP000096840001, pp372-373. 54. 'Instructions for Match Day Staff', with internal SWFC communication dated 8 June 1988, SYP000047780001, pp497502. 55. 'Instructions to stewards', with internal SWFC communication dated 8 June 1988, SYP000047780001, p501. 56. SYP final submission to the Taylor Inquiry, HOM000018350001, pp26-32.

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¶FA view of crowd management responsibility 2.3.95 The FA submission to the Taylor Inquiry claimed that crowd management was a police responsibility. In its resumé of the FA submission, SYP criticised the FA for being confused:

¶The [FA] submission comes down firmly on poor crowd distribution as being the main causal factor and is dismissive of the non-ticket holder factor as being contributory ...

¶It wrongly asserts that 'the evidence is overwhelming that the responsibility for preventing overcrowding of the central pens had been undertaken by the Police, and that the cause of the disaster was accordingly a failure in policing.' This confuses the Police practice at league games of ensuring specified pens are used to ensure segregation and proper crowd control. The club cannot be absolved from its statutory duty.57 (emphasis in original)

¶2.3.96 It stated further that the FA submission:

¶... confuses the issue of pen filling and wrongly states that operational orders for league matches provide for checking the levels in pens 3 and 4, directing the crowd away from them, closing the tunnel if necessary and for communication between officers charged with these duties ... This is a total misinterpretation of the Leppings

¶Lane terraces Serial Instruction for a league game which has a requirement to

¶'ensure pens are filled in accordance with instructions from Control' at Phase I of the operation.

¶2.3.97 SYP concluded that the key concern was 'occupancy of pens in terms of segregation and not packing', underlining the policing priority established by C/Supt Mole.

¶The Operational Order and the tunnel 2.3.98 The West Midlands Police (WMP) report submitted to the Director of Public Prosecutions (DPP) concluded that in the 1989 SYP Operational Order responsibility for managing crowd access to the pens via the tunnel was overlooked. Regarding the 'Tunnel/Terraces – West Stand' the submission stated:

¶It is relevant that whilst a number of officers in this sector were posted to the turnstiles or terracing area in the time prior to kick off, no officers were specifically posted to supervise the tunnel. It appears that officers had a dual responsibility for searching supporters at the turnstiles and ensuring order on the terraces and responsibility for the tunnel fell between. However, because of their commitments at the turnstiles they were unable to comply with their instructions in relation to the terraces. During the match two serials were posted to the tunnel to maintain order as required.

¶This is mentioned because the police failure to close off the tunnel prior to authorising the opening of gate 'C' to prevent supporters going into pens 3 and 4 had a direct bearing on the disaster.58

¶2.3.99 Significant in this statement is the WMP conclusion that the police failure to anticipate that mass entry through Gate C would result in most fans descending the tunnel opposite into the already packed central pens.

57. Hillsborough Disaster Inquiry – Phase 1, Written Submission of the Football Association, with SYP resumé, 58. WMP's submission to the DPP, Part V, SYP000038790001, p26.

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¶2.3.100 While it recognises a profound failure at the 'moment' of opening Gate C, it demonstrates a foreseeable failure in preparing for such an eventuality given prior knowledge of the problems of crushing at the turnstiles, overcrowding in the central pens and the need to redirect the incoming crowd to the side access points.

¶The closure of the tunnel 2.3.101 According to a turnstile operator, in 1981 Club stewards were instructed by police on duty in the inner concourse area behind the West Stand and Leppings Lane terrace to close the gates at the head of the tunnel. Fans were redirected to access points at either end of the terrace.59 Although he could not recall details, CI Creaser stated that in 1987 the tunnel was closed '[w]hen it was considered that the pens were full'.60

¶2.3.102 In 1988, there is evidence that the tunnel was also closed for an unspecified period. A typed summary of the 1988 Semi-Final video tapes recorded that at '15.02.44' two police officers were standing at the back of the terrace by the central tunnel. Police officers, therefore, were at the mouth of the tunnel when it was said to have been closed.61 The 'ground control room book' had no entry or details relating to any action taken in 1988 regarding tunnel closure or restricted access.62

¶2.3.103 Fans described how in 1988 they were prevented by police and stewards from entering the tunnel. According to Frederick Eccleston, stewards and police officers blocked the tunnel. Questioned at the Taylor Inquiry, he considered there might have been more stewards than police but he was not certain.63 As he and his daughter left the turnstiles they met 'a line of police officers and stewards that stopped us going through the tunnel. They quite gently but forcefully said, "Look, this is full, you've got to go to the left or the right"'.64

¶2.3.104 Another fan, Mr P Mahew, also gave evidence at the Taylor Inquiry and stated that he had been directed by stewards: '[w]hen you got through the turnstiles you were met by a steward or I think he was a steward, anyway, and you were told to go down to the other section'.65

¶2.3.105 A HOLMES66 category record print cross-reference for 1988 disclosed to the Panel records that at least 58 people recalled that the tunnel was closed in 1988. Police or stewards or a combination of both directed fans to the side pens. Documents released to the Panel reveal a significant number of witnesses who gave evidence about the closure of the tunnel and redirection of fans to the side pens.67

¶What police officers knew about the tunnel 2.3.106 A number of police officers confirmed in their statements that the tunnel was closed in 1988 when the central pens became full. Sergeant William Crawford was responsible for a serial of officers located on the inner concourse at the rear of the West Stand and Leppings

59. Statement of turnstile operator, SYP000038700001, pp78-82. 60. CI Creaser's evidence to the Taylor Inquiry, HOM000025950001, p50. 61. Summary of video evidence from the 1988 Semi-Final, SYP000119170001, p6. 62. Action 725, 11 June 1990, SYP000110270001, p5. 63. Evidence of Mr Eccleston, a fan, to the Taylor Inquiry, HOM000025850001, p28. 64. Evidence of Mr Eccleston, a fan, to the Taylor Inquiry, HOM000025850001, p11. 65. Evidence of Mr Mahew, a fan, to the Taylor Inquiry, HOM000025830001, p155. 66. The HOLMES computer database records statements and other police material and allows systematic searching and cross-referencing. 67. HOLMES category record print, SYP000123530001, pp297-341.

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¶Lane terrace. He stated that 'at 14.50 hours we had an instruction believed verbal, that no more fans were to be allowed in the central pens, therefore, the wooden gate at the rear of the tunnel was closed denying access. This was done by PC 1278 Lang'.68

¶2.3.107 PC Lang closed 'one half of the gate for a period from about 2.45pm, I do not know how long this was for, to assist in the prevention of further persons going down the tunnel into pens 3 and 4, I presume because of congestion in those pens'.69 PS Crawford stated that he believed that PC Lang's action was 'a result of his being ordered to do this by a supervisory officer at least Inspector rank [sic]'.

¶2.3.108 He was 'unable to say which officer gave the order or whether it was done orally or via the radio' but recollected 'as I told the Inquest, of going to see Constable Lang to ensure he had carried out the order so that tends to indicate that I heard the order being given so it probably was given via the radio'.

¶2.3.109 Reflecting on what happened in 1989, PS Crawford noted that the police were 'very light on manpower at this end'. Further, in relation to the tunnel, he noted that '[n]ormally we have had a serial at the centre tunnel to direct fans to the North or South pens when the Centre pens had been filled'.70

¶2.3.110 Re-interviewed during SYP investigations for the contribution hearings, PS Crawford adhered to his original statement that an instruction was received to close the tunnel. He reiterated that he had not acted on his own initiative but could not recall whether the instruction had come from a police officer or a Club steward.71

¶2.3.111 Confirming PS Crawford's account, PC Lang recalled receiving an order to close the tunnel:

¶Sometime between 2.45 (14.45) and 2.50pm (14.50) I received an order to close the gates at the top of the tunnel leading to the central pen and remain at these gates to prevent entry by any further fans into the centre. I closed the right hand gate and remained at this post directing fans to the wing entrances … A short time after the kick off further officers attended at my location and the gates were again opened after they took up duty in the tunnel. I do not know who gave the order to close these gates or why the order was given.72

¶2.3.112 Other officers confirmed that an instruction was given to seal the tunnel in 1988. Officers within Serial 14 were initially responsible for ensuring that fans entering the Leppings Lane terrace turnstiles (A–G) were not carrying items prohibited by the ground rules. This was Phase One (pre-match). During the match (Phase Two) the officers moved to the central tunnel. Sergeant Trevor Higgins described receiving an instruction to seal the tunnel:

¶During the game and because of the amount of fans within pens 3 and 4, I received instruction to close the gates to the entrance and thereafter direct fans to the two outer pens of the stand. I cannot recall where the instruction came from. Under normal circumstances instruction came from a Serial Inspector or via radio from control. I cannot say from which the instruction came.73 68. Statement R170A of PS Crawford, 31 May 1989, SYP000110730001, p39. 69. Ghost statement of PS Crawford from the disciplinary investigation file, SYP000110370001, pp20-21. 70. Statement R170 of PS Crawford, 28 April 1989, SYP000110730001, p6. In the process of review and alteration of statements described in Chapter 11, PS Crawford's comments were deleted. The amended version of his statement is available at SYP000038810001, p56. 71. Re-interview of PS Crawford, 26 May 1990, SYP000098390001, p7. 72. Statement R333A of PC Lang, 2 June 1989, SYP000114060001, p13. 73. Statement R516 of retired PS Trevor Higgins, 2 June 1989, SYP000038700001, pp462-463.

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¶2.3.113 Subsequently, he stated that 'it was a police instruction but I could not remember whether it was via control or directly from a serial inspector. There were definitely no SWFC stewards in the immediate area'.74

¶A 'commonsense' response 2.3.114 Officers in Serial 17 also recalled that the tunnel was closed in 1988. They considered the action was a commonsense response by officers on duty rather than a consequence of an instruction from senior officers. These officers were also located in the central tunnel during the match.

¶2.3.115 Police Constable Hughes stood at the back of pens 3 and 4 for a few minutes and realised the pens were packed.75 He recalled 'no specific instruction that I was aware of to form a cordon across that tunnel but commonsense told me as obviously the other officers had realized that there was limited space in the pens'.76

¶2.3.116 Consequently, 'together with those other officers' PC Hughes 'turned people away from the rear of the tunnel when they came to try and enter pens 3 and 4 from that time on. The match had already started by this time'. He saw no Club stewards at the location at that time.

¶2.3.117 Sergeant Howard Cable was also in the tunnel and realised that the central pens were very crowded:

¶Common sense told me and my officers that we should endeavour to prevent any more people entering the pens via the tunnel but I would clarify that my serial, together with officers from another serial, were simply standing in the tunnel to monitor the crowd in the pens. We were not physically blocking access via the tunnel, simply persuading people trying to enter through the tunnel that there was no more room in the central pens and that they should try to get in to the terracing elsewhere.

¶As far as I can recall there were no club stewards present.

¶There would have been possibly up to 20 Police Officers either in or near the outer tunnel entrance and that number may have appeared to be [a] cordon although I stress it was not a physical planned obstruction of the tunnel.77

¶2.3.118 He stated, 'there was no specific operational plan to block the tunnel by a Police cordon'. In another statement he recalled 'the pressure in the centre pen being relieved slightly by allowing supporters to leave the pen via the gates in the fencing dividing the pens. This was one way traffic only police officers allowing supporters to leave the centre pen only'.78

¶2.3.119 Another officer in Serial 17, Police Constable Barnes, was located in the tunnel at the entrance to pen 4 at the start of the match. Consistent with other officers in his serial he did not recall receiving an order to seal the tunnel but diverted supporters following PC Hughes' observations that the central pens were congested. He stated:

74. Statement R516B of retired PS Trevor Higgins, 1 July 1990, SYP000087460001, p4. 75. Statement R524 of PC Hughes, 5 June 1989, SYP000115970001, p3. 76. Statement R524B of PC Hughes, 5 June 1989, SYP000110270001, p328. 77. Statement R424B of PS Cable, SYP000110270001, pp326-327. 78. Statement R424A of PS Cable,²⁰²⁰ April 1989, HOM000016460001, pp1-5. June 1989, SYP000120630001, p2.

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¶I cannot recall any direct order for either myself or the serial I was assigned to, to start to seal off the tunnel which gave access to the 'pen' area onto the terrace behind the goal.

¶As the 'pen' began to fill with supporters I was joined by other officers who had been earlier directed to police inside the actual pen. I was informed by those officers that the pen was getting very crowded and we then observed the crowd in that pen from the rear of the terrace.

¶Myself and about six other officers were stood across the mouth of the tunnel observing the crowd. As we observed the crowd, more spectators came down the tunnel with a view to getting into that 'pen'. As they tried to get in myself and other officers began to turn them away and simply explained to them it was full already. The spectators almost immediately turned away and quickly ran back up the tunnel to find alternative standing areas.

¶Through my duties at this location I cannot recall seeing any Sheffield Wednesday club stewards, who are normally visible by their orange coloured vests.79

¶2.3.120 There is no explanation in the disclosed documents as to why these closures were not recorded in SYP debriefings and the procedure not anticipated in successive SYP Operational Orders. Clearly, such an omission regarding a fundamental crowd safety issue is a serious cause for concern.

¶The significance of closing the tunnel Review and alteration of statements 2.3.121 As noted in Part 1, police officers' statements underwent a process of review and alteration of content. This process was known to the Stuart-Smith Scrutiny and is covered in detail in Chapter 11. In 1989 the failure to effectively monitor the pens and close the tunnel once Gate C was opened was a particular focus in the review and alteration process.

¶2.3.122 In Police Constable Brian Huckstepp's statement, for example, the following sentence was deleted: 'knowing the Hillsborough Ground as I do and how the Leppings Lane end fills up it might possibly have been better to direct the fans coming in through open gates into the flank areas, which I saw were by no means full'.80

¶2.3.123 Police Constable Jim Walpole recalled that at '2.55pm the central pen for standing at the Leppings Lane end appeared to be absolutely packed solid whilst the pen towards the Police Control was about half full and the pen towards the North Stand was perhaps only one sixth full. For normal big games the standing fans at the Leppings Lane terrace have filled each pen slowly well before kick off'.81 The following sentence was deleted: 'I did not hear any radio message for the entrance to the central pen to be closed off, despite this being packed solid'.

¶2.3.124 Insp White managed the serials on the inner concourse in 1989. He retired soon after the disaster on medical grounds and did not give evidence to the Taylor Inquiry or at the inquests. He had four years' experience as an Inspector in this area of the stadium and was dealing with an arrest when the order came to open Gate C. 79. Statement R527B of PC Barnes, SYP000110270001, p324. 80. Recollection of PC Huckstepp, SYP000009590001, p7 (unamended) and p13 (amended). 81. Recollection of PC Walpole, SYP000113600001, p3 (unamended) and SYP000100790001, p3 (amended).

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¶2.3.125 Deleted from his statement was the comment that at the briefing 'no mention was made about the tunnel gates being used to control the ingress of the crowd'.82 The following commentary was also removed:

¶Although on rare occasions in the past I have used the gates nearest the concourses to control flow away from the tunnel around to the south pen. I did this only for a few moments merely as a psychological support to turn the fans round to the south pen.

¶I would not use them for any length of time as when they are in the closed position they would be an obstruction in an emergency evacuation situation as they would have to be opened against the crowd and also because this is the only ingress/egress of fans in the central pens to get to the snack bar and toilets.

¶2.3.126 Police Constable Andrew Brookes' statement was also altered and the comment 'why were the sliding doors at the back of the tunnel not closed at 2.45 (1445) when those sections of the ground were full as at the Manchester United match this season?' was deleted.83

¶2.3.127 Police Constable Powell's statement had the following passage deleted:

¶The first thing I said was, 'Where are all the bobbies, there's hardly anybody there'.

¶I saw numerous people climbing over the tops of the turnstiles and the few Police

¶Officers that I saw appeared to be doing nothing about it. My main observation at this point was the lack of Police presence. I couldn't understand how such a large crowd could have possibly gathered. I recall in previous games there was usually a large

¶Police presence concentrated on this part of the ground usually forming some sort of cordon.84

¶2.3.128 Under the direction of Insp White, PS Crawford led Serial 14 inside Gate C. The comment that '[N]ormally we have had a serial at the centre tunnel to direct fans to the North or South pens when Centre pens have been filled', was deleted from his statement.85

¶What senior officers knew about the tunnel 2.3.129 Despite the close proximity of the Police Control Box to the central pens and the bank of CCTV monitors at his disposal, C/Supt Mole stated that as Match Commander in 1987 and 1988 he was unaware of overcrowding or crushing or that the tunnel had been closed. Further, he stated that 'the de-briefs did not disclose any suggestion that supporters had been injured due to overcrowding or crushing' and none of the other agencies had mentioned these issues.86

¶2.3.130 C/Supt Mole also noted that had the tunnel been closed in 1988 it was 'the sort of incident I would have expected to have been on a de-brief sheet'. Because he was 'not made aware of the problem in 1988' his 'planning for 1989 was not influenced'. As far as he was concerned, as with the 1987 Semi-Final, '1988 was a success and formed a sound base for the 1989 match'.

82. Recollection of Inspector White, SYP000112860001, pp6-7. 83. Recollection of PC Brookes, SYP000118520001, p4. 84. Recollection of PC Powell, SYP000112300001, pp3-4 (unamended), and SYP000100520001, p3 (amended). 85. Recollection of PS Crawford, SYP000112410001, p3 (unamended), and SYP000069280001 (amended). 86. Ghost statement of C/Supt Mole as part of the disciplinary investigation, SYP000110370001, pp89-90.

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¶2.3.131 The suggestion, therefore, was that if the tunnel had been closed it was the responsibility of the police officers concerned to report back their decision through a 'debrief sheet' completed before officers went off duty and passed by them to the 'logistics team' and then to the supervisory officer debriefing meeting held soon after the match.

¶2.3.132 C/Supt Mole's professed knowledge, or lack of knowledge, of the 1988 tunnel closure formed a key element in establishing SYP responsibility for anticipating the tragic events of 1989, particularly the relationship between controlling inflow into the stadium, monitoring the central pens and regulating access to the tunnel.

¶2.3.133 While C/Supt Mole stated that he was aware of the crushing in 1981, by 1987 the control of inflow, monitoring the pens and managing tunnel access did not feature in operational planning. C/Supt Mole said he believed that he had passed a successful operational legacy to the new Match Commander, C/Supt Duckenfield.

¶2.3.134 Supt Murray, who assisted C/Supt Mole in the Police Control Box, stated he had attended the 1988 debriefing and nothing was reported to suggest there had been a problem. Questioned in a WMP interview about 'the suggestion' the tunnel had been closed in 1988, he reiterated his earlier statement that he had 'never know [sic] the tunnel to be closed under any circumstances'.87 He was also asked whether police officers who had claimed that the tunnel had been closed had been mistaken. He responded: 'I don't know, it's never come to my attention … that the tunnel's been closed at any of the matches I went to, particularly the 1988 … semi-final'.

¶2.3.135 Supt Murray recounted an incident at a league match in February 1989, just weeks before the disaster, when access to the terraces from the back had become difficult and fans were admitted by the police through the gates in the perimeter fence. He stated that the decision was not a result of overcrowding but because fans refused to move down into the pens and were blocking access. The Club had criticised the police for admitting fans via gates in the perimeter track fence.

¶2.3.136 Superintendent Roger Marshall also stated that he had no knowledge of the tunnel closure in 1988 and would have expected such a decision to have been recorded in a written debrief. Further, he questioned the truthfulness of the claim, as the large gates opened inwards and would cause a problem in the event of an emergency evacuation via the tunnel.88

¶2.3.137 Also interviewed by WMP, ACC Jackson stated he was unaware of the 1988 tunnel closure. It had not been referenced in the debrief sheet. He stated that issues such as overcrowding should have been reported and he offered no explanation as to why officers had failed to report the closure.89 He confirmed there was no consideration in the 1988 or 1989 Operational Orders given to preventing access to pens once they were filled to capacity.90

¶2.3.138 CI Creaser, however, recalled that the tunnel had been closed in 1988. He was on the inner concourse and saw that the gates to the central tunnel were closed and police and stewards were redirecting fans to the side pens. He was aware that a police officer, and not Club stewards, had closed the tunnel.91

87. Criminal interview with Superintendent Murray, 25 June 1990, SYP000038900001, pp20-26. 88. Criminal interview with Superintendent Roger Marshall, 19 June 1990, SYP000038880001, pp22-26. 89. Criminal interview with ACC Jackson, 28 June 1990, SYP000038910001, pp112-116. 90. Criminal interview with ACC Jackson, 28 June 1990, SYP000038910001, pp121-123. 91. CI Creaser's evidence to the Taylor Inquiry, HOM000025950001, pp46-53.

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¶2.3.139 PS Goddard, located in the Police Control Box, stated that he had no knowledge of tunnel closures in 1987 or 1988 but had this occurred it would have been on 'an Officer's own volition ... rather than [an instruction] from Control'.92

¶2.3.140 According to evidence given to the Taylor Inquiry by the SWFC Security Officer, Mr Lock, the Club had been aware of the tunnel closure. He stated that 'the Centre pen was closed off by the police because the fact that it was so full and they had to deviate [sic] them around ... that is what I would have expected with our system'.93

¶2.3.141 His information had come from Stuart Thorpe, chief steward at the West Stand, and the issue had been discussed with Insp Sewell and C/Supt Mole. He speculated that in his experience as a former SYP officer, Police Control might have issued an instruction to close the tunnel. The SWFC Club Secretary, Mr Mackrell, also stated that a cordon had been organised across the tunnel entrance in 1988.94

¶The acceptance of senior officers' statements 2.3.142 In his Interim Report LJ Taylor concluded that in 1988 the tunnel leading to the central pens had been closed when the pens were full. It was a straightforward manoeuvre, 'for a few officers to act as a cordon at the entrance to the tunnel and divert fans elsewhere'. He considered it unfortunate that 'the 1988 closure seems to have been unknown to the senior officers on duty at the time'.95

¶2.3.143 The subsequent WMP criminal investigation concurred with LJ Taylor that senior officers neither knew nor authorised the 1988 tunnel closure. While fans had stated that police officers had formed 'a blockade' across the tunnel entrance it had not been 'documented and was not a decision made by the Senior Officers present at the 1988 game'.96

¶2.3.144 According to the WMP report the 'probability' was that officers had acted 'on their own initiative turning supporters away having recognised that part of the terrace was full'. In 1989, the report concluded, 'the fact that access to the tunnel was not controlled aggravated the overcrowding in pens 3 and 4 and [was] a significant factor in the deaths of the 95 people'.

¶2.3.145 After investigating the matter internally, Chief Inspector Norman Bettison stated that the 'fullest information on the closure of the tunnel at the 1988 Semi-Final' showed it was 'an informal initiative at junior level not reported to command level. It was performed exclusively by the police'.97 This conclusion was also drawn by the Coroner who directed the inquest jury that the senior officers had not been aware of diversions from the tunnel by police officers in 1988.98

92. PS Goddard's evidence to the Taylor Inquiry, HOM000026040001, p41. 93. Mr Lock's evidence to the Taylor Inquiry, SYP000118450001, pp19-20. 94. Report outlining actions following witness statements taken from various people in relation to criticism of events at the

¶1989 FA Cup Semi-Final, SYP000122450001. 95. Rt Hon Lord Justice Taylor, The Hillsborough Stadium Disaster, 15 April 1989, Interim Report, Cm 765, August 1989,

¶London: HMSO, para 230. 96. West Midlands Police Interim Report (2), Hillsborough Stadium Disaster, Sheffield Wednesday Football Ground,

¶Saturday 15 April 1989, HOM000026960001, pp22-23. 97. Report of Norman George Bettison, 'PREPARATION OF CASE FOR HILLSBOROUGH CONTRIBUTION HEARINGS',

¶12 July 1990, SYP000113470001, p16. 98. Inquest transcripts, day 75, 21 March 1991, SYC000109210001, p102.

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¶Conflicting evidence about the senior officers' knowledge of tunnel closure 2.3.146 Minutes of debriefing meetings held in the immediate aftermath of the disaster and disclosed to the Panel indicate that senior officers were aware of contingency plans involving tunnel access. At a meeting on 17 April 1989 C/Supt Duckenfield explained to the Chief Constable, Peter Wright, that it was the responsibility of 'Inspector White with serials 14 and 15' to divert people from the tunnel. There were 'specific instructions on the order at phase 2 [once the match was under way]'.99

¶2.3.147 He added that 'once the central tunnel becomes full ... it is shut off and people directed to the wings'. The Chief Constable observed, 'there were contingencies to deal with the filled stand, i.e. the shutting of the tunnel'. In the minutes of discussions with SYP Counsel on 26 April it was clear that C/Supt Mole had been aware of contingency plans to seal the tunnel.100

¶2.3.148 The SYP Deputy Chief Constable, Peter Hayes, stated: 'Superintendent Freeman is alleged to have had a contingency to block off the tunnel in the event of a build up of fans in the enclosures'. C/Supt Mole replied: 'So did I. We blocked them off. The fans always go for the area behind the goal. We put a cordon and send them round'.

¶2.3.149 Statements from C/Supt Duckenfield and C/Supt Mole demonstrate that, whatever their knowledge of 1988, both officers were aware that the tunnel could be used as a means of preventing overcrowding in the central pens. This is consistent with C/Supt Mole's evidence to the Taylor Inquiry when he stated that, faced with full central pens, he would close the tunnel.101

¶Police investigation into the role of stewards in tunnel closure 2.3.150 Following the disaster and for the contribution hearings, the internal SYP team had responsibility for gathering evidence relating to the 1988 tunnel closure. Its investigation focused on the possibility that there were more stewards than police involved in the closure and on identifying the source of the instruction for closure, thus providing evidence for apportioning liability.102

¶2.3.151 A fax from Peter Metcalf, SYP solicitor, to DCC Hayes stated that if stewards were involved or if the instruction came from them 'then the Club's responsibility is correspondingly increased'.103 Obviously, this deflected responsibility from SYP to the Club.

¶2.3.152 In the course of the SYP investigation into the 1988 closure of the tunnel, Detective Inspector John Cleverley reported to C/Supt Wain. His report, a consequence of SYP inquiries requested by the SYP solicitors, included the following summary:

¶This question was covered at the time of the Taylor Enquiry, and I would refer first to the Note to Counsel (11) made at that time. Nothing has been found to alter the basic conclusion of that enquiry, namely that officers had acted on their own initiative to close off the tunnel at a critical time when the pens were becoming full. There were apparently two types of control.

99. Minutes of meeting,¹⁷¹⁷ December 1997, HOM000030920001, p1. April 1989, SYP000096360001, pp43-49. 100. Discussion with Counsel, 26 April 1989, SYP000096360001, p81. 101. Transcript of C/Supt Mole's evidence to the Taylor Inquiry, day 7,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. May 1989, SWF000002030001, pp65-66. 102. 'Hillsborough-contribution action', 30 May 1990, SYP000098230001, p3. 103. Faxed letter to DCC Hayes from Hammond Suddards, 31 May 1990, SYP000098250001, p3.

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¶We have interviewed again the officers who closed the gates. The instruction to do so came from police sources, not the club so far as they knew. No stewards were involved. The operation seems to have been simple and low key, with not much more than three officers involved, and not lasted longer than the full surge of incoming spectators before the start of the match.

¶When the match began other officers who had been on the turnstiles were no longer needed because the flow of spectators had diminished, they also went to the tunnel and stood inside near the pens. (They probably hoped to see a little of the match from there!). The gates were no longer closed off at that time. They could see that the pens were full. As late comers tried to get in down the tunnel to the pens, they were turned back by those policemen and directed to the side pens.

¶No evidence has been found of club involvement.104

¶Further internal SYP enquiries into tunnel closure for the contribution hearings 2.3.153 SYP enquiries were also carried out regarding the actions of PS Crawford, PC Lang, PS Higgins, Inspector Raymond Hooley and Inspector Raymond Walker. A Note to Counsel stated:

¶Sergeant CRAWFORD was in charge of Serial 13 which had responsibility for the West

¶Stand in 1988. Part of that duty would include officers in the Leppings Lane enclosure supervising the stairways to the West Stand seating area. He recalls receiving an instruction, from whom or how he does not recall, that there were to be no more fans allowed into the central pens, and therefore the wooden gates at the rear of the tunnel were to be closed, denying access. The actual task, according to him, was undertaken by PC LANG.

¶PC LANG was a member of Serial 13 and was responsible for the stairway giving access to the seating area in the West Stand, this stairway being at the South end of the Leppings Lane enclosures. PC LANG confirms that he received an order to close the gates at the top of the tunnel which gave access to the central pens, he closed the right hand gate and directed fans to the wings.

¶Ex [retired] Sergeant HIGGINS was in charge of Serial 14. He confirms that because of the large number of fans in pens 3 and 4 he received an instruction, again there was no indication as to how or from where, to close the gates, and thereafter direct fans to the two outer pens.

¶Inspector Raymond HOOLEY was in charge of Serial 13 with responsibility for the

¶West Stand. This officer has no recollection of any events relating to the tunnel gates.

¶So far as he is concerned, they were open.

¶Inspector Raymond WALKER was in charge of Serials 14 and 15, with responsibility for the Leppings Lane terracing. He has no recollection of any actions being taken to shepherd fans to any particular part of the ground nor any problems with fans in the tunnel. He recalls passing through the tunnel himself on several occasions.

¶You will recall that Chief Superintendent MOLE was not aware of any policy or instructions in relation to the filling of the central pens. 104. 'Interim Report 3: Result of enquiries requested by Hammond Suddards', 1 July 1990, SYP000119460001, p8.

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¶It seems therefore that officers have acted on their own initiative to exercise control and direction of the tunnel. They are, of course, expected to use initiative and take independent action as circumstances dictate, which were the very matters we were discussing in respect of command structure last week. It does seem, however, that the hierarchy were not made aware of this independent action.

¶It also seems likely in the light of events to date, 5 June, as revealed by Chief

¶Inspector CREASER, that we exercised some control over that tunnel in 1987. West

¶Midlands have already asked for the 1987 Operational Order, and I anticipate that we shall have requests for statement from serials working at the Leppings Lane enclosures. I do not, therefore, at this moment in time, propose to initiate our own enquiries unless you yourself indicate you would like some early indication of what is going to be said.105

¶2.3.154 Thus, knowledge of the 1988 tunnel closure apparently was related inversely to rank and seniority – and managerial responsibility. The lower ranked officers involved directly claimed they followed instructions. The more senior officers claimed they had no knowledge of the closure or of any difficulties regarding the crowd management or overcrowding in the pens.

¶2.3.155 In advance of the civil trial, and as a consequence of commissioning the Phillips Report, SYP did not concede 'that the failure to block the entrance to the tunnel on the opening of Gate C itself amounted to negligence'.106 Referring to the evidence given by officers Creaser, Calvert, Darling and Sewell, the SYP solicitor, Peter Metcalf, proposed that the use of the word 'monitoring' was ambiguous. He stated:

¶What I would like to understand is whether those officers, on reviewing the transcript, agree that it gives the true flavour of what they meant to say. In other words in relation to this semi-final: 1. Were they expecting any Police Officer to be checking the pens, not merely for individual signs of overcrowding, but by way of making regular and deliberate assessments as to whether they were full with a view to closing off such pens? 2. If not were they expecting any other body to be undertaking this duty? ...

¶I would be grateful if the Officers referred to could review their inquiry evidence and if, in the light of that review, they believe that statements explaining the purport of their evidence can be given, then perhaps these could be taken by the Hillsborough

¶Inquiry Team. I attach a draft format but, as long as the points are covered, it would be preferable if the statements were self taken to preserve individual style.

¶2.3.156 Mr Metcalf concluded: 'I am sure I don't need to emphasise that there is no point in any officer putting forward evidence which he cannot honestly sustain in cross examination'. He required a further statement '[o]nly if the officers consider that the transcript does not fairly state their true position'.

¶2.3.157 Following a request from the solicitors, officers Creaser, Darling, Calvert and Sewell were approached and asked to review the evidence in their statements in relation to filling the pens. All four declined to add to their original evidence.107

105. Note to Counsel, SYP000098390001, p7. 106. Letter from Peter Metcalf, Hammond Suddards, to DCC Hayes, 19 July 1990, SYP000118290001, pp4-6. 107. 'Interim Report 6: Further enquiries requested by Hammond Suddards', 8 August 1990, SYP000098530001, p2. See also SYP000118290001, p1 for details of police action raised in this regard.

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¶
• 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.
• 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.
• 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.
• 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.
• 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.
• 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'.
• 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.
• 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.
• 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.
• 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

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¶'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. • 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. • 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'. • 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. • 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. • 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.

¶Emergency response and aftermath: 'routinely requested to attend'

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¶'We are requesting a fleet of ambulances'

¶'Fleet of ambulances[?]'

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

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

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

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

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

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

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

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

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

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

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

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

9. Statement of Detective Constable Malcolm Turner,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 1989, SYP000008960001, p17. 10. Transcript of call from police to Fire Service Control, SFR000000610001, p9.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

16. Letter to the Taylor Inquiry from Dibb Lupton Broomhead (Solicitors) – Ambulance Service submission, 17. Statement of Station Officer Paul Eason, YAS000001490001, p8.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¶2.4.85 This judgement was shared by others:

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

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

¶Disaster Team was not called upon.25

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

36. Letter to the Taylor Inquiry from Dibb Lupton Broomhead (Solicitors) – Ambulance Service submission, 37. Statement of Chief Ambulance Officer Albert Page, YAS000001940001, p25.

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

¶Defibrillation and the Administration of Drugs.38

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¶Centre was being implemented.65

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¶Medical evidence: the testimony of the dead

¶What was already known 2.5.1 Evidence relating to the cause of death was central to the 95 'mini-inquests' conducted by the South Yorkshire West District Coroner, Dr Stefan Popper, alongside the summaries from West Midlands Police about the place of death. Three features recurred across the medical and pathological evidence given to the inquests. 2.5.2 First, traumatic asphyxia was a central feature, in most cases as the underlying cause of death. Second, in their evidence the pathologists presented a common account that consciousness would have been lost within a matter of seconds and irreversible brain damage would have occurred in minutes. 2.5.3 Taken together, these features presented an unvarying picture of a uniform, rapid process that led inevitably to death once an irresistible pressure had built up within the central pens. As such, as discussed in Chapter 10, it underpinned the Coroner's decision to impose a 3.15pm cut-off on evidence presented at the generic stage of the inquests. 2.5.4 The third recurring feature was the emphasis attached to alcohol, as the blood alcohol level of the deceased was read to the court at the start of each 'mini-inquest' and immediately reported in the media. 2.5.5 The disclosed documents add significant new information on each of these crucial aspects of the medical evidence. The first part of this chapter considers the evidence available from systematic review of the pathology reports. The second part highlights the significance of the Coroner's exceptional decision to take blood alcohol samples from the deceased, and how the results were presented.

¶Pathology 2.5.6 The investigation into the deaths included a post mortem examination of each body. This was carried out under the jurisdiction of the Coroner for the district in which the deaths occurred, in this case the South Yorkshire West District Coroner, Dr Popper. It is usual to conduct post mortem examinations when deaths occur that cannot be attributed reliably to natural causes. 2.5.7 Yet Dr Popper's contemporaneous notes indicate that this was not a foregone conclusion: 'I considered the need for post mortem in these cases, bearing in mind that visual inspection indicated that a probable conclusion would be Traumatic Asphyxia and bearing in mind that many of the deceased were young people'.1 1. File note by Dr Popper,¹⁶¹⁶ April 1989. The Prime Minister's Press Secretary later revealed, however, that he had been informed on the day that drunkenness and violent crowd behaviour were significant causes of the disaster. • The disclosed documents show that in the immediate aftermath of the disaster SYP prioritised an internal investigation and the collection of self-taken, handwritten statements in preparation for the imminent external inquiries and investigations. SYP Counsel advised that the police should approach its information-gathering exercise by considering themselves 'the accused'. • A subsequent internal report ('the Wain Report') informed the SYP submission to the Taylor Inquiry. Key elements of the SYP submission emphasised exceptional, aggressive and unanticipated crowd behaviour: large numbers of ticketless, drunk and obstinate fans involved in a concerted action, even 'conspiracy', to enter the stadium. 172. South Yorkshire Police press release, 13 January 1992, SYP000123580001, pp7-8. 173. Press clipping from unidentified newspaper, undated, SYP000123580001, p3.Show full note April 1989, SYC000001360001, p245.

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

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¶2.5.8 It is instructive that as early as the morning of Sunday 16 April 1989, within 24 hours of the disaster and before any post mortems had been conducted, the Coroner had surmised that the probable cause of death was traumatic asphyxia for all 94 people who, at that time, had died. It was a conclusion of sufficient certainty that he questioned the need for post mortem examinations.

¶Arrangements for post mortems 2.5.9 Yet, on balance, Dr Popper decided that post mortems were required and all would take place at the Medico-Legal Centre in Sheffield, in as short a time as practicable. To expedite the process, additional pathologists attended the Medico-Legal Centre, and nine pathologists carried out 94 post mortem examinations over two days.

¶2.5.10 Two people died later, one following two days in hospital and a second in 1993, after being in a persistent vegetative state since the disaster. These two post mortems were carried out by different pathologists, the latter under the jurisdiction of the West Yorkshire Coroner, as he had died in Airedale Hospital.

¶2.5.11 The arrangements for the post mortem examinations were in accordance with legal requirements and with standard practice, although to a demanding timescale. The reason for this haste is not clear from the documents. Nor is the reason for the other outstanding feature, the unusual direction that blood be taken from all of the deceased at post mortem to determine a blood alcohol level.

¶2.5.12 From subsequent statements2 it is clear that this directive was decided by Dr Popper before the post mortem examinations began, and it is clear from the post mortem records that the directive was followed in each of the 94 post mortems on those who died, regardless of age. In addition the documents confirm that a blood alcohol level was estimated in the 95th, a boy of 14 who died in hospital two days after the disaster, using a sample taken previously.3

¶2.5.13 Blood alcohol levels are routinely checked in those driving or piloting motor vehicles, railway trains, ships and aircraft involved in fatal incidents, but not in mass disaster victims.

¶Post mortem reports 2.5.14 The Panel regards the records of the post mortem examinations as confidential to the family concerned and not for public disclosure. Its terms of reference, however, require a report on the overall content of material shared with the Panel. All post mortem reports were scrutinised in detail by a medically qualified Panel member, and are described in aggregate here.4 The results show some striking features, considered under four headings: cause of death; traumatic asphyxia and venous compression; cerebral oedema; and implications of post mortem reports.

2. Inquest transcript, opening statement by the Coroner, 18 April 1990, SYC000109270001, p31. 3. Inquest transcript, 1 May 1990, SYC000109960001, p8. 4. In view of the specialist nature of some of the pathology the overall findings were discussed with an independent expert forensic pathologist, and the Panel is grateful for his helpful advice.

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¶Cause of death 2.5.15 As required in England and Wales, recording of cause of death allows for a chain of up to three conditions, the first of which is the 'immediate cause of death' and the last being the 'underlying cause of death'. They might be common if only one cause is listed. It is also possible to note 'associated conditions' which contributed, but did not lead directly, to death.

¶2.5.16 The immediate cause of death was given as traumatic asphyxia5 in 68 cases and as crush asphyxia in 14. Most forensic pathologists would regard the terms 'traumatic asphyxia' and 'crush asphyxia' as interchangeable, although some may seek to draw a distinction between a single impact or compression causing traumatic asphyxia, and a more gradual compression causing crush asphyxia.

¶2.5.17 This approach was taken, for example, by Mr James Wardrope, Accident and Emergency Consultant at the Northern General Hospital Sheffield, and his colleagues in describing the outcome of treatment of those admitted to hospital following the disaster.6

¶2.5.18 However, it is clear from the answers given repeatedly to questions during the inquests that the pathologists drew no such distinction and regarded the two terms as synonymous. For example, Professor Alan Usher, the senior pathologist at the Medico-Legal Centre, was explicit in his evidence: 'Traumatic asphyxia, which we talked about yesterday, is sometimes crush asphyxia for obvious reasons and some of the pathologists have used that term and some have used traumatic asphyxia. There is no difference'.7

¶2.5.19 Other immediate causes of death recorded were inhalation of stomach contents8 (6), inhalation of stomach contents together with traumatic asphyxia (1), respiratory failure9 (2), cerebral anoxia10 (1), pyelitis11 and bronchopneumonia12 (1), cardiorespiratory arrest13 (2), and shock and haemorrhage14 (1).

¶Traumatic asphyxia 2.5.20 The underlying cause of death shows an even greater preponderance of traumatic asphyxia (73) and crush asphyxia (17) – 90 in total (one jointly with inhalation of stomach contents). Of the remaining six, the underlying cause of death was given as inhalation of stomach contents in three, traumatic pulmonary contusions15 in two, and transection of the aorta16 in one. In four of these six where neither traumatic nor crush asphyxia was the underlying cause, one or other was given as an associated cause contributing to death.

5. Asphyxia is a lack of oxygen in the body, often due to a problem with breathing. Traumatic asphyxia is a lack of oxygen due to compression of the chest preventing breathing, and often obstructing the blood flow back to the heart. 6. Wardrope J, Ryan F, Clark G et al. The Hillsborough Tragedy. British Medical Journal 1991; 303: 1381-1385. Available on the Panel's website at HOM000038420001. 7. Inquest transcript in respect of Stephen Francis O'Neill, 14 May 1990, SYC000109290001, p7. 8. Obstruction of breathing due to the effect of stomach contents on the airways if regurgitated and inhaled. 9. Inability of the lungs to function adequately, particularly to supply oxygen to the bloodstream. 10. Lack of oxygen affecting the brain. 11. Inflammation of the upper part of the urinary system, particularly due to infection. 12. Infection of the lungs and the airways leading to them. 13. Cessation of heartbeat and breathing, for example due to the brain ceasing to function. 14. Blood circulation inadequate due to loss of blood. 15. Bleeding into the substance of the lung due to injury, for example from pressure on broken ribs. 16. Complete division of the main blood vessel leading from the heart.

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¶2.5.21 Thus in only two cases does neither traumatic nor crush asphyxia appear on the certificate. In these, respiratory failure due to traumatic pulmonary contusions associated with fractured rib and pulmonary lacerations was recorded. Even when the cause of death was certified as shock and haemorrhage due to transection of the aorta, one of the most rapid causes of sudden death, traumatic asphyxia was given as an associated cause contributing to death.

¶The 'mini-inquests' 2.5.22 The issue of traumatic asphyxia recurred consistently during the preliminary hearings into each individual death ('mini-inquests'). The pathologist who carried out the post mortem was invited to agree that, as a result of traumatic asphyxia, loss of consciousness would have occurred rapidly, within seconds, and that death would have followed within a few minutes at most.17

¶2.5.23 In each case, the pathologist accepted this interpretation. This was emphasised to the families as a matter of comfort, but it also established an unvarying pattern of death, a matter of importance to the Coroner in his approach to the inquests. Subsequently, when aspects of the conduct of the inquests were challenged through Judicial Review, he prepared a statement of evidence explaining his decisions.

¶2.5.24 His initial draft stated: 'In every one of the 95 cases the uncontested evidence of the pathologists was that the pathological cause of death was traumatic asphyxia and that within a matter of seconds the individual would have been unconscious and unaware of anything further and would have died within a matter of minutes thereafter'.18 Subsequently, 'In every one of the 95 cases' was amended to 'in the majority of the cases' and presented as the final version.19

¶2.5.25 While this insistence on a single unvarying pattern of rapid death may have been motivated, at the time of the mini-inquests, by a desire to ease the emotional burden on relatives, it was a crucial factor in the imposition of the 3.15pm cut-off. Consequently, as shown in Chapter 10, evidence concerning events after that time was not considered at the generic stage of the inquests, a cause of significant distress to relatives.

¶2.5.26 The Coroner argued that the outcome for each of those who died was determined entirely by events before 3.15pm, and that no new significant event could have intervened in the chain of causation of death beyond that time:

¶As a marker I picked the arrival of the first ambulance on the pitch which was timed at

¶3.15pm because on the overwhelming pathological evidence available to me, by that time permanent irreversible damage would have already occurred.20

¶2.5.27 This view of the rapidly fatal and irreversible nature of traumatic asphyxia also influenced LJ Taylor, who concluded that the potential impact of the emergency services was limited: 'in view of the nature and extent of the crushing, the time when police rescue began and the pathetically short period for which those unable to breathe could survive, it is improbable that quicker recourse to the emergency services would have saved more lives'.21

17. For example, at the inquest in respect of Peter McDonnell,²⁰²⁰ April 1989, HOM000016460001, pp1-5. April 1990, SYC000109440001, p7. 18. Draft Affidavit by Dr Popper, undated, SPP000002120001, p7. 19. Affidavit by Dr Popper, undated, SYC000001290001, p12. 20. Affidavit by Dr Popper, undated, SYC000001290001, p14. 21. Interim Report of the Inquiry into the Hillsborough Disaster (Taylor Report), HOM000011140001, p59.

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¶2.5.28 However, the portrayal of an unvaryingly rapid and inevitable death was not supported by the post mortem findings in a substantial number of cases. Two principal findings emerged from the Panel's review of all of the post mortem reports.

¶Traumatic asphyxia and venous compression 2.5.29 In an expert medical opinion provided for the Judicial Review of the Inquests, Dr Iain West, a consultant forensic pathologist, was critical of key aspects of the eight post mortem reports on which he had been invited to comment.22

¶2.5.30 In particular, he stated that a distinction should be drawn between 'classic' traumatic asphyxia, where a sudden rise in venous pressure results in rapid cessation of circulation and a high probability of death, and asphyxia due to suppression of breathing through mechanical compression of the chest wall without venous obstruction.

¶2.5.31 This takes longer to develop and is associated with a greater likelihood of rescue from mechanical compression of someone partially asphyxiated but still alive. These distinct conditions present different appearances at post mortem. The venous compression characteristic of 'classic' traumatic asphyxia results in intense congestion and a deep purplish-blue skin colouration (cyanosis) with many small (petechial) haemorrhages, occurring over the head, neck and upper chest.

¶2.5.32 Asphyxia without venous compression may result in cyanosis and a few fine petechial haemorrhages, particularly over the head, neck and extremities, but not the marked pattern restricted to the upper part of the body and associated with congestion that is caused by venous compression.

¶2.5.33 Dr West found no evidence of 'classic' traumatic asphyxia in three or four of the eight reports that he scrutinised. He concluded that:

¶it is impossible to state purely from the medical point of view that a number of the young men that I have indicated above could not have been alive at 3.15pm. Those dying as the result of anoxic damage consequent to their chests being crushed could well have survived for a much longer period only to die subsequently from the effects of irreversible anoxia.

¶Access to post mortem records 2.5.34 Dr West had access to only eight post mortem records. With access to all post mortem records, the Panel was able to review the entire set against these criteria. In 15 of the post mortem records there is a clear description of the findings of 'classic' traumatic asphyxia with venous obstruction, and in a further 25 the description suggests probable venous obstruction.

¶2.5.35 In 28, however, the findings described clearly do not support the occurrence of 'classic' traumatic asphyxia with venous obstruction, and in a further 16 a significant degree of venous obstruction is unlikely from the description given. (In 11 the appearances were insufficiently clearly described to decide, while in the 96th, death occurred after a prolonged period in hospital by which time the initial changes had reversed.)

22. Written opinion of Dr I West, Department of Forensic Medicine, Guy's Hospital,²⁰²⁰ April 1989, HOM000016460001, pp1-5. August 1992, SYC000001280001,

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¶2.5.36 The occurrence of a substantial proportion with evidence of this different form of asphyxia calls into question the medical evidence presented to the inquest of a single unvarying pattern of death due to traumatic asphyxia. 'Classic' traumatic asphyxia results in cessation of the blood circulation unless relieved, because the venous obstruction prevents blood returning to the heart. In contrast, those without significant venous obstruction and circulatory arrest are likely to have survived for a significantly longer period.

¶2.5.37 Had their chest compression been relieved during this period, for example by removal from the pens, resuscitation of a partially asphyxiated individual with a continuing heartbeat would have been a very different proposition from resuscitation of someone who had already suffered cardiac arrest, and significantly more likely to lead to a successful outcome.

¶2.5.38 Importantly, a person in this condition would also have been vulnerable to further potentially fatal asphyxia from a new cause, such as airway obstruction from being positioned on their back or from inhalation of stomach contents.

¶Cerebral oedema 2.5.39 The Panel's scrutiny of all the post mortem reports showed a second feature that casts significant doubt on the notion of a single, unvarying mode of death: the description in some of cerebral oedema.

¶2.5.40 Cerebral oedema is a swelling of the substance of the brain due to fluid that has left the bloodstream and accumulated in and around the cells of the brain. In this context it occurs as an effect of shortage of oxygen in the blood. The accumulated fluid compresses the substance of the brain, gradually affecting brain function, and increases its weight.

¶2.5.41 Because the brain is almost totally enclosed in the rigid bony cavity of the skull, if sufficient swelling occurs it results in parts of the brain being forced by the increased pressure through the main opening at the base of the skull where the spinal cord passes. This is described as 'coning'.

¶2.5.42 The appearance of cerebral oedema was clearly described in 31 of the post mortem records, and was sufficient to cause coning in 16 of these. In a further ten, coning was described but the brain was not recorded as enlarged. As the significance of this description is not clear, these have been disregarded, as have two in whom coning was associated with, and probably due to, bleeding around the brain.

¶Significance of cerebral oedema 2.5.43 The importance of this finding is that cerebral oedema takes significant time to develop, and longer to progress to the point at which coning occurs. During this time, the blood circulation to the brain must have continued, since once it ceases, cerebral oedema cannot develop further as no more fluid is being supplied to the brain.

¶2.5.44 Cerebral oedema is not described in cases of immediate complete asphyxiation, for example full strangulation, hanging or rapidly fatal traumatic asphyxia with venous compression, because the circulation stops within a few minutes, before detectable cerebral oedema can accumulate. It is found, consistently, however, in people who have survived for prolonged periods after partial strangulation or hanging, and among survivors of traumatic asphyxia, when there has been sufficiently severe asphyxia to cause unconsciousness through lack of oxygen but not sufficient to cause immediate circulatory arrest.

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¶2.5.45 It is notable that not only was cerebral oedema described at post mortem in the person who survived for two days, it was also found in the most seriously ill individuals who were admitted to intensive care after the disaster and subsequently survived. These patients were cared for by Dr Frank Ryan, Consultant Physician at the Northern General Hospital Sheffield, who observed that:

¶[w]ithin ten or fifteen minutes, a total of 13/14 patients appeared to exhibit a very similar syndrome. They were either unconscious already or were partially conscious, appearing confused and bewildered ... All of them went on to develop status epilepticus.23 This, under the circumstances, was life-threatening ... It was my opinion that every patient who was fitting had cerebral oedema and they should all be ventilated and receive intensive care.24 2.5.46 The finding of cerebral oedema at post mortem was raised during some mini-inquests. Generally it was attributed by the pathologist giving evidence to the effects of particularly severe asphyxia, without comment on the time necessary for its development. 2.5.47 The fullest account occurred in evidence given by Professor Alan Usher.25 He observed that: 'The signs of traumatic asphyxia both internally and externally were quite marked'. In fact there were only a few petechial haemorrhages described and no upper body cyanosis or venous congestion. He continued:

¶In this case there was swelling of the brain and coneing [sic] of the hind brain and I thought this was sufficiently significant to include it in the cause of death ... when you insult the brain, in almost any way, by shaking it about in the head or by not supplying it with oxygen, it has one reaction and that is to swell and, in this case, it swelled inside the closed box of the skull and protruded down through an opening which the spinal cord goes down into the spine through and that caused pressure on the vital areas of the brain which would kill very rapidly ... I think that once the pressure was onto his chest, then he would have become unconscious ... in a very short time indeed – a matter of seconds – probably between 10 and 20 seconds, so whatever happened subsequent to that he would not feel. 2.5.48 He was asked: '... once that unconsciousness sets in, the swelling of the brain, as I understand it, is very rapid. It is not a slow process, it is a very rapid process?' His answer was 'Yes'. He was then asked: 'So that there would have been nothing that could have been done by the time this young man had, for example, been taken onto the pitch minutes after the crushing?' He responded: 'No, as I say, had he survived he would almost certainly have been physically disabled because of brain damage'. 2.5.49 These responses omit the most important aspect – the length of time that cerebral oedema takes to develop. It is correct to say that cerebral oedema may begin to develop soon after the onset of the shortage of oxygen affecting the brain, and it is also correct to say that after it has progressed to the point of coning of the lower part of the brain severe damage will occur that may be rapidly fatal. 2.5.50 The crucial point, however, is that progression of cerebral oedema from its first onset to the point of coning is not a rapid process. It takes significant time to develop. It is regrettable that this was not brought to the Coroner's attention in response to this questioning. Nor was the occurrence of cerebral oedema in such a large number of those who died, many with coning, which was not recorded as part of the cause of death.

23. Status epilepticus is the occurrence of an uninterrupted series of convulsions or 'fits'. 24. Dr FP Ryan, 'Summary of my experience with the Hillsborough Tragedy', 19 April 1989, FPR000000110001, p2. 25. Inquest transcript in respect of Carl David Lewis, 3 May 1990, SYC000110140001, pp6-7.

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¶2.5.51 These individuals must have survived for a period sufficient for cerebral oedema to develop to the onset of coning. During this period the circulatory system would have functioned, with at least some continued respiration to maintain the circulation, or cerebral oedema would have stopped developing. 2.5.52 Although these individuals were unconscious and in imminent danger of death from asphyxiation, it is difficult to conclude with certainty that rescue and resuscitation attempts during this period were irrelevant to their survival. As shown in Chapter 4, people did survive cerebral oedema due to partial asphyxiation, the majority without lasting neurological damage. It is also difficult to maintain that no new event could have occurred to precipitate death in somebody in this condition who might otherwise have survived.

¶Implications of post mortem reports 2.5.53 Taken together, these features of the post mortem reports not only confirm Dr West's conclusion that some individuals died later than 3.15pm, but more significantly they imply that there remains considerable doubt concerning the assumption that once maximum compression had occurred in the central pens the outcome was predetermined for all who died, and that no new factor could have intervened in the chain of causation of death. 2.5.54 This was a key part of the Coroner's reasoning leading to his determination of the 3.15pm cut-off, and his decision not to systematically consider evidence post 3.15 at the generic inquest. In reviewing this decision Lord Justice Stuart-Smith defended the Coroner's approach:

¶It should be noted that the Coroner did not say that all those who died did so before

¶3.15, or that the medical evidence was to this effect … Nor did he say that all those who became unconscious subsequently died. The evidence was that it was only those people whose chests were in a state of permanent fixation as a result of the crush for four to six minutes, so that they could not breathe at all for that time, whose condition was irreversible.26 2.5.55 The evidence that in some people respiration and circulation continued for a significant period, from the release of compression until they died, clearly challenges the assumption that their condition was irreversible. Some in this condition survived after treatment in an intensive care unit, while some died at the ground. It is likely that what happened to them during that period played a major part in determining the outcome. 2.5.56 This point was clearly illustrated by Dr James Burns, a forensic pathologist who reviewed a single post mortem report at the request of a bereaved family:

¶... in the case of a person removed from the enclosure at, say, 3.10pm and who was unconscious, but not brain dead, and was then placed in a position other than the correct 'recovery' position, or who, having been placed in the correct position, such a position was not maintained, a feared consequence, an inadequate airway, may well have produced a prolonged state of unconsciousness, with death eventually occurring at a much later time than 3.15pm.27 2.5.57 Dr Burns and Dr West had access only to a few post mortem reports of those who died at Hillsborough. A systematic review of all disclosed reports shows that 28 clearly had no signs of venous compression and that traumatic asphyxia, at least in its 'classic' form, was not an appropriate description of the cause of death. 26. Scrutiny of evidence relating to the Hillsborough football stadium disaster, by Lord Justice Stuart-Smith, 27. Letter from Dr James Burns to Brian Thompson & Partners solicitors, 11 March 1991, SYP000096240001, pp46-47.

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¶2.5.58 There is also evidence in 31 cases that circulation and respiration continued for a period of time, sufficient in 16 for cerebral oedema to progress to its fullest extent. This renders untenable the notion, first voiced by the Coroner before any post mortems had been carried out, of a single, unvarying cause and pattern of death.

¶2.5.59 Further, it challenges the Coroner's conclusion that nothing that happened after release from the pens could affect survival. On the one hand, basic first aid aimed at clearing and maintaining an airway might have kept people alive long enough for them to be treated in hospital, as in the case of those people admitted to hospital who subsequently developed cerebral oedema, all but one of whom survived.

¶2.5.60 On the other hand, placing an unconscious person flat on their back, as is known to have happened in some cases, potentially would lead to further asphyxia from obstruction of the airway. Unless promptly relieved this would most likely prove fatal, without leaving any further post mortem signs in addition to those already expected from asphyxia due to restriction of breathing by chest compression.

¶Blood alcohol measurement Introduction 2.5.61 The emphasis placed at the opening of each mini-inquest on reading out the blood alcohol level of the deceased person, estimated from a blood sample taken from each of the deceased under the direction of the Coroner, was a recurring feature of the inquests. Except for the first two mini-inquests, when it appears to have been overlooked, this was the first evidence presented to the jury at each mini-inquest. Inevitably, the impact was to suggest that alcohol was central to the disaster and relevant to each death under consideration.

¶2.5.62 Media coverage reinforced this impression, as did repeated comments by police sources, but the scene was set at the mini-inquests. Two witnesses who gave evidence at the generic stage of the inquests returned to this theme. Dr Alexander Forrest, a forensic toxicologist at Sheffield's Royal Hallamshire Hospital who had carried out the analysis of the blood samples removed at post mortem, suggested that even modest blood alcohol levels might be associated with an impaired reaction to novel situations.

¶2.5.63 Dr Jonathan Nicholl, an epidemiologist commissioned by the Coroner to investigate a possible relationship between blood alcohol levels and the time of entry of the deceased into the ground, claimed that those who entered later were more likely to have a raised blood alcohol level.28 In his final summing up, the Coroner reinforced the impression that alcohol was a relevant factor, drawing on the evidence of Dr Forrest and Dr Nicholl and linking them with impressionistic, subjective accounts by police officers of unspecified, intoxicated fans.

¶Blood alcohol levels 2.5.64 Although the results of blood alcohol estimations were read out at the Coroner's direction during the initial stage of each individual mini-inquest, after the first two, and reported daily in the press coverage of the inquests, there was no attempt to assess whether the results had any significance for the individual or for the occurrence of the disaster.

¶undated, SYC000000960001, pp21-32.

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¶2.5.65 Media coverage related the results to the 'drink-drive limit' of 80mg of alcohol per 100ml of blood. Although only 15 of those who died had a blood alcohol reading above this threshold, each was reported as if it was a significant factor in the context of the disaster. Yet there was no suggestion that any of the deceased over this limit had driven, or intended to drive, a vehicle.

¶2.5.66 Nor was there any systematic consideration of what relevance there might be for those attending a social occasion, a football match, of a drink-drive limit that is set to prevent people driving who are not visibly or behaviourally intoxicated but whose delayed reactions and coordination would impair control of a motor vehicle at speed.

¶2.5.67 The blood alcohol estimations were carried out by Dr Forrest. In evidence to the preliminary proceedings of the mini-inquests, he commented on the significance of blood alcohol levels for individuals:

¶People do vary enormously in their response to alcohol. Objective tests by the Road

¶Traffic Research Laboratory and also studies on the rate of accidents after people have particular amounts of alcohol in their blood, show that people with a blood alcohol concentration of between 20mg to 40mg of alcohol/100ml of blood are perhaps somewhat impaired in their ability to respond to a novel situation.

¶I have seen individuals with blood alcohol concentrations of 200mg to 300mg of alcohol/100ml of blood who on cursory examination would appear to be perfectly sober and to be able to conduct a normal conversation ...

¶On the other hand, I have seen a young man from this part of the world with nothing else to show for it who was dead with a blood alcohol concentration of less than

¶80mg of alcohol/100ml of blood.29

¶2.5.68 Neither Dr Forrest nor the Coroner, in reiterating the remark about the Road Traffic Research Laboratory tests, made the obvious point that they measured response times to very rapidly changing situations, relevant to drivers in charge of a motor vehicle, but not to pedestrians attending a leisure event.

¶The Jones Report 2.5.69 The measurement of blood alcohol and its significance were the subject of a report prepared by Professor Wayne Jones, an international authority on alcohol testing, commissioned for the private prosecution.30 The report criticised several technical aspects of the testing, including the sites from which blood was taken, the failure to obtain confirmatory samples from the bladder or eye, and the analytical technique.

¶2.5.70 Professor Jones disagreed with Dr Forrest that a blood alcohol level of 20mg per 100mg was of any significance. Dr Forrest had suggested in evidence that this level might be found in someone who had drunk a pint or two of beer the previous night, but the Jones Report pointed out that the rate of metabolism would have cleared alcohol consumed the previous night. Professor Jones also emphasised that any post mortem level of less than 50mg per 100ml is of dubious significance and likely to be an artefact due to post mortem changes.31

29. Evidence of Dr Forrest at the Hillsborough Inquest, 18 April 1990, SYC000109270001, p71. 30. 'Review and Opinion, Preliminary Report', by Professor AW Jones, 18 April 1990, FAM000000010001, pp3-11. 31. Fermentation due to bacteria can produce alcohol in the body after death.

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¶Irrelevance of drink-drive limit 2.5.71 The Jones Report was also critical of the use of the drink-drive limit as if it had relevance to attendance at a football match. The report is quite clear: 'the insinuation that many of the victims were drunk (BAC>80mg/dL) at the time of the disaster and thus too impaired through drink to respond to a novel situation and that this played some role in their death is unjustified'.

¶2.5.72 If all results of the blood alcohol testing are reclassified according to levels indicated by Professor Jones, a clear picture emerges. Of the 95 individuals who died as an immediate result of the disaster, a total of 68 had undetectable (55), or insignificant and probably artefactual (13) levels of alcohol.

¶2.5.73 A further 12 had levels compatible with minor social disinhibition, and nine had some impairment of rapid responses, therefore unable to drive legally. Only six of the 95 had levels at which they may have been expected to show signs of being intoxicated.

¶2.5.74 In marked contrast to the prevailing assumption originating at the inquests, and widely promulgated through public statements made by senior South Yorkshire Police officers and published in the press, this notably modest pattern of alcohol consumption would bear comparison with any social, sporting or leisure occasion, and clearly endorses LJ Taylor's conclusion that drunkenness played no part in the disaster.

¶The Nicholl Report 2.5.75 The restrained nature of this overall pattern of alcohol consumption among spectators at a football match was not considered or explored at the inquests. In fact, Dr Jonathan Nicholl of Sheffield University was commissioned by the Coroner to write a report investigating a possible association between time of entry to the ground and blood alcohol level among those who died, suggesting that latecomers with higher blood alcohol levels may have been significant in what developed.32

¶2.5.76 Dr Nicholl presented a summary of his report at the inquests which, he claimed, confirmed an association between later entry to the ground and raised alcohol levels.33 Dr Nicholl did not make a link between the levels involved and the occurrence of the disaster. Yet it is clear from the Coroner's summing up that he placed emphasis both on the 'fall off in quality and manoeuvrability' in those over the drink-drive limit, and on Dr Nicholl's finding that those who had entered the ground after 2.30pm were more likely to have a raised blood alcohol level.

¶2.5.77 Disclosure of the original data analysed by Dr Nicholl, however, casts substantial doubt on his findings.34 In order to demonstrate this, the Panel has both replicated Dr Nicholl's original analysis and also reanalysed the original figures, revealing six significant problems with his report.

¶2.5.78 The first is Dr Nicholl's treatment of the data on time of entry. He established five categories, as well as an 'unknown entry' group who were excluded from analysis. There were three groups known to have entered via a turnstile, either before 2.30pm, between 2.30pm and 2.47pm, or after 2.47pm. There was a group known to have entered via Gate C, after 2.47pm when the gate was first opened. Another group were those whose route

32. 'Hillsborough – Association between time of entry to the ground, age and alcohol consumption', by Dr JP Nicholl, undated, SYC000000960001, pp21-32. 33. Evidence of Dr Nicholl at the Hillsborough Inquest, 14 March 1990, SYC000109160001, pp4-33. 34. Data used by Dr Nicholl, SYC000000960001, pp5-20.

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¶of entry via a turnstile or Gate C was unknown, but their entry time was believed to be 'probably' after 2.30pm. These groups are shown diagrammatically in Figure 5. The group whose entry route was unknown and who 'probably' entered after 2.30pm clearly constitute an awkward category for the analysis.

¶Figure 5: Route and time of entry of those who died Each oval represents one person. Note route of entry of middle group unknown, time 'probably after 2.30pm'. (Excludes 13 whose route and time are unknown.)

¶2.5.79 Dr Nicholl's solution was to construct two broader entry groups: those who entered before 2.48pm via a turnstile, which he categorised as 'early', and those who entered at 2.48pm or after, categorised as 'later', regardless of whether this was via turnstiles or Gate C. 2.5.80 Crucially this 'later' category also included the composite group whose entry time could only be described as 'probably' after 2.30pm. Even without considering the uncertainty of the assessment, the result as shown in Figure 6 was that those known to have entered between 2.30pm and 2.47pm were placed in the 'early' group, whereas those who entered at an indeterminate time after 2.30pm were included in the 'later' group, even though some or all may have entered before 2.47pm.

¶2.5.81 Dr Nicholl justified this muddle by proposing that the age profile of the indeterminate group was similar to that of the 'later' group. In fact, the age profile would have been just as consistent with the age profile of the 2.30pm to 2.47pm group entering through turnstiles and placed in the 'early' group. This is an unsatisfactory basis for analysis.

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¶Figure 6: Route and time of entry of those who died As Figure 5, showing construction of 'early' and 'later' groups in Nicholl Report.

¶2.5.82 The second problem evident from the data is that the focus on those who entered 'probably after 2.30pm' is crucial to Dr Nicholl's overall finding. There were many comparisons that could have been made between different entry groups and different blood alcohol levels, but the only comparison that suggested any statistical evidence of a relationship was that which required inclusion of the 'probably after 2.30pm' entrants in the 'later' group, and the 2.30pm to 2.47pm entrants in the 'early' group.

¶2.5.83 All other combinations of entry groups gave results that were likely to have arisen by chance variation alone. Specifically, this includes all analyses omitting the 'probably after 2.30pm' group and all analyses comparing entry before 2.30pm with entry after 2.30pm.

¶2.5.84 The third problem that emerges from replicating Dr Nicholl's analysis is that this sole result that could be described as providing any statistical evidence of an effect also depends on comparing all who had a blood alcohol level of 10mg/100ml or greater with those whose blood alcohol level was reported either as nil or as less than 10mg/100ml. There are clear biochemical reasons, established in the independent Jones Report already discussed, to consider that levels between 10mg/100ml and 20mg/100ml should also be treated as nil, and that levels between 20mg/100ml and 50mg/100ml are either artefactual or insignificant.

¶2.5.85 However, all cut-offs higher than 10mg/100ml, even with Dr Nicholl's flawed construction of 'early' and 'later' groups, produce results that are likely to have arisen through chance alone, and do not provide any evidence of a relationship between entry time and blood alcohol level. It is noteworthy that this includes a cut-off of 80mg/100ml, which was the basis of all of the evidence pursued by the Coroner at the inquests.

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¶The odds ratio 2.5.86 The fourth problem with the results follows from the use for all Dr Nicholl's comparisons of a statistic known as the odds ratio, an approach followed initially in replicating the analysis of the original data. The odds ratio is generally straightforward to calculate, and some types of epidemiological study cannot generate any better estimate.

¶2.5.87 However, the odds ratio is not an intuitively obvious concept, and often it is erroneously assumed to be the same as relative probability (or relative risk in epidemiological terms). In fact, the odds ratio provides an approximate estimate of relative probability at very low levels of frequency, such as the occurrence of uncommon diseases, but for more common events such as those in this data set the odds ratio differs greatly from relative risk.

¶2.5.88 Dr Nicholl used the correct definition of an odds ratio in his report and in his evidence to the inquests, but at no stage did he clarify that an odds ratio does not estimate the relative probability of the outcome in two different groups in these circumstances, which is what would understandably be assumed by a non-specialist. For example, the only explanation during his evidence to the inquests was:

¶Now one convenient way of expressing this is to say that amongst those victims, the odds of having a raised blood alcohol level for later entrants were three times as great as the odds for earlier entrants. Anybody who is betting on the Cheltenham Gold Cup this after [sic] will understand that as being a useful way of representing this.35

¶2.5.89 Leaving aside the questionable taste of the reference given the circumstances, his first sentence is technically correct (given the flawed definition of entry groups and the inappropriate use of a 10mg/100ml cut-off) but his second is highly questionable.

¶2.5.90 Very experienced punters – or statisticians – may know that the bookmakers' estimate (ignoring their inbuilt 'margin') of the probability of a horse winning that is quoted at evens is twice that of a horse quoted at 3 to 1 against, not three times (odds ratio 3.0, relative probability 0.5/0.25=2.0), but it is unlikely that anybody else will identify the implied exaggeration of the effect. The odds ratio Dr Nicholl quoted for the single statistically significant effect was 3.1 yet the relative probability, which in this case can be calculated from the same data, is less than 2.0.

¶2.5.91 The fifth problem that emerges from replicating the analysis is that in seeking to attribute robustness to his single statistically significant finding, Dr Nicholl crucially misrepresented some results. First, he attempted to counter the criticism that a high proportion of the females and young males amongst those who died both entered the ground before 2.30pm and had low or zero blood alcohol readings, possibly explaining any apparent relationship between time of entry and blood alcohol level.

¶2.5.92 He did this by omitting females and males aged less than 18 years and recalculating the odds ratio relating 'early' and 'later' groups with blood alcohol levels less than 10mg/100ml and 10mg/100ml and greater. He quoted the resulting odds ratio as '3.0 (95% CI: 1.0, 9.3)36 ... exactly as before'.37

35. Evidence of Dr Nicholl at the Hillsborough Inquest, 14 March 1990, SYC000109160001, pp9-10. 36. 95% CI: confidence interval within which true result is estimated to be with 95% probability given the observed results.

¶undated, SYC000000960001, p23.

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¶2.5.93 An odds ratio with a 95 per cent confidence interval that includes 1.0 (that is, no difference between the groups) implies that the result was sufficiently likely to have arisen by chance that the finding has borderline significance at best. Hence this cannot be represented as 'exactly as before', where the 95 per cent confidence interval did not include 1.0.

¶2.5.94 More seriously, it is clear from the data that Dr Nicholl resorted to a numerical device to present the lower 95 per cent confidence limit even as 1.0. Recalculating his analysis shows that the true value is 0.97 to two significant figures, so the confidence interval clearly includes unity and provides no statistical evidence of a relationship, but he chose to round to one decimal place instead of two significant figures. This was a dubious approach even in 1989.

¶2.5.95 Dr Nicholl anticipated potential criticism concerning his handling of the 'probably after 2.30pm' group of entrants by reclassifying entrants into two groups, entry pre-2.30pm and entry at or after 2.30pm. The problem, however, remains. He described the odds ratio in this case as '2.9 (95% CI: 1.0, 8.6)', which he interprets in his report as 'some evidence that late entrants after 2:30 were more likely to have raised alcohol levels'.38

¶2.5.96 Again, the lower confidence limit is 0.97, which Dr Nicholl chose to round to one decimal place rather than two significant figures. A 95 per cent confidence interval which extends below 1.0 fails to provide evidence of an effect other than chance.

¶2.5.97 The sixth problem concerns the size of the supposed difference in blood alcohol levels, which Dr Nicholl failed to consider. A small difference can be statistically significant if based on large numbers of observations, but it is unlikely to have any practical importance (for example, a dietary regime that produced a weight loss of 10 grams).

¶2.5.98 The first indication that any difference in this case could only be small comes from the lack of significance in any other comparisons based at higher cut-off values for blood alcohol levels, regardless of how the entry groups are constructed (including Dr Nicholl's flawed construction). The second indication is the small number of people with raised levels of blood alcohol in comparison to the much greater number without, as shown in Figure 7.

¶2.5.99 It is possible to estimate the size of the supposed difference directly, however, although this is not straightforward because of the skewed nature of the data, with all groups (bar one small sub-group of three people) showing a substantial proportion of zero readings. An approach based on regression analysis, for example, is inappropriate as the residual values are non-normally distributed.

¶undated, SYC000000960001, p23.

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¶Figure 7: Route and time of entry of those who died As Figure 6, showing blood alcohol readings.

¶2.5.100 Yet an approach based on the median difference in blood alcohol level between an 'early' and a 'later' group is possible, defining these groups in the same (flawed) way as Dr Nicholl so as to generate an estimate as favourable to his case as possible. Even under these extreme assumptions, the estimated median difference in blood alcohol level between the two groups is 13mg/100ml (for reference only, approximately 16 per cent of the legal driving limit) and the underlying median difference is unlikely to exceed 38mg/100ml39 (for reference only, less than half the legal driving limit).

¶Weight placed on blood alcohol levels 2.5.101 The Panel's analysis of the original data represents significant criticism of Dr Nicholl's findings and his report. It also brings into question the reliability of his evidence to the inquests, based on his report. At the conclusion of the generic stage of the inquests the Coroner's summing up relied heavily on the Nicholl Report in interpreting the significance of alcohol.40

¶2.5.102 The Coroner stated: 'Of the later entrants, the 2.30 pluses, 43 had had nothing to drink or negligible amounts – I call that nothing – and 22 per cent were over 80 milligrams'. This, he deduced, amounted to 'a fifth in round terms of the people who were those who died who had more than 80'.

39. Ninety-five per cent confidence interval 0mg/100ml to 38mg/100ml. 40. Dr Popper's summing up of the Hillsborough Inquest, 22 March 1991, SYC00010922, pp46-56.

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¶2.5.103 In fact this was incorrect, because 16 per cent of those who died had blood alcohol levels above the irrelevant 80mg/100ml marker. Even when referring to later entrants, the 22 per cent figure applied to those in Dr Nicholl's artificially created and paradoxical 'later entrants' group, which did not differ significantly from 'earlier entrants' at the 80mg/100ml level. Thus the correct estimate is 16 per cent.

¶2.5.104 The misleading 22 per cent figure was relied on as significant corroborative evidence by the Coroner:

¶It is very interesting because you may recollect Superintendent Mackay [sic], he was the Detective Superintendent who was standing somewhere around, and he was asked about alcohol and people drinking and he gave an estimate. He said 'I thought about a fifth', about a thousand I think he said people, 'had had perhaps a little bit too much to drink'. That is remarkably close to Dr Nicholl's figures ... That I thought was quite interesting.

¶2.5.105 The Coroner further developed this aspect:

¶... a fifth would probably be about right and that is in fact, as I have told you, what

¶Superintendent Mackay estimated, which I think was very smart of him. It was also very smart of Mr Creaser because he had described the people whom he saw as '3 pint men' which fits in exceedingly well [with] what I have told you the people selling the drinks told you, and it also fits in exceedingly well with Dr. Nicholson's [sic] figures, if you think about [sic].

¶2.5.106 This mix of unreliable 'scientific' evidence and unsubstantiated opinion underpinned the Coroner's summing up to the jury on the possible effect of alcohol:

¶[L]et's ... say 20% and let's take it that they were the '3 pint people'. What effect if any did that have on their behaviour and in particular their response or otherwise to direction and on their mood in the sense of increasing their frustration; decreasing their frustration; increasing their aggressiveness; decreasing their aggressiveness, or what effect did it have ? ...

¶Mr Marshall was quite clear. He did not say the whole lot were drunk. On the contrary, he said there was a minority, a significant minority he said, but a minority who were affected by alcohol ...

¶The big problem is what effect, if any, can that minority have on the group? We have all had the experience that if you get one person in a group who is loud or misbehaves or does something, that one person can actually cause a disproportionate amount of disruption and that is the problem. You may well find you get caught up in a situation which may not necessarily be of your making but which you cannot do anything about because of the activities of various other people.

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¶2.5.107 This leaves a clear impression that alcohol consumption was of major significance, particularly when expressed negatively in terms of 'frustration', 'aggressiveness' and 'big problem'. In fact, the literal meaning of the passage would be consistent if these words were replaced by 'well-being', 'calmness' and 'difficult question', yet the impression given would be very different.

¶2.5.108 In contrast to the picture presented to the jury, there was no reliable evidence of a significant link between time of entry to the ground and blood alcohol level among those who died at Hillsborough. Even accepting the flawed foundation on which the original analysis was based, it would show a small and inconsequential difference between earlier and later entrants, unimportant for any practical purpose.

¶2.5.109 Nor was any credible evidence presented that established the relevance of the 'driving limit' threshold. Fans were attending a social function, not requiring the swift reactions and anticipation necessary to control a motor vehicle. Such an inappropriate portrayal, and all that emanated from it, was insufficient to support a reasoned proposition that alcohol played a part in the genesis of the disaster. There was no evidence on which to base the inflammatory rumours, told to the Prime Minister on the day after the disaster, that a 'tanked up mob' charged into the central pens.

¶2.5.110 Finally, the Coroner's interweaving of flawed statistical analysis of the blood alcohol levels of those who died and senior officers' uncorroborated evidence provided a profoundly unreliable indication to the jury that alcohol consumption was a significant element in explaining how the disaster came about.

¶Criminal record checks on the deceased 2.5.111 A solicitor involved in the Hillsborough inquests disclosed a document to the Panel showing that criminal record checks were conducted selectively on some of the deceased who had recorded blood alcohol levels. To protect the privacy of the deceased the Panel has decided not to make public the document but to describe the process through which an attempt was made to establish links between blood alcohol levels and previous criminal convictions.

¶2.5.112 The document indicates that a Police National Computer (PNC) check was conducted on all who died at Hillsborough for whom a blood alcohol reading above zero was recorded. It includes a handwritten list of the names, dates of birth, blood alcohol readings and home addresses of 51 of the deceased and provides screen-prints apparently drawn from the PNC. A summary of the results appears on the front page, establishing the number 'with cons' (convictions).

¶2.5.113 The document was not formally part of the West Midlands or South Yorkshire Police inquiries and there is no record in the documents provided by either force or by the Coroner. There is no record of who conducted the checks or precisely when the checks occurred. The National Policing Improvement Agency, the organisation responsible for the PNC, confirmed to the Panel that information has not been retained within the PNC.

¶2.5.114 It is the Panel's view that criminal record checks were carried out on those of the deceased with recorded blood alcohol levels in an attempt to impugn personal reputations. There is, however, no evidence to suggest that this inappropriate – and possibly unlawful – exercise was used in the investigations, inquiries or inquests.

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¶Blood alcohol levels in survivors 2.5.115 It was known that blood alcohol levels were tested in those who died, because of the prominence given to the results during the mini-inquests. It has not been previously recognised that blood alcohol levels were tested in at least some of the survivors, but this is the implication of some of the material disclosed to the Panel.

¶2.5.116 The most clear-cut evidence is a document among medical papers headed 'In strict confidence',41 continuing 'Blood Alcohol concentrations in samples taken from patients admitted to the Royal Hallamshire Hospital following the Hillsborough Disaster'. There follows a list of 11 names (redacted as confidential medical information) and/or 'Majax Numbers '42 and the corresponding blood alcohol levels, which were all 'not detected' bar two.

¶2.5.117 The same set of documents also contains some text apparently intended to be put onto 'acetates' for overhead projection.43 Under the heading 'ALCOHOL', the text notes the numbers of deceased with alcohol levels of over 80mg/100ml (15) and over 120mg/100ml (6). The text continues: 'FEW OF THOSE ADMITTED HAD APPRECIABLE LEVELS'.

¶2.5.118 It is clear from these disclosed documents that blood alcohol levels were tested in some of those taken to the Sheffield hospitals. Two questions arise: for what reason were these tests carried out, and how extensive was the testing?

¶2.5.119 The individual hospital notes disclosed to the Panel are not of direct help. The only notes that contain reference to blood alcohol are those of a person who survived for two days before dying. Both the laboratory report, naming the pathologist who conducted the post mortem, and the relevant preliminary hearing transcript ('Yes, blood alcohol, this was done on a specimen taken at the time the patient was admitted'44) suggest that this test was carried out after death on a blood sample taken for another purpose on admission.

¶2.5.120 No other medical notes that were traced contained reference to blood alcohol testing, or any reference to the results, including the notes of those identified in the list of 'Blood Alcohol concentrations in samples taken from patients admitted to the Royal Hallamshire Hospital following the Hillsborough Disaster'.

¶2.5.121 The absence of reference to blood alcohol testing in the medical notes does not help to clarify how extensively this testing was carried out, but it is of concern. If these tests were done as part of clinical care – for example to indicate whether alcohol consumption might have contributed to reduced consciousness levels – the results should have been filed in the notes.

¶2.5.122 Further, the notes of some of those identified in the Royal Hallamshire Hospital list, where available, show no medical reason to test blood alcohol levels. The list includes individuals who were fully conscious and orientated, were suffering only from minor injuries, and were not admitted to hospital.

¶2.5.123 The Panel was concerned to trace all relevant documents that might explain why blood alcohol levels were taken and in how many people. No further information has been disclosed but the decision remains contentious and disturbing. 41. File labelled 'AC Crosby', undated, JWR000000250001, p1. 42. 'Majax Numbers': consecutive identifying numbers given to casualties resulting from a major incident on arrival at hospital, pending subsequent confirmation of identity. 43. File labelled 'Hillsborough Reports', undated, JWR000000220001, p1. 44. Inquest transcript, 1 May 1990, SYC000109960001, p8.

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¶
• In the great majority of cases, the cause of death given after post mortem examination was either traumatic asphyxia or crush asphyxia, each regarded as synonymous terms. The disclosed documents show that this corresponded to an assumption made by the Coroner and formed before the post mortems were conducted.
• The detailed review of all post mortem reports casts significant doubt on the single unvarying pattern, described consistently during the 'mini-inquests', of traumatic asphyxia causing unconsciousness within seconds, followed inevitably by death within a few minutes.
• There was clear evidence from the post mortem reports that 28 of those who died did not have traumatic asphyxia with obstruction of the blood circulation, and asphyxia may have taken significantly longer to be fatal. There was separate evidence that in 31 the heart and lungs had continued to function after the crush, and in 16 of these this was for a prolonged period. (These numbers cannot be added to the 28 as some featured in both groups.)
• It was asserted repeatedly, by the Coroner, by the High Court in the Judicial Review proceedings and by the Stuart-Smith Scrutiny, that the effects of asphyxia were irreversible by the time each of those who died was removed from the pens. Yet individuals in each of the groups now identified could have had potentially reversible asphyxia. Resuscitation of an unconscious person with a heartbeat is much more likely to be successful than if cardiac arrest has already occurred, as was previously assumed. While they remained unconscious, these individuals were vulnerable to a new event, particularly further airway obstruction from inappropriate positioning.
• It is not possible to establish with certainty that any one individual would or could have survived under different circumstances. It is clear, however, that some people who were partially asphyxiated survived, while others did not. It is highly likely that what happened to these individuals after 3.15pm was significant in determining that outcome. On the basis of this disclosed evidence, it cannot be concluded that life or death was inevitably determined by events prior to 3.15pm, or that no new fatal event could have occurred after that time.
• Disclosed documents provide no rationale for the Coroner's exceptional decision to take samples for blood alcohol measurement from all of the deceased.
• The implicit and explicit use of a blood alcohol level of 80mg/100ml as a marker was unjustified. This level has relevance to the rapid response times of individuals in charge of motor vehicles, but none to people attending a leisure event.
• Analysis of the data demonstrates that the attempt to draw statistical correlation between the time of arrival and alcohol level was fundamentally flawed in six respects, and no such link could be deduced.
• The weight placed on alcohol levels, particularly in the Coroner's summing up at the inquests, was inappropriate and misleading. The pattern of alcohol consumption among those who died was unremarkable and not exceptional for a social or leisure occasion.
• A document disclosed to the Panel has revealed that an attempt was made to impugn the reputations of the deceased by carrying out Police National Computer checks on those with a non-zero alcohol level.

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¶
• The disclosed documents show that blood alcohol levels were tested in some survivors who attended hospital, as well as in all those who died. There is no record of these tests or their results in the medical notes of survivors, and in some there was no apparent medical reason for the test. The extent of this testing remains unknown.
• There was no evidence to support the proposition that alcohol played any part in the genesis of the disaster and it is regrettable that those in positions of responsibility created and promoted a portrayal of drunkenness as contributing to the occurrence of the disaster and the ensuing loss of life without substantiating evidence.

¶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,⁴⁴ March 1988, SYP000096970001, p600. May 1989, HOM000007740001, p1. 3. Home Office file note entitled 'Link Between Taylor Inquiry and West Midlands Police Inquiry', undated, 4. Notes of Chief Constable's briefing with operational staff engaged on FA Cup duties, 9.00am 16 April 1989,

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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,¹⁷¹⁷ December 1997, HOM000030920001, p1. 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:

¶
• 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,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 1989,

¶HOM000002700001, pp2-3. 17. 'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Davies, Arnold, Cooper,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 1989,

¶TSO000000260001, pp3-4.

¶'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Keeble Hawsons,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 1989,

¶HOM000002700001, pp4-5. 18. 'Salmon' letter sent by fax from David Brummell, Assistant Treasury Solicitor, to Reynolds, Porter, Chamberlain,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May

¶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,

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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, 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'.

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¶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, 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'.

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¶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,²⁴²⁴ April 1989, HOM000016480001, p1. 43. Memorandum from White's News Agency to News Editor, London Evening Standard, re. allegations over behaviour of Liverpool fans at the Hillsborough semi-final, NGN000000070001. April 1989,

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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,¹⁶¹⁶ April 1989. The Prime Minister's Press Secretary later revealed, however, that he had been informed on the day that drunkenness and violent crowd behaviour were significant causes of the disaster. • The disclosed documents show that in the immediate aftermath of the disaster SYP prioritised an internal investigation and the collection of self-taken, handwritten statements in preparation for the imminent external inquiries and investigations. SYP Counsel advised that the police should approach its information-gathering exercise by considering themselves 'the accused'. • A subsequent internal report ('the Wain Report') informed the SYP submission to the Taylor Inquiry. Key elements of the SYP submission emphasised exceptional, aggressive and unanticipated crowd behaviour: large numbers of ticketless, drunk and obstinate fans involved in a concerted action, even 'conspiracy', to enter the stadium. 172. South Yorkshire Police press release, 13 January 1992, SYP000123580001, pp7-8. 173. Press clipping from unidentified newspaper, undated, SYP000123580001, p3.Show full note 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 68/1989,⁴⁴ March 1988, SYP000096970001, p600. 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,⁴⁴ March 1988, SYP000096970001, p600. 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, 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,¹⁷¹⁷ December 1997, HOM000030920001, p1. 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,²⁰²⁰ April 1989, HOM000016460001, pp1-5. 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,⁹⁹ August 1991, SPA000000600001. 140. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 28 March 1991, SYP000123570001, p98. 141. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Anderson, South Yorkshire Police, 10 April 1991, SYP000123570001, pp91-92. 142. Letter from ACC Anderson, South Yorkshire Police, to Brigadier Pownall, Police Complaints Authority, 10 April 1991, SYP000123570001, p95. 143. Letter from Brigadier Pownall, Police Complaints Authority, to ACC Moore, South Yorkshire Police, 7 May 1991, SYP000123570001, pp75-78.Show full note May 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,

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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,²⁰²⁰ April 1989, HOM000016460001, pp1-5. 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:

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• 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,¹⁶¹⁶ April 1989. The Prime Minister's Press Secretary later revealed, however, that he had been informed on the day that drunkenness and violent crowd behaviour were significant causes of the disaster. • The disclosed documents show that in the immediate aftermath of the disaster SYP prioritised an internal investigation and the collection of self-taken, handwritten statements in preparation for the imminent external inquiries and investigations. SYP Counsel advised that the police should approach its information-gathering exercise by considering themselves 'the accused'. • A subsequent internal report ('the Wain Report') informed the SYP submission to the Taylor Inquiry. Key elements of the SYP submission emphasised exceptional, aggressive and unanticipated crowd behaviour: large numbers of ticketless, drunk and obstinate fans involved in a concerted action, even 'conspiracy', to enter the stadium. 172. South Yorkshire Police press release, 13 January 1992, SYP000123580001, pp7-8. 173. Press clipping from unidentified newspaper, undated, SYP000123580001, p3.Show full note 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:

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• 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.

208

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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:

South Yorkshire Police

2. Sheffield Wednesday Football Club and their safety engineers