The Rt Hon Lord Justice Taylor

“ But the final surge at 3.04 pm, and the struggle to reach the open gates, caused a horrendous blockage of bodies. The dead, the dying and the desperate became interwoven in the sump at the front of the pens, especially by the gates. Those with strength left clambered over others submerged in the human heap and tried to climb out over the fence. They were now helped by police and other fans who hauled them up and over. Numbers of fans were climbing over the radial fences into adjacent pens. At the back, many were hauled up into the west stand to relieve the pressure. ”

“ Play was still going on and I was in a terrible position trying to concentrate on play and having my attention taken by what was happening behind me. The ball came down to our end and Nottingham Forest won a corner, it was taken and we cleared our box area and as play was going forward over the centre line I heard a shout, 'Bruce - please help' - a desperate shout from a fan squashed up against the fencing to the right of my goal as I looked at Leppings Lane terraces. ”

“ It is fair to state that over many years the South Yorkshire Police have given excellent service to the public. They have handled crowd problems sensitively and successfully at a large number of football games including major matches, during strikes in the coal industry and the steel industry, and in other contexts. Unfortunately, their policing on 15 April broke down in the ways already described and, although there were other causes, the main reason for the disaster was the failure of police control. ”

“ A drunken fan tried to push him off: a beer can was thrown at a mounted officer. But these were isolated acts by individuals; the menace came from the massive numbers single-mindedly determined to be in for the kick-off with time running out. At the back of the crowd fans were frustrated by the lack of progress as 3 o'clock approached. Some, mostly young men who had been drinking, tried to push and force their way forward. At the front, people were jammed together and against the turnstile walls. Some panicked as the pressure intensified. ”

“ Even taking the highest figure suggested in the Green Guide, the problem remained that those supposed to be monitoring pens visually had and have little idea of what 54 persons per 10 square metres look like. Mr Duckenfield's opinion was that when a pen was full to capacity, the spectators would be "shoulder to shoulder and chest to back". That view may derive from seeing the sort of density crowds regularly endure without injury resulting. But it is much more dense than the Green Guide maximum. ”

“ The Operational Order for each match at a designated stadium should enable the police to cope with any foreseeable pattern in the arrival of spectators at a match and in their departure. It should provide for sufficient reserves to enable rapid deployment of officers to be made at any point inside or outside the ground. ”

“ FIRST AID AND EMERGENCY SERVICES
No Fault by the Emergency Services
296. I say at the outset of this chapter that no valid criticism can be made of the response by the St John Ambulance Brigade, by SYMAS or by the fire brigade on 15 April. Indeed, no represented party ventured any criticism of them. The only attack on SYMAS came from two Liverpool doctors. One claimed that ambulances did not arrive swiftly or with sufficient equipment and that there was a lack of triage. He was proved to be wrong in all three respects. ”

“ A final submission was made by Counsel for the South Yorkshire Police that since the investigation by West Midlands Police is still continuing, all the evidence has not been assembled and it would be unsafe for me to make findings of fact. I should therefore make clear that the investigation continues principally to furnish as much detail as possible to HM Coroner for the City of Sheffield as to the cause of death, the precise position at death and the care and movement of each of the 95 victims individually. ”

“ At 3.13 pm a St John's ambulance came onto the pitch at the north-east corner and drove to the perimeter fence close to gate 3. There was no call for doctors and nurses on the public address system until nearly 3.30 pm. Nevertheless, as the minutes ticked past, some of them came onto the pitch to help of their own accord when they saw the casualties and the ambulance and realised the gravity of the situation. Many fans also worked prodigiously in attempts to revive the dead and the dying, in some cases their own relatives and friends. ”

“ There remains, however, the question whether there are some grounds or parts of grounds where the club may need to rely upon the police (whom they pay to attend) to control filling of pens and monitoring them for overcrowding. In other words, whilst the duty in law to ensure safety rests upon the club, they may need, and by agreement be entitled, to employ the police to act as their agents in certain circumstances. This very difficult and grey area as to club and police responsibility will need to be reviewed in greater depth at stage two of this Inquiry. ”

“ There should be an immediate review of each Safety Certificate by the responsible local authority, which should consult the club in respect of which the Certificate is issued, the police, the fire service, the ambulance service and the building authority. Such a review should include an inspection of the stadium. Its object should be to ensure that the operative conditions of the Certificate are complied with and to add or substitute any condition shown to be necessary as a matter of urgency following the findings and recommendations in this report. ”

“ A police presence is there to assist in the enforcement of law and order. Those responsible for organising a private function, however, have the primary and continuing obligation and responsibility to ensure reasonable safety for those who are invited on to their premises." Mr Justice Popplewell ended that section as follows: "It cannot be too strongly emphasised that it is upon the club, or the occupier of the ground who is putting on the function, that the primary and continuing obligation rests." ”

“ Mr Duckenfield, under pressure of cross-examination, apologised for blaming the Liverpool fans for causing the deaths. But, that apart, the police case was to blame the fans for being late and drunk, and to blame the Club for failing to monitor the pens. It was argued that the fatal crush was not caused by the influx through gate C but was due to barrier 124a being defective. Such an unrealistic approach gives cause for anxiety as to whether lessons have been learnt. It would have been more seemly and encouraging for the future if responsibility had been faced. ”

“ Mr Duckenfield feared that the crowd might turn hostile or might all attempt to leave together thereby hampering the emergency services if they were given information about what had happened. The result was that apart from those close enough at the west end to see the terrible truth for themselves, the majority of the crowd were left in ignorance. Many, especially Nottingham supporters in the Kop, still thought there had been a pitch invasion or other misbehaviour by Liverpool fans. ”

“ At each match, there should be on the perimeter track, for each self-contained pen or other terraced area, a steward (if the club is monitoring that area) or a police officer (if the police are monitoring it) whose sole duty is to check crowd conditions in that area for possible overcrowding or distress throughout the period the area is occupied by spectators. Whoever is so appointed should be in addition to any other steward or police presence. He should have ready access to the police officer authorised under Recommendation 9 below, and by radio to the control room. ”

“ The layout of the turnstiles and the number they were required to serve left no margin of safety against an uneven flow of fans. Because police strategy in advance and on the day did not cater for it, the arrival of a large number of supporters between 2.30 pm and 2.40 pm created an unmanageable crush. The presence of a substantial minority of fans who had drunk too much aggravated that problem. Having lost control and rejected the option of postponing kick-off, the police were faced with a serious danger of deaths or injuries. ”

“ A number of individual officers and fans worked frantically to free those trapped but the gateways were so narrow that only two or three could get at the entwined bodies Willing hands got in one another's way. More officers arrived from the gymnasium and elsewhere in the ground. Many used their own initiative to help those laid out on the pitch, to assist in getting others over the fencing and to comfort the distressed. But some stood in groups near the perimeter fence not knowing what to do. ”

“ There was a meeting of the emergency services in August 1988 to discuss procedure in the event of a major disaster at Sheffield Wednesday's ground. It was pointed out and minuted that "It was imperative that the Police Control give the exact location of any fire or incident and as much detail as possible. No senior fire officer is on duty at the match... Fire service will attend via Penistone Road or Leppings Lane as directed by the police."
20. The message from PC Bichard contained all the necessary information - Leppings Lane end, hydraulic cutting equipment, to cut metal fences. ”

“ Whilst the Club, Dr Eastwood, the Officer Working Party and the local authority can be criticised for failing strictly to conform to the Guide, the real failure was common to all those who have been responsible for considering safety on the terraces. The anxiety to protect the sanctity of the pitch has caused insufficient attention to be paid to the risk of a crush due to overcrowding. ”

“ Within the control room, there should be a public address system to communicate with individual areas outside and inside the ground, with groups of areas or with the whole ground. Important announcements should be preceded by a loud signal to catch the attention of the crowd despite a high level of noise in the ground. ”

“ The football continued to joyous shouting and singing round the rest of the ground while those crushed and trapped slowly expired.
80. When Mr Greenwood's signals to move back proved fruitless, he tried to radio for the match to be stopped. At first, his message was not received by control, so he signalled with his arms towards the control box. Mr Duckenfield sent Mr Murray down from the box to have the match stopped via the linesman, the agreed emergency drill. Before he could do so, Mr Greenwood ran over the pitch to the referee who stopped the game. ”

“ Obviously, an open gate is a more ready escape route than one which has to be locked. Secondly, the sight of open gates will be reassuring to spectators on the terraces. Thirdly, the existence of gaps in the fencing by reason of the open gates will concentrate the minds of police officers or stewards on the track to the need for careful monitoring of those on the terraces. ”

“ The Officer Working Party had discussed in 1985 the need, and Dr Eastwood's various schemes, for improvement of the turnstile arrangements. The mathematics are elementary. Both the police and the Club should have realised that the Leppings Lane turnstiles and the waiting area outside them would be under strain to admit all the Liverpool supporters in time. Success depended on the spectators arriving at a steady rate from an early hour and upon the maximum turnstile rate being maintained. ”

“ Experience in recent years has produced a policy of segregation to prevent trouble between supporters of rival teams. The need for this policy to be maintained was endorsed and emphasised by the Popplewell Report following the Bradford City disaster in 1985. Accordingly, before the 1988 semi-final the police decided that sections of the Hillsborough Stadium should be allocated so as to achieve efficient segregation of Liverpool and Nottingham Forest fans. ”

“ They believe the discomfort will pass and nothing very untoward will happen. Usually that is the case and they are reassured by it. Most clubs have not, until very recently, consulted their supporters as to their grievances or suggestions. The practice has been to pack them in on the assumption that if they are prepared to put up with it the conditions must be tolerable. Although crowd figures at football grounds have been reduced in recent years, this has been due principally to the increased proportion of seating as against standing accommodation. Terraces have still been packed. ”

“ All police officers and stewards with duties in relation to the terraced areas and especially those with duties under Recommendation 5 above, should be fully briefed and trained with regard to the recognition of crowd densities, to the recognition of signs of distress and to crowd dynamics. Training should include demonstrations at the ground and photographs, designed to enable stewards and officers to recognise different crowd densities. ”

“ The nerve centre for police control is the control room or box situated at the south-west corner of the ground between the south stand and pen 1 of the west terracing. The box is elevated and reached by a number of steps. It has windows commanding views across the pitch and straight along the line of the west perimeter fence. The box is very small and has seats for only three officers. Superintendent Murray was in control of it and was advisor to Mr Duckenfield as he had been to Mr Mole the year before. ”