The report of the Hillsborough Independent Panel HC 581

1 HillsboroughThe report of the Hillsborough Independent PanelSeptember 2012 Return to an Address of the Honourablethe House of Commonsdated 12 September 2012forThe report of the Hillsborough Independent PanelOrdered by the House of Commons to be printed on 12 September 2012HC 581 London: The Stationery Office Hillsborough Independent Panel 2012 All intellectual property rights for this report belong to Hillsborough Independent Panel and/or third parties (which may include you or other users). Nothing in these terms grants you a right or licence to use any of the intellectual property rights owned or controlled by the Hillsborough Independent Panel without the prior written permission of the Editor-in-Chief: in these terms grants you a right or licence to use any of the intellectual property rights owned or controlled by any other third party and you acquire no ownership of intellectual property rights or proprietary interest in any of the materials on this publication is available for download at document is also available from our website at.

2 9780102980356 Printed in the UK for The Stationery Office Limited on behalf of the Controller of Her Majesty s Stationery OfficeID P002501090 09/12 22947 19585 Printed on paper containing 75% recycled fibre content 1 report summary 3 Part 1: Hillsborough : what was known 27 Part 2: Hillsborough : what is added to public understanding 59 Chapter 1. 1981 1989: unheeded warnings, the seeds of disaster 61 Chapter 2. The moment of 1989 87 Chapter 3. Custom, practice, roles, responsibilities 103 Chapter 4. Emergency response and aftermath: routinely requested to attend 131 Chapter 5. Medical evidence: the testimony of the dead 159 Chapter 6. Parallel investigations 181 Chapter 7.

3 Civil litigation 227 Chapter 8. The Coroner s inquiry: from the immediate aftermath to the preliminary hearings 255 Chapter 9. The generic hearing, Judicial Review and continuing controversies 271 Chapter 10. The cut-off 291 Chapter 11. Review and alteration of statements 315 Chapter 12. Behind the headlines: the origins, promotion and reproduction of unsubstantiated allegations 341 Part 3: The Permanent Archive for the Hillsborough Disaster 369 Appendix 1. Hillsborough Independent Panel terms of reference 377 Appendix 2. Disclosure process 381 Appendix 3. Research process and method 387 Appendix 4. Retained tissue following post mortem examination 391 Appendix 5. Freedom of information and Parliamentary debate 393 Contents1 ForewordThe fourth-century philosopher, Lactantius, wrote:The whole point of justice consists precisely in our providing for others through humanity what we provide for our own family through 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.

4 The disclosed documents show that the bereaved families met a series of obstacles in their search for Hillsborough Independent Panel , in accepting its terms of reference from the Home Secretary, acknowledges the legitimacy of the search for justice by the bereaved families and survivors of Hillsborough through the disclosure of documents relating to the disaster and its Panel was asked to consult with the Hillsborough families. We decided to meet with the three established groups on the very first day that we met as a Panel . Our meetings with the groups that day were the foundation of the Panel s work in the intervening two and a half years. In that period, we have made contact with at least one member of each of the families bereaved by Hillsborough . This includes a number of families who are not affiliated to any of the established groups.

5 We should like to pay tribute to the individual families and to the representative groups. Their comments have informed the work of the Panel . But, more than that, the Panel has been impressed constantly by the determination of the families and survivors and by their dignity in their search for justice. This came to the fore when, in 2009, the Hillsborough Family Support Group met the Home Secretary, who then took the decision to appoint the Hillsborough Independent Panel has overseen full public disclosure of information relating to Hillsborough . The new Hillsborough website makes this information available publicly. Most of it is now being published for the first Panel was also asked to illustrate how the information disclosed adds to public understanding of the tragedy and its aftermath. The Panel does so through this report , firstly by providing an overview of what was previously known and then by explaining, in 12 chapters, how the disclosed information changes public the Panel began its work in February 2010, it could not and did not know whether the information it would reveal would add to public understanding and change that Foreword2 The report of the Hillsborough Independent Panelunderstanding.

6 Over the intervening months, we have discovered that the information disclosed will add significantly to public Panel was also asked to consult with statutory agencies in securing maximum possible disclosure of the documents. The Panel is grateful for the cooperation of over 80 organisations who made available their own records, and especially to South Yorkshire Police who set an example for the process of over 30,000 came to Anfield for the 20th Anniversary of Hillsborough , it showed that the wound of grief was still sore because so many questions were yet unanswered. These disclosed documents address many of those questions. The Panel , which was set up deliberately and distinctly from an inquiry, produces this report without any presumption of where it will lead. But it does so in the profound hope that greater transparency will bring to the families and to the wider public a greater understanding of the tragedy and its aftermath.

7 For it is only with this transparency that the families and survivors, who have behaved with such dignity, can with some sense of truth and justice cherish the memory of their 96 loved Right Reverend James Jones, Bishop of LiverpoolSeptember 2012 report summary3 IntroductionOn 15 April 1989 over 50,000 men, women and children travelled by train, coach and car to Hillsborough Stadium, home of Sheffield Wednesday Football Club, to watch an FA Cup Semi-Final between Liverpool and Nottingham Forest. It was a sunny, warm, spring day and one of the high points of the English football was a neutral venue, like so many stadia of its time a mix of seated areas and modified standing terraces. As the match started, amid the roar of the crowd it became apparent that in the central area of the Leppings Lane terrace, already visibly overcrowded before kick-off, Liverpool fans were in considerable fact, the small area in which the crush occurred comprised two pens.

8 Fans had entered down a tunnel under the West Stand into the central pens 3 and 4. Each pen was segregated by lateral fences and a high, overhanging fence between the terrace and the perimeter track around the pitch. There was a small locked gate at the front of each crush became unbearable and fans collapsed underfoot. To the front of pen 3 a safety barrier broke, creating a pile of people struggling for breath. Despite CCTV cameras transmitting images of distress in the crowd to the Ground Control Room and to the Police Control Box, and the presence of officers on duty on the perimeter track, it was a while before the seriousness of what was happening was realised and rescue attempts were the match was stopped and fans were pulled from the terrace through the narrow gates onto the pitch, the enormity of the tragedy became evident.

9 Fans tore down advertising hoardings and used them to carry the dead and dying the full length of the pitch to the stadium women, men and children died as a consequence of the crush, while hundreds more were injured and thousands traumatised. In the immediate aftermath there was a rush to judgement concerning the cause of the disaster and culpability. In a climate of allegation and counter-allegation, the Government appointed Lord Justice Taylor to lead a judicial followed, over an 11-year period, were various different modes and levels of scrutiny, including LJ Taylor s Interim and Final Reports, civil litigation, criminal and disciplinary investigations, the inquests into the deaths of the victims, judicial reviews, a judicial scrutiny report summary 4 The report of the Hillsborough Independent Panelof new evidence conducted by Lord Justice Stuart-Smith, and the private prosecution of the two most senior police officers in command on the this range of inquiry and investigation, many bereaved families and survivors considered that the true context, circumstances and aftermath of Hillsborough had not been adequately made public.

10 They were also profoundly concerned that following unsubstantiated allegations made by senior police officers and politicians and reported widely in the press, it had become widely assumed that Liverpool fans behaviour had contributed to, if not caused, the 2009, at the 20th anniversary of the disaster, Andy Burnham, Secretary of State for Culture, Media and Sport, announced the Government s intention to effectively waive the 30-year rule withholding public records to enable disclosure of all documents relating to the July 2009 the Hillsborough Family Support Group, supported by a group of Merseyside MPs, presented to the Home Secretary a case for disclosure based on increasing public awareness of the circumstances of the disaster and the appropriateness of the investigations and inquiries that Home Secretary met with representatives of the Hillsborough Family Support Group and in January 2010 the Hillsborough Independent Panel , chaired by James Jones, Bishop of Liverpool, was remit of the Hillsborough Independent PanelThe remit of the Hillsborough Independent Panel as set out in its terms of reference was to.