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.

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. 55. 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. 56. 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. 57. 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 limited access to public telephones. 58. 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. 59. 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. 60. 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.

¶Chapter 5. Medical evidence: the testimony of the dead The medical evidence from pathologists who had conducted post mortem examinations on the deceased was central in establishing the picture of an unvarying pattern of death within a few minutes of crushing. This evidence was the basis for the assertion by the Coroner and others that the outcome was predetermined from an early stage for all who died.

¶This underpinned the imposition of the 3.15pm cut-off on the generic inquest and the repeated assumption that the emergency services' response could not have helped. The Panel's access to all of the relevant records has confirmed that the notion of a single, unvarying and rapid pattern of death in all cases is unsustainable. Some of those who died did so after a significant period of unconsciousness during which they might have been able to be resuscitated, or conversely may have succumbed to a new event such as inappropriate positioning.

¶The idea that alcohol contributed to the disaster was raised at an early stage, and has proved remarkably durable despite being dismissed by the Taylor Report. The disclosed documents confirm the repeated attempts that were made to find supporting evidence for this.

¶They also show that available evidence was significantly misinterpreted, including an attempt to establish a link between later arrival and drunkenness that was fundamentally flawed.

¶The weight placed on alcohol in the face of objective evidence of a pattern of consumption modest for a leisure event was inappropriate. It has since fuelled persistent and unsustainable assertions about drunken fan behaviour.

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.
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.

¶Chapter 6. Parallel investigations Following a disaster that claimed so many lives, inevitably the investigation and inquiry into its circumstances and causes were complex. Because there were fatalities the Coroner was involved immediately. Within SYP an internal investigation was established, including a process of information gathering involving 'self-taken' statements written by police officers.

¶Lord Justice Taylor was appointed to conduct a judicial inquiry. The Chief Constable of West Midlands Police (WMP) was invited to establish a full investigation carried out by a WMP team. The WMP team served the criminal investigation, the Taylor Inquiry and the Coroner's inquiry and inquest.

¶Thus multiple investigations proceeded in parallel. It is evident from the disclosed documents that from the outset SYP sought to establish a case emphasising exceptional levels of drunkenness and aggression among Liverpool fans, alleging that many arrived at the stadium late, without tickets and determined to force entry.

¶A less well-known investigation was conducted by the Health and Safety Executive (HSE), and found that restricted access, poor condition and inadequate means of escape rendered the Leppings Lane terrace – particularly its central pens – structurally unsafe. This risk was known.

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

¶Sheffield on 16 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.
The SYP submission also noted structural deficiencies within the stadium and its management by SWFC. This line of argument was further developed in advice from a senior police officer from another force commissioned by SYP in support of civil proceedings. In contrast, the SWFC submission specified serious failures in policing in monitoring the pens, processing the crowd and opening Gate C without preparing for the consequences.
Reports commissioned by SYP and SWFC from two experienced senior police officers reveal how, when confronted with consistent information from two distinct and potentially culpable institutional interests, significantly different conclusions were drawn.
The submission by Counsel to the Taylor Inquiry focused on the build-up of fans outside the stadium, insufficiency of turnstiles and lack of control of the numbers distributed between the pens.

An initial investigation into the condition of the Leppings Lane terrace and its approaches was conducted by Sheffield City Council. It found deficiencies in the placement of safety barriers and in the width of the perimeter fence gates.
In its more detailed investigation, the Health and Safety Executive (HSE) established that the safe maximum capacity of the pens had been set too high and that the crowd density in pen 3, where most of the deaths occurred, was substantially higher than the Green Guide maximum.
The HSE established not only that the maximum capacity of the terrace and the central pens had been significantly over-calculated, but that alterations to the terrace had not been considered in establishing safe capacity. It concluded that the terrace safety barriers were considerably below the recommended height and that this deficiency should have reduced further the maximum safe capacity.
The restricted approach to the Leppings Lane end and the comparatively low number of turnstiles resulted in inevitable congestion and delays in entering the stadium at capacity matches. The HSE noted that the number of fans that had to pass through each of the Leppings Lane turnstiles was between 2.9 and 3.5 times higher than at turnstiles serving other parts of the stadium. The calculated rate of admission shows that the crowd could not have completed entering the ground until approximately 40 minutes after the kick-off.
Many of these issues were also raised in Professor Leonard Maunder's advice as one of the assessors to the Taylor Inquiry. The advice from the police assessor,

¶Chief Constable of Lancashire Brian Johnson, criticised SYP's failure to review the

¶1988 Police Operational Order to identify 'shortcomings'; poor communications between senior officers; and the consequent failure to divert the crowd away from the tunnel once Gate C had been opened.

It is evident from the Salmon letters issued to SYP, SWFC, Sheffield City Council and Eastwood & Partners (disclosed to the Panel) that there was an understanding within the Home Office of the central issues of responsibility to be examined by the

¶Taylor Inquiry. 86. In documents disclosed to the Panel it is evident that the primary concern of the

¶Government at the time was the potential impact (positive or negative) on the

¶Parliamentary passage of the planned Football Spectators Bill. 87. Following the publication of the Taylor Report, the Prime Minister was briefed that

¶'the defensive – and at times close to deceitful – behaviour by the senior officers in South Yorkshire sounds depressingly familiar'. The Government did not seek to protect the SYP Chief Constable and it was considered inevitable that he would resign. His resignation, however, was rejected by South Yorkshire Police Authority. 88. Access to Cabinet documents reveals that in an exchange about her Government

¶'welcoming the Report' the Prime Minister, Margaret Thatcher, expressed her concern that the 'broad thrust' of the Taylor Report constituted a 'devastating criticism of the police'. 89. In reaching a decision on criminal prosecutions, the Director of Public Prosecutions was advised that responsibility for the disaster lay with SWFC, Eastwood & Partners engineers, Sheffield City Council and SYP. While the most significant proportion of responsibility was attributed to SYP, it was considered that the legal case for manslaughter or any other criminal offence could not be established.

Disciplinary proceedings against Chief Superintendent David Duckenfield and

¶Superintendent Bernard Murray were brought only following a direction from the

¶Police Complaints Authority (PCA). Responding to legal advice, SYP had decided that disciplinary charges should not be brought. The PCA was concerned that subsequent delays in bringing disciplinary proceedings were 'tactical'. A significant cause of the delay was the impact of the 'review and alteration' of SYP statements and their evidential unreliability.

¶Chapter 7. Civil litigation The documents disclosed to the Panel show that SYP sought to avoid any admission of liability in the settlement of compensation claims and in contribution proceedings against other organisations. SYP officers who claimed compensation were pressured within the Force to withdraw their claims.

The decision by SYP to settle certain categories of compensation claims from the injured and bereaved in November 1989 was sudden and taken for legal and tactical reasons. It was made deliberately without any admission of liability so as not to prejudice the position of any police officers subsequently under criminal investigation.
Following legal action by SYP, other organisations agreed to contribute to the payment of compensation to the injured and bereaved as follows:

• Sheffield Wednesday Football Club – £1.5 million • the Club's engineers Eastwood & Partners – £1.5 million • Sheffield City Council – £1 million.

It was estimated that total compensation to the injured and bereaved might reach

¶£12 million, suggesting that SYP would have accepted two-thirds of the liability and the other organisations one-third. Ultimately the cost of compensation rose to

¶£19.8 million. SYP's public liability insurance cover was limited to £8.5 million. The remainder of the total was paid from the Police Authority's financial reserves and through special payments from the Home Office.

Compensation claims from SYP officers caused considerable tension within the

¶Force. Senior officers viewed the claims with 'great concern' and junior officers felt 'immense pressure' from the Force to withdraw them. SYP accepted internally that they had 'no defence' in relation to a category of claims in late 1992, but did not agree to make payments until mid-1995. This was a strategic decision to deter

¶'copy-cat' claims. Those claims not settled were successfully defended in court.

¶£1.5 million was ultimately paid out by SYP to 16 officers. The costs were met from the Force's employers' insurance cover.

¶Chapter 8. The Coroner's inquiry: from the immediate aftermath to the preliminary hearings The most striking feature of the Coroner's inquiry was the decision to hold the inquest in two separate parts. The initial phase was a series of preliminary hearings or 'mini-inquests', one for each death, followed later by a single generic inquest to consider the circumstances of the disaster. The decision to hold separate preliminary hearings had far-reaching consequences.

¶Each preliminary hearing before a jury heard a pathologist give evidence on cause of death, preceded by the contentious reading of the deceased's blood alcohol level. This was followed by an account by a WMP officer, summarising what was known concerning the deceased's prior movements, location in the pens and events after evacuation from the pens. Because the account was given by a WMP investigating officer, this evidence could not be questioned during the inquest.

¶The disclosed documents show that while the families' lawyers welcomed the Coroner's unusual decision to hold individual, preliminary hearings, many families were dissatisfied with the denial of an opportunity to enquire into the precise circumstances in which their loved ones died.

In public statements the Coroner explained that his decision to hold preliminary hearings on a limited basis (mini-inquests) was in response to representations from families' lawyers. The disclosed documents show that the Coroner took Counsel's advice before deciding to hold mini-inquests, a decision initially rejected by the

¶WMP investigation team.

The procedures adopted for the presentation of evidence to the jury, particularly

¶WMP investigating officers reading witnesses' summarised statements, prevented examination of the evidence. This undermined its reliability and this became a serious issue of concern regarding 'sufficiency' of inquiry.

This process, while agreed by the bereaved families' legal representatives, was accepted on the assumption that questions and inconsistencies within summaries would be fully examined at the generic stage of the inquests. This occurred only in a limited number of cases.
Following the mini-inquests, the families' legal representatives conveyed their clients' satisfaction with the process to the Coroner. Yet families' correspondence demonstrates serious concerns regarding what they considered to be a flawed process which left many questions unanswered.

¶Chapter 9. The generic hearing, Judicial Review and continuing controversies The second stage of the inquests was the generic hearings held after the decision had been taken by the Director of Public Prosecutions not to pursue criminal prosecutions.

¶The documents disclosed to the Panel show that there were concerns raised in discussions between the Coroner and the WMP investigators about the status and ownership of information gathered and statements made for the Taylor Inquiry and the criminal investigation.

¶It is clear from the documents that SYP considered that the generic hearings provided an opportunity to use the court to respond to criticisms levelled against the Force and its senior officers by Lord Justice Taylor's Interim Report. Consequently the nature of the generic hearing was adversarial rather than inquisitorial.

¶While the High Court in the Judicial Review proceedings considered that the inquests had been unorthodox, it did not consider that the process had been insufficient in establishing how the deceased came by their deaths.

The Coroner decided against relying on the Taylor Inquiry to meet the requirements of the generic stage of the inquests. As the disclosed documents show, the

hearings became adversarial as SYP attempted to use the proceedings to respond to criticisms in Lord Justice Taylor's Interim Report.

The Coroner anticipated that SYP would attribute responsibility for the disaster to

'drunkenness and disobedience' and 'ticketless' fans while also proposing that failings by SWFC and its safety engineers and the 'nepotism' of Sheffield City Council were relevant factors.

The Coroner's file notes also indicate his acceptance, regardless of Lord Justice

Taylor's findings, that the relationship between alcohol consumption, late arrivals and crowd behaviour could have contributed to the disaster. The reason for this assumption is not evident from the disclosed documents.

Exchanges between the lead investigating officer, Chief Constable Leslie Sharp,

and the Coroner demonstrate strong differences of opinion regarding the status of the information gathered for the criminal investigation and the access to the information granted to SYP prior to completion of the inquests.

These differences were settled by Chief Constable Sharp's decision to release

documents to SYP and the Force's agreement that they would be used only for disciplinary purposes and not in preparation for the inquests.

Confusion and controversy about the status and ownership of documents

and statements gathered by the WMP investigation team reveal the problems associated with sharing evidence between interested parties and the privilege enjoyed by SYP in preparation for the generic stage of the inquests.

It is also evident that, in order to fulfil an expectation that the Coroner had all

documents 'available' to him, he arranged for their delivery to his home for a few days even though he would not have the capacity to consider them thoroughly.

It is clear from the disclosed documents that the Coroner considered the

mini-inquests had answered issues of relevance to each of the bereaved. The task of the generic hearing was to establish 'how' the 95 had died.

Having invited all interested parties to identify who they wanted to be called as

witnesses at the generic stage, in the disclosed documents there is no explanation for the Coroner's final selection.

There is a substantial amount of documentary evidence concerning the inadequacy

of the inquest process. In subsequent Judicial Review proceedings the High Court recognised that the inquests were 'unorthodox' and failed to comply with the Coroners Rules. Yet the High Court rejected claims that there had been insufficiency of process.

Lord Justice Stuart-Smith raised concerns with the Coroner that families had

been misled into believing that questions that remained unanswered at the mini-inquests would be addressed at the generic stage. The Coroner reassured him that, wherever relevant, this was achieved, although subsequent correspondence from families suggests otherwise.

While Lord Justice Stuart-Smith recognised the complexities and difficulties facing

the Coroner, he considered that the generic hearing became 'out of control'. He suggested that it might have been more appropriate to have adopted the findings of the Taylor Inquiry than to have conducted a generic hearing.

¶Chapter 10. The 3.15pm cut-off The Coroner's decision to limit evidence to events before 3.15pm was based on pathologists' evidence, then uncontested and accepted as incontrovertible, that all who died were by that time beyond recovery. It remains one of the most significant causes of concern for bereaved families because it eliminated examination of the adequacy of the emergency response and rescue.

The disclosed documents establish that 'evidence gathering' by SYP in the immediate aftermath of the disaster focused on the 'incident itself', specifying a cut-off at 3.15pm or 3.30pm.
From the disclosed documents it is clear that, prior to the mini-inquests, the

¶Coroner understandably was concerned about his capacity to control the scope of the inquests – a concern reflected in the advice he received from other coroners.

¶'Response' and 'rescue' attempts were considered to be 'post-incident' and would not be addressed at the inquests.

Prior to the generic stage of the inquests, the WMP investigation team (acting as coroner's officers) advised that its scope should be restricted to the period 2.20pm to 3.05pm.
The rationale presented by the Coroner for selecting 3.15pm as the cut-off, acknowledged as appropriate by the High Court in the Judicial Review proceedings and the Stuart-Smith Scrutiny, was that all who died had suffered fatal and irreversible injuries by that time.
3.15pm was chosen because it was an undisputed and recorded time when an ambulance arrived on the pitch. This served as a 'marker' and the Coroner rounded the time to the nearest quarter-hour.
The pathologists' medical opinion underpinned the Coroner's final decision. It concluded that all who died suffered irretrievable, fatal injury and there could be no recovery regardless of whether the deceased lived beyond 3.15pm. This opinion neglected the significance of the particular circumstances in which each individual died, including the absence of appropriate medical or treatment intervention.
The acceptance of the pathologists' medical opinion as incontrovertible is evident from the Coroner's notes, in his affidavit to the High Court in the Judicial

¶Review proceedings (in which he described the 'expert' pathological evidence as

¶'overwhelming') and in his evidence to the Stuart-Smith Scrutiny.

Records of meetings between the Coroner and the families' legal representatives reveal that the representatives accepted the 3.15pm cut-off and portrayed families' concerns about the mini-inquests as 'minimal'.
As the extent of the correspondence from families demonstrates, this assumption was mistaken. The Coroner dismissed the families' requests to extend the cut-off beyond 3.15pm to incorporate the period of rescue and evacuation because he believed they misunderstood the role and function of the inquests.
The disclosed documents show that the Coroner formed the view that the case for extending the generic stage of the inquests beyond 3.15pm would require evidence of a new causal act that resulted in any one death (novus actus interveniens). He

concluded that there was no evidence of such acts or interventions, a conclusion supported by the High Court in the Judicial Review proceedings and by the Stuart-Smith Scrutiny.

The families accepted that the primary cause of injuries was crushing but,

supported by further medical opinion, they challenged the certainty that all who died had suffered irretrievable fatal injury by 3.15pm. Thus they sought further inquiry into the emergency response, rescue and treatment.

In his evidence to the Stuart-Smith Scrutiny, the barrister who had represented the

families at the generic stage of the inquests informed Lord Justice Stuart-Smith that he had advised the families there was no new causal act beyond 3.15pm.

In the Coroner's summing up he accepted that had resuscitation been administered

correctly, and before the onset of 'irretrievable brain damage', some of those who died might have survived. Taken literally, this comment raises concerns about the sufficiency of inquiry into the period of rescue and resuscitation.

In the well-documented case of Kevin Williams and successive submissions by his

family to the Attorney General, the initial pathologist's opinion appeared definitive, but further authoritative opinions raised significant doubts about the accuracy of that initial opinion.

The documents disclosed show that, considered alongside the restrictions placed

by the Coroner on the examination of the evidence presented to the mini-inquests and the presentation of the pathologists' medical opinion as incontrovertible, the imposition of the 3.15pm cut-off severely limited examination of the rescue, evacuation and treatment of those who died. This raised profound concerns regarding sufficiency of inquiry and examination of evidence.

¶Chapter 11. Review and alteration of statements Eight years after the disaster it was revealed publicly for the first time that statements made by SYP officers were initially handwritten as 'recollections', then subjected to a process of 'review and alteration' involving SYP solicitors and a team of SYP officers. In a number of cases police officers were asked to reconsider and amend their initial statements before they were forwarded to the Taylor Inquiry.

¶The documents disclosed to the Panel show that there was confusion concerning the status of the recollections, the rationale behind their review and alteration, the extent of the amendments and officers' acceptance of the process. While Lord Justice Stuart-Smith raised concerns about the appropriateness of the process, he considered there was no malpractice involved.

¶Other disclosed documents show that the practice of review and alteration extended to the South Yorkshire Ambulance Service.

From the documents disclosed to the Panel it is apparent that the decision to

gather self-taken recollections from SYP officers, rather than following the standard procedure of contemporaneous pocket-book entries as the foundation for formal Criminal Justice Act statements, originated in the immediate aftermath of the disaster on 16 and 17 April. The initial justification was to provide SYP and the Force solicitors with candid, 'warts-and-all' accounts from officers that would be used to inform SYP's submission to the Taylor Inquiry.

What followed, however, was an extensive process of review and alteration of the recollections and their transition to multi-purpose statements. The disclosed documents reveal confusion about the purpose of recollections, initially taken for

¶SYP 'internal' purposes, and their subsequent use by the WMP investigation. It was brought into stark relief in the confusion surrounding the status of statements presented to the Taylor Inquiry and the Inquiry's acceptance of the 'final versions' of the reviewed and altered statements. 128. It was the Taylor Inquiry's understanding that the 'final versions' of SYP statements differed from the initial 'recollections' only with regard to the removal of officers' opinions. The Inquiry team considered there to be 'absolutely no reason' why opinion should be removed, but did not consider the process improper and did not raise any objection. 129. The process of transition from self-taken recollections to formal Criminal Justice Act statements was presented as removing 'conjecture' and 'opinion' from the former, leaving only matters of 'fact' within the latter. Disclosed correspondence between

¶SYP and the Force solicitors reveals that comments within officers' statements

¶'unhelpful to the Force's case' were altered, deleted or qualified (rewritten by the

¶SYP team). 130. A significant number of SYP officers were uncomfortable with the methodology adopted in reviewing and altering their initial accounts and with the role of the SYP solicitors in this process. Senior SYP officers, including the Chief Constable, were aware of these concerns and the disclosed 'Hillsborough updates' demonstrate their attempts to assuage these concerns. An SYP inquiry liaison team was available to provide junior officers with 'necessary information and assistance' prior to giving evidence to the Taylor Inquiry. 131. Examination of officers' statements shows that officers were discouraged from making criticisms of senior officers' responses, their management and deficiencies in the SYP operational response: 'key' words and descriptions such as 'chaotic' were counselled against and, if included, were deleted. 132. Some 116 of the 164 statements identified for substantive amendment were amended to remove or alter comments unfavourable to SYP. 133. Lord Justice Stuart-Smith raised concerns about the derivation and operation of the process of review and alteration with SYP's Chief Superintendent Donald Denton and Peter Metcalf (Hammond Suddards, SYP solicitors). 134. Lord Justice Stuart-Smith also wrote directly to a number of officers to investigate the extent to which they were 'pressurised' into making alterations to original statements. 135. One officer stated he had accepted the changes only because he was suffering from depression and post-traumatic stress. He considered it an 'injustice for statements to have been "doctored" to suit the management of South Yorkshire

¶Police'. Another officer had accepted the process, but had not realised how much of his statement had been removed. 136. Detective Chief Superintendent Nick Foster of the WMP investigation team informed the Stuart-Smith Scrutiny that in five out of a sample of six amended statements material should not have been removed. In one case he 'question[ed]

the objectivity … of the person vetting'. He considered that the investigation had not been affected by the deletions made.

The disclosed documents demonstrate that the role played by the Force solicitors was more significant and directive than was understood by Lord Justice Stuart-Smith.
Lord Justice Stuart-Smith accepted that SYP edited those statements that were

'unhelpful to the police case' but 'at worst this was an error of judgement' as there were only a few examples 'where matters of fact were excluded'. The process reflected an 'understandable desire' to protect the interests of a Force on the 'defensive'. Yet Lord Justice Stuart-Smith found no 'irregularity or malpractice'. There had been no negative consequences for the Taylor Inquiry, the criminal investigations, the disciplinary proceedings or the coronial inquiry.

The documents disclosed to the Panel show that the review and alteration of

statements extended to the South Yorkshire Metropolitan Ambulance Service (SYMAS) and its solicitors. While there is variation in the amendments, in a number of cases they deflected criticisms and emphasised the efficiency of the SYMAS response.

¶Chapter 12. Behind the headlines: the origins, promotion and reproduction of unsubstantiated allegations In the days after the disaster the media, particularly the press, published allegations and counter-allegations apportioning blame. This came to a head on 19 April when a number of newspapers, The Sun being the most prominent, reported serious allegations about the behaviour of Liverpool fans before and during the unfolding tragedy.

¶The documents disclosed to the Panel show that the origin of these serious allegations was a local Sheffield press agency informed by several SYP officers, an SYP Police Federation spokesperson and a local MP.

¶They also demonstrate how the SYP Police Federation, supported informally by the SYP Chief Constable, sought to develop and publicise a version of events that focused on several police officers' allegations of drunkenness, ticketlessness and violence among a large number of Liverpool fans. This extended beyond the media to Parliament.

¶Yet, from the mass of documents, television and CCTV coverage disclosed to the Panel there is no evidence to support these allegations other than a few isolated examples of aggressive or verbally abusive behaviour clearly reflecting frustration and desperation.

As the severity of the disaster was becoming apparent, SYP Match Commander,

Chief Superintendent David Duckenfield, told a falsehood to senior officials that Liverpool fans had broken into the stadium and caused an inrush into the central pens thus causing the fatal crush. While later discredited, this unfounded allegation was broadcast internationally and was the first explanation of the cause of the disaster to enter the public domain.

Within days, further serious allegations emerged from unnamed sources, a Police

Federation spokesperson and a local Conservative MP, Irvine Patnick. These were that Liverpool fans had conspired to arrive late, many were without tickets, were exceptionally drunk and aggressive and determined to force entry into the stadium.

On 19 April, four days after the disaster, The Sun newspaper published a front-page story under the banner headline, 'THE TRUTH', alleging that Liverpool fans had assaulted and urinated on police officers resuscitating the dying, stolen from the dead and verbally sexually abused an unconscious young woman. Although less prominently, and often with a lesser degree of certainty, other regional and national newspapers published similar allegations.
In a letter revealed to the Panel, within days of The Sun's article its Managing

¶Editor wrote to people, including bereaved families, who had complained about the allegations. While regretting the presentation of the article, he refused to apologise for its 'substance', claiming it was factually accurate. Subsequently the coverage was condemned by the Press Council.

Given the broader press reporting of the allegations, the Panel sought to establish their origins. Documents disclosed to the Panel show that the allegations were filed by White's News Agency, a Sheffield-based company. They were based on meetings over three days between agency staff and several police officers, together with interviews with Irvine Patnick MP and the South Yorkshire Police Federation

¶Secretary, Paul Middup.

From the documents, it is clear that Mr Patnick based his comments on a conversation with police officers on the evening of the disaster while the officers were in considerable distress. Mr Patnick submitted a detailed account of this meeting and his overall involvement that evening to the Taylor Inquiry.
Months after the disaster White's News Agency confirmed to the London Evening

¶Standard that its filed stories originated from 'unsolicited' allegations made by

¶'high ranking' SYP officers to agency 'partners'. There were four separate police sources plus the interview with Mr Patnick. Together these sources were considered sufficient verification for the story to be considered factually accurate and it was distributed accordingly.

A document disclosed to the Panel shows that while the Taylor Inquiry was in session White's News Agency received copies of several SYP officers' sworn statements alleging drunken and violent behaviour by Liverpool fans. The agency forwarded the statements to Mr Patnick.
A further document records a meeting in Sheffield of Police Federation members on the morning of the publication of the controversial story in The Sun. The Police

¶Federation Secretary, Mr Middup, confirmed that 'putting our side of the story over to the press and media' had been his priority. He told the meeting that the Chief

¶Constable had stated that 'the truth could not come from him' but he had given the

¶Police Federation a 'free hand' and his support.

At the meeting police officers repeated many of the allegations published in the media. The Chief Constable joined the meeting and advised that the SYP case had to be pulled together and given to the Inquiry. A 'defence' had to be prepared and a 'rock solid story' presented. He believed that the Force would be 'exonerated' by the Taylor Inquiry and considered that 'blame' should be directed towards 'drunken ticketless individuals'.
Lord Justice Taylor's Interim Report condemned the evidence and testimony of senior police officers and rejected as exaggerated the allegations made against

Liverpool fans. He stated categorically that fans' behaviour played no part in the disaster. The South Yorkshire Police Federation held a meeting in Sheffield attended by its Parliamentary representative, Michael Shersby MP. Records of the meeting disclosed to the Panel show that the Police Federation considered the Interim Report was unfair and unbalanced. Mr Shersby was invited to assist in the development of a 'counter attack' to 'repudiate' Lord Justice Taylor's findings.

The meeting's afternoon session heard from unnamed police officers who repeated

the allegations of exceptional levels of abuse, drunkenness and violence. The Interim Report was dismissed as a 'whitewash' and the meeting would provide the basis for promoting the police version of events through 'public channels'. The meeting's content, particularly the allegations, directly informed an article published subsequently in the Police Federation magazine. It was written by its editor who attended and contributed to the meetings.

In a press interview the South Yorkshire Chief Constable, Peter Wright, also

criticised the findings of the Interim Report and expressed confidence that a 'different picture' would emerge at the inquests. His comments drew many complaints and were investigated by WMP. It was decided that no breach of discipline had occurred.

Consistent with Lord Justice Taylor's findings, the Panel found no evidence among

the vast number of disclosed documents and many hours of video material to verify the serious allegations of exceptional levels of drunkenness, ticketlessness or violence among Liverpool fans. There was no evidence that fans had conspired to arrive late at the stadium and force entry and no evidence that they stole from the dead and dying. Documents show that fans became frustrated by the inadequate response to the unfolding tragedy. The vast majority of fans on the pitch assisted in rescuing and evacuating the injured and the dead.

¶Hillsborough: 'what was known'

¶1.1 On 15 April 1989 Liverpool and Nottingham Forest were scheduled to play in the semi-final of the world's oldest and most celebrated soccer competition – the Football Association Cup (FA Cup).

¶1.2 By coincidence, it was a re-match of the 1988 Semi-Final between the two clubs. Both matches were played at a neutral venue, Hillsborough Stadium, the home of Sheffield Wednesday Football Club. On the same afternoon the other semi-final, between Everton and Norwich, was scheduled for Villa Park in Birmingham, home of Aston Villa FC.

¶1.3 At Hillsborough the match kicked off at 3pm. Six minutes later the referee stopped play and took the players from the pitch. At one end of the stadium, on the Leppings Lane terrace where Liverpool spectators were standing, a crush had become so severe that people were climbing the fences onto the pitch. Others were being pulled up into the seated area of the West Stand above the terrace.

¶1.4 It was soon realised that many people were injured, some fatally. A tragedy was unfolding, witnessed by over 54,000 people inside the stadium, television and radio broadcasters, numerous journalists and press photographers, and recorded on CCTV.

¶1.5 As a consequence of the crush 96 men, women and children died, 162 were treated at hospitals in Sheffield and Barnsley, many more were traumatised and the families of those who died and survived were changed forever. Others have died prematurely, their deaths probably hastened by the physical injuries or psychological suffering endured at Hillsborough and its aftermath.

¶1.6 In terms of lives lost, the Hillsborough disaster is the most serious crowd-related tragedy at a sports event in Britain. It is also the most investigated and studied. Within two days of the disaster a Judicial Inquiry, chaired by Lord Justice Taylor, was appointed (the Taylor Inquiry).

¶1.7 South Yorkshire Police (SYP), responsible for the policing at Hillsborough, immediately organised an internal inquiry (the Wain Inquiry) and the Chief Constable of the West Midlands Police (WMP), Geoffrey Dear, was invited to conduct a full criminal investigation.

¶1.8 This was agreed and the WMP investigators, led by Assistant Chief Constable Mervyn Jones, serviced the Taylor Inquiry, the Director of Public Prosecutions (DPP) and the South

Part 1 Hillsborough: 'what was known' — 27

¶Yorkshire West District Coroner, Dr Stefan Popper. The public inquiry, the WMP investigation and the inquests formed the three distinct but related strands of inquiry.

¶1.9 The Taylor Inquiry published its Interim Report in August 1989, focusing on the circumstances of the disaster, and a Final Report in January 1990, broadening the focus to consider all matters of safety at sports events. The DPP's decision not to prosecute any individual or corporate body was taken in late August 1990.

¶1.10 Inquests were held in two parts. Limited preliminary hearings of the evidence concerning the deaths of each of the then 95 deceased were held before the jury between 18 April and 4 May 1990. The inquests resumed in generic form, taking place between 19 November 1990 and 28 March 1991 culminating in verdicts of accidental death. A challenge to those verdicts on behalf of six bereaved families, commenced in April 1992, eventually was dismissed by the High Court in November 1993.

¶1.11 On 11 July 1991 the Police Complaints Authority directed that the two officers with overall command at Hillsborough, Chief Superintendent David Duckenfield and his assistant, Superintendent Bernard Murray, should face a disciplinary hearing to answer the charge of 'neglect of duty'. C/Supt Duckenfield retired on medical grounds and in January 1992 it was decided not to pursue a case against Supt Murray alone.

¶1.12 Throughout this period there was a range of civil litigation, including test cases for compensation in respect of the pre-death pain and suffering of the deceased, the trauma suffered by close relatives who were not directly affected or injured in the events, and the trauma suffered by police officers on duty. These cases were significant and appeals progressed to the House of Lords.

¶1.13 In March 1993 the decision was taken to withdraw feeding and hydration from Tony Bland who had remained in a persistent vegetative state since receiving his injuries at Hillsborough. His case was also subject to appeal and also progressed to the House of Lords.

¶1.14 In June 1997, following persistent campaigning by the Hillsborough Family Support Group, and representations by Merseyside MPs, the Home Secretary, Jack Straw, announced an unprecedented 'judicial scrutiny' of new evidence not previously available to the Home Office Inquiry, the DPP or the police disciplinary process.

¶1.15 The Home Secretary appointed Lord Justice Stuart-Smith, who reported on 18 February 1998 and recommended that no further action was warranted. A House of Commons Adjournment Debate followed in May 1998.

¶1.16 The Hillsborough Family Support Group proceeded with a private prosecution for manslaughter against former C/Supt Duckenfield and former Supt Murray. In August 1999 the Leeds Stipendiary Magistrate allowed the private prosecution to proceed and in February 2000 both officers appealed to the Divisional Court.

¶1.17 Their appeals failed. The trial was held in Leeds between 6 June and 24 July 2000. Bernard Murray was acquitted and the jury was undecided on David Duckenfield. Application for a re-trial was refused.

¶1.18 In 2009, following a public announcement by Andy Burnham, Secretary of State for Culture, Media and Sport, concerning the possible early release of Hillsborough-related documents, the Hillsborough Family Support Group met with the Home Secretary. As a consequence the Hillsborough Independent Panel was appointed in January 2010.

¶1.19 Its terms of reference committed the Panel to 'maximum public disclosure' of all documents held by official agencies and to the publication of a comprehensive report demonstrating how the disclosed material 'adds to public understanding' of the disaster, its context, circumstances and aftermath. The Panel was also expected to oversee the establishment of the Hillsborough Archive, containing all primary documents held by the contributing agencies.

¶Crowd safety at sports venues – a history of tragedy 1.20 The FA Cup was founded in the 1871/72 season and by the late 1980s over 650 professional, semi-professional and amateur clubs competed in the competition, including all clubs in the four main professional divisions. From 1923 to the present, with the exception of the 2000–07 seasons, the FA Cup Final has been held at Wembley Stadium.

¶1.21 The 1923 Final, the first at Wembley, gained notoriety because the estimated 200,000 crowd well exceeded the stadium's capacity and spilled onto the pitch. Although people were injured in the crush there were no fatalities and the Government commissioned an Inquiry chaired by former Home Secretary Edward Shortt.

¶1.22 Mr Shortt made numerous recommendations, including improved stadium access and egress, and smaller self-contained terrace enclosures. The FA did not attend the Shortt Inquiry and there is no evidence that it acknowledged or acted on the Inquiry's recommendations.

¶1.23 At that time, the majority of spectators at a match stood on terraced steps (terraces) while others were seated in grandstands (stands). Most stadia dated back to the late 19th century, their stands, terraces, turnstiles and access areas upgraded occasionally to comply with minimum safety standards.

¶1.24 While safety was the responsibility of stadium owners, they were required to comply with national guidelines and to obtain safety certificates based on regular inspections from local authorities. All modifications were subject to agreement between owners, structural engineers and local authorities in consultation with other agencies, including the police, fire and ambulance services.

¶Burnden Park 1946 and the Moelwyn Hughes Report 1.25 In March 1946, 33 spectators died in a severe crush on the terraces at Burnden Park, Bolton Wanderers' stadium. Over 500 were injured. Many more people arrived at the stadium than had been anticipated and gained entry through an opened exit gate.

¶1.26 A subsequent Home Office Inquiry, chaired by Moelwyn Hughes, made a range of crowd safety recommendations, including the review of safety barriers, the prevention of uninterrupted movement on terraces and appropriate means of entrance and exit. A key recommendation was the introduction of 'mechanical means' to establish when an enclosure had reached maximum capacity to prevent further access.

¶1.27 Moelwyn Hughes quoted an FA official who 'feared that the disaster at Bolton might easily be repeated at 20 or 30 other grounds'. 'How simple', the Report concluded, 'and how easy it is for a dangerous situation to arise in a crowded enclosure. It happens again and again without fatal or even injurious consequences'. All that was needed was one or two additional influences and 'danger' could be translated into 'death and injuries'.

¶Ibrox Park 1971 and the Wheatley Report 1.28 In January 1971 66 spectators died after a crush at Ibrox stadium, Glasgow, as the Rangers–Celtic match was drawing to a close. As many were leaving, the roar of the crowd drew them back up the stairwell they were descending from the terraces to the exit gates. People lost their footing and fell, crushed by the compression of bodies at the foot of the stairwell. 1.29 The Ibrox tragedy, the second in its history, led to the 1972 Wheatley Report on crowd safety at sports grounds, the Safety of Sports Grounds Act 1975, a centralised licensing system for designated grounds and supporting guidelines, the Guide to Safety at Sports Grounds (known as 'the Green Guide'). 1.30 Lord Wheatley warned club owners that crowd safety should be a 'primary consideration' and that stadia should be modified and conditions implemented even if clubs were forced 'out of business' as a consequence. 1.31 The Green Guide, first issued by the Home Office in 1976, noted that 'voids' beneath the floor were a 'common feature' in stands vulnerable to fire. They became a 'resting place for paper, cartons and other combustible materials which can be ignited, unnoticed, by a carelessly discarded cigarette end'. The Guide recommended inspections before and after every event to clear rubbish.

¶Bradford 1985 and the Popplewell Report 1.32 On 11 May 1985 the fear voiced in the Green Guide was realised. Bradford City played Lincoln City in an end-of-season match celebrating Bradford's promotion from the Third Division. Close to half time the main stand, a timber construction with a pitch roof, caught fire when a discarded cigarette ignited rubbish beneath the stands. 1.33 The rubbish had accumulated over three decades. While many fans fled onto the pitch, others attempted to escape a fireball by heading for the exit gates, which were locked. Fifty-six spectators died and many more were seriously injured. 1.34 A Committee of Inquiry into Crowd Safety at Sports Grounds was commissioned on 15 May 1985, chaired by Mr Justice Popplewell. It concluded, 'the available exits were insufficient to enable spectators safely to escape the devastating effects of the rapidly spreading fire'. Had there been perimeter fences to the front of the stand, 'casualties would have been on a substantially higher scale'. It noted that 'emergency evacuation' could be anticipated in a range of circumstances and could be achieved only if 'sufficient and adequate means of exit, including exits through the perimeter fence itself', was provided. 1.35 The Popplewell Report also considered the relationship between football clubs and the police, focusing on responsibility for crowd safety within the stadium. It concluded that clubs were responsible for physical safety and maintenance of the stadium, but the police had a 'de facto responsibility for organising the crowd, with all that entails, during the game'. 1.36 The Report expressed concern that police forces provided no training or briefing 'in the question of evacuation'. While praising the police on duty at Bradford, it recommended that 'evacuation procedure should be a matter of police training and form part of the briefing by police officers before a football match'. 1.37 Given the clear safety guidelines established by the Green Guide, the Bradford fire raised serious doubts about the effectiveness of implementation and the complacency regarding risks to safety prevalent among those owning, licensing and regulating established sports grounds and other leisure venues.

¶The 'lens of hooliganism' and the introduction of 'pens' 1.38 Complacency regarding crowd safety was compounded by the emergence and consolidation of a growing emphasis on crowd control. During the late 1960s what became known as 'football hooliganism' was established as the key priority for the organisation, management and reconstruction of stadia.

¶1.39 Virtually every Parliamentary exchange or media feature on soccer was dominated by 'hooliganism' and its policing. Yet the 1968 Harrington Report into 'hooliganism' noted the 'ease with which a dangerous situation' could 'occur in crowded enclosures'. It continued, 'some club managements do not feel obliged to put their grounds into a state … necessary for (safe) crowd control'.

¶1.40 Noting the tragedy at Burnden Park, the Report instructed 'appropriate authorities' to respond 'before another disaster occurs'. John Harrington warned that perimeter fences 'could be dangerous in the event of massive crowd disturbances as safety exits to the field would be blocked'. Gangways and tunnels servicing terraces created bottlenecks, rendering them 'useless' for evacuation in an emergency.

¶1.41 Despite Mr Harrington's warnings, in 1977 the McElhone Report into football crowd behaviour recommended lateral fences within terraces to restrict sideways movement. Terraces were constructed as relatively shallow concrete steps interspersed with safety barriers to ease downward compression as a packed crowd moved forward during access or in the course of a match.

¶1.42 The McElhone Report stated that 'improvements designed to prevent crowd movement should include the provision of suitable access points'. Perimeter fencing should be 'not less than 1.8 metres in height' but 'access points' or gates were essential 'to allow the pitch to be used if necessary for the evacuation of spectators in an emergency'.

¶1.43 By the late 1980s many terraces were equipped with high, overhanging perimeter fences to prevent pitch access and lateral fences to prevent sideways movement along the terraces. It was difficult to reconcile perimeter fencing, constructed to prevent pitch invasions, with the availability of the pitch for immediate emergency evacuation.

¶1.44 Yet some terraces were divided into a series of pens. Access was usually from the rear with small lockable gates in the lateral and perimeter fences. As with all areas of the stadium, gates were managed by a combination of stewards employed by the football club whose ground it was, and the local police at the invitation of and paid for by the club. Their responsibilities combined stadium security, crowd management and crowd safety.

¶1.45 Approaches and access points to the stadium, often along narrow roads and walkways, were controlled exclusively by the police. Entry to the stadium was via turnstiles, while egress was generally through large exit gates opened at the end of the match.

¶1.46 Following Moelwyn Hughes' Report, turnstiles at most stadia were fitted with automatic counters to record the number of spectators entering a terrace or stand, if necessary allowing access to be closed when capacity was reached. The introduction of pens within some terraces, however, undermined the process as some pens could be overpopulated while others were underpopulated.

¶1.47 It was well established that spectators gravitated to the central pens behind each goal. These pens became tightly packed while adjacent pens were often half-empty. Yet the only reliable record of crowd distribution was the count of the number of fans entering the turnstiles and accessing the terrace overall. There was no record of the distribution between pens. Thus with the advent of pens within terraces, the very risk that Moelwyn Hughes sought to eliminate was compounded. 1.48 An added complication for semi-final matches was that the FA hired the stadium, as a neutral venue, from the host football club. The participating clubs had no influence over ticket allocation to the stands and terraces or to segregation arrangements within the stadium. 1.49 Spectators were visiting unfamiliar locations, travelling by trains, coaches, minibuses or private cars. They were met by the police at railway stations and coach parks and escorted, a tactic known as corralling. Spectators' arrival at stadia was determined primarily by transport management, escorting and filtering the crowd through the streets surrounding the stadium. 1.50 As major events in the sporting calendar, FA Cup semi-finals were all-ticket games. Demand well exceeded supply. Consequently, ticketless spectators regularly travelled in the hope that they might make a purchase at a considerably inflated price from a ticket tout outside the stadium. Buying tickets from touts was an unregulated but well-known practice.

¶Hillsborough Stadium 1.51 Hillsborough Football Stadium opened in 1899. Two miles from Sheffield's city centre, it was located initially on what was described as a greenfield site adjacent to the River Don. Eventually, it became tightly confined by terraced housing on its west and north flanks. 1.52 Considered one of England's leading football grounds, it underwent significant structural change, particularly when it became a venue for the 1966 World Cup. Like so many other venues, it was modified to meet the requirements of the Safety of Sports Grounds Act 1975. 1.53 The Act was a response to the Wheatley Report into the 1971 Ibrox Park disaster. Almost three decades after the Moelwyn Hughes Report, the Act introduced a licensing system including safety certificates for designated stadia. As noted above, it was supported by the 1976 Green Guide. The Guide was reviewed in 1986 following recommendations made in the Popplewell Report. 1.54 In 1981, following serious crushing at the FA Cup Semi-Final between Tottenham Hotspur and Wolverhampton Wanderers, resulting in injuries to 38 fans, Hillsborough was withdrawn from the FA Cup semi-final list. Tragedy had been averted by opening gates in the perimeter fencing and allowing spectators to sit on the perimeter track. 1.55 Modifications to the Leppings Lane terrace introduced lateral fences dividing the terrace into three separate enclosures or pens. In 1985 the police requested further lateral fences, resulting in five pens. 1.56 The two central pens were fed from the rear by a tunnel sloping downwards at a gradient of 1 in 6 beneath the West Stand, the latter constructed in preparation for the 1966 World Cup. Emerging from the tunnel, fans walked to the right or left of a fence into pens 3 or 4 respectively. A high, overhanging fence mounted on a wall separated the terrace from the perimeter track. Access to the track was restricted to a single narrow, locked gate at the front of each pen.

¶Figure 1: Map of Hillsborough Stadium and surrounding area From Lord Justice Taylor's Interim Report.

¶Figure 2: Arrangement of barriers on the Leppings Lane terrace From Lord Justice Taylor's Interim Report.

¶1.57 Previously reviewed in 1979, the crush barriers were a mix of recent and old. Modifications made in 1985 and 1986 resulted in a different barrier distribution in each pen. In pen 3, for example, a diagonal uninterrupted channel stretched from the tunnel access to a barrier close to the foot of the terrace. Congestion down this channel placed the front barrier under considerable pressure.

¶1.58 While parts of the stadium had been upgraded, the essential fabric of the Leppings Lane terrace remained unchanged. Terrace modifications had prioritised crowd control and segregation. At the east end of the stadium, the Spion Kop was a modern standing terrace licensed to accommodate 21,000 spectators.

¶1.59 The capacity of the uncovered Leppings Lane terrace was set at 10,100. Above the terrace, the West Stand seated 4,500 spectators. Entry into the North Stand was also from the Leppings Lane turnstiles. Thus 24,256 fans converged on 23 turnstiles located within a small, divided outer concourse. The 10,100 fans with tickets for the Leppings Lane terrace walked through outer gates onto the concourse to queue at seven turnstiles.

¶1.60 The remaining 14,156 ticket-holders for the North and West Stands accessed 16 turnstiles via the adjoining section of the concourse. In the hour before kick-off this tightly confined concourse, with a shop wall to the left and a fence above the River Don to the right, received the majority of 24,000 people unfamiliar with the layout of the stadium.

¶1.61 The old turnstiles frequently malfunctioned. An electronic counting system recorded the numbers accessing the terrace, but the distribution between the pens was not recorded. The two central pens, with capacities of 1,000 and 1,100, were always the first to fill. The doors at the head of the tunnel feeding the central pens could be closed once it was estimated that the pens' capacities had been reached. It was a calculation based on observation rather than an accurate counting system. This ignored the 1946 Moelwyn Hughes recommendation that each enclosure should be accurately monitored.

¶Policing Hillsborough: Operational Orders 1.62 Operational Orders are issued within police forces to meet the particular demands of a time-limited and pre-planned operation. They form the basis for briefing officers involved, covering their deployment and, where appropriate, the responsibilities and duties of all involved. 1.63 Policing a large-scale operation such as a football match, involving hundreds of officers, many with discrete responsibilities, is underpinned by an extensive Operational Order naming all officers involved, the serials (or small operational teams) to which they are assigned, the duties of each serial and the chain of command. 1.64 Reinstated as an FA Cup venue, Hillsborough hosted the Semi-Final between Leeds United and Coventry City on Sunday 12 April 1987. The match was due to start at 12 noon. Approximately 20 minutes before the kick-off, Chief Superintendent Brian Mole, the experienced Match Commander who had written the Operational Order, delayed the kick-off to accommodate spectators from both clubs who had been held up while travelling to Sheffield. 1.65 Despite the sequence of events in 1987, the Operational Order for the 1988 Semi- Final between Liverpool and Nottingham Forest provided no contingency plan for delays in travelling to the stadium. While Nottingham Forest supporters had a relatively short journey, this was not the case for those travelling from Liverpool.

¶1.66 The 1988 match passed without serious incident. There were, however, two issues of significance. First, on approaching the ground spectators recalled being requested by police officers to show their tickets. Second, others, including police officers on duty, remembered being crushed in the central pens, 3 and 4. Police officers closed access to the tunnel once these pens were considered full and fans were redirected to the side pens. 1.67 On 20 March 1989 Liverpool were drawn again to play Nottingham Forest and Hillsborough was chosen by the FA as the most suitable venue. Following a controversial but serious incident, unrelated to his duties as Match Commander, C/Supt Mole was relieved of his duties just three weeks before the Semi-Final and moved to another location. He was replaced by C/Supt Duckenfield, who had minimal experience of managing football matches.

¶The Police Operational Order, 1989 1.68 With minor amendments, the previous year's Operational Order was re-issued. It consisted of a 12-page general overview, signed by C/Supt Duckenfield, and a detailed account of the responsibility of each serial of officers on duty. The officers allocated to the serials, usually ten police constables under the command of one sergeant, were named. 1.69 The Operational Order emphasised 'public order and safety both inside and outside the football ground' and the responsibility to 'segregate and control opposing fans' to prevent 'unnecessary obstruction of the highway and damage to property'. There was an implicit acceptance within the Order that the police took responsibility for managing crowd safety inside the stadium. 1.70 No detail was given as to what this responsibility entailed. It referenced 'emergency and evacuation procedures' but solely in terms of a bomb call or fire response. In such circumstances, and following the public broadcast of a coded message, senior officers would initiate evacuation. There was no reference to emergency procedures in the event of overcrowding, congestion or problems on the terraces.

¶1.71 Twenty-one officers were allocated to the perimeter track, facing the crowd before the kick-off, at half time and full time or if there was 'crowd unrest'. They were instructed to pay 'particular attention … to prevent any person climbing the fence to gain access to the ground'. The perimeter fence gates were to 'remain bolted at all times' with 'no-one … allowed access to the track from the terraces without the consent of a senior officer'. The latter statement was capitalised and underlined.

¶1.72 Two serials of officers were responsible for policing both rear north and south enclosures of the Leppings Lane terrace. They were instructed to enforce ground rules concerning banners, weapons, missiles and alcohol. No mention was made of crowd management or safety. In the event of evacuation, officers were to assist fans in leaving safely through the exit gates. Four serials were stationed at the Leppings Lane turnstiles, their duties consisting of enforcing ground rules.

¶1.73 The Operational Order provided details of the regulatory functions governing the policing of football. Spectators travelling to and arriving in Sheffield were to be tracked, directed, randomly stopped and searched, disembarked and 'supervised'. Those met at railway stations were to be bussed or 'walked … under police supervision' to the stadium. Street access was controlled and crowd barriers outside the stadium were policed to guarantee segregation of supporters.

¶1.74 Coaches and minibuses were to be stopped at random by 'search squads' to check match tickets and ensure that passengers were not under the influence of drink or carrying alcohol. Officers had to be satisfied that fans were 'fit to attend this event'. Following a thorough search, vehicles would be permitted to complete their journey displaying labels of approval.

¶1.75 According to the Order, a 'great majority' of public houses would close throughout the afternoon, and those opening would 'operate a "selective door" whereby football supporters are not admitted'. Responsibility for enforcing these agreements lay with police serials outside the stadium, monitoring 'the behaviour of persons resorting ... to those premises that remain open'.

¶1.76 The Operational Order did not provide information or advice about the known bottleneck outside the Leppings Lane turnstiles, nor did it comment on the well-established risk of congestion. These problems were known to SYP and there had been serious congestion the previous year. There were no contingency plans in the Order for delaying the kick-off, as had happened in 1987, for relieving congestion at the turnstiles, for identifying overfull pens or for closing the tunnel, as had happened in 1988.

¶15 April 1989 The circumstances 1.77 Consistent with the Operational Order, many spectators arriving in Sheffield on trains and coaches were escorted by the police from their point of arrival to the stadium. As they approached the stadium there was no filtering of the crowd and the bottleneck at the concourse in front of the turnstiles became tightly packed. With walls, fences or gates to the sides and front of this small area, the only relief was to move backwards. Many more fans arrived, oblivious to the mounting crush at the front, and the situation in the vicinity of the turnstiles soon became critical.

¶1.78 As kick-off time approached, the crush worsened, and men, women, children and police officers struggled to breathe. Mounted police officers were trapped in the crowd. In later testimonies police officers stated that the crowd grew 'unruly', 'nasty' and 'violent', but people caught in the crush gave a contrasting account. They felt there had been no attempt to manage the crowd, no filtering and no queuing.

¶1.79 The Police Control Box, the centre of the policing operation at the stadium, was positioned inside the ground, elevated above the Leppings Lane terrace, giving a commanding view of the pens below. At 2.30pm the bank of CCTV monitors in the box showed the build-up of fans in Leppings Lane and at the turnstiles.

¶1.80 As the crush became critical, C/Supt Duckenfield faced a serious dilemma. The senior officer outside the ground, Superintendent Roger Marshall, radioed that unless the large exit gates were opened to relieve the crush there would be serious injuries, possibly deaths. Hesitating, C/Supt Duckenfield gave the command to open the gates.

¶1.81 Gate C was adjacent to the turnstiles and once opened the crowd walked through into the inner concourse behind the Leppings Lane terrace and the North Stand. Fans recalled 'hanging back' to wait for the congestion to ease. When Gate C opened they walked onto the inner concourse and down the tunnel.

¶1.82 The tunnel was directly opposite Gate C and the sign above read: STANDING. The gates at the head of the tunnel were fastened back against the wall. Oblivious to the layout of the terrace, and unable to view the terrace from the tunnel entrance, more than 2,000 fans descended into the already packed central pens.

¶1.83 When they arrived at the bottom of the tunnel the central fence forced them left into pen 4 or right into pen 3. There were no stewards at either end of the tunnel. The central pens soon held twice their capacity. There was no respite to the sides or front and the sheer volume of people prevented escape back up the tunnel.

¶1.84 As the teams ran onto the pitch for the 3pm kick-off, the crowd cheered but already in the central pens people were screaming. Others fell silent, already unconscious. Survivors described being gradually compressed, unable to move, their heads 'locked between arms and shoulders ... faces gasping in panic'. They were aware that people were dying and they were helpless to save themselves.

¶1.85 In pen 3 the pressure became so severe that the faces of fans at the front were pressed into the perimeter fencing, distorted by the mesh. As fans lost consciousness some slipped to the ground under the feet of others unable to move. Survivors recall the gradual compression on their chests preventing them from breathing.

¶1.86 Fans screamed at the police on the perimeter track to open the small gate in each pen onto the pitch, 'but they just seemed transfixed. They did nothing'. As fans tried to climb the overhanging perimeter fence, officers on the track pushed them back into the crowd.

¶1.87 In the Police Control Box, C/Supt Duckenfield and his colleagues had a clear view of the packed central pens and the underpopulated side pens. Having opened the exit gate, he had failed to order the closure of the tunnel. He stated later that he had confidence that officers 'were patrolling the concourse area' and acting 'on their own initiative ... would have taken some action in the tunnel'.

¶1.88 From the Police Control Box he watched fans trying to climb from the pens. Subsequently he reflected that it did not occur to him that they were trying to escape a crush. Then he saw a perimeter gate open, apparently without authority. 'My perception is [sic] … it was a pitch invasion'.

¶1.89 This was the message transmitted to officers throughout the stadium as they rushed to the Leppings Lane perimeter track. They assumed they were dealing with crowd disorder and a pitch invasion rather than severe crushing. Initially, they responded accordingly.

¶Rescue and evacuation 1.90 Fans were pulled from the pens through the two narrow perimeter track gates and were laid out on the pitch. As bodies multiplied the area became crowded. Many of the injured were unconscious, some were not breathing, and some had no heartbeat. It was clear that if any could be rescued, urgent resuscitation was necessary.

¶1.91 The first-aid assistance at Hillsborough was provided by 30 St John Ambulance officers, five of whom were young cadets. Four South Yorkshire Metropolitan Ambulance Service (SYMAS) staff were also present in case a more serious or widespread emergency occurred. The number of injured requiring urgent resuscitation overwhelmed first aiders, and their efforts were supplemented by police officers and by spectators, including doctors and nurses who were at the match.

¶1.92 Ambulances arrived at the loading area designated in the Hillsborough major incident plan, and it was necessary to carry injured spectators almost the full length of the pitch. Fans tore down advertising hoardings as makeshift stretchers and ran to the ambulances. When they arrived they were directed to lay people down in the stadium gymnasium, located at the rear of the North Stand.

¶1.93 Those considered beyond help were placed in a part of the gymnasium designated as a temporary mortuary, while others were placed separately to await removal to hospital. By 4.30pm all of these casualties had been transported by ambulance.

¶The gymnasium as a temporary mortuary 1.94 It was decided to continue using the gymnasium as a temporary mortuary pending the identification of the dead. The gymnasium was divided into three sections by drawing sports nets across the width and hanging sheets from them. At the end furthest from the entrance the bodies were laid out in body bags. The central section was used as a police rest area and the section closest to the doors was arranged for statement-taking.

¶1.95 In the entrance area to the gymnasium noticeboards were used to display Polaroid photographs of the dead. Each photograph was given a number corresponding to a body on the gymnasium floor. Each body was allocated a police officer who was given a bucket, water and a flannel to clean the faces of the dead. Those who were dead on arrival at the hospital or who died there were returned to the gymnasium.

¶1.96 On the suggestion of a vicar, a disused Boys' Club close to Hammerton Road Police Station, the police centre of operations, was opened as a reception centre for relatives and friends seeking information. It was an old, damp and unwelcoming place with no adequate amenities for receiving people. 1.97 At the hospitals that had received casualties, survivors and those searching for their loved ones were accommodated in the canteen areas. These locations comprised the route followed by many people throughout the evening as they searched for friends and relatives. 1.98 Following consultation with the Coroner, the police-led process was set in motion shortly after 9pm. People were bussed from the Boys' Club to the gymnasium. There they waited in the car park, blankets around their shoulders, before being called to the entrance. They queued to view the unclear photographs of the dead. 1.99 When a face was recognised the number was called and the corresponding body was wheeled on a trolley to the gymnasium door. There was little time allowed for contemplation, touch was restricted and privacy denied. Relatives and friends of the deceased were then escorted to police officers sitting at tables, who took statements. 1.100 The identification process caused distress for families: the use of poor-quality Polaroid photographs, uncategorised by gender or age; the presentation of the dead in body bags, often in a dishevelled state; time and privacy, crucial for grieving, were denied as the police, pressured by the need to process waiting relatives, were keen to complete the identification quickly. 1.101 Following identification, relatives or friends were interviewed by CID officers. Questioning included details of their journeys to Sheffield, whether they had attended the match and whether they had consumed alcohol. Personal questioning extended to the reputations of their loved ones whom they had just identified. The primary objective appeared to be investigation rather than identification, a view corroborated by other workers involved.

¶1.102 Relatives had faced a long and uncertain wait. Although the bodies were quickly laid out in the gymnasium it took over four hours to initiate the identification process. Many of the bereaved waited for over seven hours before they made an initial identification. They had been searching hospitals and/or waiting at the disused Boys' Club. In some cases they were given inaccurate information. At the Northern General Hospital a hospital administrator stood on a table to give information, including descriptions, to those waiting in the canteen. 1.103 Most survivors, some of whom had rescued others and had attempted to resuscitate them, left Hillsborough to travel home. They had assisted the evacuation of bodies from the pens, back through the tunnel and onto the pitch. In both locations supporters tried to revive and comfort the seriously injured and to transfer them to ambulances or to the gymnasium. Others, some with medical training, helped in the gymnasium. 1.104 The boundaries between the categories of 'bereaved', 'survivor', 'witness', 'rescuer' and 'helper' were blurred. Yet there was no recognition of the enormous contribution of, and the impact suffered by, supporter-survivor-rescuers in formal debriefing. Most fans who had contributed did not consider asking for help, and those who did were dismissed.

¶The Taylor Inquiry 1.105 The Prime Minister, Margaret Thatcher, and the Home Secretary, Douglas Hurd, visited Hillsborough on 16 April. They were accompanied by the Chief Constable of South Yorkshire Police, Peter Wright, and other senior officers. The following day Lord Justice Taylor was appointed by the Home Secretary to conduct a judicial inquiry into the disaster. The terms of reference were: 'to inquire into the events at Sheffield Wednesday football ground on 15 April 1989 and to make recommendations about the needs of crowd control and safety at sports events'.

¶1.106 Geoffrey Dear, Chief Constable of West Midlands Police, was invited to conduct the criminal investigation into Hillsborough and to gather evidence for the Taylor Inquiry, which commenced its work on 24 April. He appointed his Assistant Chief Constable, Mervyn Jones, to the Inquiry. The WMP team also had the responsibility for the criminal investigation for the SYP Chief Constable and the DPP. WMP officers also worked as coroner's officers for the inquests.

¶1.107 On 26 April a group of SYP officers met to discuss a process of statement-taking from officers involved at Hillsborough. This followed advice from the Force solicitors regarding the gathering of all officers' 'recollections' of their experiences on the day. The group was convened by Chief Superintendent Terry Wain and established the process of collating recollections as the basis for the 'proof of evidence' necessary for the Taylor Inquiry.

¶1.108 The recollections, referred to as 'self-written' or 'self-taken', were not taken under Criminal Justice Act rules. They would also form the foundation for the presentation of a 'suitable case' to the Inquiries that followed. The Wain Inquiry was announced by the South Yorkshire Deputy Chief Constable, Peter Hayes, on 2 May and a document was issued explaining the process to be followed in responding to the internal Inquiry's requirements.

¶1.109 In C/Supt Wain's written announcement he stated:

¶On behalf of the Chief Constable, Mr Wright, I am gathering information to enable the

¶Force to present its evidence to the forthcoming Committee of Inquiry. This exercise has no connection with the investigation into the policing of the FA semi-final which is being conducted by a team headed by Mr Dear, Chief Constable of West Midlands.

¶1.110 The internal Inquiry was the first of several 'parallel investigations' to evolve and raise important questions about their standing and relationships.

¶1.111 The day after his appointment LJ Taylor and his team visited Hillsborough and ten days later he held a preliminary hearing at which the date of oral hearings was announced. Solicitors representing families formed the Hillsborough Solicitors' Group Steering Committee, often referred to as the Hillsborough Steering Committee. The Committee's priority was to 'ensure that all facts ... come out', concentrating 'upon issues which will affect civil liability … issues of safety and crowd control'.

¶1.112 It stated that LJ Taylor had 'made clear' his intention 'to find facts and not apportion blame'. Evidence taken by LJ Taylor would be 'determined by Counsel and Solicitors to the Inquiry' (the Treasury Solicitor's team) after their consideration of 'all witness statements submitted'. Evidence submitted to the Inquiry was not disclosed.

¶1.113 LJ Taylor 'accorded representation' to:

the bereaved and injured
the Football Supporters' Association
the FA
Sheffield City Council
Sheffield Wednesday Football Club (SWFC)
SYP
the South Yorkshire Fire and Civil Defence Authority.

¶1.114 This list was extended to include SYMAS and Dr Wilfred Eastwood, consultant engineer to the Club. LJ Taylor authorised that costs of legal representation incurred by the bereaved and survivors would be met from public funds.

¶1.115 On 15 May the Taylor Inquiry hearings opened at Sheffield Town Hall. Members of the public were invited to call a Freephone number to offer information. Twenty-eight lines were open for six days and WMP officers evaluated 2,666 calls, using a basic questionnaire, to assess the 'quality' of evidence.

¶1.116 The investigation team also registered 3,776 statements, and 1,550 letters were received. LJ Taylor stated that 'From this mass it was essential to select only sufficient good and reliable evidence necessary to establish the facts and causes of the disaster'.

¶1.117 SYP, however, submitted that in such a brief time period the WMP investigation was insufficient, arguing that much evidence had not been collected. It concluded that it was 'unsafe' for LJ Taylor 'to make findings of fact' at such an early stage.

¶1.118 While accepting that witnesses selected to give oral evidence constituted 'only a small fraction of those from whom statements were or could have been taken', LJ Taylor was 'satisfied that they were sufficient in number and reliability' to ensure 'the necessary conclusions' could be achieved.

¶1.119 In aiming to publish an Interim Report within four months he had been 'assured' by the WMP Chief Constable that it was 'most unlikely' that further evidence gathered would 'significantly alter or add to the history of events which emerged at the hearing'.

¶The Taylor Interim Report 1.120 On 1 August 1989, LJ Taylor published his Interim Report making 43 recommendations. He concluded that the immediate cause of the disaster was the failure to close access to the central pens once Gate C had been opened, leading to overcrowding, injury and deaths. At the time of Gate C's opening the central pens were beyond capacity but there was a failure to recognise the problem and control further entry to each pen.

¶1.121 The pressure in pen 3 led to the collapse of the barrier, and there followed a 'sluggish reaction and response' by the police. Poor police leadership, including the failure to respond to the urgency of the unfolding disaster, alongside the restricted size and small number of perimeter fence gates, hindered the rescue of those dying on the terraces.

¶1.122 The Report was clear that the dangerous congestion at the turnstiles should have been anticipated and planned for accordingly, that unless fans arrived steadily over a period of time the turnstiles would not cope and congestion would be inevitable.

¶1.123 Neither the Operational Order nor the policing strategy on the day had considered the possibility and consequences of heavy congestion at the turnstiles in the period before kick-off. The Report noted that some turnstiles malfunctioned and that the signage and ticketing were inadequate.

¶1.124 LJ Taylor noted that a minority of fans had been drinking but concluded that they had not caused the congestion, nor had 'hooliganism' played any part in the disaster. The 'fear of hooliganism', however, had influenced 'the strategy of the police', resulting in an 'imbalance between the need to quell a minority of troublemakers and the need to secure the safety and comfort of the majority'. The 'real cause' of the disaster, LJ Taylor concluded, was 'overcrowding' and the 'main reason' was 'the failure of police control'.

¶1.125 LJ Taylor directed severe criticism towards senior officers. He emphasised that once C/Supt Duckenfield acceded to Supt Marshall's request to open Gate C, he should have ordered the closing of the tunnel. It constituted 'a blunder of the first magnitude'.

¶1.126 C/Supt Duckenfield's 'capacity to take decisions and give orders seemed to collapse' and 'he failed to give necessary consequential orders or to exert any control when the disaster occurred'. Further, he 'gave Mr Kelly [Chief Executive of the FA] and others to think that there had been an inrush due to fans forcing open a gate'. LJ Taylor continued: 'This was not only untruthful' but it 'set off a widely reported allegation against the supporters which caused grave offence and distress'.

¶1.127 The 'reluctance [of C/Supt Duckenfield] to tell the truth … did not require that he [Mr Kelly] be told a falsehood'. The 'likeliest explanation' for C/Supt Duckenfield's 'lack of candour' was that he 'simply could not face the enormity of the decision to open the gates and all that flowed therefrom'.

¶1.128 It was LJ Taylor's conclusion that C/Supt Duckenfield's failure to reflect on the consequences of his decision to open Gate C 'would explain what he said to Mr Kelly, what he did not say to Mr Jackson [Assistant Chief Constable (Operations), SYP], his aversion to addressing the crowd and his failure to take effective control of the disaster situation. He froze'.

¶1.129 LJ Taylor did not restrict criticisms of SYP to C/Supt Duckenfield. It was 'a matter of regret' that 'at the hearing, and in their submissions' senior officers 'were not prepared to concede they were in any respect at fault in what occurred'. He noted: 'the police case was to blame the fans for being late and drunk, and to blame the Club for failing to monitor the pens'. His assessment was unequivocal: 'Such an unrealistic approach gives cause for anxiety … It would have been more seemly and encouraging for the future if responsibility had been faced'.

¶1.130 Sixty-five police officers gave evidence to the Inquiry and LJ Taylor considered the 'quality of their evidence' was 'in inverse proportion to their rank'. Some junior officers were 'alert, intelligent and open' witnesses and as the disaster was happening 'many … strove heroically in ghastly circumstances'. Most senior officers, however, 'were defensive and evasive witnesses … neither their handling of problems on the day nor their account of it in evidence' demonstrated the 'qualities of leadership expected of their rank'.

¶1.131 LJ Taylor expressed further concern that the police had initiated a vilification campaign directed towards Liverpool fans. Widely published allegations had included drunken fans urinating on police officers and on the bodies of the dead and stealing from the dead.

¶1.132 He found 'not a single witness' to support 'any of those allegations although every opportunity was afforded for any of the represented parties to have any witness called … those who made them, and those who disseminated them, would have done better to hold their peace'.

¶1.133 LJ Taylor also considered the role and performance of other agencies. He accepted the FA's decision to hire Hillsborough as a suitable venue because the 1988 FA Cup Semi- Final 'had been considered a successfully managed event'. Yet he acknowledged that the FA should have been 'more sensitive and responsive to reasonable representations'.

¶1.134 Significantly, the FA 'did not consider in any depth whether it [Hillsborough] was suitable for a high risk match with an attendance of 54,000 requiring to be segregated, all of whom were, in effect, among supporters lacking week in week out knowledge of the ground'. The choice of venue, however, was not 'causative of the disaster' and he did not accept that the Leppings Lane terrace 'was incapable of being successfully policed'.

¶1.135 He found that SWFC had 'adopted a responsible and conscientious approach to its responsibilities', and had retained a consultant engineer, Dr Eastwood. Yet, he was concerned about a 'number of respects in which failure by the Club contributed to this disaster'.

¶1.136 These included the condition of the 'unsatisfactory and ill-suited' Leppings Lane terrace. The Club was aware of the problems, and had attempted solutions between 1981 and 1986, but 'there remained the same numbers of turnstiles, and the same problems outside and inside them'.

¶1.137 Such alterations had affected capacity 'but no specific allowance was made for them' and both Dr Eastwood and the Club 'should have taken a more positive approach'. He noted that monitoring pens was a police responsibility, but also that, 'the Club had a duty to its visitors and the Club's officials ought to have alerted the police to the grossly uneven distribution of fans on the terraces … the onus here was on the Club as well as on the police'.

¶1.138 He considered that the removal of a pen 3 barrier in 1986 should have brought a reduction in the pen's capacity. It also created pressure inside the pen, pushing 'fans straight down by the radial fence to the lowest line of barriers'. Consequently the 'pressure diagonally from the tunnel mouth' down to the front barrier which collapsed was 'unbroken by any intervening barrier'. 1.139 In evidence, Dr Eastwood had accepted that the barrier's removal was a probable cause of the front barrier's collapse. LJ Taylor concluded that its removal, following the advice of Dr Eastwood and Sheffield City Council's Safety of Sports Grounds Advisory Group, 'was misguided'. 1.140 He also criticised the Club for breaches of national guidelines, poor sign-posting and the 'unhelpful format' of the tickets. This was particularly pertinent given the confusion and difficulties experienced by fans unfamiliar with the venue, its layout and established routines. 1.141 Sheffield City Council had a statutory duty to issue, monitor and revise the stadium's safety certificate. LJ Taylor found that SWFC and the Council failed in their respective duties as the safety certificate 'took no account of the 1981 and 1985 alterations to the ground'. In fact, the certificate in force was issued in 1979 and had not been updated. There was no FA procedure for checking its validity. In conclusion, LJ Taylor considered the 'performance by the City Council of its duties in regard to the Safety Certificate … inefficient and dilatory'. 1.142 In marked contrast to his criticisms of the Club, the consultant engineer, the Sheffield City Council Advisory Group and the FA, LJ Taylor considered 'no valid criticism' could be directed towards the St John Ambulance, SYMAS or the Fire Service. 1.143 He criticised a Liverpool doctor who had attended the dead and injured for his public condemnation of SYMAS for the slow arrival of ambulances, insufficient equipment and lack of triage.1 Another doctor was also criticised for claiming that defibrillators should have been deployed. LJ Taylor relied on expert evidence that deploying defibrillators 'with people milling about would have been highly dangerous owing to the risk of injury from the electric charge'. 1.144 The emergency services had 'responded promptly when alerted', bringing 'appropriate equipment' and efficient personal intervention. Vehicles outside the gymnasium had hindered the ambulance operation. In refuting the claim that ambulances did not arrive quickly, LJ Taylor noted that the Major Accident Vehicle did not arrive until 3.45pm. LJ Taylor also concluded that there had not been a failure in triage, which 'ensur[es] that those most likely to benefit from treatment are seen first'. 1.145 While the gymnasium's use as an 'emergency area', and later as a temporary mortuary, was mentioned in the Report, there was no evaluation of its adequacy or operational effectiveness. LJ Taylor commented that there was 'intense distress amongst the injured and the bereaved; relatives were reluctant to be parted from the dead and sought to revive them … there were scuffles. Some of these involved those who were the worse for drink'. Clearly, LJ Taylor did not consider the immediate aftermath to be part of his remit.

¶Civil actions and criminal prosecution 1.146 Civil actions for damages commenced within days of the disaster. The issue was liability for the fatalities and for those who had sustained physical injuries and/or psychological distress while in the pens. 1. Triage is the prioritisation of casualties so that those with life-threatening injuries are attended to ahead of those with lesser injuries and those already beyond help.

¶1.147 By 26 July 1989 there had been an appearance before Mr Justice Steyn in the High Court for his directions on the progress of the litigation. Neither SYP nor the Club were prepared to make a formal admission of liability, nor were they prepared to make any compensation payments.

¶1.148 While denial of liability is not unusual, insurers often settle civil claims in an attempt to mitigate their loss. Following publication of LJ Taylor's Interim Report in August 1989, SYP and SWFC blamed each other for different elements of the disaster and each refused to accept liability.

¶1.149 However, by 30 November 1989, the SYP Chief Constable and the South Yorkshire Police Authority had offered an out-of-court damages settlement to some of the bereaved and injured. In conjunction with their insurers, Municipal Mutual Insurance, they issued a press statement committing 'to open negotiations with the aim of resolving all bona fide claims against [the Chief Constable] for compensation arising out of the Hillsborough disaster'.

¶1.150 Other parties – SWFC, the safety engineers Eastwood & Partners and Sheffield City Council – who were named as defendants in the civil proceedings declined the invitation to join SYP in the settlement. SYP made it clear that they would 'pursue legal action against those parties to recover moneys paid out to the claimants'.

¶1.151 In due course, SYP commenced 'contribution' or 'third party' proceedings against SWFC and Eastwood & Partners to reclaim an appropriate proportion of the costs of the out-of-court settlements.

¶1.152 At the eventual trial of these proceedings in the High Court in October 1990, Counsel for SYP argued that SWFC and Eastwoods were liable because there were four key factors which created an inherently 'unsafe system' at Hillsborough:

no means of controlling the capacity of pens 3 and 4 – 'the main cause of the disaster'
an 'unsafe system' of management by SWFC
an 'unsafe system' of escape
an 'unsafe system' of inspection and testing of barriers.

¶1.153 Mid-way through the trial, however, following private negotiations, a confidential deal was struck between the parties, each of whom agreed not to disclose details to the public. By doing so, the parties avoided a court ruling.

¶1.154 In the months and years that followed, SYP made numerous compensation payments. They also settled a number of claims brought by police officers who had been active as 'rescuers' in the immediate vicinity where the deaths and injuries occurred. The settlements of these cases were mired in controversy, given that many of the bereaved and injured were denied compensation.

¶1.155 Settlements were made 'without admission of liability', drawing criticism from bereaved families and survivors. They had wanted SYP and SWFC to accept, without ambiguity, their respective responsibilities in causing death and injury.

¶1.156 Yet, in November 1991, in a House of Lords ruling on a different but related group of claims, Lord Keith of Kinkel stated that the 'Chief Constable of South Yorkshire has admitted liability in negligence in respect of the deaths and physical injuries'.2

Alcock and others v Chief Constable of South Yorkshire Police [1992] 1 A.C. 310, at 392.

¶1.157 His remarks were made in the context of one of three different sets of claims against SYP, each pursued all the way to the House of Lords on behalf of those whose claims were not settled.

¶1.158 The first involved those who sought to claim compensation for trauma as 'secondary' victims insofar as they were not directly affected or injured in the events. The second involved those who claimed compensation for the pre-death pain and suffering of their loved ones.

¶1.159 The third set involved police officers who sought to claim compensation for trauma as 'secondary' victims in circumstances where they had not been active in the immediate area where the deaths and injuries occurred. Each set of claims was ultimately unsuccessful before the House of Lords, for different reasons concerning public policy.

¶1.160 On 30 August 1990 the Head of the Police Complaints Division of the Crown Prosecution Service wrote a brief letter to the SYP Chief Constable. Following the 'most careful consideration' of 'all the evidence and documentation', the DPP had 'decided that there is no evidence to justify any criminal proceedings' against SYP, SWFC, Sheffield City Council or Eastwoods. Further, there was 'insufficient evidence to justify proceedings against any officer of the South Yorkshire Police or any other person for any offence'.

¶1.161 The decision not to prosecute senior police officers had been taken by the DPP in consultation with two independent senior Counsel. While senior police officers could still face internal Force disciplinary charges, there would be no criminal prosecution. Given the DPP's decision and the prohibitive costs involved, the families and their lawyers discounted a private prosecution.

¶1.162 Once the DPP decided against the prosecution of senior officers or any corporate body, the 17 complaints made to the Police Complaints Authority (PCA) by members of the public were considered for disciplinary action. The PCA examined the material gathered by the WMP investigators, considering each complaint on its merits.

¶1.163 In the cases of C/Supt Duckenfield and Supt Murray, the PCA concluded that there was sufficient evidence to pursue disciplinary action for 'neglect of duty'. There followed a protracted dispute between the PCA and SYP. It was resolved on 11 July 1991 when the PCA directed that C/Supt Duckenfield and Supt Murray should face a disciplinary hearing charged with 'neglect of duty'. While the SYP Chief Constable opposed the action, it was later revealed that he 'wanted the discipline process to be worked through' given the 'significance of the disaster'.

¶1.164 While this process was progressing, C/Supt Duckenfield was on sick leave, 'too ill to be amenable to the disciplinary process, let alone face the necessary tribunal'. On 10 November 1991 he retired early on medical grounds. Following judicial advice the PCA decided against proceeding against Supt Murray alone. This decision ended the disciplinary proceedings.

¶The inquests Preliminary hearings 1.165 Given the potential for prosecutions with the Taylor Inquiry in process, the Hillsborough inquests were opened and adjourned immediately after the disaster. As stated above, the WMP investigation serviced not only the DPP and LJ Taylor but also the Coroner; the police investigators eventually were deputed as coroner's officers.

¶1.166 Following publication of LJ Taylor's Interim Report in August 1989, the bereaved were concerned about the slow progress of the criminal investigation and the delayed inquests. They were eager to establish the precise circumstances in which their loved ones died and why the Coroner had considered it necessary to record blood alcohol levels of all who died. The bereaved and survivors considered allegations of drunkenness had been compounded by the decision to take and publish blood alcohol levels, impugning the reputation of those who died.

¶1.167 In July 1989, the Hillsborough Steering Committee informed families that the Coroner was contemplating holding a generic inquest 'covering the general facts and matters which gave rise to the deaths immediately followed by 95 individual Inquests [at that time the death toll had not reached 96] dealing with the situation of each of the deceased'.

¶1.168 The generic element would 'set the scene', exploring the circumstances of the disaster. Before a jury it would hear expert and general evidence. Following the generic element there would be individual hearings with each family.

¶1.169 After further exchanges with the Steering Committee, the Coroner decided to hold limited, preliminary inquests before a decision was reached on the criminal prosecution. Having taken advice from a range of sources, including the DPP, the Coroner met Doug Fraser, the Steering Committee solicitor representing the families.

¶1.170 On 6 March 1990, the Coroner called a pre-inquest review attended by Mervyn Jones, the WMP Assistant Chief Constable heading the Coroner's investigation, together with solicitors representing other 'interested parties'. ACC Jones informed the meeting that the DPP had yet to receive all the information necessary to rule on prosecution. Following discussions with the DPP, the Coroner explained his intention to hold inquests on a limited basis. It reversed his previously intended sequence.

¶1.171 He proposed preliminary hearings with each family to hear the medical evidence on the deceased, blood alcohol levels, where possible the deceased's location before death, and subsequent identification.

¶1.172 The Coroner was 'prepared to take some evidence to meet the legitimate needs of the bereaved' but this would be restricted so as not to interfere with the ongoing criminal investigation. He planned for eight family hearings, or 'mini-inquests', each day hearing medical evidence from pathologists.

¶1.173 This would be followed by relevant evidence specific to the deceased, including witness accounts, summarised and presented to the jury by WMP investigating officers. It was an unprecedented decision as the evidence would not be examined.

¶1.174 On 9 March Mr Fraser wrote to all families' solicitors, stating that it was 'not possible' for 'all the information' to be released because of the possibility of criminal prosecution. The summaries, compiled and presented by the WMP investigating officers, would be 'scrutinized' by senior WMP officers and the Coroner before being released to families ahead of the mini-inquests. This would 'ensure they contain no controversial details and they are as accurate as possible in the circumstances'.

¶1.175 Mr Fraser stated that families would be 'satisfied with the factual information [in the summaries] … and not want to take any further action'. The preliminary hearings would be

¶'low key … an exercise in distributing information to families about precisely how their loved ones died and where, and not an attempt to discover why or who was to blame'.

¶1.176 Their purpose was to provide an 'information dissemination exercise'. The senior pathologist, Professor Alan Usher, would present 'distressing' evidence but 'will hopefully clear up much anxiety and show that many fans simply "went to sleep" without any great discomfort because of lack of oxygen'. This was a curious comment pre-empting the evidence pertinent to each death.

¶1.177 Mr Fraser concluded:

¶For our part we believe that this move by HM Coroner to impart information to families is to be applauded and we have taken the liberty of making that point in open court and through the Press … we believe his stated intentions to assist families in any way he can by providing this information are entirely genuine and we trust that those families who you represent will accept this move on his behalf.

¶1.178 The Coroner wrote to the families' solicitors reiterating the format: 'the intention is to take post-mortem evidence together with a summary of the evidence as it relates to the location of the deceased, the time of death as far as it can be reasonably established and to clear up any minor matters such as the spelling of names'.

¶1.179 Evidence would be presented in a 'non-adversarial' form and would be 'non-controversial'. Early in April 1990, the Coroner wrote to families informing them of the date and time of 'their' mini-inquests. The opening session was set for 18 April at Sheffield Town Hall's Council Chamber, just three days after the first anniversary.

¶1.180 Accompanied by ACC Jones, the Coroner introduced the proceedings, welcoming 'interested parties' and their legal representatives. He repeated the plan agreed at the pre-inquest review meeting. Selected extracts from statements would be used at his discretion. The families' lawyers accepted the format although it limited disclosure of evidence and prevented its examination. Expert witnesses gave generic evidence, including a chemical pathologist on blood alcohol levels and the Northern General Hospital's Accident & Emergency consultant on the injuries suffered by the deceased, focusing particularly on asphyxia.

¶1.181 The preliminary hearings then moved to the Coroner's Court at Sheffield's Medico- Legal Centre where each family, accompanied by social workers, attended at a prescribed time. For the first time they were given the WMP's summary of evidence relating to the death of their loved one.

¶1.182 In a public forum, facing the deeply emotional pressure of hearing evidence about the death of their loved one, they had little time to digest the contents and some identified factual errors, causing further distress. Two WMP officers were assigned to each family, some already familiar through previous home visits.

¶1.183 Each family was escorted into court, along with social workers and police officers. The Coroner introduced the process followed by the pathologist's evidence. The recorded blood alcohol level was presented to the court. A WMP officer then read a summary of the evidence. On a map of the stadium another WMP officer showed all recorded sightings of the deceased in photographs and video material.

¶1.184 Families left the court through another door to a small room where they met the pathologist who gave words of reassurance, informally answering questions. Many families had questions they wanted addressed but this had not been possible as the abridged evidence could not be examined. Once the preliminary hearings were completed the inquests were adjourned to await the decision on criminal prosecution.

¶The generic hearing 1.185 On 19 November 1990 the inquests resumed, in generic form, at Sheffield Town Hall. They concluded on 28 March 1991, having heard evidence from 230 witnesses. At the time they were the longest inquests in English legal history. Twelve 'interested parties' were represented, six of which were 'police interests'. Forty-three families each contributed financially to representation by one barrister. A bereaved mother represented her family. In the absence of legal aid, survivors were not represented.

¶1.186 The Coroner announced that the generic proceedings would be extensive but no evidence would be heard relating to events beyond 3.15pm on the day of the disaster. The families' Counsel argued that there had been 'no investigation directed to the global organisation of what happened immediately after they [the dying and injured] were brought off the terraces' and that 'to ignore … concerns as to the adequacy of the attentions and the rescue efforts after 3.15' amounted to failing to 'investigate what could well have been a major reason for why somebody died and did not survive'.

¶1.187 Having taken legal submissions, the Coroner argued that by 3.15pm 'the real damage was done'. The 'overwhelming medical evidence, the pathological evidence, and that is the crucial one [sic] I am interested in, is the damage that caused the death was due to crushing'. Once the 'chest was fixed so that respiration could no longer take place, the irrevocable brain damage could occur between four and six minutes'.

¶1.188 Thus, 'the latest, when this permanent fixation could have arisen would have been approximately six minutes past, which is when the match stopped'. The Coroner added a further six minutes to accommodate the pathologist's assessment of a six-minute period for irreversible brain damage, taking the time to 3.12pm. He identified a clear 'marker' close to that, the ambulance appearing on the pitch at 3.15pm.

¶1.189 He reasoned that the 3.15pm cut-off was consistent with the medical evidence and 'each individual death' was 'in exactly the same situation'. He concluded 'the fact that the person may survive an injury for a number of minutes or hours or even days, is not the question which I as a Coroner have to consider'. Crushing, he maintained, was the sole cause of death.

¶1.190 The 3.15pm cut-off was the most controversial decision of the generic stage of the inquests. Consequently, those most directly concerned with rescue, evacuation and medical treatment did not give evidence.

¶1.191 The Coroner, in consultation with others 'behind the scenes', selected the witnesses. The 'order' of witnesses was also his decision: licensees and local residents, police officers, senior police officers, survivors and 'experts'. The combined evidence of local residents and police officers provided a strong foundation for the accounts of senior officers responsible for crowd management and control on the day. Senior officers, discredited as witnesses by LJ Taylor, repeated their previous allegations about the behaviour of Liverpool fans.

¶1.192 Much of the senior officers' evidence focused on responsibility for crowd management, foreseeability and communication between officers after Gate C was opened. The Duckenfield–Murray relationship was central to the examination of both men's evidence, focusing on division of responsibilities, the monitoring of the pens, the custom and practice of fans being left to 'find their own level' and the decision to open Gate C and its consequences.

¶1.193 Considerable attention was paid to C/Supt Duckenfield's lack of experience. Following the 'expert' evidence of those associated with Sheffield City Council, SWFC and the Health and Safety Executive, survivors were called to give their personal accounts. 1.194 At the conclusion of the evidence, legal submissions were made to the Coroner over two days in the absence of the jury. Most oral submissions were supported in writing. They concerned a possible verdict of unlawful killing and the required standard of proof to demonstrate a failure of a duty which comprised a substantial cause of death. 1.195 The families' Counsel focused on the 'logical chain' of events set in motion by C/Supt Duckenfield's decision to open Gate C. It had been, it was proposed, a positive act and the failure to divert was an 'omission'. Taken together they constituted unlawful killing. 1.196 The Coroner directed the jury on two possible verdicts: unlawful killing and accidental death. He stated that 'the word "accident" straddles a whole spectrum of events from something over which no-one has control' where 'no-one could be blamed – to a situation where you are in fact satisfied that there has been carelessness, negligence, to a greater or lesser extent and that someone would have to make, for instance, compensation payments in civil litigation'. A verdict of accidental death did not mean that individuals were absolved from 'all and every measure of blame'. 1.197 At 12.33pm on 26 March 1991 the jury retired to consider its verdict. Two days later, at 12.08pm, on the 80th day of the generic stage of the hearings, the jury returned. It was a nine to two majority verdict: 'accidental death'.

¶Judicial Review 1.198 On 6 April 1993 six bereaved families were granted leave by the High Court to proceed with an application for a judicial review of the inquest verdicts. Grounds of challenge included: irregularity of proceedings; insufficiency of inquiry; and the emergence of new facts or evidence. 1.199 Effectively these were test cases for all who died. The barrister for the six families, Edward Fitzgerald, stated: 'whatever else this death was, it was not accidental and it would be some assuagement of feelings if the verdict was struck down'. 1.200 In consenting to a judicial review, Mr Justice Macpherson concluded that 'a case can be sensibly argued'. Yet he sounded a cautionary note: 'I don't know what will happen in the end. I don't know how desirable it is that these agonies be prolonged'. 1.201 Christopher Dorries, the South Yorkshire West District Coroner who succeeded Dr Stefan Popper, said: 'All that has happened today is that the families have gone along and won the right to a full review. No-one else was in court'. 1.202 Nineteen months after the initial submission to the Attorney General, the Judicial Review opened in the Divisional Court before two judges. 'In many respects', argued Alun Jones QC on behalf of the families, the inquests were 'empty'. There had been an 'appearance of bias' towards the police and authorities by the Coroner, particularly in the withholding and suppression of evidence. These claims were strongly contested by the Coroner's barrister.

¶1.203 On 5 November 1993 Lord Justice McCowan rejected the families' submission that the accidental death verdicts were either misleading or in error. Together with Mr Justice Turner he considered that the inquests had been properly conducted and there had been no suppression of important evidence.

¶1.204 LJ McCowan stated, 'I would hold the inquisition was correctly completed and the coroner's direction to the jury as to the manner in which they should approach its completion was impeccable'. J Turner concluded, 'There is nothing to show any lack of fairness or unreasonableness – there was no error'.

¶1.205 LJ McCowan commented on liability and also the 3.15pm cut-off. He asked what would be the purpose of fresh inquests as the police had already been criticised by the Taylor Report. He noted that SYP 'had admitted fault and paid compensation'.

¶1.206 He considered that no criticism could be levelled against the emergency services. Such criticism would be 'irrelevant if all six were brain dead by 3.15pm'. Further 'examination of the last minutes of their lives' would provide no further information, would be 'harrowing' and involve 'large numbers of witnesses ... lasting if not for 96 days, for not far short'.

¶1.207 The families argued that the summarised evidence presented at the mini-inquests and the imposition of the 3.15pm cut-off had combined to deprive them of the opportunity to hear evidence significant to their specific case and have it cross-examined. LJ McCowan acknowledged the 'deep instinct to know the circumstances in which their relatives died' shared by the bereaved.

¶1.208 He accepted that this was 'their motive' but hoped that the families could understand that he had 'to take an objective view and ... consider the interests of all concerned including those of all the witnesses who would have to come along five years later and try to cast their minds back to events they must have been trying to forget'. On this basis, and using his 'discretion', he considered 'this was not a case in which it would be right to order fresh inquests'.

¶Tony Bland 1.209 Having been crushed on the terraces, 18-year-old Tony Bland suffered severe anoxic brain damage. He was admitted to the Northern General Hospital in Sheffield, where he was ventilated. Able to breathe, his condition was consistent with being in a 'vegetative state'. He was transferred to Airedale Hospital, close to his home in Keighley, where he was treated by a team headed by neurologist Dr Jim Howe.

¶1.210 Dr Howe stated that despite excellent nursing, 'there was no improvement'. Mr Bland 'remained unresponsive ... no eye contact and no sign of communication'. After full consultation among the medical teams and the Bland family, Dr Howe decided that treatment should be withdrawn, including nutrition and fluids supplied by tubes direct to Mr Bland's stomach.

¶1.211 A date was agreed for withdrawal. Dr Howe informed the South Yorkshire West District Coroner, Dr Popper, whose response was that he would risk a murder charge should treatment be withdrawn. Dr Popper warned that he 'could not countenance, condone, approve or give consent to any action or inaction which could be, or would be construed as being designed or intended to shorten or terminate the life of this young man'. This applied specifically 'to the withholding of the necessities of life, such as food and drink'.

¶1.212 The Coroner's letter was copied to the WMP Chief Constable, the Yorkshire Regional Health Authority solicitor and Dr Howe's medical defence society. Dr Howe was interviewed by the police and advised that, should treatment be withdrawn, he would be charged with murder. The status quo obtained.

¶1.213 In 1993 the Bland family agreed that a legal application should be made to withdraw treatment. The case was heard in the High Court Family Division. It was concluded that withdrawal of treatment would not be unlawful. The Official Solicitor appealed the ruling and the case was heard in the House of Lords. The initial ruling was upheld and treatment withdrawn. Almost four years after the disaster, on 3 March 1993, Tony Bland died peacefully, his parents with him.

¶The Stuart-Smith Scrutiny 1.214 On 30 June 1997, accompanied by Merseyside MPs, over 40 Hillsborough families met the Labour Government Home Secretary, Jack Straw, at Westminster. The Home Secretary expressed concern about 'whether the full facts have emerged' regarding the disaster. He acknowledged that families' grief had been 'exacerbated by their belief that there are unresolved issues which should be investigated further'.

¶1.215 Mr Straw proposed an independent judicial scrutiny of new evidence, 'to get to the bottom of this once and for all'. A senior appeal court judge, Lord Justice Stuart-Smith, would consider 'further material that interested parties wished to submit'. Mr Straw was determined to 'ensure that no matter of significance is overlooked'.

¶1.216 The Scrutiny would review evidence not available to the Taylor Inquiry, the DPP, the Attorney General or the SYP Chief Constable. 'New' evidence would be 'of such significance' that it could lead to criminal prosecutions or disciplinary charges.

¶1.217 While the media erroneously portrayed the intended judicial scrutiny as a 'new inquiry', questions remained concerning the powers and discretion afforded to the judge in progressing such an unprecedented process.

¶1.218 In fact, LJ Stuart-Smith had considerable discretion. Although the terms of reference were limited, they included a broad rider: 'and to advise whether there is any other action which should be taken in the public interest'.

¶1.219 SYP held all information gathered by the WMP investigation into Hillsborough. This included statements, documentation, video footage and photographic evidence gathered for the criminal investigation, the Taylor Inquiry and the Coroner.

¶1.220 LJ Stuart-Smith visited SYP to view the archive. He also visited SWFC. The Hillsborough Family Support Group emphasised and presented 'new evidence' from a video technician and serious claims concerning improper conduct by the police investigators.

¶1.221 On 6 October 1997 the bereaved families met LJ Stuart-Smith in Liverpool. At a general meeting he stated that, guided by the terms of reference, he would 'look at all the information that people are now coming forward with to see whether it is fresh evidence about the disaster'. He would then 'decide whether to recommend that any fresh evidence that I find justifies a new public inquiry, new inquest or any other kind of legal proceedings or action by the authorities'.

¶1.222 It would be restricted to evidence 'not available' or 'not presented' to the Inquiries, the courts or the prosecuting authorities. It would have to 'lead somewhere and … show that the outcome of the legal procedures that have taken place might have been different or that those responsible for instituting criminal or disciplinary proceedings might have taken different decisions'. Evidence 'broadly in line' with that already known would 'not be of much help'.

¶1.223 LJ Stuart-Smith reiterated the Taylor Inquiry findings, emphasising that the failure to close the tunnel once Gate C had been opened constituted 'a blunder of the first magnitude'. LJ Taylor, he affirmed, had been 'highly critical of the police operation' and had extended criticism to Sheffield City Council, SWFC and the civil engineers Eastwood & Partners.

¶1.224 Accepting the Taylor Report without reservation, he concluded it was 'not difficult to discern what happened'. The inquest verdicts of accidental death were 'in no way inconsistent with the deaths having been caused by negligence or breach of duty'.

¶1.225 The inquests had been subject to judicial review in the Divisional Court and were considered sound. The Scrutiny, however, would evaluate 'whether there is any fresh evidence which might show that some or all of the verdicts of accidental death should be quashed and a fresh inquest ordered'.

¶1.226 This would extend to decisions made by 'the Director of Public Prosecutions and the Police Complaints Authority'. If 'fresh evidence' was so significant that it would have 'caused them to reach different decisions', they would be invited to reconsider their previous decisions. LJ Stuart-Smith conceded there had been procedural problems and difficulties, particularly concerning the inquests, but he noted that families' lawyers had complied with the Coroner's arrangements for proceeding. 'No full scale investigation', stated LJ Stuart- Smith, 'will resolve these problems'.

¶1.227 LJ Stuart-Smith also noted that the SYP Chief Constable had 'paid compensation to those who were injured and the families of those who were killed on a basis of full liability'. While he had 'not seen any formal admission of liability by the police … they have never contested that they are liable'.

¶1.228 By liability he meant 'damages for negligence or breach of duty' consistent with the Chief Constable's responsibility 'in law for the acts or omissions of his junior officers'. Such damages related to collective 'faults of the police, their negligence overall'.

¶1.229 There was 'no difference in principle between accepting liability and paying on a one hundred per cent basis than there is making a formal admission of liability … no distinction between the two'. As SYP had never contested civil liability the acceptance was implicit: 'it is a distinction without a difference'.

¶1.230 LJ Stuart-Smith met individual families and their representatives over three days, each for approximately 40 minutes. Meetings were transcribed. Some families provided written submissions prepared by the Family Support Group's solicitor.

¶1.231 Long and unexplained delays by SYP in supplying 'body files' of the deceased limited their submissions. Of the 34 families who made written submissions, 18 eventually met the judge. He also interviewed 14 witnesses, drawing on 16 others for assistance 'on various aspects' of the Scrutiny. Throughout the information-gathering period of the Scrutiny, regular telephone contact was maintained between the Scrutiny office and families. This included 'off-the-record' exchanges.

¶1.232 On 18 February 1998 the bereaved families, accompanied by Merseyside MPs, met Mr Straw before his announcement in the House of Commons of the Scrutiny's outcome. He assured the families that following LJ Stuart-Smith's 'thorough' and 'impartial' Scrutiny no new evidence had emerged of such significance that it brought into question previous decisions, judgments, rulings or inquest verdicts.

¶1.233 Soon after, addressing the House of Commons, the Home Secretary stated that the Scrutiny was the 'latest in a series of lengthy and detailed examinations' of Hillsborough. LJ Stuart-Smith's report was 'comprehensive' and went into 'immense detail to analyse and reach conclusions on each of the submissions'. All allegations and representations of 'new' evidence had been considered 'with great care'.

¶1.234 Mr Straw summarised the findings: all police video evidence had been presented to the Taylor Inquiry and to the Coroner; allegations that video evidence had been suppressed and false evidence given were unfounded; the 3.15pm cut-off had not limited the inquiry of the inquests; and there had been 'no improper attempt' by the police to 'alter the evidence' of witnesses.

¶1.235 Mr Straw concluded: 'Taking those and all other considerations into account, the overall conclusion that Lord Justice Stuart-Smith reaches is that there is no basis for a further public inquiry … for a renewed application to quash the verdict of the inquest' and 'no material that should be put before the Director of Public Prosecutions or the police disciplinary authorities'. The evidence made available to LJ Stuart-Smith had not 'added anything significant to Lord Taylor's inquiry or the inquests'.

¶1.236 Mr Straw stated that he, the Attorney General and the DPP had examined LJ Stuart- Smith's findings and had 'no reason to doubt his conclusions'. He acknowledged that the outcome would 'be deeply disappointing for the families of those who died at Hillsborough and for many who have campaigned on their behalf'.

¶1.237 He commented that he fully understood 'that those who lost loved ones at Hillsborough feel betrayed by those responsible for policing the Hillsborough football ground and for the state of the ground on that day'. He also noted that LJ Stuart-Smith accepted 'the dismay that [the families] have that no individual has personally been held to account either in a criminal court, disciplinary proceedings, or even to the extent of losing their job'.

¶1.238 Mr Straw reflected on the 'serious shortcomings in the police disciplinary system', and the inappropriateness of holding public inquiries and inquests thus repeating the inquisitorial process.

¶1.239 He considered that LJ Stuart-Smith had been 'dispassionate' and 'objective', and concluded: 'I hope that the families will recognise that the report represents – as I promised – an independent, thorough and detailed scrutiny of all the evidence that was given to the committee'.

¶1.240 The bereaved families rejected the report. A House of Commons adjournment debate followed on 8 May.

¶Review and alteration of police statements 1.241 Prior to the Stuart-Smith Scrutiny an SYP officer had revealed that in the immediate aftermath of the disaster officers had been instructed not to make entries in pocket-books but to submit handwritten recollections for word-processing.

¶1.242 The recollections had been sent to Peter Metcalf, a senior partner in Hammond Suddards, the solicitors representing SYP, who returned them to Chief Superintendent Donald Denton, with recommendations for 'review and alteration'.

¶1.243 Officers were visited by members of an internally appointed SYP team and their agreement to the alterations secured. They were expected to sign the amended recollections as formal statements.

¶1.244 The statements were then passed to the WMP investigation team and to the Taylor Inquiry who were aware of and accepted the process of review, alteration and submission. The explanation of the process, distributed throughout SYP, was 'to collate what evidence SYP officers can provide their Chief Constable in order that we can provide a suitable case, on behalf of the Force to subsequent enquiries'.

¶1.245 While the justification for the review and alteration of statements was the removal of personal opinion and conjecture, it was clear that statements were also amended to eliminate criticism of senior officers and their management of the crowd. As the extent of the process materialised, it became a focus for the Scrutiny.

¶1.246 LJ Stuart-Smith recorded that, in five weeks, over 400 recollections were processed via the solicitors. He estimated that 253 passed without comment and 60 were 'slightly' amended. Over 90 statements were recommended for alteration.

¶1.247 LJ Stuart-Smith examined 'approximately 100 amended statements where on the face of the comments by the solicitors something of substance might have been referred to'. He concluded that 74 were 'of no consequence'. From the remaining 26, 'comment and opinion' had been excluded, mainly officers' criticisms of the police operation.

¶1.248 Criticisms concerned lack of radios and poor communication, shortage of police at Leppings Lane and 'lack of organisation by senior officers in the rescue organisation'. As matters of 'comment and opinion', LJ Stuart-Smith felt that the solicitors 'could not be criticised for recommending their removal'.

¶1.249 LJ Stuart-Smith acknowledged 'that the solicitors had to exercise judgement as to whether material unhelpful to the police case should be excluded'. SYP 'perceived themselves to be on the defensive' and this was a 'perception' shared by their 'legal advisers'. It was 'understandable' that SYP should not 'give anything away'.

¶1.250 He concluded, however, that 'at least in some cases it would have been better' had some of the deletions not been made. This was 'at worst … an error of judgement' and he did not accept that 'the solicitors were guilty of anything that could be regarded as unprofessional conduct'.

¶1.251 LJ Taylor had been 'clearly well aware that the original self-written statements [recollections] were being vetted by the solicitors and in some cases altered'. LJ Stuart- Smith was in 'no doubt' that LJ Taylor 'knew or suspected that criticisms of the police operation or conduct of their senior police officers were being excluded'.

¶1.252 In November 1997 LJ Stuart-Smith interviewed Richard Wells, who had succeeded Peter Wright as Chief Constable of South Yorkshire, noting, 'there was a tendency to remove opinion and intemperate language about senior police officers but leave in similar material about misbehaviour by Liverpool fans'. It was 'a matter of concern that there seemed to be a pattern of changing this material in this way'.

¶1.253 Interviewing former C/Supt Denton, LJ Stuart-Smith stated that there had been 'a removal of criticisms of senior officers but no corresponding removal of criticisms of the fans'. Further, he asked Mr Denton: 'some of these alterations do seem to alter the factual position … it is not your function, is it, to change factual matters?' Mr Denton replied, 'No it isn't, and I didn't change it either, sir … Mr Metcalf suggested all the changes. There were no changes suggested by the police at all'.

¶Private prosecution 1.254 In August 1998 the Hillsborough Family Support Group initiated a private prosecution against David Duckenfield and Bernard Murray. It was the culmination of a decade's campaigning to establish criminal liability and to access key documents, witness statements and personal 'body files' on each of the deceased compiled by the police investigators.

¶1.255 On 16 February 2000 the former officers were committed for trial, charged with manslaughter and misconduct in a public office. Mr Duckenfield was also charged with misconduct 'arising from an admitted lie told by him to the effect that the [exit] gates had been forced open by Liverpool fans'.

¶1.256 The judge, Mr Justice Hooper, summarised the prosecution case for manslaughter as the failure by the officers to prevent a crush on the terraces and to divert fans from the tunnel. The risk of serious injury, therefore, had been foreseeable. The 'apparent' defence case was that neither officer 'in the situation in which they found themselves, thought about closing off the tunnel or foresaw the risk of serious injury in the pen if they did not do so'.

¶1.257 The judge noted the 'enduring grief' suffered by the bereaved. It was compounded by 'a deep seated and obviously genuine grievance that those thought responsible' had not been prosecuted or 'even disciplined'. Both defendants, however, 'must be suffering a considerable amount of strain'.

¶1.258 While committing Mr Duckenfield and Mr Murray for trial he took a 'highly unusual course' to 'reduce to a significant extent the anguish being suffered'. He stated that if the former officers were found to be guilty of manslaughter, neither would face a prison sentence. This extraordinary assurance could not be disclosed until after the trial.

¶1.259 The trial opened on 6 June 2000 at Leeds Crown Court and ran for seven weeks. The prosecution's case was that fans died because they could not breathe in a crush due to overcrowding 'caused by the criminal negligence of the two defendants'.

¶1.260 Both had been 'grossly negligent, wilfully neglecting to ensure the safety of supporters'. Their negligence was not the sole cause of the disaster as the ground was 'old, shabby, badly arranged, with confusing and unhelpful sign-posting … there were not enough turnstiles'.

¶1.261 Further, an entrenched 'police culture ... influenced the way in which matches were policed'. Nevertheless, the 'primary and immediate cause of death' was the consequence of the defendants' failures. Each defendant 'owed the deceased a duty of care' and 'his negligent actions or omissions were a substantial cause of death'. Their 'negligence was of such gravity as to amount to a crime'.

¶1.262 Mr Duckenfield declined to give evidence but his evidence to the Taylor Inquiry was presented in detail. The judge called as a witness Mr Duckenfield's predecessor, former

¶Chief Superintendent Mole, as he had drafted the Police Operational Order, introducing him as a crowd safety 'expert'.

¶1.263 Mr Murray gave evidence. Closing off the tunnel was 'something that did not occur to me at the time and I only wish it had'. While not recognising how packed the central pens had become, he had not been 'indifferent to the scenes … I did not see anything occurring on the terrace which gave me any anxiety'. 1.264 Between 14 and 20 June the prosecution called 24 witnesses. At the conclusion of the evidence the judge identified four questions for the jury to consider. First, 'Are you sure, that by having regard to all the circumstances, it was foreseeable by a reasonable match commander that allowing a large number of spectators to enter the stadium through exit Gate C without closing the tunnel would create an obvious and serious risk of death to the spectators in pens 3 and 4?' If 'yes', they were to move to question 2; if 'no', the verdicts should be 'not guilty'. Second, could a 'reasonable match commander' have taken 'effective steps … to close off the tunnel' thus preventing the deaths? If 'yes', they were to move to question 3; if 'no', the verdicts should be 'not guilty'. Third, was the jury 'sure that the failure to take such steps was neglect?' If 'yes', it was on to question 4; if 'no', the verdicts should be 'not guilty'. Fourth, was the 'failure to take those steps … so bad in all the circumstances as to amount to a very serious criminal offence?' If 'yes', the verdicts should be 'guilty'; if 'no', they should be 'not guilty'. 1.265 Each question had to be contextualised 'in all the circumstances' in which the defendants had acted. Centrally, did the circumstances of chaos and confusion impede or mitigate the senior officers' decisions? On opening Gate C, was an obvious and serious risk of death in the central pens 'foreseeable' by a 'reasonable match commander?' Not someone of exceptional experience and vision, but an 'ordinary' or 'average' match commander. Even if gross negligence could be established, question 4 demanded that it had to be so bad in the circumstances that it constituted a serious criminal offence. 1.266 The prosecution argued that the police 'mindset' of 'hooliganism' at the expense of crowd safety was 'a failure' best captured 'in the word neglect'. It was not a failure caused by the immediacy of a 'split-second decision' but 'a case of slow-motion negligence'.

¶1.267 Like all others in the stadium, Mr Duckenfield and Mr Murray could see the 'dangerously full pens' and had adequate 'thinking time' to seal the tunnel and redirect the fans. Their failure was negligent and not postponing the kick-off 'intensified the responsibilities of those who had taken the decision to get it right'. It was a serious criminal offence because 'thousands of people' had been affected by the breach of trust in the officers.

¶1.268 Mr Duckenfield's Counsel considered that the events were 'unprecedented, unforeseeable and unique'. He maintained that a 'unique, unforeseeable, physical phenomenon', unprecedented in the stadium's history, occurred in the tunnel. People were projected forward with such ferocity that others died on the terraces in the consequent surge. It was the result of a small minority of over-eager fans who had caused crushing at the turnstiles, whose actions were perhaps responsible for the projection of unprecedented force in the tunnel.

¶1.269 Mr Murray's Counsel argued that what happened was not slow-motion negligence but 'a disaster that struck out of the blue'. The deaths were not foreseeable and no 'reasonably competent' senior officer could have anticipated the sequence of events as they progressed. While the police operation might have 'had many deficiencies', Mr Duckenfield and Mr Murray should not be singled out to 'carry the can'. The terraces had been authorised as safe, the fans 'finding their own level' was taken for granted. It was 'Mole's policy, Mole's custom and practice'. A conviction would make Mr Murray a 'scapegoat'.

¶1.270 Having heard the closing speeches, the judge emphasised that the case had to be assessed 'by the standards of 1989' when 'caged pens were accepted' and 'had the full approval of all the authorities as a response to hooliganism'. The defendants had to be regarded as 'reasonable professionals' – each of them 'an ordinary competent person', not a 'Paragon or a prophet'.

¶1.271 When the exit gates were opened, 'death was not in the reckoning of those officers'. They were responding to a 'life and death situation' at the turnstiles and the jury had to 'take into account that this was a crisis'. The jury should 'be slow to find fault with those who act in an emergency'; a situation of 'severe crisis' in which 'decisions had to be made quickly'.

¶1.272 J Hooper noted the 'huge difference between an error of judgement and negligence', that 'many errors of judgement we make in our lives are not negligent' and 'the mere fact that there has been a disaster does not make these two defendants negligent'.

¶1.273 For a guilty verdict, the negligence would have to have been 'so bad [as] to amount to a very serious offence in a crisis situation'. There were two key questions: 'Would a criminal conviction send out a wrong message to those who have to react to an emergency and take decisions? Would it be right to punish someone for taking a decision and not considering the consequences in a crisis situation?'

¶1.274 After 16 hours of discussion the jury was instructed that a majority verdict would be accepted. Over five hours later, Mr Murray was acquitted. The jury was discharged without reaching a verdict on Mr Duckenfield and the judge refused the application for a re-trial.

¶Beyond the private prosecution 1.275 Following the private prosecution, the Hillsborough Family Support Group (HFSG) continued its campaign for full disclosure of all documents relating to the Hillsborough disaster. The HFSG is not the only campaign group. The others are the Hillsborough Justice Campaign and Hope for Hillsborough (focusing on the case of Kevin Williams). On 15 April 2009 at the 20th Anniversary Memorial of the disaster organised by the HFSG, the Secretary of State for Culture, Media and Sport, Andy Burnham, addressed over 30,000 people at Anfield, home of Liverpool FC.

¶1.276 In his address Mr Burnham committed the Government in principle to disclosing all public documents relating to Hillsborough. This would mean waiving the restriction placed on government documents and public records for a minimum 30-year period, known as the '30-year rule'.

¶1.277 Subsequently, the HFSG submitted a request to the Home Office for a 'full and frank disclosure of all documents, their careful evaluation and the production of a balanced report' independent of government. Its detailed request noted that disclosure was a matter of 'public interest' as well as offering 'resolution for bereaved families, survivors and others affected by Hillsborough'.

¶1.278 Following meetings between the HFSG, Merseyside MPs and the Home Secretary, in December 2009 the Home Secretary, Alan Johnson, announced the appointment of the Hillsborough Independent Panel and published its terms of reference.

¶Hillsborough: 'what is added to public understanding'

¶Within its terms of reference the Hillsborough Independent Panel was given responsibility for deciding on the detailed content of its Report. It was envisaged by the Government that the Report would provide an overview of the documents and other material made available by the contributing organisations.

¶In carrying out its work, the Panel was greatly assisted by consultations with families and has taken account of their views when researching and analysing the disclosed documents. In that context, the Report focuses primarily on 'how the information disclosed adds to public understanding of the tragedy and its aftermath'.

¶Part 1 provides a review of 'what was known' or publicly available prior to the Panel's work. Through a detailed analysis of the material disclosed, Part 2 further expands on 'what was known' to explore in detail the key issues raised by families and to provide a full review of what disclosure adds to public understanding.

¶Chapters 1 to 3 cover the longer-term context through to the circumstances of the disaster, focusing on the relationships between the control, management and safety of the crowd and providing a review of institutional responsibilities before, during and after the disaster.

¶Chapters 4 and 5 consider the emergency response, medical evidence and pathology, the latter focusing on the recording and publicising of blood alcohol levels of all who died, as well as on findings concerning their cause of death.

¶The range of investigations and inquiries are covered in Chapters 6 and 7, considering the significance of and relationship between parallel investigations. Chapters 8 to 10 address concerns raised by bereaved families regarding the inquests.

¶Chapter 11 returns to the contentious issue of the process adopted by the South Yorkshire Police and, to a more limited extent, by the South Yorkshire Ambulance Service, for reviewing and altering officers' statements. Finally, Chapter 12 examines the disclosed material to establish how in the immediate aftermath unsubstantiated allegations about the behaviour of Liverpool fans received such prominence in the press.

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

¶1981–1989: unheeded warnings, the seeds of disaster

¶Introduction 2.1.1 When disasters occur it is rare that causation can be attributed to one single overarching act or omission. Even when there is unequivocal evidence that such a single action by an individual or individuals occurred or there was negligence, the historical context and the immediate circumstances are vital ingredients to understanding and explaining how a failure or failures in systems, and the judgements of those responsible, came together. Because systems, their design and monitoring, and their operators evolve over time they are susceptible to custom and practice. For that reason, particularly in situations where people gather in large numbers as travellers, spectators or participants, public events are regulated and managed to create the safest possible environment. That responsibility falls on the owners and, if appropriate, the hirers of the facility, on those responsible for managing and policing people before, during and after the event and on those responsible for responding effectively and efficiently to any emergency should it occur.

¶2.1.2 While the Panel's work focuses on a disaster involving mass fatalities, injuries and trauma, it is important that the circumstances of the Hillsborough disaster are placed in the context of previous incidents at the stadium and the lessons that were learned, or not, from debriefings and from negotiations between the owners, the safety engineers, the local authority, the police and the other emergency services. The structural condition of the stadium, including alterations to the stands and terraces, was a significant factor in establishing whether it provided a safe environment for spectators, especially when full to capacity. Given the pre-eminent climate in which soccer was policed throughout the 1970s and 1980s, the custom and practice adopted by Sheffield Wednesday Football Club (SWFC) and South Yorkshire Police (SYP) in the management and regulation of the crowd were also important factors.

¶2.1.3 Following the 1989 disaster considerable evidence relating to the context, circumstances and consequences of the 1981 crushing on the Leppings Lane terrace was gathered by the key agencies concerned, primarily to establish whether the tragedy was foreseeable and preventable. What follows draws significantly on that evidence as disclosed to the Panel. Not all the evidence sought has been provided, in some cases because it no longer exists.

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

¶The 1981 FA Cup Semi-Final 2.1.4 The 1981 FA Cup Semi-Final, between Tottenham Hotspur and Wolverhampton Wanderers, took place at Hillsborough on Sunday 11 April. The kick-off was scheduled for 3pm but was delayed until 3.15pm. The fans of both clubs travelling to Sheffield approached the stadium from the city's south. Several traffic incidents on the M1, including an accident involving 13 cars, the breakdown of a public service vehicle and road works, caused considerable travel delays, culminating in the late arrival of many fans close to kick-off.

¶Crushing at the turnstiles and opening Gate C 2.1.5 Fans described considerable congestion at the Leppings Lane turnstiles.1 By 2.10pm congestion on the outer concourse was severe.2 Stuart Thorpe, the chief steward for the West Stand, organised three stewards to open exit Gate C as an additional point of monitored entry. Approximately 50 people were admitted and their tickets were checked.3 While the use of the exit gates for entry established a precedent for relieving the crush at the turnstiles, in 1981 the police and stewards combined to manage the situation effectively. Mr Thorpe described how fans were lined up outside the gate while stewards and police inside the stadium prepared to receive them.4

¶Crushing on the terraces and opening of the perimeter gate 2.1.6 In 1981 the Leppings Lane terrace, although accessed from various points including the central tunnel, was not divided into pens by lateral fences. It was an open terrace. As fans arrived onto the already packed steps there was crushing resulting in serious injuries including broken bones, cuts and bruises.5 Thirty-eight people received treatment from St John Ambulance volunteers and some were taken to hospital.6 The crushing was most severe when Tottenham Hotspur scored a goal three to four minutes into the game and fans entering pushed forward. One supporter described how 'people were passing out and having difficulty breathing, people were getting hysterical, shouting and screaming'.7

¶2.1.7 As the game continued a senior police officer, Assistant Chief Constable Robert Goslin, stated it was decided to remove fans from the Leppings Lane terrace 'to ease a dangerous situation where serious injuries or even fatalities were a real possibility'.8 He gave the order to open the gates in the perimeter fence, thereby releasing approximately 150 spectators onto the perimeter track and relieving the crush. The evidence suggests that the perimeter gates were opened after the crushing was recognised. Yet one eye witness suggests that fans had been allowed onto the perimeter track as early as 2.30pm.9 Certainly, the opening of the gates at the time of the crush averted further, possibly fatal, injuries. Inspector Roger Greenwood (Superintendent and Ground Commander in 1989) stated

Statement of football supporter Gary Vaux, 14 May 1989, SYP000038700001, p75. These recollections are reiterated in Vaux's evidence to Lord Justice Taylor: see HOM000026190001, pp3-4. 2. Letter from a Tottenham Hotspur supporter to the Secretary of Liverpool FC,²⁰²⁰ April 1989, HOM000016460001, pp1-5. April 1989, SYP000028950001, pp2-3. 3. Evidence of chief steward for the West Stand, Stuart Thorpe, to Lord Justice Taylor, 14 June 1989,

¶HOM000026170001, p36. 4. Evidence of chief steward for the West Stand, Stuart Thorpe, to Lord Justice Taylor, 14 June 1989,

¶HOM000026180001, p18. 5. Statement of ACC Robert Goslin, 14 August 1990, SYP000096840001, p286. 6. Letter from SYP to FA, 3 June 1981, SCC000001730001, p239. 7. Statement of football supporter Gary Vaux, 14 May 1989, SYP000038700001, p76. These recollections are reiterated in Vaux's evidence to Lord Justice Taylor, HOM000026190001, p5. 8. Minutes of the 1981 SYP debriefing, undated, SYP000096520001, p1. 9. Letter from a Tottenham Hotspur supporter to the Secretary of Liverpool FC,²⁰²⁰ April 1989, HOM000016460001, pp1-5. April 1989, SYP000028950001, p2.

¶that he was stationed at one of the perimeter gates and radioed the Police Control Box for authority to open the gates. He received no response and together with another officer he opened the gates.10 The fans sat on the track, their backs against the perimeter fence wall.

¶Managing the crowd in the stadium 2.1.8 In addition to opening the perimeter gates to ease the crush on the terrace, the police also managed fans entering the terrace. According to a turnstile operator, before the start of the match stewards had been instructed by police on duty in the inner concourse area behind the West Stand to close the gates to the tunnel and to divert fans to the access points at either end of the terrace.11 This alleviated the concentration of fans behind the goal.

¶2.1.9 At half time ACC Goslin attempted to move fans from the perimeter track to the Spion Kop end. Because this mixed rival fans, it was a decision unpopular with some, resulting in 'a minor break-out' or pitch invasion as they refused to be relocated.12 In fact approximately 50 to 100 fans were successfully transferred to the Spion Kop. ACC Goslin subsequently admitted that his decision might have been ill-conceived, especially as the fans on the perimeter track had caused no problems for policing. The half-time interval was restricted to five minutes rather than ten minutes, giving insufficient time to move people. The second half was delayed, to the annoyance of the match referee, Clive Thomas. Further, the Club criticised the police strategy for seemingly 'helping fans to climb over the railings'. SYP replied that they had helped fans who had tried to climb the perimeter fence to escape the crush. Their officers' intention was to prevent further injury.

¶2.1.10 A letter of complaint from a member of the public alleged the police had 'herded more and more people into the Leppings Lane enclosure when it was obvious that it was full'. SYP Superintendent David Chapman refuted this, explaining that the entrances to the Leppings Lane end were controlled to ensure an even distribution across the terrace but as the terrace filled, 'the usual packing problems occurred'. He insisted that there was space for even distribution within the terrace but that fans had refused to move. Police officers entered the terrace to ensure better distribution. According to the stadium's safety certificate, the capacity for the Leppings Lane terrace was 10,100. The turnstiles' tally recorded 10,435. Also, a significant number of Tottenham Hotspur supporters had obtained tickets allocated to Wolverhampton Wanderers. Police officers moved them from the Spion Kop to Leppings Lane for their own safety. Thus the authorised limit for the terrace was exceeded by just over 400.

¶2.1.11 There was also controversy regarding the quality of the communications systems. Supt Chapman noted that the extensive media coverage at the ground resulted in high levels of interference, yet Acting Superintendent PJ Ruddy insisted that the communications systems were successful. Further, the number of senior officers present in the control room had caused confusion.

¶Post-match meeting 2.1.12 Eric England was SWFC Secretary and after the match an acrimonious meeting took place in his office. It was attended by Chief Constable JH Brownlow, ACC Goslin and SWFC Chairman, Bert McGee. The 30-minute meeting focused on the crushing outside the stadium and on the terrace. The SWFC representatives were extremely critical of the police

Transcript of interview and written submission of Superintendent Roger Greenwood to West Midlands Police, 29 June 11. Statement of turnstile operator, 13 May 1989, SYP000038700001, pp78-82. 12. Minutes of the 1981 SYP debriefing, undated, SYP000096520001.

¶action, for allowing the situation to develop and for how it was resolved. ACC Goslin insisted that 'circumstances beyond our control had brought about the crushing situation and conventional methods of control had failed'.13

¶2.1.13 He stated that he had been on the perimeter track and had instructed that the perimeter fence gate be opened and spectators assisted in evacuating the terrace to prevent serious injury. Fans were then allowed to sit on the track against the perimeter fence wall. Mr McGee argued that the police action was 'completely unnecessary and made the ground look "untidy"'. He considered that it might prevent Hillsborough hosting future semi-finals. ACC Goslin insisted that due to crushing on the terraces there had been a 'real chance of fatalities' to which Mr McGee replied 'Bollocks – no one would have been killed!' Following this disagreement, the relationship between SYP and SWFC became strained.

¶1981 debrief 2.1.14 A debrief of the 1981 Semi-Final was attended by ACC Goslin, Chief Superintendent R Herold, Acting Chief Superintendent Thompson, Supt Chapman, A/Supt Ruddy, Chief Inspector Smith, Inspectors Greenwood, Clive Calvert and Gordon Sykes and Sergeant Purdy (date unrecorded: several of these officers were on duty at Hillsborough in 1989).

¶2.1.15 Reflecting on the crushing, the discussion focused on the construction of the Leppings Lane terrace and its safe capacity. The officers, with the exception of Supt Chapman, agreed the maximum capacity of 10,100 was set too high.

¶2.1.16 C/Supt Herold suggested the construction of a lateral segregation gap providing a 6 to 8ft wide channel down the centre of the terrace to divide and segregate opposing fans for regular league matches. ACC Goslin disagreed, arguing that a relatively narrow gap would encourage missile throwing, with the police caught in the middle. Insp Calvert was concerned that the entrance at the Leppings Lane end of the stadium was characterised by delays and blockages and would benefit from reconstruction.14 All who attended the meeting received the minutes and a copy was filed in the 'F' Division policy file relating to policing Hillsborough.

¶Disagreement over crowd capacity 2.1.17 On 28 April 1981 C/Supt Herold met with Mr England, SWFC Secretary.15 C/Supt Herold informed Mr England that the SYP 'consensus view is that the 10,100 crowd figures specified in the Safety Certificate is too high'. Mr England disagreed, noting 'the former capacity, prior to the implementation of the Safety of Sports Grounds Act at Hillsborough was 11,000 and that on a number of occasions in previous all-ticket matches the terracing has accommodated that number'.

¶2.1.18 At this meeting C/Supt Herold introduced the SYP proposal for radial fences: 'the Leppings Lane terracing should be sectioned "vertically" front to back to produce pens to enable more accurate crowd control and prevent sideways movement and he [England] is already actively considering this'. C/Supt Herold also conceded that it had been a poor decision to move fans from the perimeter track to the Spion Kop at half time.

Statement of ACC Goslin, 14 August 1990, SYP000096840001, pp285-287. 14. Minutes of the 1981 SYP debriefing, undated, SYP000096520001, pp2-3. 15. Internal SYP memorandum from C/Supt Herold to ACC Goslin, 30 April 1981, SYP000096960001, pp144-145.

¶Club–police tensions 2.1.19 SWFC remained critical of SYP, attributing to the police responsibility for the crushing incident. In a letter to CC Brownlow on 20 May 1981, Mr McGee described supporters' complaints about how 'crowd control at Leppings Lane end didn't do what it set out to do'.16 SWFC's investigations concluded that 'the major contributory factor was that police turned away many supporters at the Spion Kop end wearing Tottenham favours but producing tickets that they had obtained from the Wolverhampton ground – they were turned back to Leppings Lane to be with the Tottenham supporters'. This then caused 'the congestion that resulted into the spill-over at the fence'.

¶2.1.20 Mr McGee concluded that 'clearly as a Club and you as a police force, we mustn't have this kind of trouble again if it can possibly be avoided'. This continuing criticism of SYP soured relations after the 1981 match yet the SYP Chief Constable defended his officers and 'his only criticism of his senior officers was for not opening the gates earlier'.17

¶2.1.21 A decade later, in its submission to the Taylor Inquiry, SWFC's position appears to have mellowed: 'the two parties most directly concerned with it [the 1981 crushing] appear to have reacted to it sensibly: the Police reconsidered the whole question of an open terrace and devised the penning system and the club accepted the recommendation and acted upon it in accordance with the advice of Dr. Eastwood and the authority of the Council'.18

¶SYP position on the 1981 Semi-Final 2.1.22 On 3 June 1981 ACC Goslin, on behalf of the SYP Chief Constable, wrote to Ted Croker, the Football Association (FA) Secretary, outlining the SYP position on the 1981 match.19 He noted the late arrival of fans due to travel delays and condemned Wolverhampton Wanderers' sale of tickets to Tottenham Hotspur fans. He stated: 'Neither of the two participating Semi-Final clubs saw fit to inform the South Yorkshire Police, Sheffield Wednesday Football Club or the Football Association about this situation and in that event the mixing of supporters was not properly catered for'. Consequently, 'some 400 Tottenham fans had to be removed from the Spion Kop, in the interests of general safety and public order, and were accommodated in the Leppings Lane end of the ground, which had been designated for use by Spurs supporters'.

¶2.1.23 ACC Goslin also raised the SYP assumption that the 10,100 capacity figure for the Leppings Lane terrace 'obviously contains a safety factor'. He described how the police had opened the fence gates to the perimeter track to relieve pressure and how they had refused further access to the terrace, concluding that 'no other course of action could have been adopted in the interest of public safety'. He received a bland reply.20

¶2.1.24 The issues of capacity and reconstruction raised at the SYP debrief were included in a key letter from SYP to Mr McGee on 5 June 1981.21 The letter stated that 'the Leppings Lane end is not constructed to give maximum aid to the packing and control of the crowd and the accepted crowd capacity is such that there is no safety margin'. Further, it repeated concerns that had earlier been passed to Mr England, the Club Secretary, by C/Supt Herold at their previous meeting in April.

Letter from Bert McGee to CC Brownlow,²⁰²⁰ April 1989, HOM000016460001, pp1-5. May 1981, SYP000098450001, p4. 17. Final submission of South Yorkshire Fire Service and Civil Defence Authority to Lord Justice Taylor,

¶SYP000098170001, pp16-17. 18. Final submission of SWFC to Lord Justice Taylor, SYP000098200001, p12. 19. Letter from ACC Goslin, SYP, to Ted Croker, Secretary of the FA, 3 June 1981, SCC000001730001, pp238-239. 20. Letter from the FA to ACC Goslin, SYP, 12 June 1981, SYP000019280001, p17. 21. Letter from SYP to Chairman of SWFC, 5 June 1981, SYP000096530001.

¶Responding to the 1981 Semi-Final 2.1.25 On 7 August 1981 a meeting was convened at SYP headquarters to discuss the organisation of football matches within the South Yorkshire area for the 1981/82 season. It was attended by SYP officers and representatives of South Yorkshire County Council (SYCC), SWFC, Sheffield United FC, Rotheram FC and Barnsley FC. In the minutes of meeting there is no mention of the 1981 incident.22 A letter from the Secretary of the Sheffield branch of the Tottenham Hotspur Supporters' Club was sent to the FA and SYP seeking an explanation for the crushing on the terrace but no response was received.23 2.1.26 A number of parallels can be drawn between the 1981 FA Cup Semi-Final and subsequent matches: late arrival of fans, delayed kick-off, opening exit gates to ease congestion at the turnstiles, problems with packing the terraces, the closure of the tunnel to divert fans away from the terrace immediately behind the goal and the opening of the perimeter gates. Reflecting back on 1981, SWFC argued that crushing occurred 'before the pens were devised or installed and it is accordingly plain that this type of tragedy could have occurred in circumstances similar to those with which this Inquiry [Taylor] is concerned even if there had been no pens'.24 Had 'a thousand people ... been allowed rapidly to enter the most popular area of the terrace at a time when the entrance leading directly to that area should have been "closed" to them it must have been foreseeable that those at the front could have been crushed even in the absence of radial fences'.

¶1981–86 ground modifications and safety issues Certification for Hillsborough 2.1.27 A working party including the Fire Service, SYP, Sheffield City Council (as building authority) and SYCC had been established in the mid-1970s to consider safety certification at venues across the region. In April 1977 there were injuries and arrests at a Hillsborough match. A member of the public made a complaint about an incident at Leppings Lane. This prompted the SYP Chief Constable to contact the Home Office regarding 'designation' of the ground under the Safety of Sports Grounds Act 1975. 2.1.28 The Home Office stated that the matter would be reconsidered. A further representation by SYCC was also declined. In April 1978 SYCC submitted a lengthy paper arguing that crowd safety could only be ensured if the stadium was designated. In August 1978 the Home Office finally agreed and the safety certificate drafting exercise began.25 2.1.29 Dr Wilfred Eastwood of Eastwood & Partners was appointed consultant engineer to SWFC in 1978.26 As part of the application for a safety certificate, Eastwoods prepared

Minutes of a meeting to discuss the organisation of football matches within the SYP area, 7 August 1981,

¶SYP000013780001, pp331-334. 23. Letter from a Tottenham Hotspur supporter to the Secretary of Liverpool FC,²⁰²⁰ April 1989, HOM000016460001, pp1-5. April 1989, SYP000028950001, pp2-3. 24. Final submission of SWFC to Lord Justice Taylor, SYP000098200001, p12. 25. Statement submitted to Lord Justice Taylor by Acting Head of the Administration and Legal Department of

¶Sheffield City Council, SCC000001960001, pp33-34. See letter from Home Office to SWFC, 23 August 1978,

¶SYP000096970001, pp4-13. Includes Appendix A which is the procedure regarding applications for general safety certificates and Appendix B which is the procedure regarding applications for special safety certificates.

¶See also Home Office circular no. 136/78 – The Safety of Sports Grounds (Designation) Order 1978, 23 August

¶1978, sent to the Chief Executive of the County Council and the Director General of the Greater London Council, 26. Letter from SWFC to Eastwood & Partners, 1 December 1978, SYP000096970001, p57. SYCC were informed of

¶Eastwood & Partners' appointment by letter, 1 December 1978, SYP000096970001, p55.

¶a report on ground capacity for SYCC.27 Its report was completed in January 1979. The report focused on strengthening and supplementing crush barriers on the terraces and calculating exit times. The 1976 Guide to Safety at Sports Grounds (the Green Guide) was used as a basis for the calculations, although the report noted 'as with probably all existing grounds, it will not be possible to satisfy all the recommendations in the guide. Reasonable compromise will be needed on the part of the fire officer and the police'.

¶Eastwoods' report findings 2.1.30 Eastwoods' report disregarded the stadium's failure to meet the requirements of the Green Guide. Regarding the Spion Kop, for example, 21 of 101 barriers tested in 1973 failed to carry the required test load. The report, however, concluded 'it should be emphasised that the general situation was satisfactory compared with most grounds'. From the report it appears that SYP were consulted in the design of the terraces. For example, regarding the Spion Kop barriers, Eastwoods noted, 'we are prepared to accede to the police view and use peak viewing area standards for all barriers'.

¶2.1.31 The report concluded that the Spion Kop capacity was 15,973, noting 'it should be kept in mind that as many as 20,000 spectators have been admitted to the Kop in the past'. The projected time period to evacuate 16,000 people was 11¾ minutes, more than the eight minutes maximum recommended in the Green Guide. Eastwoods' response was: 'we do not consider this to be a serious matter. Rapid evacuation (in say eight minutes) is very desirable for stands where there may be a risk due to fire, or explosion, or structural failure. In the case of terracing it is only the impatience of spectators which might create danger'.

¶2.1.32 In relation to the Leppings Lane terrace (excluding its north-west corner) the report calculated a capacity of 7,200 spectators exiting in six minutes. However, some fans would be 25m from an exit, well beyond the recommended 12m. The report stated, 'but we feel this is of no consequence as movement horizontally along this terrace will be easy and quick'.

¶Leppings Lane terrace capacity 2.1.33 In February 1979 a meeting of the Officer Working Party commented on the capacity of the Leppings Lane terrace, concluding 'it would be unreasonable to insist that gangways or additional exits would be provided'.28

¶2.1.34 Eastwoods calculated the Leppings Lane terrace capacity, including the north-west corner, as 10,100, noting that 'exits serving this part of the terraces are very adequate in width and there will be no difficulty in emptying in eight minutes'.29 An attached, but unattributed, handwritten note reads: '4½ min'. The North Stand exits were assessed as being less than the recommended width of 1.1m but Eastwoods noted 'we do not consider this to be of great consequence'. Gangways were also well below the recommended width but this finding was also dismissed: 'it is clearly appropriate to take into account the general nature of the stand, the number as well as the width of the gangways, and above all the ease and speed with which spectators can evacuate the stand'.

Report to South Yorkshire County Council on ground capacity of Sheffield Wednesday Football Club in connection with application for certificate of ground safety, prepared by Eastwood & Partners, January 1979, SYP000038710001, pp48-57. 28. Minutes of the Officer Working Party meeting, 12 February 1979, SYP000038720001, p361. 29. Report to South Yorkshire County Council on ground capacity of Sheffield Wednesday Football Club in connection with application for certificate of ground safety, prepared by Eastwood & Partners, January 1979, SYP000038710001,

¶2.1.35 The evacuation time for the South Stand was 11 minutes, also above the recommended time of eight minutes, but the report noted that 'because the stand is open to the air and there is very ready access to the pitch we do not think this rather long emptying time is of any great consequence'. Overall there were several areas where the stadium fell well short of the requirements specified in the Green Guide but these shortfalls were rejected as being of little consequence.

¶2.1.36 The report concluded by establishing overall capacity for the stadium at 50,100, stating 'it should also be emphasised that the ground has an excellent safety record stretching over very many years'. This capacity was lower than the capacity of 55,000 previously agreed with SYP, following a 1970 report by Husband and Co., consulting engineers.30

¶2.1.37 A general safety certificate was issued to SWFC on 21 December 1979 subject to remedial works being carried out to South Stand steel columns and emergency lighting.31 A programme of inspections was scheduled.32 There was an inspection on 7 April 1981, prior to the FA Cup Semi-Final. Issues were raised relating to means of escape and there was some disagreement regarding works to be carried out.

¶Sheffield City Council assumes responsibility for ground safety 2.1.38 On 1 April 1986, in accordance with the Local Government Act 1985, SYCC ceased to exist and Sheffield City Council (SCC) assumed responsibility for the discharge of functions under the Safety of Sports Grounds Act 1975. As part of this reorganisation the Officer Working Party was replaced by the Safety of Sports Grounds Advisory Group (SSGAG) which provided professional advice to the Council. SWFC and Eastwoods did not have a role in the SSGAG. David Bownes, Chief Licensing Officer for Sheffield City Council, commented that following the changeover he 'was entitled to assume (in the absence of any contrary evidence), that the sports grounds in Sheffield, including Hillsborough Stadium, were reasonably safe'.33

¶2.1.39 The SSGAG's inspections at Hillsborough in 1986, 1987 and 1988 appear less than adequate. There is no written record of the 1986 inspection claimed to have been carried out on 7 August 1986. The reason given was that efforts were concentrated on a lengthy and complex debate relating to the Spion Kop. Twice-yearly inspections ceased in 1987. One annual inspection was carried out thereafter.34

¶The Green Guide: a matter of interpretation? 2.1.40 No FA Cup semi-finals were played at Hillsborough from 1981 until 1987. According to SYP the reasons for this were first, that the clubs scheduled to play the semi-finals were not located in close proximity to Sheffield and second, that there had been complaints

Letter from Eastwood & Partners to Sheffield City Council,⁴⁴ March 1988, SYP000096970001, p600. January 1990 enclosing a 1970 report by Husband and

¶Co. Consulting Engineers, SYP000038710001, pp187-190. 31. SWFC completed application form for a safety certificate, SYP000096970001, pp16-19. A copy of the safety certificate is available at SYP000038710001, pp62-73. Background correspondence on this is available at

¶SYP000096970001, pp52-61. 32. Statement submitted to Lord Justice Taylor by the Acting Head of the Administration and Legal Department of

¶Sheffield City Council, SCC000001960001, pp34-39. 33. Statement of David Bownes, Chief Licensing Officer with the Administration and Legal Department of Sheffield City

¶Council,²⁰²⁰ April 1989, HOM000016460001, pp1-5. June 1990, SYP000038720001, p413. 34. Letter from Eastwood & Partners to SWFC, 1 June 1987, SYP000096970001, pp481-482. See for example letter from

¶SCC to SWFC,⁴⁴ March 1988, SYP000096970001, p600. December 1987 re their annual inspection of the grounds which was carried out on 6 August 1987 enclosing a list of comments arising from that inspection, SYP000096970001, pp641-643.

¶received from local residents.35 Clearly, however, the 1981 incident and the disputes that followed had a bearing on this decision.

¶2.1.41 Dr Eastwood considered that SWFC officials were conscious of safety and willing to invest in stadium improvements. Retrospectively, he described how 'McGee has been Chairman of the Club throughout this time, and he has taken a keen interest in safety matters including attending some of the meetings with the Working Party ... He has always stressed the need for the ground to be safe and has been a driving force in getting work done'.36

¶2.1.42 Dr Eastwood was informed initially by the 1976 Green Guide and subsequently by the revised 1986 edition. The Green Guide was a voluntary code with no legal force. It was characterised by a 'flexible approach ... in order to take account of the particular circumstances at individual grounds'. Thus, the 'relevant criterion when assessing the adequacy of safety for spectators in new work or re-construction is that of a reasonable degree of safety'.

¶2.1.43 Writing to SWFC in 1986 in relation to the Home Office document Fire Safety and Safety at Sports Venues, Dr Eastwood commented, 'there is a welcome statement ... that due account should be taken of the need to keep the costs to clubs and local authorities to reasonable proportions'.37 Further, he stated: 'it is comforting to know that the new Green Guide will not become a statutory code and will continue to be subject to interpretation'.

¶2.1.44 A 2.7m vertical wire mesh perimeter fence at the front of the terrace was in place before Eastwoods were retained in 1978. Perimeter fences also acted as crush barriers at the front of the terrace. Accordingly, under the provisions of the 1976 Green Guide, they were strengthened in 1979.38 To prevent fans climbing out of the terrace, cranked extensions were fitted to the top of the perimeter fencing leaning towards the spectators at an angle of 45° with spikes projecting inwards. Eastwoods were not involved in this design.

¶2.1.45 On the terraces crush barriers were designed to break up the crowd standing on the shallow steps. Initially, SYCC requested Eastwoods to test one in five barriers every five years. They agreed, however, that Eastwoods would test a block of 37 barriers every five years.39 Eastwoods also conducted an annual inspection as required by the safety certificate.40

¶Introduction of radial fences on the Leppings Lane terrace 2.1.46 In September 1981, Eastwoods were instructed by SWFC to prepare the installation of two radial fences on the Leppings Lane terrace, as had been suggested by SYP (see paragraph 2.1.18). The recommendation was to divide the terrace into three discrete areas each with its own entrance. It was anticipated that this would improve the control and management of fans. At the head of each fence, adjacent to the back wall, narrow gates

South Yorkshire Police submission to Lord Justice Taylor, SYP000096730001, p4. 36. Dr Eastwood's submission to Lord Justice Taylor, SYP000096940001, p6. 37. Letter from Eastwood & Partners to SWFC, 14 July 1986, SYP000096970001, p381. A copy of the Home Office's

¶Fire Safety and Safety at Sports Venues document can be found at SYP000096970001, pp383-431. 38. Dr Eastwood's submission to Lord Justice Taylor, SYP000096940001, pp17-18. 39. Letter from Eastwood & Partners to SYCC, 15 July 1980, SYP000096970001, pp103-104. Reply from SYCC to

¶Eastwood & Partners, 18 July 1980, SYP000096970001, p105. 40. See for example annual inspection report for 1980 at SYP000096970001, pp108-115; report for 1981 at

¶SYP000096970001, pp155-156; report for 1982 at SYP000096970001, pp163-164; report for 1983 at would provide access between the three areas, fastened open during matches to allow movement when necessary.41

¶2.1.47 Dr Eastwood envisaged that the discrete areas would be 'serviced and served by individual and specific dedicated facilities'.42 While the introduction of radial fences was accepted, the proposal to provide each area with access via discrete turnstiles and dedicated facilities was not pursued. Thus there would be no way of knowing accurately how many fans were in each area.

¶2.1.48 On 11 September 1981 a meeting was held attended by representatives of SYP, SYCC, Eastwoods, the Fire Service and the Buildings Department. According to Superintendent W O'Neill of SYP, 'the only reservations expressed were by the Fire Service, who indicated that the security gates – which will be open during football matches – should not in any way restrict the egress routes, which they feel are of minimum width as it is'.43

¶2.1.49 SYCC wrote to Eastwoods stating that radial barriers were acceptable but with some reservations.44 The correspondence considered the management of the rear radial fence gates. The 'increased control on the Terrace' was welcomed but 'concern was expressed as to the problems which could occur with opposing fans mixing at the rear of the West Stand and/or at the entry/exit gates'. This would be known only with 'experience' and 'if realised, whether the problem was of such a small scale that it could be easily coped with by the police'. Consequently 'the Officer Working Party at this stage sees no objection to the proposals to install two 1680mm high radial barriers, with 1.15 metre gates at the rear'. A key condition was that the 'new gates at the rear of the Terrace' would be 'under police control'.

¶Radial fence gates: a police responsibility? 2.1.50 In its subsequent submission to Lord Justice Taylor, the Fire Service reiterated its understanding that the radial fence gates were 'manned' at all times by a police officer.45 The Officer Working Party, of which SYP was a member, noted in its minutes of a meeting in August 1985 that 'the gates at the top of the Terrace [were] under the control of the Police'.46 Contrary to this generally accepted and agreed assumption, however, Chief Superintendent Brian Mole, the Match Commander through the 1980s, stated that 'at no time did the police agree to steward the gates or permanently man them'.47 He affirmed that control of the gates was restricted to segregation purposes only and 'keys were in the possession of the police, who determined which pens were to be utilized and either locked or opened and fastened back gates to necessitate segregation'.

¶2.1.51 C/Supt Mole was unequivocal: 'our role being one of the maintenance of public order through observation and segregation of opposing fans'. Fences restricted sideways

Letter from Eastwood & Partners to D Vaughan of South Yorkshire County Council, 2 September 1981,

¶SYP000038710001, pp74-75. 42. See resumed inquests transcript of day 75, 21 March 1991, SYC000001300001, pp276-277. 43. Internal police minute, 11 September 1981, SYP000096960001, p160. 44. Letter from SYCC to Eastwood & Partners, 14 September 1981, SYP000038710001, p78. Original minutes of Officer

¶Working Party meeting, 11 September 1981, SYP000038710001, p129. 45. Final Submission to Lord Justice Taylor on behalf of the South Yorkshire County Fire Service and Civil Defence

¶Authority, SYP000098170001, p21 (quote from SYP summary of the submission). See also letter from Chief Fire

¶Officer to SYCC, 30 April 1985, stating 'it is understood that these gates will be supervised by either the police or club officials', SCC000001960001, p263. 46. Minutes of Officer Working Party meeting, 7 August 1985, SYP000038710001, p154. 47. Undated statement of Chief Superintendent Mole describing a meeting which took place at SWFC on 7 August 1985, at which the Safety of Sports Grounds Act was discussed, SYP000123550001, p112.

¶movement, avoiding pressure created by the sway of the crowd. Regarding the wide expanse of the Spion Kop, C/Supt Mole explained, 'we never experienced that with a wide mass on the Kop end in the same way that the confined narrowness, the sway created pressure against the fence'.

¶2.1.52 SYP were satisfied with the installation of the radial fences in late 1981, effectively creating three pens. Within months they commented to SYCC, 'the fences are working particularly well and proving to be most satisfactory in effecting the segregation of opposing groups of fans'.48 The Officer Working Party also responded positively, confirming that the fences 'appear to be working well and satisfactorily effect the segregation of opposing groups of fans'.49

¶2.1.53 However, SYP were concerned that some of the existing barriers protruded through the radial fences thus enabling fans to climb between pens.50 SYP wanted these barriers removed. SWFC and Eastwoods disagreed and in November 1981 it was accepted that the barriers would remain for the next match.51 That took place on 17 November and as there were no problems it was agreed the barriers would be retained. Police concerns, however, persisted.52

¶2.1.54 Eastwoods' position was that removing part of the barriers would decrease capacity and would leave a funnel down the steps without crush barrier protection, resulting in 'a major hazard'.53 This was raised at the Officer Working Party meeting in February 1982 when it was agreed that 'on balance, it was preferable from a safety point of view to prevent crowd surge by the existing barriers being extended up to and/or through the new radial barriers than to completely prevent persons being able to climb from one pen to another, subject to review at the end of the current season'.54

¶1985: further alterations to the terrace 2.1.55 According to Dr Eastwood, SYP were actively involved in discussions about adaptations to the radial fences. The disclosed correspondence indicates the negotiations concerning the introduction of further radial fences in 1985.55 The Officer Working Party met on 18 April 1985 and agreed Eastwoods' proposals in principle with several qualifications.56 These proposals included the provision of additional gates, the division of the central pen by an additional lateral fence between the mouth of the tunnel and the perimeter fence, a further lateral fence and further exit gates in the perimeter fence and minimum width of gates. The Fire Service had 'requested additional time to consider the escape aspects'.

¶2.1.56 Eastwoods, however, queried a request for a second gate to be included mid-point in each radial fence, stating that 'if these gates are meant for use in emergency it would mean having a steward in attendance on each occasion, the expense of which would hardly be justified. It is our view that in the event of emergency, spectators can be evacuated

Letter from SYP to SYCC, 18 January 1982, SYP000038710001, p80. 49. Letter from SYCC to Eastwood & Partners,²⁰²⁰ April 1989, HOM000016460001, pp1-5. January 1982, SYP000038710001, p82. 50. Letter from SYP to SYCC, 18 January 1982, SYP000038710001, pp80-81. 51. Dr Eastwood's submission to Lord Justice Taylor, SYP000096940001, pp19-20. 52. Letter from SYCC to Eastwood & Partners,²⁰²⁰ April 1989, HOM000016460001, pp1-5. January 1982, SYP000038710001, pp82-83. 53. Letter from Eastwood & Partners to SYCC, 26 January 1982, SYP000046570001, p237. 54. Minutes of Officer Working Party meeting,⁴⁴ March 1988, SYP000096970001, p600. February 1982, SYP000038710001, p131. 55. See SYP000028310001, pp 326-328: 2 April 1985: Eastwoods' letter to SWFC enclosing drawings creating a corridor or no man's land;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 April 1985: letter forwarded to SYCC and SYP; 19 April 1985: Eastwoods' letter to SWFC records SYP suggestion of a central fence to divide the middle section of the West Terrace; 2 May 1985: SYCC letter to Eastwoods outlines that the police suggestion of a radial fence to separate the central area of the terrace was accepted. 56. Letter from SYCC to Eastwood & Partners, 2 May 1985, SYP000038710001, pp88-89.

¶quickly enough by the gates on to the pitch and by the normal exit gates at the rear'.57 Although the original request for a second gate came from SYP, they conceded on this issue if their other recommendations were met.58

¶2.1.57 Dr Eastwood met SYP on 13 June 1985 and discussed policing the segregated terraces. A proposal emerged to construct a double fence with a gate onto the perimeter track forming a corridor between the pens in which the police could stand.59 Dr Eastwood described how 'Chief Superintendent Moseley was favourably disposed towards the creation of a "corridor" of "no mans land" with a gate to the pitch, following the experience of his officers at the recent match between the Club and Liverpool FC. The corridor would provide an easy access for the Police to the pens on either side via the gates at the rear of the radial fences'.60

¶2.1.58 Dr Eastwood wrote to the police about this proposal on 25 June 1985 and, following further discussions, it was agreed that 'a central fence should be installed for the time being, provided that it did not make the packing of spectators in the west terrace "impossible"'.

¶2.1.59 The Officer Working Party again considered the proposals for segregation on 29 July 1985. The detailed plans were accepted with minor modifications. With reference to 'stewarding of new gates' it was considered 'essential that all the new gates are fully supervised by Stewards who must be fit, able and properly trained'.61 Construction work on further radial fences began on 22 July 198562 at the request of SYP to prevent lateral movement. It is clear from the documents disclosed to the Panel that lateral fences were introduced as an aid to segregation when away fans were accommodated for league matches rather than as a means to manage 'packing' or the distribution of fans on the Leppings Lane terrace.63

¶Gates in the perimeter fence 2.1.60 Following the modifications, there were seven gates in the perimeter fence of the Leppings Lane terrace. Four had been in place when Eastwoods took instructions from SWFC. During the August 1987 inspection the Fire Service and SYP raised the issue of gate release devices as they could not be opened easily when pushed from the terraces.64 A prototype device was prepared and fitted.65 SYP then inspected the new devices66 and they were fitted to all the remaining gates.67 The specialist welding company fitting the devices suggested that some hinges 'could do with replacing'.68 Eastwoods, however, instructed: 'just weld them and get the gates working properly'. SYP requested installation

Letter from Eastwood & Partners to SYCC, 8 May 1985, SYP000038710001, p94. 58. Letter from SYCC to Eastwood & Partners, 10 May 1985, SYP000038710001, p95. 59. Letter from Eastwood & Partners to SWFC,¹⁷¹⁷ December 1997, HOM000030920001, p1. June 1985, SYP000038710001, pp96-97. 60. Dr Eastwood's submission to Lord Justice Taylor, SYP000096940001, p22. 61. Minutes of Officer Working Party meeting, 29 July 1985, SYP000038710001, pp151-152. 62. Letter from Eastwood & Partners to Corderoy & Co., 26 September 1985, SYP000038710001, p98. 63. West Midlands Police interview with Graham Mackrell, Club Secretary, 22 June 1990, SYP000038890001, pp89-90. 64. Letter from Eastwood & Partners to SWFC, 15 January 1988, SYP000096970001, pp499-500. See also letter from Fire Service to SCC, 18 February 1987, regarding their inspection of the ground on 17 November 1986,

¶SYP000096970001, pp472-476. 65. Letter from Eastwood & Partners to SCC, 3 February 1988, SYP000096970001, pp501-506. 66. Phone memorandum between Inspector Calvert and John Strange (Eastwood & Partners), 23 February 1988, arranging to meet on 25 February 1988 to inspect the new gate release devices, SYP000096970001, p607. 67. Letter from Eastwood & Partners to Specialist Welding & Engineering Services Ltd., 26 February 1988, 68. Phone memorandum between Mr Strange (Eastwood & Partners) and Specialist Welding & Engineering Services Ltd., of a close mesh net on the gates as the existing mesh was too large, allowing the devices to be tampered with.69

¶2.1.61 Between 1978 and 1985 the width of the perimeter gates was the focus of considerable discussion led primarily by SYP and the Fire Service. To maintain control of the crowd, SYP did not want the gates widened. The Fire Service, however, considered the gates as an important means of evacuation in an emergency.70 The 1976 Green Guide made no recommendations with regard to the width of gates. The 1986 Green Guide, however, stated they should be a minimum of 1.1m wide. The seven gates were between 0.63m and 0.94m, all installed pre-1979 except Gate 3, installed in 1985 when the central pens were created. Gates 3 and 4, serving central pens 3 and 4, were 0.85m and 0.83m respectively. The width of all perimeter fence gates was thus significantly less than the 1986 Green Guide minimum.

¶Tunnel ramp 2.1.62 Access to the Leppings Lane terrace included a tunnel under the West Stand leading to what eventually became the central pens, 3 and 4. Its relatively steep gradient was raised in Dr Eastwood's submission to the Taylor Inquiry in which he noted that entrance to the stadium was planned as controlled entry via turnstiles. With a 1 in 6 gradient, the tunnel breached the Green Guide recommendation but, Dr Eastwood noted, 'any alternative arrangement (reversing the slope or even levelling it) would not have led to greater safety'. He addressed the gradient in terms of a mass evacuation rather than mass entry. The 'guidance regarding the slope of ramps is expressly stated to apply to ramps which have a downward slope when being traversed by a heavy crowd flow, that is at the time of leaving the ground not when filling it'. He noted that the 'length of the ramp' was 'relatively short', albeit 'steeper than 1 in 10', but 'when the ground is filling up spectator flow is light, because it is controlled by turnstiles'; thus he 'believe[d] that the ramp is consistent both with the spirit and the letter of the Guide'.

¶Alterations to the turnstiles 2.1.63 As stated in Part 1, the outer concourse on Leppings Lane was severely restricted yet it provided access to all turnstiles for the North Stand, the West Stand and the Leppings Lane terrace. In 1981 SWFC had approached Eastwoods to consider alterations to the Leppings Lane turnstiles. In August 1981 Eastwoods prepared drawings of additional turnstiles but the plans stalled. In 1984 SYP suggested a complete rebuild of the turnstiles. Insp Calvert presented 'a rough sketch that the whole of Leppings Lane turnstiles – then a crescent shape – should be demolished with new ones built parallel to and near rear of stand with access to individual pens and to the stands'.71 Senior SYP officers were consulted before the proposal was presented to SWFC. Dr Eastwood's 1985 proposal included the construction of two new banks of turnstiles (17–21 and 22–29) with new fencing and gates.72 2.1.64 The Bradford fire on 11 May 1985 led to unanticipated work being prioritised at SWFC (the South Stand timber decking and roof).73 In an interview with West Midlands Police in 1990 the Club Secretary, Graham Mackrell, stated that the economic climate at the

Phone memorandum between Mr Strange (Eastwood & Partners) and SYP, 15 March 1988, SYP000096970001, p597.

¶See also letter from Eastwood & Partners to SWFC, 21 March 1988, SYP000096970001, p507. 70. Dr Eastwood's submission to Lord Justice Taylor, supporting documents, SYP000028310001, pp329-341. 71. Recollection of Inspector Calvert, 2 May 1989, SYP000111290001, p4. 72. Letter from Eastwood & Partners to SYCC,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 April 1985, SYP000038710001, p84. 73. Dr Eastwood's submission to Lord Justice Taylor, supporting documents, SYP000028310001, pp348-349.

¶Figure 3: Proposed alterations to the turnstile layout at Leppings Lane, April 1985 Original available at SCC000002050001, p56.

¶time prevented the complete demolition of the turnstiles and a compromise was reached by the addition of a few turnstiles.74 Despite the risk to safety being identified, both Mr Mackrell and C/Supt Mole were confident that, with the few additional turnstiles, the appropriate flow rate of fans into the stadium could be achieved.

¶2.1.65 The possibility of the late arrival of fans was considered, but this was balanced against segregation issues. Reflecting on overcrowding on the Leppings Lane outer concourse at the turnstiles, Mr Mackrell later reflected that it was 'no worse than a lot of other grounds' and he claimed it had never been brought to his attention as a problem by Eastwoods or any other agency. 2.1.66 Despite alterations to the turnstiles, in November 1985 SYP reported to the Officer Working Party on 'the continuing problems caused by the merging of spectators from all parts of the Stadium at the Leppings Lane end'.75 The meeting 'agreed that it was difficult to see how this could be overcome, as the physical restraints to achieve this could conceivably be more of a danger than allowing the present position to continue'.

¶The removal of barrier 144 2.1.67 After a further lateral fence was introduced, creating central pens 3 and 4, the location of an existing terrace crush barrier (barrier 144) became an issue. Because of its location it blocked crowd movement and its partial removal was suggested by SYP during an inspection on 7 August 1986.76 Arthur Butler, Sheffield City Council surveyor, was clear that the partial removal of barrier 144 would alleviate the problem of spectators backing up within the tunnel, that any incoming crush would be seen on the terracing rather than be hidden inside the tunnel, that any problems on the terrace could also be easily seen from the police control box which was relatively near, that the means of escape from the area was excellent from both pens, at that point, due to the existence of the tunnel, and that it was understood that the area of the tunnel mouth would be kept clear throughout the duration of the game by the Police, who in that position could easily monitor and resolve any incidents of overcrowding and localised crushing. 2.1.68 Further, Mr Butler considered that removing part of barrier 144 would increase the load on the barrier lower down the terrace, making it 'necessary for the spectators to be encouraged to spread into the other areas of the pens'. Mr Butler assumed that fans would always enter the terrace through the turnstiles. While mass evacuation was considered, mass admission was not anticipated. During barrier testing in 1988, barrier 144 showed considerable movement and Eastwoods recommended its replacement.77 Following the partial removal of barrier 144 without replacement, there was no adjustment to maximum capacity. Certainly the impact of the removal of parts of barrier 144 on barrier 124A was not foreseen.78 2.1.69 The disclosed documents show that in 1990, when SWFC Secretary Graham Mackrell was interviewed regarding the impact on the terrace of removing parts of barrier 144, he accepted that ground safety was the responsibility of the Club. Yet he admitted

West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp142-146. 75. Letter from SYCC to Eastwood & Partners, 14 November 1985, updating them on a meeting of the Officer Working

¶Party of 13 November 1985, SCC000001960001, pp282-283. 76. Statement of Arthur Butler, Principal District Surveyor with Sheffield City Council, 27 July 1990, SYP000038720001, pp350-352. 77. Letter from Eastwood & Partners to SWFC, 2 August 1988, SYP000096970001, p546. 78. Statement of Arthur Butler, Principal District Surveyor with Sheffield City Council, 27 July 1990, SYP000038720001, that while not being a 'technical expert' he had presumed the potential consequences of removing parts of the barrier had been taken into account.79 The partial removal of barrier 144 materially affected pen 3's capacity and 'its removal made it the more easy for fans coming down the tunnel to spread out into the pen and we believe that its absence did result in a greater flow down the pen'.80

¶2.1.70 In their eventual submission to the Director of Public Prosecutions (DPP) following the disaster, West Midlands Police investigators concluded that at the time of the terrace alterations neither SWFC nor Eastwoods could have foreseen the influx onto the terrace.81

¶Increased capacity and the safety certificate 2.1.71 During its August 1984 inspection of the stadium the Officer Working Party noted 'the numerous alterations to the Stadium since the issue of the General Safety Certificate on 21 December 1979'.82 The Working Party 'agreed that updated plans were required for incorporation into the General Safety Certificate in order to indicate the present facilities at the Stadium'.

¶2.1.72 In 1986 substantial extension and modification to the Spion Kop increased its capacity by 5,981.83 There were three conditions for extending its capacity to 21,000, one of which was 'the provision of extra stewarding to the satisfaction of the Police and Fire Service for the next two matches'.84

¶2.1.73 It was noted that the 'original Safety Certificate has never been formally amended in terms of the additional crowd capacity or need for extra stewarding'. In July 1986 the Club wrote to Eastwoods following a request from the local authority to 'consider the terms and conditions relative to same and express any recommendations we may have for amending the conditions'.85 Eastwoods' reply in September 1986 was minimal, commenting only on provision for people with disabilities and a reference to 'adequate number of police officers'.86

¶2.1.74 Dr Eastwood was aware that alterations to the terraces would impact on capacity yet he did not directly address this issue. In February 1987, John Strange, Dr Eastwood's assistant, queried: 'Has any account been taken for alteration done on Leppings Lane over the last few seasons? Is the 10,200 or so figure still correct? I said that in my opinion it needs to be adjusted, better do it now than later'.87 A record of a subsequent telephone call noted Dr Eastwood's response to 'leave the capacity at Leppings Lane end as it is, providing police have gates under West stand open so that people can distribute throughout the terrace evenly'.88

West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp97-98. 80. Final submission to Lord Justice Taylor on behalf of Treasury Counsel, SYP000098180001, pp18-19. 81. West Midlands Police report to the DPP, SYP000038850001, p123. 82. Minutes of Officer Working Party meeting,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 August 1984, SYP000038710001, p145. 83. See SYP000096970001, pp433-436 for background correspondence on increasing capacity of the Spion Kop, August
1. Original safety certificate – Hillsborough Stadium, A Brief Assessment, June 1989, SYP000027590001, p5. 85. Letter from SWFC to Eastwood & Partners enclosing a copy of the safety certificate,¹⁷¹⁷ December 1997, HOM000030920001, p1. July 1986,

¶SYP000096970001, p432. 86. Letter from Eastwood & Partners to SWFC regarding updating the safety certificate, 10 September 1986,

¶SYP000096970001, pp437-438. 87. Transcript of proceedings in the contribution trial, SYP000098630001, pp13-14. Original internal Eastwood & Partners memorandum, 26 February 1987, SYP000038710001, p104. 88. Phone message from Eastwood & Partners to SWFC, 2 March 1987, SYP000038710001, p105.

¶2.1.75 SWFC Secretary, Graham Mackrell, recalled consulting Mr Strange about the safety certificate because of the alterations since it had been issued: 'I wondered if it had been amended by way of correspondence or whatever'.89 Mr Mackrell's concern was in response to a standard annual communication from the FA requesting updated information on stadium capacity. Eastwoods, responsible for calculating capacities for the original safety certificate, were unconcerned. They replied that 'providing the police had the gates under the West Stand open, so that people can distribute themselves throughout the terraces, there was no problem with the capacities remaining'.

¶2.1.76 Mr Mackrell's concern about capacity related to the stadium as a whole rather than each discrete area. He assumed that the figures and distributions were accurate. His primary motivation was to comply with the FA request, knowing that the information provided would in part determine whether the stadium would be deemed suitable for an FA Cup semi-final. On reflection, Mr Mackrell considered his approach appropriate given involvement in negotiations 'right from day one of the ground being designated'.90

¶Safety inspections 2.1.77 The safety certificate inspections comprised a walk around the stadium with Officer Working Party representatives, particularly Sheffield City Council and Eastwoods, accompanied by SYP officers. Issues were then raised in subsequent letters or reports. According to Mr Mackrell, issues relating to barriers, the elevation of the tunnel or the width of perimeter gates were 'never brought up' nor raised by SYP.91

¶2.1.78 In 1988 the annual safety inspection was moved from August to May 'to give the Club plenty of time to carry out any necessary work that might be required as a condition of issuing the licence'.92 Eastwoods routinely carried out an inspection prior to the Officer Working Party inspection 'to make sure that, so far as we can, it is in first class condition before the Safety Committee inspect. In fact as part of the process the consulting engineers will issue a certificate confirming their inspection, and they are also required to carry out certain tests – for example tests on crush barriers'.

¶2.1.79 Mr Mackrell stated he had no knowledge of concerns regarding capacity following the 1987 or 1988 FA Cup semi-finals. After each match he held informal debriefs with managers and no issues were raised in either year about the terraces.93 Reflecting on these matches he commented later: 'the fact is that the Police after the 87 and 88 semi-final never at all came to me and told me that there were any problems with the way that the, that the actual, the great game had been run for want of a better word'.

¶2.1.80 SWFC retained an annual contract with SYP for policing the stadium on league match days and, according to Mr Mackrell, the Club deferred to the police and their requirements: 'the position is that if the Police with their knowledge of policing matters ask me to cooperate with them in relation to particular matches I will always attempt to do so in every way possible and I would not for example require a detailed explanation from them as in that instance as to why they wished a particular change to be made'.94 An example he gave concerned the change to the kick-off time in 1987 in response to a police request.

West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp46-54. 90. West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, p119. 91. West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp41-42. 92. Graham Mackrell's written statement to Lord Justice Taylor, 26 June 1989, SYP000096840001, p407. 93. West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp74-80. 94. Graham Mackrell's written statement to Lord Justice Taylor, 26 June 1989, SYP000096840001, p408.

¶2.1.81 At a meeting with their legal counsel soon after the 1989 disaster, SYP noted the difficulties regarding the administration of the safety certificate.95 Deputy Chief Constable Peter Hayes stated: 'Chief Superintendent Denton tells me that we wrote to the new Sheffield City Council about this Safety Certificate. We received a reply and Mr Denton referred them to a specimen of the certificate that they may wish to use in drawing up their new certificate'. The certificate that emerged, however, 'had been diluted in many areas, including the section which deals with the policing of the ground'. C/Supt Mole responded: 'It seems we [SYP] have been ruled out of the safety considerations'.

¶2.1.82 The safety certificate was not updated after the introduction of the two radial fences in late 1981 and the radial fence from the middle of the tunnel in 1985 (creating pens 3 and 4).96

¶Hillsborough as an FA Cup semi-final venue 2.1.83 In 1987 discussions were held to consider Hillsborough's reinstatement as an FA Cup semi-final venue. Months earlier Sheffield City Council had invited SYP, the Fire Service and the building surveyor to comment on the condition of the stadium.97 In January 1987 SYP informed the City Council that 'both stadia [including Sheffield United], so far as the police are concerned, meet our requirements under the 1975 regulation'.98 Sheffield City Council wrote to SWFC stating that the police 'are quite satisfied with the stadium and have indicated that the degree of cooperation which they receive is very satisfactory'.99 The building surveyor did not comment but the Fire Service was not satisfied and raised its concerns with the City Council in February 1987. These focused on whether regular inspections, and compliance with certification, were carried out effectively. The Fire Service presented five pages of concerns regarding safety and evacuation procedures that required attention, including the need to install more effective release devices on the perimeter gates. 2.1.84 There was some discussion between Eastwoods and the Fire Service about the provision of a ramp to meet the requirements for the disabled. Initially SWFC and Eastwoods appear to have ignored the issues raised by the Fire Service and were pressed for a response by Sheffield County Council.100 SWFC's eventual response suggested that the Fire Service was overly critical and that some of the requirements were excessive.

¶Safety inspections 2.1.85 Arthur Butler, the City Council's Building Surveyor, was requested to report on whether the stadium complied with the Safety of Sports Grounds Act 1975. He stated that a full survey would be 'a long and time consuming job which should not be approached in anything other than a thorough manner'.101 2.1.86 In 1987 the annual inspection took place in August.102 Following the inspection, the Director of Health and Consumer Services raised 'minor' concerns and referred to SWFC's agreement to appoint a safety officer of 'adequate status and authority'.103 It concluded:

Minutes of meeting with Counsel, 26 April 1989, SYP000096360001, p97. 96. Report to the DPP Part 1 – Ground Staff,²⁰²⁰ April 1989, HOM000016460001, pp1-5. April 1990, SYP000038670001, p11. 97. Letter from Sheffield City Council to SWFC, 22 April 1987, SYP000038710001, pp107-108. 98. Letter from SYP to Sheffield City Council, 6 January 1987, SYP000028310001, p586. 99. Letter from Sheffield City Council to SWFC, 22 April 1987, SYP000038710001, p107. 100. Letter from Sheffield City Council to Graham Mackrell,⁴⁴ March 1988, SYP000096970001, p600. December 1987, SYP000096960001, p433. 101. Memorandum from Arthur Butler to David Bownes, Head of Administration and Legal Department, Sheffield City

¶Council,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. June 1987, SYP000096960001, p389. 102. Letter from Chief Fire Officer to Sheffield City Council, 13 August 1987, SYP000096960001, pp412-413. 103. Internal memorandum from D Moore, Director of Health and Consumer Services, to David Bownes, Head of

¶Administration and Legal Department, Sheffield City Council, 18 August 1987, SYP000096960001, pp414-415.

¶'During the inspection ... it became obvious that the stands and associated areas are subject to excellent standards of maintenance and upkeep ... I was suitably impressed with the level of ground management being maintained'. 2.1.87 In October 1987 Sheffield City Council wrote to SWFC drawing attention to the publication of the Popplewell Report and requesting written confirmation that the Club had obtained and would keep at the ground a copy of the Green Guide; that the Club and its officers were familiar with the Guide and intended to carry out management responsibilities accordingly; and that they would appoint a safety officer without delay.104

¶2.1.88 Mr Mackrell replied, confirming that the Club had received a copy of the Guide and that his role incorporated the function of safety officer.105 Yet it was unclear how safety issues concerning building works and maintenance were handled at the Club. The security officer, Doug Lock (previously a senior SYP officer who had assisted C/Supt Mole in the Police Control Box), was also involved with maintenance connected to the safety certificate but expenditure had to be referred to Mr Mackrell who was also safety officer. An SWFC director, Keith Addy, sometimes dealt with proposals for works with Eastwoods. On other occasions 'we relied on our consulting engineers' – Eastwoods.106 The relationship with Eastwoods was reactive rather than proactive. 2.1.89 On 14 November 1987 emergency evacuation procedures were practised under operational conditions. This led to the discovery that the public address system was inaudible and required upgrading.107

¶Concerns about stewarding 2.1.90 Early in 1988 a member of the City Council's Building Surveyors' staff attended a match. He expressed concerns about the lack of effective stewarding on the Spion Kop which had resulted in the crowd occupying radial gangways and other areas throughout the match. He stated: 'stewarding must be of a quality and of such numbers as to maintain these gangways free from congestion during performances'. 2.1.91 There was also reference to the turnstile capacity at Penistone Road, the opposite end of the stadium to Leppings Lane, as 'many of the spectators were still entering the ground up to 15 minutes after kick-off'. He was concerned that the 'combination of late arrival and ineffective stewarding could lead to dangerous occurrences ... a matter that should be raised at the next meeting of the Working Party so that the police and fire authority comments may be sought'.108

¶The 1987 FA Cup Semi-Final 2.1.92 The first FA Cup semi-final to be played at Hillsborough since 1981 was held on 12 April 1987, between Coventry City and Leeds United. Kick-off was scheduled for 12.15pm with access to the stadium from 9.30am. The day (Sunday) and the earlier kick-off time were intended to prevent fans' alcohol consumption before the match.109 The FA all-ticket ruling

Letter from Sheffield City Council to Sheffield Wednesday Football Club, 15 October 1987, SYP000096960001, p423. 105. Letter from Graham Mackrell to Sheffield City Council, 23 October 1987, SYP000096960001, p424. 106. West Midlands Police interview with Graham Mackrell, 22 June 1990, SYP000038890001, pp20-30. 107. Letter from SYP to Graham Mackrell,⁴⁴ March 1988, SYP000096970001, p600. December 1987, SYP000046570001, p381. 108. Memorandum from Arthur Butler to David Bownes, Head of Administration and Legal Department, Sheffield City

¶Council, 2 February 1988, SYP000096960001, p436. 109. SYP Operational Order for the 1987 FA Cup Semi-Final, 1 April 1987, SYP000097650001.

¶on all Leeds away games was lifted for the Semi-Final and tickets were on open sale. It was judged that the early kick-off would assist with policing.110 2.1.93 The pre-match briefing took place on 20 March and involved SYP, the participating clubs and SWFC, represented by Graham Mackrell, the Club Secretary. A total of 51,372 supporters attended the game.111 Leeds fans were allocated the Leppings Lane terrace and Coventry fans were allocated to the Spion Kop. C/Supt Mole was the Match Commander. Assistant Chief Constable Walter Jackson assumed overall control of planning and operational policing. He attended the 1987 match in uniform 'because it was a Leeds– Coventry match and at that time Leeds had a bad reputation'.112

¶2.1.94 There were plans in place for monitoring the Spion Kop's capacity and, according to the Operational Order, the police, not the stewards, assumed this responsibility: 'In the event of parts of the Spion Kop terraces becoming crowded to capacity these Officers will close the approach ramps and direct fans to appropriate entrances where access may be gained to the terraces'.113 There was no equivalent reference to monitoring crowd capacity in the Leppings Lane terrace.

¶2.1.95 The SYP/SWFC relationship had been poor following the 1981 incident but by 1987 it had improved. A letter from Sheffield City Council to SWFC, dated 22 April 1987, reflected the improved working relationship: 'The Police have indicated that as at 6th January, 1987 they are quite satisfied with the stadium and have indicated that the degree of co-operation which they receive is very satisfactory'.114

¶1987: delayed kick-off 2.1.96 The 1987 Semi-Final kick-off was delayed. Vehicles leaving the motorway intersection were checked by the police, slowing the traffic. Both groups of supporters were affected by the delays. Shortly before kick-off the police decided to delay the match by 15 minutes to ensure that arriving fans could be accommodated. The decision was announced over the public address system.

¶2.1.97 C/Supt Mole, the Match Commander, accepted that the delay was partly caused by police operations yet within SYP was a broadly held assumption that some fans chose to arrive late. A 1987 document presented to the Taylor Inquiry within the Association of Chief Police Officers' submission noted that delayed kick-offs were 'another situation where supporters were seen to be forcing the police into taking action against their better judgement'.115 The document stated that it had 'become increasingly apparent that large numbers of spectators are arriving extremely late at the ground, this may be related to the restricted access to alcohol in grounds and the prohibition on taking alcohol into grounds'. Consequently, to avoid disorder, 'police ground commanders have occasionally requested that the kick-off be delayed' but 'this pressure should not be acceded to in future, the police should not be dictated to by supporters'.

Daily Mail journalist David Walker in evidence to Lord Justice Taylor, HOM000026140001, p61. 111. Internal SYP memorandum from PC Rosevear (Football Liaison Section) to Chief Superintendent Mole, 13 September

¶1990, SYC000001360001, p3. 112. West Midlands Police interview with ACC Walter Jackson, 28 June 1990, SYP000038910001, p13. 113. SYP Operational Order 'F' for the 1987 FA Cup Semi-Final, SYP000097650001, p24. 114. Letter from Sheffield City Council to SWFC, 22 April 1987, SYP000038710001, p107. 115. Association of Chief Police Officers' submission to Lord Justice Taylor, Appendix D: 'Notes of the meeting of second division football league police commanders and liaison officers held at Greater Manchester Police Training School on

¶Thursday/Friday 28th/29th May 1987, 27 June 1989', written by Mr J David Phillips, SYP000038690001, p164.

¶2.1.98 The issue of delay was investigated further in 1989 at the Taylor Inquiry. C/Supt Mole was questioned about whether the reason for delaying the kick-off was relevant to the decision. He confirmed that the reason was irrelevant, the key concern being processing fans through the turnstiles.116 Other factors to be considered in the decision to delay included whether or not the players were on the field and the attitude of the fans in the stadium to the prospect of a delay.

¶1987: an experience at the turnstiles and the tunnel 2.1.99 Reflecting on the 1987 Semi-Final, Ferenc Morath, a Leeds United fan, recalled that his ticket was checked by police before he disembarked from the coach and was checked again as he approached the ground. At the turnstiles there was 'just a mass of people outside, with no orderly queues being formed'.117 Police officers were on foot and on horseback. By the time he entered the stadium the match had started, 'there was no direction being given by police officers or stewards inside the ground and everyone like myself headed for the tunnel under the West Stand'. He continued:

¶As I entered the tunnel I noted that the crowd was back up the tunnel. I believed this was the only way onto the terraces, not having seen any other signs directing otherwise. I therefore, pushed my way through the tunnel not knowing what was ahead of me. I noted that people, generally fathers with young lads or girls, were pushing back out of the tunnel, away from the pitch. At this point there was what I would describe as a bad crush.

¶2.1.100 The crowd was tightly packed and he was unable to clap his hands. He saw fans climbing the fencing and others helped up into the West Stand. For the second half he left the central pen and moved to pen 7. He concluded that 'outside the turnstiles and inside the ground there was a total lack of organisation'. Events in 1987 are discussed further in Chapter 3 from paragraph 2.3.31.

¶1987: debrief 2.1.101 According to C/Supt Mole, the 1987 debrief did not mention overcrowding or crushing.118 A post-match summary form had been introduced during the 1980s to inform the national football liaison officer network. A subsequent report in October 1989 noted that the content and quality of post-match reports fell far short of what was anticipated. The report made specific reference to the delayed 1987 match noting 'the fact that the kick off was delayed and the reasons leading to the delay were not recorded in the post match summary report'.119

¶The 1988 FA Cup Semi-Final 2.1.102 The 1988 FA Cup Semi-Final between Liverpool and Nottingham Forest was played at Hillsborough on 9 April 1988. The pre-match briefing was held on 23 March 1988 involving SYP, the participating clubs and SWFC. SYP also met with the South Yorkshire Metropolitan Ambulance Service (SYMAS).120 A total of 51,622 supporters attended the 116. Transcript of Chief Superintendent Mole's evidence to Lord Justice Taylor, day 6, 23 May 1989, SWF000002030001, pp52-53. 117. Statement of Leeds United supporter Ferenc Morath, 12 May 1989, SYP000038700001, pp87-89. 118. Statement of Chief Superintendent Mole, 26 April 1990, SYP000038700001, p191. 119. 'Review of National and Local Arrangements to deal with football related intelligence/information' by Superintendent

¶Brookfield, October 1989, SYP000097020001, p51. 120. Inspector Sewell's evidence to Lord Justice Taylor, SYP000123550001, p5.

¶match.121 Early in 1988 a meeting of Sheffield City Council Safety of Sports Grounds Advisory Group had identified a trend in latecomers to matches, noting 'a pattern has developed of people arriving some 15 minutes before the start of the game hoping to gain admission'.122

¶2.1.103 Interviewed by the DPP in 1990, Superintendent Bernard Murray (who was assistant to the Match Commander in 1988 and 1989) stated that during C/Supt Mole's briefing for the 1988 match he did not mention that there had been overcrowding in 1987.123

¶2.1.104 On 9 August 1988 a meeting was held at Hammerton Road Police Station between SYP and the fire and ambulance services to consider the emergency response to a major disaster at SWFC. The meeting was chaired by Supt Murray and attended by Superintendent Roger Marshall, Chief Inspector David Beal and Inspector Steven Sewell, Deputy Chief Ambulance Officer Alan Hopkins and Assistant Chief Ambulance Officer (Operations) Jones, SYMAS and Assistant Divisional Officer Rowlands of the South Yorkshire Fire Service. 2.1.105 It was noted that a senior ambulance officer attended all home matches at Hillsborough and was allocated a complimentary ticket for the South Stand. Insp Sewell commented that while the North Stand offered better access to the gymnasium, 'Sheffield Wednesday Football Club only wish to allocate the complimentary tickets to the ambulance service for use in the South Stand, so that the club physio, Alan Smith, can signal straight away to the ambulance officer if an ambulance is required for a Wednesday player'.124 This view was not shared by SYMAS, who regarded the presence of liaison officers as important in the event of a major incident and not only to treat players who might be injured.

¶1988: fans' experience of crushing 2.1.106 In correspondence written after the 1989 disaster it became clear that fans had experienced crushing on the Leppings Lane terrace in 1988. One fan wrote to the Football Association outlining the full extent of his experience of congestion, beginning in the tunnel feeding the central pens. Once out of the tunnel, 'if anything the situation became worse and the pressure behind became worse, causing many fans to stumble and fall down the steps only to disappear under the crowd'. 2.1.107 His letter continued:

¶… it was impossible to move sideways as the momentum of the crowd continued to push us forward. We were forced to duck under metal barriers or suffer even more crushing. Finally we were forced right up against the barriers which prevent the fans from getting on to the pitch. During the match we had to constantly bear the crushing force of the crowd swaying forward from behind. It would not have been so bad if we had been able to move sideways, away from this central part, but it was so packed, and the constant pushing, jostling and surging of the fans made this prospect appear even more dangerous.

¶During the game some fans actually collapsed or fainted and were passed over peoples [sic] heads towards the front of this section of the ground …

Internal SYP memorandum from PC Rosevear (Football Liaison Section) to Chief Superintendent Mole, 13 September

¶1990, SYC000001360001, p3. 122. Minutes of Safety of Sports Grounds Advisory Group, 23 March 1988, SYP000038710001, p166. 123. West Midlands Police interview with Superintendent Murray, 25 June 1990, SYP000038900001, pp15-21. 124. Memorandum from Inspector Sewell to Chief Superintendent of 'F' Division,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 August 1988, SYP000047780001, p273.

¶Some fans tried to open this gate but it had been padlocked. Some fans attracted the attention of a policeman or steward, I can't remember which, but he appeared to be totally unaware of the situation …

¶During the whole of this game we were very concerned for the safety of our youngsters but the police were only allowing injured fans through the gate. After the match finished we all vowed never to enter the Leppings Lane end ever again.

¶As far as I am concerned, when there is a large crowd entering this part of the ground, it will always be a death trap.125 2.1.108 Other fans also referred to problems in 1988 in their statements to West Midlands Police: 'I have been to this ground several times and have been into the central pens before and it has always been uncomfortable. Last year I climbed over the fencing and went to the terrace near to the North Stand'.126 2.1.109 In the immediate aftermath of the 1988 Semi-Final, a fan wrote to the Minister for Sport and the FA. Unfortunately, his letter to the Minister for Sport was sent to an incorrect address and never arrived. He received no reply from the FA. When asked in 1989, the FA could not trace a record of having received his letter. He wrote that:

¶I attended the above football match on Saturday April 9th 1988, and write to protest in the strongest possible terms at the disgraceful overcrowding that was allowed to occur (in an all ticket match) in the Leppings Lane Terrace area …

¶The whole area was packed solid to the point where it was impossible to move and where I, and others around me, felt considerable concern for personal safety (as a result of the crush an umbrella I was holding in my hand was snapped in half against the crush barrier in front of me). I would emphasise that the concern over safety related to the sheer numbers admitted, and not to crowd behaviour which was good.

¶My concern over safety was such (at times it was impossible to breathe) that at half time when there was movement for toilets, refreshments etc. I managed to extricate myself from the terrace, having taken the view that my personal safety was more important than watching the second half.127

¶Debriefing: who knew what after the 1988 Semi-Final? 2.1.110 The 1988 Semi-Final was considered a success.128 Retrospective evidence from a police officer on duty at the Leppings Lane turnstiles suggested there were no serious public order problems.129 According to SWFC 'everything went extremely smoothly'.130 C/Supt Mole stated that the 1987 and 1988 debriefing sessions made no mention of any injuries due to overcrowding or crushing.131

Letter to the Football Association,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, FFA000003180001. 126. Statement from Liverpool fan,¹⁷¹⁷ December 1997, HOM000030920001, p1. May 1989, SYP000069080001. 127. Letter from Liverpool fan, 13 April 1988, HOM000028660001, p4. Internal FA note, 'Surely someone must have filed it somewhere', 15 May 1989, FFA000004940001. 128. The police operation and the experience of spectators is discussed further in Chapter 3, at paragraphs 2.3.35, 2.3.45 and from paragraph 2.3.102. 129. Statement of PC Ian Selwood, 29 April 1989, SYP000038800001, p39. 130. Statement of Graham Mackrell, 19 May 1989, SYP000038670001, p80. 131. Statement of Chief Superintendent Mole, 26 April 1990, SYP000038700001, pp190-193.

¶2.1.111 Thus C/Supt Mole's planning for the 1989 Semi-Final was based on the previous year's operation. He claimed that the only changes were the removal of air cover and the removal of a serial of police officers from the Leppings Lane concourse area. Yet according to Supt Murray, Mole also requested SWFC to reconsider the colour and presentation of tickets to avoid problems at the turnstiles.132

¶2.1.112 The ACC responsible for operations, Walter Jackson, was in overall control of planning and operational policing for the 1988 Semi-Final. He did not attend but, interviewed by the DPP in 1990, he recalled receiving reports following the match indicating the occurrence of a 'minor pitch invasion' at the end of the match which had been handled quickly and efficiently.133 Overall, he continued, it had been 'a fairly joyous occasion' and he was not aware of crushing or overcrowding in 1987 or 1988.

¶2.1.113 In his 1988 debrief Supt Murray informed C/Supt Mole that 'we have noted locally the lessons that were learned and the improvements that can be made for any similar future event. Generally I was well satisfied with the event'.134 In his debrief, Sergeant Hoyland informed C/Supt Herold that 'generally the operation went well and was certainly an improvement on last year's operation'.135 A lesson learned from 1988 related to traffic and the need to have contingency planning for tailbacks in 1989.136

¶2.1.114 Supt Marshall could not remember a debrief in 1988 and, interviewed in 1990, he indicated initially that he had not held a debrief with his inspectors. Later, however, he stated that inspectors produced a written debrief and C/Supt Mole 'would always have a debrief after a game'.137 He concluded that he may have been off duty when a debrief was held or he may have been absent. Regarding overcrowding and crushing, Supt Marshall stated he was unaware of injuries on the terraces and concluded 'there is obviously the possibility that injured people had gone off themselves and gone to hospital'.

¶2.1.115 In their submission to the Taylor Inquiry SYP referred to the 1988 debrief.138 They noted that 'some resources', meaning police officers, were 'under employed in and around the ground, particularly in peripheral areas', mainly as a consequence 'of the general change in policy for policing semi-finals in that during normal matches officers are used for more than one role and are moved to different locations during the various phases of the match'.

¶2.1.116 At semi-finals 'officers would be allocated a specific task and would remain with that task throughout the operation, the intention being to ensure that the police had control both inside and outside the ground throughout the operation in an effort to thwart those individuals intent on causing disorder or attempting to enter the ground without tickets'.

¶2.1.117 This statement makes the first mention of policing 'anticipated roaming gangs of disappointed supporters causing disorder during the match'. Despite this unsubstantiated claim, 'the levels of officers available was found to be excessive, particularly at the Liverpool end of the Stadium where this type of activity had been expected as a consequence of their reputation and considerable following of supporters'.

West Midlands Police interview with Superintendent Murray, 25 June 1990, SYP000038900001, pp41-43. 133. West Midlands Police interview with ACC Jackson, 28 June 1990, SYP000038910001, pp14-16. 134. Superintendent Murray debrief for 1988 Semi-Final to Chief Superintendent Mole, 14 May 1988, SYP000047780001, p277. 135. Three-page debrief on 1988 match from Operations Room duty Sergeant to C/Supt Herold, 11 April 1988,

¶SYP000047780001, pp278-280. 136. Internal police minute from C/Supt for Operations and Traffic to ACC for Operations, 26 April 1988, 137. West Midlands Police interview with Superintendent Roger Marshall, 19 June 1990, SYP000038880001, pp16-21. 138. SYP submission to Lord Justice Taylor, SYP000047780001, pp362-363.

¶2.1.118 Evidence from fans and police officers identified overcrowding in 1988. The level of knowledge within SYP and the steps taken to manage the crowd are discussed in detail in Chapter 3. There is no confirmation that SWFC directors were aware of overcrowding and crushing in 1988. According to Mr Mackrell, the SWFC Club Secretary, 'everything went extremely smoothly and indeed I have referred to the file I kept for that fixture and the records indicate that we had comparatively little by way of damage to the ground afterwards'.139

¶Conclusion: what is added to public understanding • In 1981 before the FA Cup Semi-Final between Tottenham Hotspur and Wolverhampton

¶Wanderers there was serious congestion at the Leppings Lane turnstiles and crushing on the confined outer concourse. It resulted in the opening of exit Gate C to relieve the crush.

¶The disclosed documents indicate that entry into the stadium was managed by South

¶Yorkshire Police (SYP) officers on duty and Sheffield Wednesday Football Club (SWFC) stewards. • What followed was a serious crush on the terraces in which many people were injured and fatalities narrowly avoided. At that time lateral fences did not divide the Leppings

¶Lane terrace into pens, and fans were able to move sideways along the full length of the terrace; others escaped onto the perimeter track through the narrow gates in the perimeter fence. • The disclosed documents show that police officers located on the inner concourse, between the turnstiles and the rear of the terrace, restricted access to the central tunnel under the West Stand, diverting fans to the side access points to the terrace, thus relieving pressure at the centre. Crowd density figures available to the Panel demonstrate that the maximum capacity for the terrace was significantly exceeded. • The disclosed documents demonstrate that, following the 1981 incident, there was a breakdown in the relationship between SWFC and SYP. SWFC refused to accept the seriousness of the incident and held SYP responsible for the mismanagement of the crowd. SYP considered that the maximum capacity for the Leppings Lane terrace, set at 10,100, was too high, a view strongly contested by SWFC. • On the recommendation of SYP the construction of lateral fences in 1981 created three pens, with movement between pens limited to a small gate at the head of each lateral fence. According to SYP these gates were used to manage segregation at league matches but were not 'stewarded' by the police. • From the earliest safety assessments made by safety engineers commissioned in 1978 by SWFC, it was apparent that the stadium failed to meet minimum standards under the Safety of Sports Grounds Act 1975 and established in the Guide to Safety at Sports

¶Grounds (known as the 'Green Guide'), 1976. Documents released to the Panel confirm that the local Advisory Group for Safety at Sports Grounds carried out inadequate and poorly recorded inspections. There is clear evidence that SWFC's primary consideration was cost and, to an extent, this was shared by its primary safety consultants, Eastwood

¶& Partners. • Following the near tragedy in 1981, Hillsborough was not used for FA Cup semi-finals until 1987. During this period the Leppings Lane terrace underwent a series of significant modifications and alterations, none of which led to a revised safety certificate. The

Statement of Graham Mackrell, 19 May 1989, SYP000038670001, p80.

¶introduction of further lateral fences created two central pens accessed via the tunnel beneath the West Stand. Recommendations to feed fans directly from designated turnstiles into each pen, thus monitoring precisely the distribution of fans between the pens, were not acted on because of anticipated costs to SWFC. • Consequently, the turnstile counters were rendered irrelevant. Although they provided a check on the overall numbers entering the terrace, there was no information regarding crowd distribution between pens, each of which had an established maximum capacity. • It is evident from the disclosed documents that SYP were preoccupied with crowd management, segregation and regulation to prevent potential disorder. SWFC's primary concern was to limit costs. The Fire Service, however, raised concerns about provision for emergency evacuation of the terraces. As the only means of escaping forwards was onto the pitch, concern was raised specifically about the width of the perimeter fence gates which was well below the standard recommended by the Green Guide. The gradient of the tunnel under the West Stand leading down onto the terrace also significantly breached the Green Guide's recommendation. • While modifications were made inside the stadium, the issue of congested access to the turnstiles outside the stadium remained unresolved. As Lord Justice Taylor's Interim

¶Report noted, of the stadium's 54,000 capacity, over 24,000 fans were channelled through

¶23 turnstiles feeding the North Stand, the West Stand and the Leppings Lane terrace. • Following alterations, the safety of the existing maximum capacity for the Leppings Lane terrace was questioned repeatedly yet the decision was taken by the Club and the safety engineers not to revise the figure. • From the documents disclosed to the Panel, key issues – positioning of safety barriers, elevation of the tunnel, adequacy of the perimeter fence gates – were not discussed or recorded at the annual safety inspections. Following the delayed kick-off at the

¶1987 FA Cup Semi-Final and the crushing at the 1988 FA Cup Semi-Final, it is evident that debriefings held by all parties were inadequate. Crucial information arising from these events was not shared within SYP, nor was it exchanged between SYP and other agencies. There is no record provided by SWFC of debriefings held between Club stewards and their managers. The Club denied knowledge of any crowd-related concerns arising from the 1987 or 1988 FA Cup Semi-Finals.

¶The 'moment' of 1989

¶2.2.1 Part 1 of this Report establishes the recent historical context to the 1989 Semi-Final at Hillsborough, coincidentally a repeat of the previous year's match between Liverpool and Nottingham Forest.

¶2.2.2 The strong assertion made in previous reports and analyses that the period from the near tragedy of 1981 on the Leppings Lane terrace to the 1989 disaster was infected by institutional complacency regarding crowd safety is affirmed by the documents disclosed to the Panel and reviewed in the previous chapter.

¶2.2.3 The decision by the Football Association (FA) to hire Hillsborough Stadium for a semi-final for a third consecutive year was, in itself, a demonstration of confidence in the facility, its management and its policing. Further, it confirmed that in the professional judgements of all agencies concerned the stadium and its operation was once again 'fit for purpose' following a five-year absence from the FA's roster of semi-final venues.

¶2.2.4 Issues of concern, not least the chilled relationship between Sheffield Wednesday Football Club (SWFC) and South Yorkshire Police (SYP) but also negotiations about stadium safety and alterations, had not been made public.

¶2.2.5 Relying on limited documentary disclosure, the previous chapter reveals the focuses of these concerns. Significantly, given the controversy about safety, stewarding and policing after the ill-fated 1981 Semi-Final, the not dissimilar problems that occurred in 1987 and 1988 apparently were not debriefed and nor were they recorded.

¶2.2.6 In retrospect, as the previous chapter demonstrates, taken alongside the near tragedy of 1981, the 1987 and 1988 events provided, at minimum, a clear warning of potential dangers on the concourse outside the Leppings Lane end, at the turnstiles, in the tunnel approach to the central pens and on terraces confined by perimeter and radial fences.

¶2.2.7 Despite this, the FA had been reassured by SWFC and by SYP that the previous semi-finals had been successful, had passed without problems, and that the 1989 Semi- Final could operate as a rerun of the 1988 match. This was reinforced when it transpired that the same two clubs were involved.

¶2.2.8 Yet there was one significant difference regarding policing. Chief Superintendent Brian Mole, Hillsborough's most senior and experienced match commander, was transferred from the local police division in highly controversial circumstances.1 He was replaced by Chief Superintendent David Duckenfield 21 days before the Semi-Final. No further information on this sequence of events has been made available to the Panel but, as this chapter shows, it was a significant development. Based on the documents disclosed to the Panel, what follows considers the immediate context, circumstances and aftermath of the disaster.

¶The 1989 FA Cup Semi-Final 2.2.9 According to Graham Mackrell, the SWFC Secretary, there was no inter-agency pre-match briefing before the 1989 Semi-Final. His understanding was that SYP 'felt one was not necessary as the game involved effectively an action reply [sic] of the year before'.2

¶2.2.10 Mr Mackrell's recollection conflicts with SYP's liaison officer, Inspector Steven Sewell, who recalled a planning meeting held on 22 March 1989 attended by 'various people' concerned 'with the police operation'. However, neither the South Yorkshire Metropolitan Ambulance Service nor the Fire Service, was invited.3

¶2.2.11 The notes of this meeting could not be traced when requested by Counsel for SYP.4 According to C/Supt Mole, while there was no meeting with the FA the 1988 arrangements were confirmed for 1989 by telephone.5

¶2.2.12 The Match Commander in 1989 was C/Supt Duckenfield. As in 1988, SYP's Assistant Chief Constable for Operations, Walter Jackson, assumed overall control of planning and operational policing on the day.

¶2.2.13 Interviewed by West Midlands Police (WMP) for a report to the Director of Public Prosecutions (DPP), he stated that as Match Commander C/Supt Mole's 'kind of community policing' strategy was to try 'to get the same … people at the same place all the time, and so he did that and he used a lot of his, community bobbies, so that they were at the same place, would identify the people concerned, so that if there were any particular problems … they could identify them quickly'. ACC Jackson stated that 'it was good practice, and ... we always shared it with everyone else'.6

¶2.2.14 As stated above, C/Supt Duckenfield replaced C/Supt Mole 21 days before the match. According to ACC Jackson, C/Supt Mole was not asked to police the match. C/Supt Duckenfield was an experienced divisional commander who would be supported by C/Supt Mole's established team.

¶2.2.15 However, C/Supt Duckenfield had not worked at Hillsborough for ten years.7 Because the change of command happened within a month of the Semi-Final, C/Supt Mole initiated the planning with C/Supt Duckenfield involved from the first meeting.

Phil Scraton (2009) Hillsborough: The Truth Edinburgh: Mainstream, pp18-20. 2. Statement of Graham Mackrell, 19 May 1989, SYP000038670001, p79. 3. Inspector Sewell's evidence to the Taylor Inquiry, SYP000123550001, p5. 4. Letter from ACC Anderson, SYP, to Hammond Suddards, 5 May 1989, SYP000097360001, p2. 5. Note of internal SYP meeting to discuss 'Proof of Evidence' for the Taylor Inquiry, 26 April 1989, SYP000097190001, p4. 6. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p61. 7. Final submission to the Hillsborough Inquiry on Behalf of the Treasury Counsel, SYP000098180001, p20.

¶2.2.16 The detailed planning was processed by the same SYP team as 1988 overseen by Superintendent Bernard Murray who, as second-in-command, liaised with C/Supt Duckenfield. Reflecting on C/Supt Duckenfield's new role, ACC Jackson considered that the 'open and frank policy' which he operated in SYP would have allowed C/Supt Duckenfield to make known his reservations about policing the match.8 2.2.17 During his interview for the eventual criminal investigation into the disaster, Supt Murray observed that C/Supt Duckenfield and C/Supt Mole exhibited contrasting leadership styles. Whereas C/Supt Mole operated on the ground and was mobile within the stadium, remaining in radio contact with the Police Control Room, Supt Murray stated that C/Supt Duckenfield viewed his role as supervising the policing of the stadium from the Control Room.9

¶Pre-match briefings 2.2.18 C/Supt Duckenfield briefed senior officers the day before the match, his notes emphasising public order and crowd safety. They contained no reference to crowd safety issues from the previous year. He emphasised that as it was an all-ticket match, 'if supporters do not have a ticket then whatever they say they will not be allowed into the ground' as 'safety limits' had to be protected.10 2.2.19 He noted that the 'stadium has been divided to ensure maximum segregation and to reduce any possibility of public disorder'. As it would be 'full to capacity' and some officers 'may never have experienced a football match of this nature' the priority was 'to ensure the safety of spectators and you must make sure you know the escape routes and that you are fully conversant with your responsibilities should a crisis arise'. He stated: 'I cannot stress too highly the word "Safety"'. 2.2.20 Superintendent Roger Greenwood was Ground Commander inside the stadium and raised the issue of overcrowding, specifically because there was concern to avoid a situation in which Liverpool fans who gained tickets for the Spion Kop would be transferred to the Leppings Lane terrace, thus repeating the events of 1981. 2.2.21 He briefed Inspectors under his command not to transfer Liverpool supporters from the Spion Kop to the Leppings Lane terrace, contrary to the instructions in the Operational Order. His briefing concentrated on public order problems: 'the question of supporters from the Leppings Lane terrace being hauled up by fellow supporters into the West Stand [seated area] at half time thus creating over capacity in the West Stand'.11 2.2.22 Further, given the experience of the 1988 Semi-Final, 'it was quite foreseeable that there would be a large element of Liverpool supporters who by whatsoever means would be purchasing tickets for the Spion Kop'. This 'problem had been evident last year and … cordoning Police officers had come under threat to personal safety'. 2.2.23 He advised that 'generally speaking if things are going well for Liverpool supporters crowd management should be reasonably well achieved, however should things in any way not go well [with] them then they had proved extremely difficult to contain and moods would easily change'.

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p66. 9. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp53-54. 10. Chief Superintendent Duckenfield's briefing notes for the 1989 FA Cup Semi-Final, 14 April 1989, SYP000038820001, pp318-323. 11. Notes of Superintendent Greenwood's briefing on 14 April 1989, document dated 20 April 1989, SYP000010690001,

Chapter 2 The 'moment' of 1989 — 89

¶2.2.24 Reflecting on an incident at a Sheffield Wednesday v Liverpool league match, Sheffield Wednesday supporters had been transferred to the Leppings Lane terrace where 'Liverpool supporters went wild attempting to scale the fencing in an attempt to get to the Sheffield Wednesday supporters. It was necessary for some officers to draw truncheons to contain the Liverpool supporters'.

¶2.2.25 Interviewed by WMP for a report to the DPP a year after the disaster, Supt Greenwood stated that from experience he expected crowd distribution to be monitored by officers in the Police Control Box 'visually and with screens'.12 His recollection that at the briefings he made specific references to 1981 was confirmed by SYP officers Inspector Gordon Sykes and Inspector Graham Delaney.13

¶2.2.26 Superintendent Roger Marshall was Ground Commander outside the Leppings Lane end of the stadium. His briefing focused on public order rather than safety. While C/Supt Duckenfield had, as stated above, included safety in his briefing Supt Marshall's mindset was influenced by the events of 1988.

¶2.2.27 Interviewed a year after Hillsborough by WMP for a report to the DPP, Supt Marshall recorded his 'fairly jaundiced view of football supporters', noting 'incidents that had taken place in 1988 ... that I found disturbing and distasteful, for instance there was a fight and a stabbing which took place in Hillsborough Park ... and there was some shoplifting which took place down in the precinct and generally the reputation of, of Liverpool fans left a lot to be desired in my view'.14

¶2.2.28 Focusing on alcohol and disorder, Supt Marshall stated he was aware of the late arrival of Liverpool fans but understood it within the context that 'one associates football matches with, with heavy drinking and that was precisely what was taking place'.15

¶2.2.29 He took no action to encourage fans to move quickly into the stadium because he considered that this would have had a deleterious effect on their mood and behaviour. He considered that crowd congestion in the concourse outside the Leppings Lane turnstiles was due to non-ticket holders and poor intelligence from Merseyside Police.16

¶The Operational Order 2.2.30 The 1989 Operational Order replicated the 1988 Order. Given the format, wording, postings and spelling errors it was a redraft with few changes. The most significant difference was a 19 per cent reduction in manpower and the exchange of roles between Supt Marshall and Supt Greenwood (in 1988 Supt Marshall had been Ground Commander and Supt Greenwood had been responsible for the police operation outside the stadium in Leppings Lane).17

West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, p22. 13. Statement of Inspector Gordon Sykes, 18 July 1990, SYP000038800001, pp248-250. See also statement of Inspector

¶Graham Delaney, SYP000038800001, p334. 14. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p31. 15. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p45. 17. Document giving comparison of Operational Orders at Hillsborough Football Ground, SYP000027020001, p3.

¶2.2.31 Supt Marshall policed a semi-final only in 1988 and previously earlier than 1981. Supt Greenwood had more recent experience. According to Supt Marshall there was no reason for the change in operational roles between 1988 and 1989 other than 'variety'.18

¶2.2.32 The reduction in police personnel was concentrated in the Leppings Lane area of the stadium and had 'a direct affect [sic] on sector 2 who's [sic] responsibility was the Policing of the Liverpool supporters'.19 The reduction was three inspectors, five sergeants and 58 constables.

¶2.2.33 Some operational changes reflected concerns about a minor post-match pitch invasion in 1988. Additional officers were allocated to the perimeter track at the end of the match and instructions were given to stop fans climbing the perimeter fence, ensuring the gates in the perimeter fence remained locked. The 1989 Order stated that 'these gates will only be opened if a specific message to evacuate is given on the public address system'.

¶2.2.34 Police officers were positioned on the track in front of each perimeter fence gate. The Operational Order instructed: 'No-one is to be allowed access to the track from the terraces without consent of a Senior Officer except to receive medical attention'.

¶2.2.35 In 1987 and 1988 the word 'No-one' was underlined. In 1989 the entire sentence was in capitals and underlined. Despite the wording, C/Supt Mole stated that during his time as match commander he had expected individual officers to use their own initiative in situations of distress.

¶2.2.36 However, C/Supt Mole considered that use of personal initiative could lead to a further problem, 'because there is a tendency, if you open gates – and we have found that with the Kop – that to let a couple of people out because of some reason; they may have lost daddies at the other pen; that a lot of people then think they want to come as well, so the message is to clear it with Control before you actually open the gate because you can create a problem in isolation that that Officer is not aware of'.20

¶2.2.37 The Operational Order also specified that perimeter fence gates could be opened only after a coded message had been announced via the public address system. Thus officers were not expected to work on their own initiative.

¶2.2.38 Further, neither the Operational Order nor the briefings alerted officers to the possibility of crushing. In the final submission to Lord Justice Taylor made by the Fire Service it was affirmed that 'Chief Superintendent Duckenfield had concluded, in the light of the discussions and information he had, that the pens on the Leppings Lane terraces did not present a major problem. The probability of crushing was not specifically mentioned in any briefings'.21

¶2.2.39 While the 'Operational Orders emphasized the need to prevent spectators gaining access to the pitch ... the function of the perimeter fence gates in providing a means of escape in certain eventualities, particularly crushing, was not referred to'. Consequently, in the pre-match briefing at the stadium on the day, and in earlier briefings, SYP officers 'on the ground do not appear to have been made aware of the dangers of crushing in the pens particularly if they became overcrowded'. 18. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p26. 19. Document giving comparison of Operational Orders at Hillsborough Football Ground, SYP000027020001, pp9-10. 20. Transcript of Chief Superintendent Mole's evidence to Lord Justice Taylor, 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, 21. Final submission of South Yorkshire Fire Service and Civil Defence Authority to Lord Justice Taylor,

¶2.2.40 Finally, the boundaries between Supt Greenwood's responsibilities as Ground Commander and Supt Marshall's responsibilities outside the Leppings Lane turnstiles – and the communication between both senior officers – remained unclear and did not form part of C/Supt Duckenfield's briefings.22

¶The mindset 2.2.41 In its submission to the Taylor Inquiry, SYP claimed that '1988 intelligence stated that when Liverpool played at Tottenham, the Stadium was filled to capacity, 2,000 Liverpool fans were locked out and ran riot outside the ground, stealing from shops and causing public annoyance'.23 2.2.42 While no other evidence has been provided to support this claim, SYP stated that it influenced the 1988 Operational Order. Consequently, 'the formulation of Serials included officers giving special attention to shopping areas, to counter such eventualities. This contingency was repeated in the 1989 Order'. 2.2.43 The submission described how manpower levels were determined by Force intelligence and experience while noting, 'it is not possible to form contingencies for unprecedented changes in behavioural attitudes' thus suggesting that the only variable in crowd management was fan behaviour. 2.2.44 In 1989 officers were not assigned specifically to the tunnel entrance on the inner concourse but SYP, in its submission to the Taylor Inquiry, explained how 'the Operational Order has inbuilt flexibility and perceived problems which result in the request for redeployment of manpower can be facilitated via Ground Control, dependant [sic] upon the developing situation. To this end there were 7 Serials consisting of 7 Sergeants and 72 Constables in the immediate vicinity of the Leppings Lane turnstiles and West Stand'. 2.2.45 The minor pitch invasion in 1988 also influenced the mindset for 1989. It was 'drummed into all officers that access to the pitch must not be permitted except in the most exceptional circumstances', leading 'to the failure to react quickly enough to the emergency that in fact arose'.24 2.2.46 Police Constable Peter Smith and Police Constable David Illingworth were deployed on the perimeter track supervising the gates into central pens 3 and 4 respectively. The gates were not to be opened without permission given by a supervisory officer, other than to allow injured persons onto the track to receive medical attention. PC Smith's experience in 1988 influenced his expectations for 1989:

¶The 1988 … Semi Final between the same teams had taken place with myself and

¶Police Constable ILLINGWORTH on the perimeter track. That year the terraces were filled well prior to the kick off. We had a constant job asking people to get off the top of the perimeter fence. I noticed that a large number of fans were worse for drink and

¶I suffered much abuse from them consisting of the usual verbal and spitting.

¶At the conclusion of the game the gates from the terraces to the pitch both opened by bodily pressure and by fans reaching through the fencing and releasing the gates.

¶The wire meshing on the perimeter fence was also ripped out by the fans to gain access to the track. Others simply climbed over the fence and dropped onto the track. Others had climbed over during the match and were either escorted from the track or returned when approached by Police Officers.

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp71-77. 23. South Yorkshire Police submission to Lord Justice Taylor, Part IV: Policing at Hillsborough, SYP000096730001, 24. Treasury Council submission to Lord Justice Taylor, SYP000098180001, p19.

¶One fan who re-scaled the fence to return, was later treated for an ankle injury. Having

¶Policed that match and other matches involving Liverpool over the last two years, I had no doubt of what my duties would entail in 1989.25 2.2.47 There had been some friction between supporters at the 1988 match. Supt Greenwood recalled that police officers had drawn truncheons to control the situation. Thus he 'anticipated that such a situation was likely to occur at the 1989 semi-final'.26 2.2.48 According to SYP, there were six significant changes between 1988 and 1989: reduction in overall manpower levels; improvement in the ticket identification system; use of a portable video camera for evidence gathering; attention paid to off-licences as well as licensed premises; abandonment of a spotter plane; and redeployment of coach reception officers to stand-by duties in Leppings Lane and Penistone Road North.27 2.2.49 In 1987 ten 'football special' trains had been used, reduced to three in 1988 and only one for Liverpool supporters in 1989. Transport arrangements were not within the control of SYP.28 C/Supt Mole considered that it was easier to maintain control when fans arrived by train. 2.2.50 In 1989 Liverpool supporters arrived by special train at Wadsley Bridge station and were walked to and from the ground by police officers. Liverpool supporters who arrived at Midland station, allocated to Nottingham trains, were segregated from Nottingham Forest fans and bussed to the ground under police supervision.29

¶15 April 1989 2.2.51 The Police Control Room log book for 15 April 1989 began at 8am but there was no entry beyond 2.21pm.30 Consequently information about much of what happened at the time of the disaster is derived from statements, interviews conducted by WMP for the criminal investigation and evidence presented to the Taylor Inquiry. 2.2.52 Supt Murray and C/Supt Duckenfield arrived at the Police Control Box at approximately 1.50pm. ACC Jackson arrived soon after 2pm. He remarked that more Nottingham Forest fans appeared to be in evidence than Liverpool fans. He left the Control Box at approximately 2.15pm and took his seat in the Directors' Box at 2.35pm.31 Supt Murray stated that he was also aware that more Nottingham Forest fans than Liverpool fans were inside the stadium.32 2.2.53 Leppings Lane was closed to traffic when large numbers of fans began to arrive. This had not happened in 1988.33 While Supt Murray and C/Supt Duckenfield exchanged comments about the possibility of delaying the kick-off, Supt Murray was confident that the crowd would pass through the turnstiles in time.

Statement of PC Peter Smith, 29 April 1989, SYP000038810001, pp189-190. 26. Statement of Inspector Roger Greenwood, 3 May 1989, SYP000038790001, p117. 27. South Yorkshire Police submission to Lord Justice Taylor, Part IV: Policing at Hillsborough, SYP000096730001, p49. 28. Minutes of meeting with Counsel, 26 April 1989, SYP000096360001, p65. 29. Appendix to a report by British Transport Police re. arrangement and experiences at 1989 FA Cup Semi-Final at

¶Hillsborough, 10 April 1989, SYP000097420001, pp10-11. 30. Extract from Control Room log book, 15 April 1989, SYP000121610001, pp21-25. 31. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp152-157. 32. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001,

¶2.2.54 As Ground Commander, Supt Greenwood was in radio contact with the Control Box and was positioned close to the players' tunnel. According to Supt Murray, Supt Greenwood could have made contact quickly with the referee.34 At 2.54pm a request to delay kick-off was made to the Control Box by Police Constable Michael Buxton. Without conferring with C/Supt Duckenfield or Supt Murray, Sergeant Michael Goddard, whose Control Box role was to operate the radios, immediately replied that it was too late as a team was on the pitch.

¶2.2.55 He believed that C/Supt Duckenfield and Supt Murray had heard the message and was under the impression that C/Supt Duckenfield had decided already not to postpone the kick-off. This was not because of any comments made in the Control Box but the assumption that 'if a game is going to be delayed it will be delayed before the teams come out'.35 The 1987 delay had been sanctioned before the teams left the dressing rooms.

¶2.2.56 It was PS Goddard's impression that if C/Supt Duckenfield was considering a delay he would have contacted FA officials rather than remaining in the Control Box. PS Goddard's understanding of the policy was that should there be 'a particular reason such as a motorway blockage or fog for people to be late it would be delayed, but if they just turned up late it wouldn't'.36 This interpretation contrasted markedly with the position of the previous Match Commander, C/Supt Mole.37

¶2.2.57 At 2.40pm Mr Mackrell and Glen Kirton from the FA stood on the perimeter track by the players' tunnel. They recognised there was a substantial number of fans still to enter the stadium. Mr Kirton queried whether the police required a delay. Mr Mackrell said they did not, since 'pulling back the kick-off produced all sorts of organisational problems at the end of the game'.38

¶The build-up to kick-off 2.2.58 Supt Marshall stated that at 2pm he was on the outer concourse on Leppings Lane and all was calm. The build-up began approximately 20 minutes later. Soon after he discussed with Inspector Sykes the large number of fans 'spilling off the pavements into Leppings Lane'. He closed the road to traffic but estimated that there was sufficient time before kick-off to process the increasingly dense crowd.39

¶2.2.59 In a statement a year later to WMP for the criminal investigation he commented, 'it did not cross my mind' to suggest delaying the kick-off to C/Supt Duckenfield. He had been influenced by C/Supt Duckenfield's policy on late arrivals and considered that any delay 'was a matter for Control'. It was a 'question for Mr Murray and Mr Duckenfield, having regard to the intelligence which ... they could have … obtained or had received from other people'.

¶2.2.60 Supt Marshall considered that the police lost control of the crowd outside the stadium at approximately 2.44pm.40 He recalled standing on a parapet to view the tightly 34. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, p90. 35. Sergeant Goddard's evidence to Lord Justice Taylor, HOM000026040001, p42. 36. This was a question put to PS Goddard to which he replied in the affirmative. It was put to him by Mr Phillips before

¶Lord Justice Taylor, HOM000026040001, p42. 37. See Chief Superintendent Mole's understanding of the grounds for delaying kick-off, relating to his experience in

¶1987, in Chapter 1. 38. Statement of Glen Kirton, Head of External Affairs at the Football Association,¹⁷¹⁷ December 1997, HOM000030920001, p1. May 1989, SYP000038700001, p151. 39. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990, packed crowd at the approach to the turnstiles. This moment was caught on CCTV. He was unable to make direct contact with the Control Box, and he changed channels to contact Hammerton Road Police Station to pass a message to the Control Box. 2.2.61 On reflection he considered that more officers or better organisation would not have helped as he estimated six to eight thousand people in the crush.41 The situation at the turnstiles became severe, he claimed, because there had been a failure in intelligence and the police resources available were inadequate to respond effectively. 2.2.62 It is evident from the disclosed documents that the situation in the Control Box after 2.35pm became chaotic. There were constant incoming calls and radio messages, the radio system failed and police reinforcements were sent to Leppings Lane under the wrong assumption that there was crowd disorder. 2.2.63 Yet the main focus remained on the Spion Kop where trouble was anticipated because officers expected Liverpool fans to gain entry among Nottingham Forest fans. Supt Murray was unclear in his recollection of the precise time, but by 2.45pm he stated that he was aware of a serious crowd problem on the Leppings Lane terrace and responded to subsequent radio requests for reinforcements.42

¶Opening the exit gates 2.2.64 A low, gated metal fence separated the outer concourse at the turnstiles and the street approach along Leppings Lane. In 1988, all but one of these gates leading from the road into the outer concourse were closed, whereas in 1989 all but one were open.43 2.2.65 Video coverage from 1988 showed these gates on the outer concourse closed from 11am. A 1989 video showed that, in this instance, they were not closed until an attempt was made once congestion was recognised.44 ACC Jackson was unable to explain the difference in approach but blamed a small element of the crowd who had been drinking and were anxious to gain entry into the stadium.45 2.2.66 As congestion built to dangerous levels, Supt Marshall radioed an urgent request for stadium exit gates, close to the turnstiles, to be opened to allow fans into the ground. In his message he stated that there was a real possibility of fatalities if relief was not immediate. 2.2.67 In his WMP interview for the criminal investigation, Supt Marshall stated that as he was unaware that the exit gates were identified as A, B and C he had not named the gate that should be opened. He acknowledged that there were other means to identify each gate. He stated that he had no information about the crowd inside the stadium and assumed, '[t]here must be nobody on the terrace cause there's all these people here trying to get in'.46 2.2.68 Supt Marshall considered he had no option to direct fans elsewhere as they 'wouldn't have gone ... this is the problem that people seem to so desperately to fail to appreciate that there were thousands and thousands of people, many of whom had far too

West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp107-110. 42. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, p112. 43. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp88-89. 44. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp91-92. 45. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp102-103.

¶much to drink ... elements of people who hadn't got tickets ... that it's eight minutes away from kick-off and I'm gonna be in that ground come hell or high water...'.47 2.2.69 Having requested the opening of the exit gates, Supt Marshall stated that it did not occur to him to inform Supt Greenwood of his actions.48 He assumed there was considerable space on the terraces. After the gates were opened, the pressure was relieved, the crowd outside was under control and fans continued to use the turnstiles.

¶2.2.70 In the Police Control Box Supt Murray recalled a brief delay before C/Supt Duckenfield authorised opening the exit gates. Supt Murray was unsure which gates had been opened and later stated: 'I thought [the fans] would come into the ground and I thought they would be absorbed by the concourse'.49

¶2.2.71 The WMP report to the DPP questioned whether C/Supt Duckenfield had sufficient knowledge of the stadium's geography and signage to appreciate the consequences of opening Gate C, particularly the impact on the already full central pens. The WMP investigation team also questioned whether C/Supt Duckenfield understood his instruction to 'open the gates' related to Gate C only or to Gates A and B as well.50

¶2.2.72 At the time the gates were opened, Supt Murray was aware the pens were not evenly filled. Yet he stated that it did not occur to him to attempt to redistribute fans. In his 1990 interview with WMP for the criminal investigation he stated that he considered this would have been a dangerous strategy as the numbers were so high. Further, closing the tunnel entrance to the packed central pens did not cross his mind.

¶2.2.73 On reflection Supt Murray considered that a line of officers across the mouth of the tunnel would not have been effective given the volume of fans who had entered through Gate C. He judged it would have caused a further build-up that would have broken the police line.

¶Consequences of opening the gates 2.2.74 At the time Supt Murray was concerned about the consequences of opening Gate A with large numbers of fans rushing into the North Stand seats. Expecting problems, police officers were despatched to that area. His action anticipated the impact of opening Gate A, but failed to consider the consequences of opening Gate C.51 PC Smith recalled looking through a glass window in Gate A at approximately 2.50pm and noticing numerous fans crushed and in great distress.52 Sergeant Wright claimed that he requested Club stewards to open the gate to relieve the pressure but the stewards refused.

¶2.2.75 Near Gate B Inspector John Bennett was on a turnstile roof assisting distressed fans over the wall and into the stadium to escape the crush outside. A number of these fans had lost shoes and clothing. Stewards also refused to open Gate B. Eventually a steward unlocked and opened the gate for approximately one minute. This relieved the crush.

West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp113-114. 48. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp119-129. 49. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp117-135. 50. WMP report to the DPP, Part VII, SYP000038850001, p69. 52. Recollection of PC Brown, 19 April 1989, SYP000096810001, pp4-6.

¶2.2.76 There remains some discrepancy about who opened Gate B. According to PC Smith, he and another officer opened the gate, not a Club steward. Then a steward helped him to replace the bolts when the gate was closed.53 Police Constable Michael Craighill noted that prior to the gate being opened, the metal began buckling inwards due to the pressure of the crush outside.54

¶2.2.77 By 2.45pm the tunnel was three-quarters full of fans attempting to descend into the central pens. No police officers were evident near the tunnel entrance.55 Video evidence shows that when Gate C, directly opposite the tunnel, was opened 'the spectators almost universally are moving towards the tunnel entrance to the terraces and there is virtually no movement nor any activity by anyone to direct these same spectators to the south side of the west stand'.56

¶After the crush 2.2.78 Supt Murray later reflected that, in the Control Box, he did not make the connection between the opening of the exit gates and the emerging problems in the central pens.57 As fans tried to climb from the overfull pens he went down to the pitch to attempt to stop the match.

¶2.2.79 Once he became aware that Supt Greenwood was contacting the referee to stop play, Supt Murray returned to the Control Box. He did not speak to anyone on the pitch nor did he go to the pens to investigate.

¶2.2.80 Meanwhile, Supt Greenwood was unaware of the problems outside the turnstiles. Realising that there was a crush in the pens likely to result in serious injuries, he gesticulated and shouted to the crowd to move back up the terrace steps. Given the density of the crowd, this was not possible.

¶2.2.81 Supt Greenwood waved to the Control Box to stop the match and ran to the referee. He stated that he 'took this action unilaterally, having received no response from the Control Box'.58 He returned to the pens to assist with rescue and evacuation.

¶2.2.82 An urgent radio message requested all available officers to move inside the stadium. Supt Marshall assumed there had been a pitch invasion and entered through Gate C. At this point fans were retreating from the terrace through the tunnel. Many were injured and it became increasingly evident to Supt Marshall that there could be fatalities.59

¶2.2.83 On Supt Murray's arrival back at the Control Box, he was instructed by C/Supt Duckenfield to return to the pitch and to try to clear fans from the goal area. There he found fans seriously injured, possibly dead, and realised he was not carrying a radio.60

Recollection of PC Smith, 19 April 1989, SYP000096810001, pp13-14. 54. Recollection of PC Craighill, 19 April 1989, SYP000096810001, pp9-11. 55. Recollection of PC Smith, 19 April 1989, SYP000096810001, p13. 56. Overview of video evidence provided by Deputy Chief Constable P Hayes, 18 April 1989, SYP000096810001, pp56-59. 57. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp169-176. 58. West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, pp29-30. 59. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶Supt Murray then contacted various officers and gave them directions. Utilising another officer's radio, he called for 'a fleet of ambulances'.

¶2.2.84 ACC Jackson had been watching the match from a seat in the Directors' Box located above the players' tunnel. He stated that he had not seen fans being moved from the central pens before kick-off. Shortly after kick-off he became aware of fans on the pitch behind the goal.

¶2.2.85 He considered three possibilities – crowd disorder, Nottingham Forest fans at the wrong end or a pitch invasion. He realised it was a serious problem when fans were on the pitch and he went to the Control Box. He was unclear at that point whether the match had been stopped or was continuing.61

¶2.2.86 On reaching the Control Box, ACC Jackson noted an air of 'concern and puzzlement as to what, what was going on'. He and C/Supt Duckenfield had a 'a short conversation about the possibility of a pitch invasion'. Nothing was said about the opening of the exit gates.

¶2.2.87 ACC Jackson then went to consult Supt Greenwood and other officers. He understood from Supt Greenwood that he was dealing with 'a crushing incident'. On a brief walk around the stadium ACC Jackson did not visit pens 3 and 4 before returning to the Control Box where, as he later described, the atmosphere was 'hyped up quite considerably, and lots of things were happening'. He 'considered that [he] was in command of a major, a major, developing major incident'.

¶2.2.88 When ACC Jackson had arrived on the pitch, Supt Greenwood assumed that, as the senior officer at the match, he would organise the necessary support and with those in the Control Box being aware of the seriousness of the situation, he would take control. Supt Greenwood, however, felt 'as if I was dealing with the disaster alone'.62

¶2.2.89 Supt Marshall stated later that he was shocked by what happened and had been unable to direct an ambulance into the stadium due to the crowds. He organised approximately 30 officers to assist with casualties and 'established three areas on the access to the South Stand, one for the walking wounded and one for the seriously injured, and one for the dead'.63 He allocated a police officer to remain with each body to establish continuity of identity. According to Supt Marshall, he took charge of the rescue operation without receiving direction from the Police Control Box.

¶2.2.90 On ACC Jackson's return to the Control Box, Graham Kelly, FA Chief Executive, and Graham Mackrell, SWFC Secretary, were present. At that stage, ACC Jackson 'didn't say much ... because basically I was ... concerned with what was happening down there [on the pitch]'.64 Mr Mackrell later recalled, when he visited the Control Box 'no reference was made at any stage to the gate having been opened, and it was clearly an urgent situation where I did not wish to interfere with the Police operations'.65

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp158-180. 62. West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, pp29-30. 63. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990, 64. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p182. 65. Written statement of Mr Mackrell to Lord Justice Taylor, 26 June 1989, SYP000096840001, p419.

¶2.2.91 ACC Jackson recalled C/Supt Duckenfield saying 'something to the effect that the gates had been stormed'.66 In the context of the rescue operation 'it seemed unimportant'. Mr Kelly also referred back to the discussion:

¶The Police in the Control Box were apparently under the impression that a gate or gates had been forced. They told me so and showed me a picture which purported to represent this. They said that the match would have to be abandoned because there had been fatalities. They did not know how many. The Police Commander

¶[C/Supt Duckenfield] was present in the Control Box together with the Assistant Chief

¶Constable, Mr Jackson … We were told that when the gate had been forced there had been an in-rush of Liverpool supporters.67

¶2.2.92 At approximately 3.30pm ACC Jackson and C/Supt Duckenfield went to the SWFC boardroom to meet FA and SWFC officials. The discussion there focused on abandoning the match, when this should be announced to the crowd still in the stadium, and on the injured fans. When ACC Jackson entered the meeting, 'running through my mind was still the fact that the gates had been stormed'. Nothing was said in the meeting to alter that perception.68

¶2.2.93 ACC Jackson was eager to evacuate all the injured from the stadium before the crowds dispersed. Despite ACC Jackson's reluctance to air such a message, the Liverpool manager, Kenny Dalglish, made the announcement using the public address system.

¶2.2.94 Soon after, ACC Jackson spoke with Detective Chief Superintendent Terence Addis, Head of CID at Hammerton Road Police Station, who arrived at the Control Box at approximately 3.50pm. He was unable to enter due to 'a fireman stuck in the door' and was directed to take charge of the temporary mortuary in the gymnasium and assume responsibility for the immediate SYP investigation of the events.

¶2.2.95 According to ACC Jackson, Det C/Supt Addis 'went to set things in motion [and] to set up the HOLMES [computer system] to appoint an officer to that, to get the Coroner down to tell him what we were doing and what arrangements did he think we should make et cetera'.

¶2.2.96 Just after 4pm, Supt Marshall met C/Supt Duckenfield, ACC Jackson and Supt Murray in the Control Box. According to Supt Marshall, 'all of them' were 'in a state of shock'.69 Supt Marshall explained to ACC Jackson that officers had been overwhelmed by the crowd outside and he had opened the gates. ACC Jackson was 'surprised', since he was still under the impression that the gates had been forced.70 Given 'the circumstances … the pressure that we were working under … the trauma of the event and all the rest of it', he did not feel it necessary to question C/Supt Duckenfield about the contradiction. ACC Jackson's assessment of C/Supt Duckenfield was that he did a 'superb job', describing him as 'calm, cool, collected and he was good with his staff, and we worked well together in the box'.

¶2.2.97 Former Match Commander C/Supt Mole arrived at the stadium having heard a request on the radio for additional support at Hillsborough. At around 4.45pm he was briefed by ACC Jackson who then left Hillsborough with Supt Murray and

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p184. 67. Statement of Graham Kelly, Chief Executive of the FA, HOM000001380001, p6. 68. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp170-225. 70. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp188-230.

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¶C/Supt Duckenfield to brief the Chief Constable and his Deputy at headquarters and to prepare for a press conference. C/Supt Mole was appointed the Incident Commander.

The SYP decision to replace the experienced match commander, Chief Superintendent Brian Mole, and appoint Chief Superintendent David Duckenfield who had minimal experience of policing at Hillsborough, just weeks before an FA Cup semi-final, has been previously criticised. None of the documents disclosed to the Panel indicated the rationale behind this decision.
A planning meeting attended by both senior officers was held less than a month before the match. The documents disclosed to the Panel give no explanation for the non-attendance of the South Yorkshire Metropolitan Ambulance Service and the Fire Service at this meeting.
Chief Superintendent Duckenfield held a briefing for senior officers on the day before the match. At that meeting he emphasised the importance of crowd safety. Briefings held by other senior officers, however, focused on potential crowd disorder, alcohol consumption, ticketless fans and the difficulties of managing Liverpool supporters. From the documents disclosed to the Panel, it is apparent that the collective policing mindset prioritised crowd control over crowd safety.
This mindset, directed particularly towards Liverpool fans, was clearly evident in SYP's submission to the Taylor Inquiry.
As previously known, the SYP 1989 Operational Order was derived, with a few alterations, from the 1988 Order and gave no indication of the crowd management problems experienced in 1988.
The SYP Operational Order concentrated primarily on the control and regulation of the crowd with no appropriate reference to crowd safety, crushing or evacuation of the stands/terraces.
From the documents disclosed to the Panel, the management roles and responsibilities of senior SYP officers were unclear, particularly the lines of communication, decision-making and information exchange between those responsible for policing outside the stadium and the ground commander inside the stadium.
There was clear evidence in the build-up to the match, both inside and outside the stadium, that turnstiles serving the Leppings Lane terrace could not process the required number of fans in time for the kick-off. Yet the growing danger was ignored. When the request to delay the kick-off eventually was made, it was considered too late as the teams were on the pitch.
For a considerable period inside the Police Control Box it was clear from the near view of the central pens below, and the CCTV coverage of the turnstiles and pens, that serious problems of overcrowding were occurring at the turnstiles and in the pens. Senior police officers' decision-making was hampered by poor communications, a malfunctioning radio system and the design of the Control Box.
Superintendent Roger Marshall was responsible for policing outside the stadium at the Leppings Lane end. As the crush at the turnstiles became severe he requested the opening of exit gates to allow fans into the stadium and relieve crowd pressure. He had no knowledge of the uneven distribution of fans on the Leppings Lane terrace. Similarly, the ground commander inside the stadium, Chief Superintendent Roger Greenwood, had no knowledge of the extreme situation developing outside the stadium. • The overview of both sites was the Control Box, with CCTV monitors and a near view of the central pens. Chief Superintendent Duckenfield acceded to Superintendent Marshall's request and authorised the opening of Gate C. Despite a clear view from the Control

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¶Box and CCTV monitors, neither Chief Superintendent Duckenfield nor his assistant, the experienced Superintendent Bernard Murray, anticipated the impact on the already packed central pens of fans descending the tunnel directly opposite Gate C. • On opening Gate C there was no instruction given to the SYP officers inside the stadium to manage the flow and direction of the incoming crowd. • From the documents provided to the Panel it is clear that the crush at the Leppings Lane turnstiles outside the stadium was not caused by fans arriving 'late' for the kick-off. The turnstiles were inadequate to process the crowd safely, and the rate of entry insufficient to prevent a dangerous build-up of people outside the ground.

¶Custom, practice, roles, responsibilities

¶2.3.1 As established in Part 1 and in the previous chapters, and central to the submissions to the Panel from bereaved families, key issues of concern focus on crowd management, crowd safety and the condition of the stadium.

¶2.3.2 While the behaviour of the crowd and its predictability was the overarching priority for those responsible for managing, controlling and policing, the important question, noted in Lord Justice Taylor's Interim Report, was whether an institutional mindset that focused on hooliganism compromised thorough planning to prioritise the safety of the crowd.

¶2.3.3 The bottleneck at the turnstiles, the restricted flow through the turnstiles and the expectation of processing a capacity crowd within a confined outer concourse area were problems identified previously by the South Yorkshire Police (SYP).

¶2.3.4 Packing the pens (especially the central pens), the steep tunnel leading down to the central pens, the policing and stewarding of fans within the inner concourse area, the recognition of overcrowding in the pens, and the monitoring and closure of the tunnel access were raised regularly following the 1981 incident.

¶2.3.5 Given these complex yet recurrent issues the debriefings after previous semi-finals, especially the near tragedy in 1981, were crucial to informing Operational Orders and the responsibilities of Sheffield Wednesday Football Club (SWFC) stewards and police officers. This was particularly significant as there was no reliable count of the number of fans entering individual pens and police officers had raised concerns about crushing inside and outside the stadium.

¶2.3.6 Regarding responsibility for the safe passage of fans and their well-being once inside the stadium, the disclosed documents demonstrate that serious deficiencies were accommodated, even rationalised, by established custom and practice. Warning signs that were clearly evident in the management of the crowd at previous semi-finals were, at best, not taken seriously. At worst they amounted to serious negligence in the face of foreseeable and imminent danger.

¶2.3.7 This chapter relies on documents disclosed to the Panel and released into the public domain that add significantly to knowledge regarding previous events and their centrality, once ignored, as factors that contributed to the disaster.

Chapter 3 Custom, practice, roles, responsibilities — 103

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¶2.3.8 It reflects on the released documents to explore the following key issues:

allocation of areas of the stadium to rival fans and the assumptions underpinning crowd segregation
organisation of the approaches to the stadium, filtering the crowd in the vicinity of the stadium and congestion at the Leppings Lane turnstiles
'packing' the Leppings Lane terrace and filling the recently constructed pens
apparently contrasting views held by SWFC and SYP regarding responsibility for crowd management and distribution within the stadium
significance of the tunnel beneath the West Stand in feeding the central pens within the Leppings Lane terrace
what was known about the tunnel, and its use as a means of restricting access to the central pens, by SYP officers of different ranks and by SWFC.

¶Choice of venue and allocation inside the stadium 2.3.9 By the late 1980s segregation was a key factor in policing soccer matches. Considerable time and effort were committed to keeping rival fans separate, not only inside stadia but also in the immediate vicinity and in the approaches. At Hillsborough for regular league matches 'away' fans were allocated the Leppings Lane end of the stadium, or a smaller portion of terrace, depending on numbers.

¶2.3.10 FA Cup semi-finals were different as neither set of fans were from the Sheffield area and all were travelling some distance. Seated areas (stands) and terraces were allocated to each club on an approximately equal basis. Because Leppings Lane turnstiles provided access to the North and West Stands and to the Leppings Lane terrace they were allocated exclusively to one team (in 1988 and in 1989 to Liverpool fans). Other stands and terraces, and their access points, were allocated to the other team (in both years, Nottingham Forest fans).

¶2.3.11 According to SYP the decision about the allocation of 'ends' was based on motorway approaches, coach and car parking, and street layout. Liverpool Football Club, however, contested the decision, proposing that because their team had the bigger fan base and following they should be allocated the biggest end – the Spion Kop.

¶2.3.12 The former match commander, Chief Superintendent Brian Mole, noted Liverpool's 'approaches ... to reverse the ends and I found that not possible to do'.1 Referring to the Popplewell Report into the tragic fire at Bradford in 1985, he confirmed that 'the recommendations we have received ... have indicated spatial separation'. He stated that segregation benefited not only the crowd but also the local population.

¶2.3.13 Allocation of segregated areas within the stadium, therefore, 'was based on the geographical location of the Stadium and was in an effort to ensure complete segregation of supporters to prevent confrontation and public disorder … this policy was followed and the operations were successful'.2

¶2.3.14 C/Supt Mole was approached by Graham Mackrell, the Secretary of SWFC, in March 1989 to confirm that SYP would be content to police the 1989 FA Cup Semi-Final should Hillsborough be hired by the Football Association (FA).

Transcript of C/Supt Mole's evidence to the Taylor Inquiry, day 6, 23 May 1989, SWF000001320001, p27. 2. Statement of C/Supt Mole, 19 May 1989, SWF000001320001, p3.

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¶2.3.15 C/Supt Mole agreed on condition that the stadium would be segregated with Liverpool fans allocated the North Stand, West Stand and Leppings Lane terrace and Nottingham Forest fans the Spion Kop and South Stand. This was the arrangement in 1988.

¶Choice of venue 2.3.16 The draw for the 1989 FA Cup Semi-Finals was made at 7.45am on Monday 20 March. Once the matches were known, 'Members of the Challenge Cup Committee, together with the Chairman of the Match & Grounds Committee' met to consider 'the choice of venue for each tie'.3

¶2.3.17 A short time before that meeting took place, Steve Clark, the FA's Competitions Secretary, received a call from Peter Robinson, Liverpool Football Club's Secretary, with a request that should Hillsborough be chosen as the venue for their tie, Liverpool should be allocated the Spion Kop end of the ground.

¶2.3.18 Responding, Mr Clark spoke to Mr Mackrell at Sheffield Wednesday.4 He, in turn, contacted SYP's C/Supt Mole. Mr Mackrell informed C/Supt Mole that in the event of Hillsborough being chosen, the FA had requested the 1988 allocation of the Leppings Lane and Spion Kop ends of the stadium be reversed to provide a greater proportion of accommodation for Liverpool fans.5

¶2.3.19 C/Supt Mole's reply reiterated his rationale for the 1988 allocation and, after consultation with Assistant Chief Constable Walter Jackson, he confirmed there was no possibility of change. Mr Mackrell contacted the FA and the SYP position was accepted.

¶2.3.20 Mr Clark 'spoke to Mr Kelly [FA Chief Executive] about the arrangements for the Challenge Cup Committee and mentioned to him the call I had had from Mr Robinson'.6 When, however, Graham Kelly spoke with Jack Wiseman, the Chairman of the Match & Grounds Committee which would take the decision on ground venue, he apparently 'did not mention the Peter Robinson (Liverpool) phone call'.7 This did not seem to matter, however, as Wiseman 'had already in his mind Hillsborough and Villa Park as the likely venue [sic]'.

¶Need for segregation takes precedence 2.3.21 Subsequent written submissions to LJ Taylor by West Midlands Police (WMP) note that the FA considered there was no option but to accept SYP's decision on the allocation of ends. Mr Kelly stated that 'allocation to competing clubs is now dictated by the need for segregation and the capacity of the sections of the ground to each club's supporters'.8 He continued, 'on matters like this (ticket allocation) the staging club and the F.A. are really bound to accept the view of the Police'.

¶2.3.22 At a meeting prior to the 1988 Semi-Final, attended by Mr Adrian Titcombe, Mr Mackrell and an 'unidentified' SYP officer, an application from Liverpool Football Club for the allocation to be changed to give Liverpool supporters the majority ticket share was considered. The police officer 'objected to any change of ticket allocation and none was made'.

Note from Steve Clark, FA Competitions Secretary, FFA000001920001, p1. 4. Note of meeting between Freshfields solicitors and FA, 27 April 1989, FFA000004820001, p1. 5. Statement of C/Supt Mole, SYP000038700001, pp176-190. 6. Statement of Steve Clark, FA Competitions Secretary, HOM000000510001, p3. 7. Note of meeting between Freshfields solicitors and Football Association, 2 May 1989, FFA000004550001, p1. 8. WMP paper on ticket allocation,¹⁷¹⁷ December 1997, HOM000030920001, p1. June 1989, SYP000027590001, pp23-24.

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¶2.3.23 The conclusion drawn by WMP was that the 'overriding necessity to segregate supporters of the two clubs has resulted in the situation whereby both the Football Association and Sheffield Wednesday FC allowed the South Yorkshire Police to effectively dictate allocation of tickets in both 1988 and 1989'. Consequently, the Nottingham Forest ticket allocation was 4,000 higher than that received by Liverpool.

¶2.3.24 In its submission to the Taylor Inquiry, the FA maintained 'the choice of venue and the allocation of ends was not in itself a contributing factor' to the disaster.9 Yet the FA considered that the uneven distribution of tickets would have caused more Liverpool fans to 'arrive without tickets and more [Liverpool] fans with "Kop" tickets would appear at the Leppings Lane end seeking entry'.

¶2.3.25 According to the FA, the only concern about the suitability of Hillsborough for a capacity match attended by two sets of fans unfamiliar with the stadium layout centred on the configuration of the turnstiles at Leppings Lane: 'The rate at which the turnstiles were expected to operate at various sections of the ground does not appear to have been the subject of sufficient consideration by the organisers'.

¶2.3.26 As stated in the previous chapter, the processing of almost half the match attendance through 23 turnstiles entering via a confined concourse at one narrow end of the stadium constituted a clear and foreseeable risk.

¶Filtering, managing approach and congestion at the turnstiles 2.3.27 In the late 1980s segregation of rival fans was planned by the police from the moment they arrived in the city. Arriving on trains and in coaches fans were met at stations or drop-off points and escorted by the police to the stadium, a strategy known as 'corralling'.

¶2.3.28 Many other fans, travelling in cars, made their own way to the stadium. The match ticket carried a request for fans to be inside the stadium 15 minutes before kick-off. For FA Cup semi-final matches fans were in unfamiliar surroundings and relied on the police for direction to the appropriate turnstiles.

¶2.3.29 The immediate approach to the west end of the stadium was on a bend in Leppings Lane. On arrival at the stadium Liverpool fans entering the West Stand, the Leppings Lane terrace and the North Stand passed through gates in an outer fence before entering a divided concourse leading to the turnstiles.

¶2.3.30 The outer concourse was a tightly confined area between a wall and a fence above the River Don. As stated in Part 1, managing the crowd approaching, and within, the outer concourse was crucial in avoiding crushing at the turnstiles.

¶2.3.31 In evidence to the Taylor Inquiry a journalist, David Walker, described the 1987 policing arrangements.10 They included 'snake queues' from the Leppings Lane turnstiles, 'two or three abreast … so there was no surge on particular turnstile entrances'. The queues were 'probably 30 or 40 yards' long. Further back, on the street approach were 'Police checkpoint barriers to check that you had a ticket before you actually got around the perimeter of the ground'. 9. FA submission to the Taylor Inquiry, SYP000033690001, pp74-75. 10. Transcript of David John Walker's evidence to the Taylor Inquiry, HOM000026140001, p62. See also statement of

¶David Walker, SYP000038760001, p292.

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¶SHEFFIELD WEDNESDAY F.C.