Part 1: 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.