UK: Ninth anniversary of the publication of the Report of the Hillsborough Independent Panel

12 September was the ninth anniversary of the publication of the Report of the Hillsborough Independent Panel, which set out the truth about what happened at Hillsborough football stadium in 1989: failures by the police and the football club to ensure safety measures, combined with a lack of coordination amongst emergency services, caused the deaths of 97 people following a crush in one of the stands. Here, we reproduce an extract from Phil Scraton's book, 'Hillsborough: The Truth', along with the presentation he gave at the launch of the Independent Panel's report in 2012.

12 September 2021: Ninth Anniversary of the Launch of the Report of the Hillsborough Independent Panel

Phil Scraton

The extract is from Hillsborough: The Truth, published 2016

Followed by my presentation at the HIP Launch, 12 September 2012


Wednesday, 12 September 2012 was the day the Hillsborough families and survivors had anticipated with hope. A day when their patient wait for the Hillsborough Independent Panel’s report would confirm the ‘truth’ as they knew it, bringing official acknowledgement of the injustices they had endured and public recognition of their suffering. The launch of the panel’s report, in closed session to the families first, was scheduled for 9 a.m. in the Nave – known as the ‘Well’ – of Liverpool’s Anglican Cathedral, to be followed immediately by the Prime Minister’s response beamed live from the House of Commons to the families.

I visited the cathedral the previous evening with Bill Kirkup to familiarise ourselves with the environment. A stage had been constructed, the width of the Well, accommodating a lectern and a row of seats for the panel. Looking out from the lectern the location was impressive, the rows of chairs for the many bereaved family members nestling in the Well below, the cathedral’s impressive Gothic-style pillars imposing solemnity appropriate to the occasion. I had harboured reservations about locating the launch in a cathedral associated with one denomination in a city historically divided by religion. I also had concerns for those with no religious beliefs. My reservations were not shared by the families and as we sound-checked the audio equipment they dissolved. It was a magnificent venue. I requested that the pink neon-lit phrase ‘I felt you and I knew you loved me’ above the doors be switched off. An installation by Tracey Emin, it seemed inappropriate in the circumstances.

I returned early next morning as dawn broke. The cathedral stands high on the city’s south side. A view I know so well – across the Mersey to Birkenhead and Wallasey, to the Welsh hills beyond and out to the Irish Sea. I paused on the steps to take it all in, places of my past, and thought of the families and survivors leaving their homes or hotels to make their journeys. For twenty-three years and five months, almost to the day, they had waited to hear the words I now knew so well, to view the PowerPoint slides I had written and uploaded for the presentation, and to receive the 395-page report. I thought of those who would not be with us, whose lives had been taken prematurely by the grief of loss and pain of injustice.

Inside the cathedral the final preparations were under way. Panel members and the secretariat arrived; we shared a light breakfast. For the first time we held the hard copy of the report in our hands. It had been driven overnight to Liverpool ready for distribution to the families, survivors and, eventually, to the waiting journalists. What for months had been a virtual reality, restricted to the multiple edited versions on my computer, was now a weighty physical reality. It was an impressive feat of production, with every textual reference within the online version live-linked to the relevant document held in the digital archive. Scanning the pages, I realised the families were arriving in the reception area. I went to meet them, to share tea and a journey’s end.

Soon we were together in the Well: the panel members on stage, the secretariat to the sides and the families seated below. No journalists were present and what followed was neither filmed nor recorded. We had remained resolutely committed to the ‘families first’ principle. I was aware that at that moment the Prime Minister was being briefed. Bishop James Jones, the panel’s chair, welcomed the families and introduced the panel. During the next 90 minutes I delivered the research findings, pausing only for Dr Bill Kirkup’s meticulous presentation of the conclusions drawn from medical evidence. There was silence throughout, interspersed with occasional gasps in response to the revelations.

1. The Panel’s Terms of Reference

2. The Report Structure

3. Permanent Archive

4. Appendices

5. Chapter 1 1981-1989

This chapter assesses the impact of the 1981 crush and the decisions taken between 1981 and 1989 by SWFC, the safety consultants, SCC and the SYP regarding modifications to the LL terrace and its consequences for crowd safety.

  • 1981 FA Cup Semi-Final: a near disaster: Serious congestion at turnstiles/ outer concourse. Opening of gate C. Crushing on terraces/ injuries/ evacuation of fans onto perimeter track. Sideways movement, full length of the terraces.
  • 1981 aftermath: breakdown in SYP and SWFC relations: SWFC considered the 1981 incident exaggerated.
  • Inadequate and poorly recorded inspections
  • Terrace alterations: a growing danger: Pens introduced/ Turnstiles unchanged, same concentration of fans on the outer concourse/ No direct feed from turnstiles to pens/ No revision of the Safety Certificate.
  • Prioritising crowd disorder ahead of crowd safety: SYP continued to stress their crowd management-disorder priority; SWFC focused on costs.
  • Further imminent warnings: 1987 and 1988 Semi-Finals

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

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

6. Chapter 2 The ‘Moment of 1989’

This chapter considers the lead up to the 1989 Semi-Final returning to key issues covered in the Taylor Report and extending the analysis focusing on the following key issues:

  • Flawed management: SYP; SWFC; FA
  • SYP Operational Order: complacent and deficient
  • Crush at the turnstiles
  • Overcrowding in the central pens
  • Opening Gate C: not anticipating the consequences
  • Failure to seal access to central pens

Concluding Comment: The documents disclosed to the Panel reveal that the flaws in responding to the emerging crisis on the day were rooted in institutional tension within and between organisations.

This was reflected in: a policing and stewarding mind-set predominantly concerned with crowd disorder; the failure to realise the consequences of opening exit gates to relieve congestion at the turnstiles; the failure to manage the crowd’s entry and allocation between the pens; the failure to anticipate the consequences within the central pens of not sealing the tunnel; the delay in realising that the crisis in the central pens was a consequence of overcrowding rather than crowd disorder.

7. Chapter 3: Custom, Practice, Roles, Responsibilities

Concluding Comment: Police custom and practice had evolved in response to crowd management issues unique to FA Cup Semi-Finals, particularly filtering of access to the concourse through ticket-checking on the approaches, directing incoming spectators away from the central pens when they were estimated to be near capacity, and closing the tunnel when capacity was estimated to have been reached.

None of these practices was recorded and none formed part of the Operational Order or the police briefings before the match.

Throughout the 1980s there was considerable ambiguity about SYP’s and SWFC’s crowd management responsibilities within the stadium.  The management of the crowd was viewed exclusively through a lens of potential crowd disorder, and this ambiguity was not resolved despite problems at previous semi-finals.  SWFC and SYP were unprepared for the disaster that unfolded on the terraces on 15 April 1989.

8. Chapter 4 Emergency Response and aftermath: ‘routinely requested to attend’ Dr Bill Kirkup

9. Chapter 5 Medical Evidence; the testimony of the dead Dr Bill Kirkup

10. Chapter 6 Parallel Investigations

The investigation and inquiry into its circumstances and causes inevitably was complex. Because there were fatalities the Coroner was involved immediately. Within the South Yorkshire Police [SYP] an internal investigation was established including a process of information-gathering involving ‘self-taken’ statements by police officers.

Lord Justice Taylor appointed to conduct a judicial inquiry. Chief Constable of West Midlands Police [WMP] invited to establish a full investigation carried out by a WMP team. The WMP team served the criminal investigation, the Taylor Inquiry and the Coroner’s inquiry and inquest, resulting multiple investigations proceeded in parallel.

Concluding Comment: It is evident from the disclosed documents that from the outset of each the SYP sought to establish a case emphasising exceptional levels of drunkenness and aggression among Liverpool fans, alleging that many arrived at the stadium late, without tickets and determined to force entry. The Health and Safety Executive investigation found that restricted access, poor condition and inadequate means of escape rendered the Leppings Lane Terrace – particularly its central pens - structurally unsafe. This risk was known.

11. Chapter 7 Civil Litigation

  • SYP settlement of claims, November 1989: Settlements made for legal/ tactical reasons; Deliberately settled without admission of liability.
  • SYP legal action to reclaim contributions: SWFC: £1.5m; Eastwoods: £1.5m; SCC: £1m.
  • Cost of compensation to the injured and bereaved: Initial estimate: £12m, rose to £19.8m; SYP’s insurance = £8.5m, rest paid by Police Authority’s reserves and Home Office special payments.
  • Compensation payments to police officers: Junior officers pressured with SYP to withdraw their claims; £1.5m paid to 16 officers; costs met by SYP insurers.

12. Chapter 8: The Coroner’s Inquiry: immediate aftermath to prelim hearings

The inquest in two separate parts: initial phase was a series of preliminary hearings or ‘mini-inquests’, one for each death, to be followed later by a single generic inquest to consider the circumstances of the disaster. The decision to hold separate preliminary hearings had far-reaching consequences.

  • Decision to hold preliminary hearings/ mini-inquests: Coroner: ‘response to families lawyers’ submissions; actually he had been advised on this course of action by his Counsel; initially resisted by WMP.
  • Procedures for presenting evidence to the jury: WMP role; undermined reliability of evidence put to the inquest; raises serious questions about ‘sufficiency of inquiry’.
  • Agreement for the procedures with families’ lawyers: The expectation was a full examination of all unanswered questions at generic stage.
  • Families’ dissatisfaction with the mini-inquests: Disclosed documents show that while the families’ lawyers welcomed the Coroner’s unusual decision to hold individual, preliminary hearings – and recorde their satisfaction at their conclusion - many families were dissatisfied with the denial of opportunity to inquire into the precise circumstances in which their loved ones died.
  • Yet Coroner assumed success of mini-inquests

13. Chapter 9: The generic hearing, Judicial Review and continuing controversies

  • Coroner’s decision not to rely on the Taylor Inquiry: Coroner decided against incorporating Taylor.
  • Contested status of/ access to investigation documents: The documents disclosed to the Panel show that there were concerns raised in discussions between the Coroner and the West Midlands Police investigators about the status and ownership of information gathered and statements made for the Taylor Inquiry and the criminal investigation; Released to SYP on the basis that they would not be used in preparation for the inquests; to fulfil the expectation that the Coroner had all documents available to him they were delivered to his home for a few days.
  • Concerted attempt to reverse Taylor findings: It is clear that the South Yorkshire Police considered that the generic hearings presented an opportunity to use the court to respond to criticisms levelled against the Force and its senior officers by LJ Taylor’s Interim Report.
  • Emphasis on drunkenness, ticketlessness, conspiracy, violence: Emphasis on drunkenness, ticketlessness and ‘conspiracy to enter’; Despite Taylor’s findings the Coroner accepted that there could be a relationship between alcohol consumption/ ‘late arrival’/ crowd behaviour YET no independent evidence in the documents.
  • The judicial review: While the High Court in the judicial review proceedings considered that the inquests had been unorthodox it did not consider that the process had been insufficient in establishing how the deceased came by their deaths.
  • The Stuart-Smith Scrutiny: Raised questions with Coroner that families had been misled re. mini-inquest; considered the generic hearing had become ‘out-of-control’.

14. Chapter 10: The 3.15pm cut-off

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

  • Scope of inquests: origins of the 3.15pm cut-off

Evidence initially gathered by SYP focused on ‘incident itself’ and specified 3.15pm/3.30pm; Coroner sought advice from other coroners about ‘scope’; it was considered that the ‘response and rescue’ stages should be considered ‘post-incident’.

  • Reliance on the opinions of the pathologists

Previously covered – all who died had suffered irreversible, fatal injuries by this time; supported by pathologists.

  • Role of families’ legal representatives

Accepted the 3.15pm cut-off, stating that families’ objections were minimal.

  • Coroner’s case against extending beyond 3.15pm

Considered that the families misunderstood the role/ function of the inquests; extension would require a new causal act resulting in death post 3.15pm; Families barrister stated to Stuart-Smith that there was no evidence of a new causal act beyond 3.15pm.

  • Alternative case for extending beyond 3.15pm

Families, supported by distinguished medical opinion challenged the certainty of the Coroner’s position; Coroner later accepted that some who died might have survived had resuscitation been administered.

Concluding comment:Documents disclosed show that, considered alongside the restrictions placed by the Coroner on the examination of the evidence presented to the mini-inquests and the presentation of the pathologists’ medical opinion as incontrovertible, the imposition of the 3.15pm cut-off severely limited examination of the rescue, evacuation and treatment of those who died. This raised profound concerns regarding sufficiency of inquiry and examination of evidence.

15. Chapter 11: Review and Alteration of Statements

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

  • Origins of the review and alteration process: Immediate aftermath: 16/17 April to provide SYP and their solicitors with ‘warts and all’ accounts from officers to inform SYP submission to Taylor.
  • The ‘purpose’ of the SYP officers’ written recollections: This initial justification extended from ‘internal purposes’ to use by WMP; known and accepted by Taylor.
  • Transformation of recollections to CJ statements: Claim was to ‘remove conjecture and opinion’; correspondence shows comments ‘unhelpful’ to the Force’s case were ‘altered, deleted or qualified; significant number of officers objected; they were ‘helped’.
  • Significance of review and alteration: Discouraged from criticising senior officers, management and deficiencies in police practice/ response; 116 of 164 were amended to remove or alter comments unfavourable to SYP.
  • Stuart-Smith Scrutiny response: Concern raised with SYP Head of Management Services; SYP officers reiterated their concerns; WMP investigator examined 6 statement, 5 of which should not have been altered; the role played by the SYP solicitors was greater than considered by Stuart-Smith; yet he found no irregularity or malpractice.
  • The South Yorkshire Metropolitan Ambulance Service: Review and alteration extended to SYMAS; variation in amendments but in a number of cases criticism was deflected and efficiency emphasised.

16. Chapter 12: Behind the Headlines

In the days after the disaster the media, particularly the press, published allegations and counter allegations apportioning blame. This came to a head on 19 April when a number of newspapers, The Sun being the most prominent, reported serious allegations about the behaviour of Liverpool fans before and during the unfolding tragedy.

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

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

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

  • Origins and content of unsubstantiated allegations

Duckenfield’s ‘falsehood’; serious immediate allegations from Police Federation and local Conservative MP, Irvine Patnick; conspiracy to arrive late without tickets, exceptionally drunk, aggressive.

  • ‘THE TRUTH’: the story behind the headlines

Part of wide coverage first in Evening Standard the previous evening; Story filed by small news agency in Sheffield and based on four separate conversations with high-ranking SYP officers, with Middup and Patnick; Patnick based his comments on conversations with an officer on the evening of the disaster; while Taylor was in session White’s received selected extracts of several SYP officers’ statements alleging drunkenness/ violence and forwarded these to Patnick.

  • The role of the Police Federation

The morning the Sun article published the PF met to establish a strategy to ‘put our side of the story over to the press and media; The PF secretary stated that while the CC could not state it publicly he had given the PF a ‘free hand’ and his support; he later attended the meeting stating that a ‘defence’ had to be prepared based on a ‘rock solid’ story and that the blame should be directed towards ‘drunken, ticketless individuals’; he believed the Taylor Inquiry would exonerate the SYP.

  • The Taylor Inquiry and the ‘counter-attack’

Following the Taylor Inquiry the Police Federation met with their lawyers and their Parliamentary representative, Michael Shersby; the meeting was introduced as developing a ‘counter attack’ in response to Taylor; the first part of the meeting was addressed by Norman Bettison who presented a film and commentary reinforcing the SYP position (he later presented this to MPs in a special meeting arranged by Shersby; the second half of the meeting was addressed by unnamed police officers who detailed the allegations; the meeting considered Taylor a ‘whitewash’.

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

As I finished the presentation there was a silent pause; time appeared to freeze. Then families rose, many in tears, to deliver a sustained standing ovation. The report was distributed to the families, the Prime Minister made his parliamentary address, we presented our findings to survivors from the Hillsborough Justice Campaign, followed by a press conference in the Lady Chapel where journalists had received the report an hour earlier.

We Never Walk Alone

Image: Beverley Goodwin, CC BY-SA 2.0


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