Hillsborough Disaster: A summary of the Report of the Independent Panel

Hillsborough Disaster: A summary of the Report of the Independent Panel

By TomTom – Your SatNav around Football

The Hillsborough Independent Panel has presented its 395-page report on the Hillsborough disaster of April 15, 1989 in which 96 Liverpool fans went to a football match and never came home.

After years of pain and anguish the families of the bereaved persuaded the Home Secretary to appoint the Independent Panel in 2009 and work began in February 2010.
After two and a half years and more than 400,000 disclosed documents analysed, the report concludes that multiple factors were responsible for the deaths of the 96 victims and the Liverpool fans were not the cause of the disaster.
This blog presents a summary of that report.


In 2009 the Hillsborough Family Support Group met the Home Secretary who took the decision to appoint the Hillsborough Independent Panel.
The Panel began its work in February 2010.
The disclosed documents show that multiple factors were responsible for the deaths of the 96 victims of the Hillsborough tragedy and that the fans were not the cause of the disaster.
The disclosed documents show that the bereaved families met a series of obstacles in their search for justice.


On 15 April, 1989 over 50,000 supporters travelled to Hillsborough Stadium to watch an FA Cup Semi-Final between Liverpool and Nottingham Forest.
As the match started it became apparent that in the central area of the Leppings Lane terrace Liverpool fans were in considerable distress.
The small area in which the crush occurred comprised the two central pens 3 and 4. There was a small locked gate at the front of each pen.
The match was stopped and fans were pulled from the terrace through the narrow gates onto the pitch.
Fans tore down advertising hoardings and used them to carry the dead and dying the full length of the pitch to the stadium gymnasium.
Ninety-six died as a consequence of the crush, while hundreds more were injured and thousands traumatised.
For years afterwards it was assumed Liverpool fans’ behaviour had contributed to, if not caused, the disaster.

The 1981 FA Cup Final

In 1981 Hillsborough was used for the FA Cup semi-final between Tottenham Hotspur and Wolves.
Congestion at the turnstiles meant around 50 people were admitted through an exit gate and a precedent was set for relieving pressure outside the ground.
But on this occasion tickets were checked and police and stewards managed the situation effectively.
Stewards were instructed by police to close the gates to the central tunnel and divert fans to the access points at either end of the terrace.
There was serious congestion at the Leppings Lane terrace but at the time no lateral fences divided the terrace into pens so fans could move sideways to relieve the pressure.
Once crushing began the order was given to open the perimeter fence to relieve the crush and avoid fatalities.
At half time police moved fans from the perimeter track to the Spion Kop end and helped some fans climb over the railings. Some fans watched the game sitting on the track.
After the match Sheffield Wednesday Football Club (SWFC) representatives were critical of the police action saying it was ‘completely unnecessary and made the ground look untidy.’
Senior officer ACC Goslin insisted that due to crushing on the terraces there had been a ‘real chance of fatalities’ to which club Chairman Mr McGee replied ‘Bollocks – no one would have been killed!’
Following this disagreement, the relationship between South Yorkshire Police (SYP) and SWFC became strained.
Hillsborough was not used again for an FA Cup semi-final until 1987.

1981-1986: ground modifications and safety issues

From the earliest safety assessments made by safety engineers commissioned in 1978 by Sheffield Wednesday FC, it was apparent that the stadium failed to meet minimum standards.
In September 1981, Eastwoods Partners engineers were instructed by SWFC to prepare the installation of two radial fences on the Leppings Lane terrace, as had been suggested by SYP.
The recommendation was to divide the terrace into three discrete areas each with its own entrance. It was anticipated this would improve the control and management of fans.
While the introduction of radial fences was accepted the proposal to install individual turnstiles for each pen was not pursued because of anticipated costs to SWFC.
There therefore would be no way of knowing accurately how many fans were in each area, only the overall number in the terrace as a whole.
In July 1985 further radial fences were built as an aid to segregation to prevent lateral movement rather than as a means to manage the distribution of fans.
SYP were focused on crowd management rather than safety and the Football Club were concerned with minimising costs.
The Fire service raised concerns about the width of the new pens and the gradient of the tunnel leading down to the terrace.
24,000 fans were channelled through 23 turnstiles.
The maximum capacity, 10,100, of the Leppings Lane terrace was questioned repeatedly by the SYP but the decision was taken by the SWFC not to revise the figure.

1987 and 1988 FA Cup Semi-Finals

The 1987 match between Coventry City and Leeds was delayed by 15 minutes because of slow traffic to accommodate arriving fans.
A document created within the Association of Chief Police Officers stated t it had ‘become increasingly apparent that large numbers of spectators…arriving extremely late at the ground…may be related to the restricted access to alcohol in grounds and the prohibition on taking alcohol into grounds’.
Consequently, to avoid disorder, ‘police ground commanders have occasionally requested that the kick-off be delayed’ but ‘this pressure should not be acceded to in future, the police should not be dictated to by supporters’.
One Leeds fan who went in 1987 concluded ‘outside the turnstiles and inside the ground there was a total lack of organisation.’
One fan wrote to the FA after the 1988 match in which he described the congestion in the tunnel and central pens. He wrote: ‘. During the match we had to constantly bear the crushing force of the crowd swaying forward from behind…During the game some fants actually collapsed or fainted…as far as I am concerned when there is a large crowd entering this part of the ground it will always be a death trap.’
After the two semi-finals the debriefings held by all parties were inadequate. The SYP failed to exchange information within the SYP and with other agencies as to what had happened.
The risks were known and the crush in 1989 was foreseeable.

Custom, practice, roles, responsibilities

At previous semi-finals SYP filtered the crowd outside the stadium by checking tickets on the roads leading to the terraces. This did not happen in 1989.
SYP proposed that preventing ticketless fans from approaching the turnstiles was not possible.
The decision as to when each pen had reached full capacity was reached ‘based on experience’ and allowed fans to ‘find their own level.’
The use of the tunnel entrance as a means of regulating access to the central pens and redirecting fans to the side pens was used previously and particularly in 1988, but this was not considered in 1989.
This information was deleted from some officers’ statements.
Senior officers denied knowledge of tunnel closure at previous semi-finals even though junior officers said they had acted under instruction on those occasions.

The moment of 1989

The flaws in responding to the emerging crisis on the day were rooted in institutional tension within and between organisations.
It is still not clear why South Yorkshire Police replaced the experienced match commander, Chief Superintendent Brian Mole, and appointed Chief Superintendent David Duckenfield who had minimal experience of policing.
The SYP’s Operational Order for 1989 was derived from the 1988 Order and gave no indication of the crowd management problems experienced in 1988.
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. The perception on the day was that they were dealing with crowd disorder rather than severe crushing.
The lines of communication and division or responsibility between officers outside the stadium and inside the stadium were unclear and inefficient.
Superintendent Roger Marshall was responsible for policing outside the stadium at the Leppings Lane end and as the congestion at the turnstiles became severe he requested the opening of gates to allow fans into the stadium.
It was clear both inside and outside the stadium that turnstiles at the Leppings Lane terrace would not be able to process the required number of fans in time for kick-off but a request to delay kick-off was rejected because by the time it was made the teams were already on the pitch.
Chief Superintendent Duckenfield could see both outside the stadium and inside the terrace on the Control Box and the CCTV monitors.
Neither Duckenfield nor his assistant, Superintendent Bernard Murray, anticipated the impact of opening Gate C and they agreed to Marshall’s request.
On opening the gate there were no instructions given to SYP officers to manage the flow and direction of the incoming crowd.
The crush was not caused by fans arriving ‘late’ but by inadequate turnstiles which were unable to process the crowd safely and prevent a dangerous build-up of people outside the ground.

Emergency response

Officers interpreted crowd unrest in the pens as disorder and consequently were slow to realise that spectators were being crushed, injured and killed.
Ambulance Service officers were even slower than police to identify and realise the severity of the crush despite being close to the central pens.
Lack of correct activation of the major incident procedure significantly constrained effective and appropriate response.
Lack of leadership and coordination lasted not for a few minutes, which would be understandable in moments of disaster, but for at least 45 minutes after spectators had been released from the pens.
South Yorkshire Metropolitan Ambulance Service failed to provide assessment, prioritisation or treatment on the site.
Basic medical equipment remained in vehicles outside the stadium as crews were unaware of what was required on the pitch.
Radio communication problems hindered SYMAS’s response but the failure to activate the major incident procedure was more significant.
The gymnasium at the ground was used as a temporary mortuary while friends and families remained in a Boys’ Club opposite.
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 were denied as the police, pressured by the need to process waiting relatives, were keen to complete the identification quickly.
Bereaved relatives were questioned immediately after identification of the bodies about their loved one’s social and drinking habits which was insensitive and irrelevant.
A swifter, more appropriate, better focused and properly equipped response has the potential to save more lives.

Parallel investigations

On the morning after the disaster senior SYP officers discussed the ‘animalistic behaviour’ of ‘drunken marauding fans’.
The SYP prioritised an internal investigation – the Wain Report – and the collection of self-taken, handwritten statements in preparation for the imminent external inquiries.
These emphasised aggressive, ticketless, drunk fans involved in a conspiracy to enter the stadium.
The SYP blamed structural deficiencies in the stadium. SWFC blamed failures in policing.
Health and Safety Executive investigation concluded the maximum capacity in the pens was too high, particularly in pen three where most of the deaths occurred.
Given the numbers of fans the crowd could not have completed entering the ground until approximately 40 minutes after kick off.
The primary concern of the Government at the time was the potential impact on the parliamentary passage of the planned Football Spectators Bill, aimed at controlling fans’ behaviour.
Disciplinary proceedings were brought against Duckenfield and Superintendent Bernard Murray but were held up by delays caused by the ‘review and alteration’ of SYP statements.

Civil litigation

Contributions to the payment of compensation to the injured and bereaved went as follows: SWFC – £1.5m, Eastwood & Partners – £1.5m, Sheffield City Council – £1m, SYP – £8.5m.
Compensation claims made by SYP officers caused considerable tension in the force and junior officers felt ‘immense pressure’ to withdraw claims.
Ultimately £1.5m was paid out by SYP to 16 officers.

Coroner’s inquiry

The inquest was held in two parts – mini-inquests for each individual death followed by another generic inquest to consider them all together.
At every mini-inquest a cause of death was given followed by a reading of their blood alcohol level.
Families were denied information regarding the circumstances of the deaths stating that it was ‘not possible’ for ‘all the information’ to be released because of the possibility of criminal prosecution.
The process 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’.
In a public forum, April 18, 1990, relatives heard the recorded blood alcohol level of the deceased and a summary of the evidence. There were factual errors in the summaries.
On 19 November, 1990 inquests resumed in generic form. 12 ‘interested parties’ were represented six of whom were ‘police interests’.
Financial limitations meant 43 families were represented by one barrister and survivors were not represented at all.
Despite protests from the families’ Counsel the Coroner announced no evidence would be heard relating to events beyond 3.15pm since:

• ‘Once the chest was fixed so that respiration could no longer take place the irrevocable brain damage could occur between four and six minutes’
• ‘the latest when this fixation could have occurred would be approximately six minutes past [three] which is when the match was stopped’
• The Coroner therefore added six minutes taking the time to 3.12pm and identified a clear ‘marker’ at 3.15pm.
• The Coroner formed the view that to extend the generic stage of the inquests beyond 3.15pm would require a new causal act that resulted in any one death – he concluded there was no evidence of such an act.
This opinion neglected the significance of the particular circumstances in which each individual died, including the absence of appropriate medical intervention.
At the end of the evidence the Coroner directed the jury on two possible verdicts: unlawful killing and accidental death. He stated ‘the word “accident” could mean anything from ‘no-one could be blamed – to a situation where…there has been carelessness, negligence’ and although accidental it did not mean individuals were absolved from ‘all and every measure of blame’.
On 26 March 1991 the jury retired to consider its verdict. Two days later the jury returned with a nine to two majority verdict of ‘accidental death’.

The Taylor Report

The Prime Minister, Margaret Thatcher, and the Home Secretary Douglas Hurd visited Hillsborough on 16 April. The following day Lord Justice Taylor was appointed by the Home Secretary to conduct a judicial inquiry into the disaster.
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 ‘real cause’ of the disaster, LJ Taylor concluded, was ‘overcrowding’ and the ‘main reason’ was ‘the failure of police control’.
LJ Taylor expressed further concern that the police had initiated a vilification campaign directed towards Liverpool fans.
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’.
The structure of the venue was problematic but he did not accept that it was ‘causative of the disaster’ or that the Leppings Lane terrace ‘was incapable of being successfully policed.’

Judicial review

On 6 April, 1993 six bereaved families applied for a judicial review of the inquest’s accidental verdicts on grounds of irregularity of proceedings; insufficiency of inquiry; and the emergence of new facts or evidence. These effectively were test cases for all those who died.
On 5 November, 1993 Lord Justice McCowan rejected the families’ submission the accidental death verdicts were in error.
He questioned the purpose of a fresh inquest when the police had already been criticised and the SYP had ‘admitted fault’.

The Stuart-Smith Scrutiny

On 30 June, 1997, over 40 families met the Labour Government Home Secretary, Jack Straw and an independent judicial scrutiny of new evidence was agreed to be led by Lord Justice Stuart-Smith.
The Scrutiny 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’.
On 18 February, 1998, the bereaved families met Mr Straw where 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, judgements, rulings or inquest verdicts.
The families rejected the report.

Private prosecution

On 6 June, 2000 David Duckenfield and Bernard Murray were committed for trial after the Hillsbrough Family Support Group carried a private prosecution against them.
At the conclusion of the evidence Justice Hooper identified four questions for the jury to consider.
• ‘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’.
• 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’.
Justice Hooper noted the ‘huge difference between an error oc judgement and negligence’ and said 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?
The jury found neither Murray nor Duckenfield guilty of negligence.

Beyond the private prosecution

The Hillsborough Family Support Group (HFSG) continued its campaign for full disclosure of all documents.
In April 2009 Secretary of State for Culture, Media and Sport Andy Burnham committed the Government to disclosing the documents and waiving the 30-year restriction of government documents and public records.
In December 2009 Home Secretary Alan Johnson announced the appointment of the Hillsborough Independent Panel.

Medical evidence

Medical evidence underpinned the notion that after 3.15pm no response could have helped.
Circumstances surrounding all the deaths were treated as ‘exactly the same’ but a detailed review casts doubt on a single unvarying pattern.
28 of those who died did not have traumatic asphyxia with obstruction of the blood circulation meaning it may have taken significantly longer to be fatal.
In 31 the heart and lungs continued to function after the crush and in 16 of these this was for a prolonged period.
It is highly likely that what happened to these individuals after 3.15pm was significant in determining their outcome.
Repeated attempts were made to support the theory that alcohol contributed to the disaster but the alcohol consumption among the dead was unremarkable and not exceptional for such an occasion.
An attempt was made to impugn the reputations of the deceased by carrying out Police National Computer checks on those with a non-zero alcohol level.
There was no evidence to support the proposition that alcohol played any part in the causes of the disaster.

Review and alteration of statements

Prior to the Stuart-Smith Scrutiny an South Yorkshire Police 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.
The justification put forward was the removal of personal opinion and conjecture but it was clear the statements were also amended to remove criticism of senior officers and their management of the crowd.
400 recollections were sent to solicitors representing SYP who returned them with recommendations for review and alteration.
116 of 164 statements made by SYP officers and SYAM were initially handwritten as ‘recollections’, then subjected to a process of ‘review and alteration’ involving SYP solicitors and a team of SYP officers.
Detective Chief Superintendent Nick Foster of the West Midlands Police investigation team informed the Stuart-Smith Scrutiny that in five out of a sample of six amended statements material should not have been removed.
These commonly included any indication that senior officials had lost control of events.
One account: ‘I at no time heard any directions being given in terms of leadership. The only messages I heard were those requesting assistance of one sort or another’
Police Constable Maxwell Groome’s observation that ‘The Control Room seemed to have been hit by some sort of paralysis’ was deleted.
As was: ‘Certain supervisory officers were conspicuous by their absence. It was utter chaos.’
References to a lack of communication were deleted such as Police Constable Philip Dexter’s recollection: ‘I have only one observation to make on the events of the game and that was the lack of communication whilst inside the ground. I did not know what was going on.’
23 officers had references to ‘chaos’, ‘fear’, ‘panic’, and ‘confusion’ altered or deleted from their original recollections.
A brief, undated, note to officers states that ‘no CRITICISMS’ should be ‘levelled at anyone in the text of your summary’ and there ‘should be no mention of the word CHAOTIC or any of its derivatives which would give rise to the assumption that complete control had been lost at the ground’.
In 33 cases statements that showed inherent bias against Liverpool fans were removed.
For example Police Constable Hemsworth’s account was amended as follows:’ …it was hopeless; the louts would not cooperate’
Review and altercation of statements was not confined to SYP, a similar process was adopted by the South Yorkshire Metropolitan Ambulance Service.
Statements from 101 ambulance personnel were submitted and in 17 cases amendments were made to material which might have been perceived as negative towards SYMAS.
It was the understanding of the Taylor inquiry that the altercations only involved removing officers’ opinions. The inquiry admitted there was ‘absolutely no reason’ why opinion should be removed but did not consider the process improper.
A significant number of SYP officers were uncomfortable with the reviewing and altering of their initial accounts and with the role of the SYP’s solicitors in this process.
One officer stated he had considered it an ‘injustice for statements to have been doctored to suit the management of South Yorkshire Police’.
Lord Justice Stuart-Smith said the process reflected an ‘understandable desire’ to protect the interests of the Force and were ‘at worst an error of judgement’.
The disclosed documents show the role played by the Force solicitors was more significant and directive than was understood by Lord Justice Stuart-Smith.

Behind the headlines

Duckenfield first claimed Liverpool fans had broken into the stadium and caused the crush. This allegation was later discredited but not before it had already become the first explanation for the disaster.
Further serious allegations came from a Police Federation spokesperson and a Conservative MP, Irvine Patrick that Liverpool fans had deliberately arrived late, many were without tickets, were exceptionally drunk and aggressive and determined to force entry into the stadium.
On 19 April The Sun published a story under the headline ‘THE TRUTH’ alleging Liverpool fans had assaulted and urinated on police officers, stolen from the dead and verbally and sexually abused an unconscious young woman.
The Sun wrote to the bereaved families who had complained about the allegations and refused to apologise for its ‘substance’.
The allegations were filed by White’s New Agency, a Sheffield-based company. They were based on meetings between agency staff, police officers, Irvine Patnick MP, South Yorkshire Police Federation Secretary Paul Middup.
On the morning the article was published officers and SYP’s Chief Constable agreed a ‘defence’ had to be prepared, a ‘rock solid story’ presented and that ‘blame’ should be directed towards ‘drunken ticketless individuals.’
From the mass of documents, television and CCTV coverage disclosed to the Panel there is no evidence to support these allegations.

The full report can be viewed here 

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About TomTom
“Having studied English at university and always been a keen footballer and fan, combining the two has always appealed to me.” - Tom Lytton-Dickie. -"I'm a recently qualified journalist and I've worked in newspapers and broadcasting. I'm a dedicated follower of all sports primarily football, tennis and cricket." Tom Allnutt

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