zmsigu.
sisail®*
mitm
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*Sr
PETER TOOTLE
1.
Peter Tootle,
Tootle,
the son of the Applicants Peter and Joan
attended
the
match
with
a
friend,
j'V-
Colin
ST*
Frodsham.
2.
The y were both in enclosure 3.
At the mini
inquest Dr. David Slater
m
put forward his
Ig*
,
vi e w that the
cause of death was
The rest of the
John Killock
which,
traumatic asphyxia.
ge
evidence was given by Police Sergeant
and Detective
wh e n taken
Inspector Michael
together,
chronological account.
produced the
Colin Frodsham
L a yto n
following
was separated
fro m Mr. Tootle when the crowd in the enclosure surged
forward,
after
came round he
which he
saw Mr. Tootle lying on the
police officer
about 1 0 - 2 0
3.40 p.m.
the end
fell unconscious.
Whe n
ground.
then attempted to resuscitate
seconds.
A
h im for
Atflsome time between. 3.20 anc
Police Constable
of the ground
he
Friend saw Mr.
opposite to the
T oo tl e at
Leppings Lane
end where he examined him and then with P.C. Grifo.i<-h,
carried him into the temporary mortuary.
Peter Tootle was
who
certified dead by Dr.
certified dead
a
total
of thirty
At 3.54 p.m.
M a t t he w Eull,
Hills bor ou gh
victims in a period of twenty minutes.
At the main inquest no evidence whatsoever was addu ce d
whi ch related to Peter Tootle.
ANNAAD
His name was me n t i o n e d
^
only when the verdicts were returned.
Yet the purpose
of the main
the question of
inquest was to deal with
ho w Mr. Tootle met his death.
4.
The complaint of the
Applicants therefore extends far
beyond one levelled at
di sallow
the decision of the coroner to
evidence relating
after 3.15 p.m.
to
events that
occurred
More fundamentally it concerns thei r
belief that there has been no inquest at all, into the
most important
question concerning their
sons death,
namely how he came to die.
5.
This
is so not merely
because no
this
issue was
at
because the
jury
as
evidence.
^
heard
issue
the main
inquest but
of lack of care
a possible
The
evidence concerning
was not put to the
inference to
Applicants
submit
also
draw
from
that the
the
minimum
requirements for a fair and proper hearing at the m a i n
inquest required
jury:
at
a
inquest and
Dr. John
jury should
the evidence
A s ht on and Mr. F.
then have
been informed
that death was aggravated by
them.
ANNAAD
to be put
summary of the evidence that
the mini
Phillips,
the following
before the
had been hear d
of Dr.
Glynn
Eccleston.
that a
The
finding
lack of care was open to
IN QU EST S INTO THE D EATHS OF T H C
V I C T I M S OF THE H I L L S B O R O U G H ,F O O T B A L L
S T A DI UM DI SA STE R
ON THE 1 STH APRIL,
. .
. .
t '---;
-Li'--'
“-------HE
1989
DEATH
PETEP. FPwA-NClS TO OTLE
Or
(S3)
\
INDEX
dr. DAVID NEIL SLATER
By THE C O R O N E R
B
-
Colled
•-
P O L I C E S E R G E A N T JO H N KI LL OC K - C«U« <J
bv THt
,-;nfiS-ex
C r o s s - e x amin ea oy
detective
L i nB
Linti
..
INSFECTOR MICHAEL LAYiON
BY T HE C O R O W E
D
OO
E
F
G
H
Harpham Ltd
I W 4 -
GO"'
Called
Mav 1990
_
F ^ NCI£_TOOSLE
INTO T H E OEATH-Of
HR.
PRASES:
__ ^
H
c
o
t
1 2 ^ ” ? ^ e ? V ^ « n ' * ’ *re
l o d i v r e l a t e s 10 t-ev.<=r
^ ai^ ilv s n d I app*ar-ir. a
in C o u r t w i t h merriDers or 1 f^ mi L
a ls o, o f c o u r s e ,
oarsonai capacity r or ^
c-t e e r .-n «» C o m n i t ^ e a in t he usm e m b e r of t h e H i l l s o o r o u g h - t e , r . n a
B
®
asv .
M
-nd Mrs. T o o t l e a n a •
THE CORONER:
Goodm o r n i n g ,
"* „
B e f o r e w e take
e v e r y b o d y elseW h i c h is m um «*n
r i b e ZQ y o u -.he
; _
t he e v i d e n c e I am j us t g o i n g
^
^
t h a t y Q U k n o w W O o.
o r o c e d u r e so that y o u c a n ^
-r is e a s i s r f o r y o u to
c o m e s n e x t , so to s p e a
^
Hhat w e a r e g o i n g to co in
f o l l o w i f i °° t h a w
r e a d ro y o u „ ha t
ths first
l 9 8 9 S « h i c h is w h e n I w a s in tni
h a p pened on
i v t h April. ^
i n ^ i a l e v i d e n c e s o t h a t , _c ?_ a
Court ana 1 dealt w u n .
f u n e r a l a n d w h e n i naV ^
allow t h e b o d y t o c o m e h o m e t o r
^
u i n z r y anG
d o n e t h a t , if ‘. h e r e ^ e ^ n y e r r o r
^
_ ^ .3 ? a r d c u u r
cor re ct themI con t
the blood a l c ohols
c a s e a n d t h e n i w i l l -el
c-l a t e r
w h o is s i t t i n g -?
D
Sihen I have - m p 1 et ec_ t ha.
Dr. - .
^
^
ev;^ - —
t here and who is ° ? a . n o i o = i
icai investigation
-esardin.: the pathoio;
±. - i *—■«— , _ - h ^ 'iiio^t Pli e l a n d s pol ice
On
c
o
m
p
l
e
t
i
o
n
or
tna.
.
pre
sent
the
. . .
.
-jill pr esent
summary
who has prep a r e d a
Insoect or" Lay t on will deal
and when he has c o mp lete d .t
there, Inspec.o.
with the visual e v l G e ^ C®:
a n d \ e l l s me all about iw.
Layton re co u n t s i. ve. Do
^
D ian n u m b e r s and one .hin_
a ives us all the r a : e r e n c «
tn e pi
aU
so
and a n o the r so the shorthanc wr
c a n ^ _
^
^ &
* h « w. M l
M . . 1 U round M r .
or‘
confus in g a. that poin
„ h -t he has b ee n t a ^ - n _
his big plan s he will *"cw u. who. ^
wili find out in a
about.
So it does o e c o m e .c ear_
.. _^^ ^
e viden cs
we
moment • When tJnar is
‘'*ls ^ h a u reasonably c l e a r ^
are de al in g with at that a.ae--^
be.
it will
=
that you know what the * ° ^ at *“r jcu l a r l v ii Y ou have V nlS
sense as we are g o i n g along, p
for el
it, it aoesn in the back of yo u r minesir you
matter.
This
Tihen
is
xhe
r
e
s
-
J
C £ n t n o n y P P * rK i
. ”Y
1 olh
Aoril 1 9 8 9 and on that occasi
A c t i n g ’ C or o n e r ' s Officer, saio:
. n .- t h is Inauest has bee:.
-The body which is the
- ^ he south Y o r k s h i r e
i d e n t i f i e d to PC 192? Fr e
£ £
x Sayponc
P ol ice as that o f Pete:r rra
!
0 *. age havin g
Frodsham, his f n e n c .
He w«i_ - 1 y
1
M
l
S " )
_ .i
. r ,h r M .
a,-v 1963 a :
been
born
single
on
man
Liverpool.
«
' r * rbo!v
livea
.
---------
||
F e o r u a i y ----------
2 n a
ana
U3.3 <=■
Liverpool-
1
occupation-
a. "i» *
ZZ
_“ e .
f o l l o s i n * «n > » « « «
fc
to the n . d i c o L . g »l
tl bl reiov.d
-■ •- -
- h e D o a y to ^
‘
Detective tor.b^ei- t h e r e h e ic e n t 1 f i
i
f i e d t h e s a m e docs
W e i jo I d w h o s u b s e q u e n t l y
‘ . h r h a t ^ h e b o d y shou.
^ = = u „ r .
It i s t h e f a m i l y w i „ h t h a
be
b u r ie d -
! ^hen
wrote
to_you
Hr- T o o t l e , b ut o n W
effect you c o n n r m e a
that
is
still
so,
I
not
-
>
I
a 1 1 th:
isn
.
i£
^
inf0rmation
1-
vou
^
was
ra.~emo«r,
rne a n d
correct
i:
~na
----------------
--- d i d r h , b l o o d a l c o h o l
level
in^
^
D r - . 0 1 !«.= ■.
j
evidence on the tirst a*/
—
P e t e r a n d h e g a v e u.= _ . h u - 1
^
and the r e s u ^
_
resumed,
in
th--.
case
? « «
of
fact,
a. o r .
. S
*P e r naDS
evidence
e v e r y w a y «ho
O a t h so tna~ ha-
° lr„3Sy
Aiaauy
n„„.
been
Now this
as P e t e r
y o u n g m a n we
T o o t 1e o e c a u
r
that
rif-nt?
m
alreacy
^ , e n
- C a l l ed
in
“
- A - tty
t h e u s u a l wo.y;
^
a C o n S , i :t3.u»
an.
^ Rq
CoiU£=
.
-
you
e
-
- ^ o
ar
Wnew
T-iUcine
c .
you ^
^
r
r
e
c
-
a b o u t w h i c h you r e c o r c e
k n o w h i s m l c c i e r.^me
w l o n
number o 9 .
. sir.
r..
-
A 1" h o u g h
^
.
sir-
that
i
has
th
men: ion
COPOHEP:
.— a 7'r
D r . Slater,
if y o u w o u : L d - a »
n a m e is D r - D a v i a N e u
S U - •
Histopathologist ana « r,-.=
Pathology,
today
should
done-
NgIL S LR T FB
P.v T H E
I
»e
h.v.
« U
'*«■
,0
parc el ve a 1 - w^s h
off ic er
the
i n i t i a l identifying Or.ic=r,
rhe
You a r e q u i t e happy
to this young m«n Pete -
yesy
you,
-
■ c
£ i~
* O •
You
A. He -;
^
e v i d e n c e y o u are g i ^ h ,e? . A . C e r t a i n l y , s:r.
^
-yes.
be kind enoug h to tali u^ .
DrSlater, perhaps you ” °r e l e v a n t fi ndings
= c=
what you r fi ndings were J
P e t er s h o w e d tnat *m_
of death? - A- My e x a m i n a t i o n
7h ese were _ _
general findings were . 1 »
_
^ e face exter.cir.x ~o
In di ca te d b Y ,e x t e n S *
°
£T w a s
also a c c o m p a n i e d o y
upDer part of the c
Qn the face c al led pe-ec.ji
nu mero us small ^ ^ J ^ - ^ a g e s
were also P « ^ ” ; , _ 0
haemorrhages.
brain
lungs, hear.
internally
including
in t h .
br*m,
I
I
ox.
T:'f=
vuiCc c <
*r
a
trs.urr.at
ir.iii r.3."
~■
tummy
and
of -:vs
.
*^ 1•
u
to
the
r
sc r-5 ~ c h
larg'a S'cr atch es 1 0
this b Luane =-s --s-i
•sx 5.m m a t ici
•id
CiSVb 1
” 1 fit anc.
i"15 -r-3.33 «'r, ich cou'.i
my coin, ion that ?e'
expect =.nc y and 1. •='
t raumit: Lc asphvx ia
?eter shewed that
-'.5.0 .
.thy , '*>i r-h no •=v '--encs '■;:
con""ibe" i'i :ou«rc3 ces
mi'id h.ius had 3. norms.:. i i■
11V
O p '
Q
c
ird this but, or course.
Seal - :t h what ycur v ;■=•-. :-=
I icnow -he Jury fio'
Can you
h a v e n ’t
~
o
io s 3 or
re £ 3>rc
80
0
•
c «sU—
which p
riec
cibou
are '-or
s
i
r
,
unconsi
c a a t :i,
within :*nrs« ;o f 1
aw ar ene S 3 of any p
after a n c t n a r t;ir ='
:ause o b vi ousl y
I
w o u l d
i jis 5
: n e
the :=-~:
r.£■---=•
?
I"i O V i’is r* -ores, w e
CCP.5C i0 usr.sss or Anyw«y *
S 6 CDP.CS
you
wh ichev er
sir
last ni a »-«t
a case uhersr someo
uncinic iO U 7i£ £ £■' G c
D
Real ly? - A . Y-as , ’He." wcvi
I am pi -B 3 S C tC h e
t S';s 0 e c 0 ie b a c Sc 1 v
c o e s n ‘c thou £ht
mere
- =-
r«u fcr rnfiT;*
TH E Cv^nO Nrz, rc
M r • Fra 3 S r •
;ir . F R A S E R :
k a n
z h e
I ib
i";a v a
would 1
would b *3 3 0 klHu
>u do no*
E CCKCN^
object: on? ~ A . Mo
i
H
n
’
in ot
Q
:ou are here
Q
Ail wOCa^ , ^^ i.d'w'-normal o r oce cur e out
•« c- c:
^
r
i I 1 e x p lain t o
u -' ! • ■■■= : ir.=
tho
I
r.svH -■•♦*.
POLICE
S~PHKANT
JOHN
2 v THE
Q-
HILLOCK
- Colled
COnONc? i
Yes - - A. P o l i c e S e r g e a n t John K i l l o c k of the 'Jest a i c U n c a
Police, sir.
I h a v e p r e v i o u s l y t a k e n the Oath-
Q. W o u l d you p i ea.se. w h e n you ar e ready, take me t h r o u g h the
s u m m a r y ? - A . At 0 9 0 0 hour s on Sa t u r d a y , 15th April i -a v ,
Mr. P e t e r F r a n c i s T o o t l e s e n i o r w o k e h i s son, also n a m e ::
P e t e r F r a n c i s T o o t le, wh o was to a t t e n d to the J i e u u - ' i
fo otba ll m a t c h to b e p l a y e d at H i l l s b o r o u g h P e t e r left L i v e r p o o l at 1030 h o u r s a n d travel l e d^ to
S h e f f i e l d w i t h his uncle, S t e p h e n T o o tle, a n d a ._ierv_^
rolin Frodsham.
T h e y t r a v e l l e d in S t e p h e n T o o t l e
3 <--r
A r r i v i n g in S h e f f i e l d at 1230 hours.
A f t e r p a r k i n g the
v - n i c l e t h e y m a d e t h e i r way to the g r p u n a a n a s t o o a o n the
L a p p i n g s L a n e b r i d g e from 1300 h o u r s until 14 4 0 , hours.
At
t hi s point S t e p h e n T o o t l e left to take h is seat in *tntr
sC'inGb
*
At 1445 hou rs , C o l i n F r o d s h a m and P e t e r j o i n e d ^ t h e c r a v e
at rh e t u r n s t i l e s . ’ G a t e C w a s o p e n e d and b o t h e r - .-rocshsm
and P e t e r e n t e r e d t h e s t a d i u m via that
Th ey
a l o n g the tunnel into Enc l o s u r e No- 3.
Witn tne
the c r o w d f r o m b e h i n d they en dec up a p p r o x i m a t e l y
i <=- i.
fr om t he o e r i m e t e r fenceMr- F r o d s h a m b e c a m e u n c o n s c i o u s
for a sh o rt time.
when he r e g a i n c o n s c i o u s n e s s he r o u n c ^
h i m s e l f f u r t h e r up the terrace- ^ He c o u l d see
his bac k ab out f iv e yar ds awa y irom him.
i her e ^. o . . Offic er , who has not u n f o r t u n a t e l y b e e n icen^i - iec ,
a t t e m o t i n g to r e s u s c i t a t e Peter.
The Officer's attempts
we re u n s u c c e s s f u l and he left P e t e r to a t t e n c
casualties.
Hr- F r o d s h a m was a s s i s t e d fro m the t = r r « c a
subsecuentlv attended hospitalS h o r t l y a f t e r 1505 hours f o l l o w i n g the s e v e r s c r u s m r . g
in the W e s t ‘S t a n d t e r r a c i n g P o l i c e C o n s t a b l e F r i e z e we n t cr. •
to the p i t c h and a s s i s t e d •-i t h _s e v e r e 1 c e s u a 111 es ■^
=
time b e t w e e n 1520 an d 1 5 4 0 ho ur s he s aw a man n«
P e t e r lying on th e p i t c h to the c o r n e r of t h e No rt n -.tan^
and the S p i o n Kop - He exam i n e d r-eter^and then,
a s s i s t a n c e o f a n o t h e r Orricer, y C Gritii<-hs, he c«- ^
P e t e r into t h e g y m n a s i u m wher e a t e m p o r a r y m o r t u a r y n « = o e —
set
up.
At 1 5 5 4 h o u r s Dr. Ma tth ew Jam es Bull e x a m i n e e
the t e m p o r a r y m o r t u a r y and c e r t i i i e d lixe e ^ a n c w
Peter
i..
At 2 2 3 0 h o u r s Mr. Paul R a y m o n d F r o d s h a m i d e n t i f i e s his
f rien d P e t e r to P o l i c e C o n s t a b l e F r i e n d in the t e m p o r a r y
mortuary.
v.^s
A
*
i-
is
*
only
.^n - n -
brids®
01 1 3 3 - r C
-3.1i‘J ■-* l'= I-
____
_
.
a
.
..l i v . - i
-
— - —
3 0 int
but
r >*i-*'.=••=• 'V-
we
5 3.li.
3.=.:*-
.....=
1 - - :J - : '"- _ J u“ -
-,r
•- ■*■
iv s .v e
ano
on •
3c’; " - I
..... ---L- - :iv- t o
— ------.irinCi :' - A- Al'i y O U 1 =-•=!•- - “ =.
:
hii
sr.*r.•=-..=nc , sir?
B
-s'^r~":r:£' to 5 *rs?raph
£in'
J r'=,-_. T‘
2” ; .
r am sorry, i «m
- _r___ - r :,£ r don.
-:«i» ~
of bis statementj. am
i =>-« Yc
Colin F r o d i h a m ‘s s^a^ement. .
.
a-? ? = -er- to t!ie
?c lies Const ab ia rri ena -^ er
I— * r-ica; ion to
Kedico Lesal C e n t r e and c o n n r n e a „ne
Oetsctive C o n s t a b l e iitsisolc- I-, r,md;v
1 6 th Aoril
19 3 1? , Hr- Pater
At 0610 h o u r s on -unc.y
.
L esai Centra
* r » n c U Too-.le w n l o r * « * n c . o
-*r“ *
iv,«
L - he re
ha
c o r
: i rrnac
= B «
io>r.ti:ic..^r.
Constable Kinsells.
C
D
-ha- c h v
following e xa mina tio n oy
..
i-«.i-e:i V.n<rv^
~
OUI Oil cvU wv-w— v
Constab 1e ileigoid, Dr.
c-use of deathIt has
._____ s - rsnort ®’uing the coU^e ->■■■
anc = w ® - - su
- f - er- ^ - c ^ e d via Gate C anc
been e s t a o 1 isnea - i - - --"D Irsonsi effects Mr.
,o u :c:-:et was fou nc in ni= y
V.*i'l~ ;i
was m possess
noes c o m i_ m -•<=- - ---‘ o n e l u c e s rny e v i c s n - - *
£rounc.
here is visual evidencehis is only a
_ -r
——i-ms
• u=.z u
bea
- >-n“or
w- a mo men ^ ”
1^.-iQ thst tne\ ---vial joint but we -=aic
^
*=. sai
bridge and I think cn ?«!= "'jT-t ^
--:;rr inj to the statement, ■='*-
- .
— ins -c oaraeraph two, page
-orry , j- « m •*. •*•-"-- * s
•_
_i .rn's st at em en t .
statement - This is - . i n r-o^n-. m_ s - _
see where you sat 2 --0 _from.
- on r- = •t.= from the statementjr. tna
is hal fw ay
s
i
ve
t
wo
t
i
mei
IC*L 1
--
H
;actually
>s -a actually
hat is not s u r p rnsinc,
i s i n g OV. «- - • __
v
i
d
e
n
c
e
we
.-:n^w v 1 S>ci *
mention 15 2 0 - :^u say some j z ^r,e
hours- _ A. -hat
=-
;icr an d ■5-'
..
-
= d at 1 5 2 0 in that areaK.nere -o
*lS 13
^^
- The two times.
15-0 from, can you rem=-mo-^
“ “ ---- ’ * - ;-n-cr
(*ne is a video soures ar._
.
=m=nt --•
!5 -'J nours , p^fa^
from one or th«
your cocumen-. , .=>—
-hat I couldn't racoliac
Anic vou verv muchit was .>
*____
3 -; friths
o.n- « u
•
7 - h ink vou saic
-une
O
u
h
^
r
po-..v.
-•«•
.
A••/
triat ■
hir.k it is withou- =•-*.=•
d
u
"
w 1 1 h an
.s Gr licit!'
ir
at'O losiss
^
H
haronan UC
\ 1_
_
-
.
?r 3 i'2 - , .anything ■=•
'He. COROi
j o h
;-:
k
: LLQt. \
;l
?a ;.jr'S f*.T.ily have no cuesr. ior.s, 'hank
you -
“ >V
_ *
B
"*
. P r o c s h a m 's statement,
I
I•
THE CORONER:
1
Z -. '
i ■j.-s‘ :hcoc
- - ---
is that
wa
is
—
_he*
n -sav whet
v ”” e S £ :
^ — c o e s say - ^ - -*1— - ^ *
1-.^ r = T a .
sins us n^r sc througn
THE CORONER:
Pareon r -,.^-=>d
through -he gats
r a c a l i s be i n s u s n e
-ur'her
on n_
say u.
_ _
__
- u,ot
con: :r*:
sr._ -
•33
SSCOnC Op'3.r:IHi •
q
iihc-£ is th at ?
Can you reminc
paragraph we have j u s t cuotec, aoou.
" E v s r v b o c y wa. be
Q.
"A large gate'
it? - A- YesMR . L :
G
Mr-
LIMB:
p4. =ur ;h 5r on :n
_ __... down whsr
t h r c u § h ...
ui
;ouid c o n fi rm the
which wouic
Thank you-
T H e. C O R O N — R :
Limb?
MR.
L. H a r o n a m l t d
Sorry?
crowd" • £.0 he obviousiy^r.«c noc o u l c n ’t have go>- in =•-^ ^~ 1 _v"
it was the 2-52 or the 2. or op^r.*.^-
F
H
oHu
refer
THE CORGNE.-: :
You rr;Ui
ith a csrtoiii amouri- <-■f caut 1 Oi.
zime vou have ~o "rsax i
but ~he says, '‘Bv this time it sas soout
D
E
I
r*'pp'0 C S h » m
sir.
MR. LIMB:
Tne gr=o-e.
- j*jo 3 •c»2 sri~iraric^*
.
-p—
=i« 5
thir d paragraph,
'-y
THE CORONER:
C a r t a : n 1y •
an h e ’goes on tal king aoout
;his time it was about _.o0 •
-h
:he 1ja 1 3 .
:hood
sir, is ~ L c=. -v- -■=
The -re
MR. LIMB:
:h< •-* s:
C
I
I
I
“■
:s it kr.o-:. by which opening ^
0 .=.= ^ . . - .
-^
a(
—oli Ig I just hoV^ & a-won*-*
patsJT s n l t i r s a ?
• U O U *a A J
Yes,
thank you
er.trv,
wou.cr.
-
.
.
^
^
i ■ 11
A
iio
Om i *•-r.r';
D E TE CTI VE
INSPECTOR MICHAEL L.-.YTCN - C a l l e d :
B
B
C
D
n-sr.?» vcLi
y
THE COR ONER :
A. Sir, M i rha .2 V Li/ton, De: sc; iv«a Inspector
C. Y-ss.
Mi dlan ds Police.
Sir, an e x a m i n a t i o n has baen made ox" vie SV
film and photogiraDh ic eviosncs anc Fscsr has o a e n L:-’=n>- i^ i sC
in Sac l o s u r a No. 3Erian Peter Tootle, Pe ter's uncle, who ir. fact is in
Court coday has vi ew ed visual evide nc e end has :cen;;;:=c
his n e o h e w aiive in Enc lo sur e No. 3 .on a pnctcirapn
oTlO .<iV
rs :c rsnc sc P R ’/ 1 O A . That z-hotoeraoh is timec -a:
of the photograph, sir, is that ^et er is at tna;
alive although it is not possiole to say at una"
st£i= of the medical process he has reachecPC Friend has viewed visual evidence but -as unac-ie t:
icsnt i i y hi ms e 11 actually ggj. ins w 1 •_n
-r;-w .*
but the O f f ice r has signec a plan or tr.e pi ter, area
inc i cat in £ the a p p r o x i m a t e location in w h i c h ne rcunc .-ete:
That clan is r e f ere nced JEF 1 .
Befo re you move on to the plans, 1 have slrsscy rsrerrsc
his comment.
He identified hi msel f I thinfc on
/ at
pa£e 22.
Can you just doubl e checic that?
He has icent:;
; but the one he has mentic
hi mse 1 2 in other
n1 mu-..“
*.•10 c i
C."C.
1
c a n
£ c V
tr.a^
*
He s
15 2 0 : i0 1 1S .
0
t he left
3
re 5 er y o u c o c v?0
.*
-
a
"11 *0
cv.r
-
C
.c>
” iTi—r
at this r
ic *3?r*ic 1 z - ed nimsei
;,
—
."V s.
VC
3
5c
i
v
;Iv=
:1o ;
c IS ZT.
“ Hci z t ime had <
r ■*:in • - A. Tha'
c
Q • Yes, becaus e I had mis reec that siisr.tl
‘1UJLo3, z h
A . If I can refe r you to a plan .
csrr«c2 s . • •
Thsnx vcu
u l c . l
^
—
And the oisn bv PC Frien
That will be C19 7. - A. Which is the plan of the p:tcn
'-fM JL«
f
KW
(mo'/eo to o Ian) if we can refer of the t errac es and the chotosra;
:h-= t 1 mec ohotojra;
which we bel ie ve Peter is snown :tne w i n
H
Harpnam L:d
\ ” ll
D . I .
M T C H A d -
>_ l
1 - ap io n here ( in d ic a v int..)
»-aci
-This here ( indicating) ^ w t e
aooroximately
N o- 3 .
here-
- n ^
LAW TON
Irn
—*
^ ^___
h i s p o s l t l ^..4
in respect o f the_pl«n of .*h * P**
i n ^ v M c h “ is '
che p osi t i o n he h «
ch* J ^ S i T T T T n d of che
.at che Sol on Kop e n d or
y
>
pitch-
B
D
it is ri sht a lot of people
» « » to
Fi"
in tact, it i»
•=
-right, sir, yesof the groun a ? - A. m a t
_
,hi - MAP 7
1520? - A.' Yes, that
t_. .
.- *ic
— r
t*e
o rfe*3r
T"*S uO ^ ii1 o 11M *
t
Q. Thar •is whe
re
is ri g h t m
--ri-sT' anv aue st ions on thac?
THE CORONER:
Mr. rra^er, any q
Q.
MR-
FRASER:
No,
Mi
L I M3:
MR.
CATCHPOL E:
the
CORONER:
No,
thank you,
sir-
sir.
thank you,
No, thank you,
sir
a case
i.: T ’
ne oury
Hr. and (!«. _Too. la,
where
ui 1 1 by
h*V *
Who have oeen here tor qu
a c - o a r e n t to you
realised, bu, it will no
^
%
his pa rti cul ar I n c e s t
because tirs. ^e are
=n th& amount of visual e v : ^ * c .
there is a great y* rl a
^ m a ttar of chance
and I think one c ^n on.y say
r i *ht dir ec ti on or
wh ether a cam er a was poinci s
the-e are some scen es
w h e t heit has b ee n p o s s i o l e oecau^e tne.
__
make out who
was whowhv !re we ju^^ can <- maKe o
_
_ronr ion to s o m e t h i n g wh: ch
ry 1 do want t.
“
b u n t e d in the
the:
F r o a s h a m s a y ® ° n d whicn
ce he <
.__ —
in T
h e te
I_sri
— could
saw
Peter in
the
rr ac e
7
c
*
*
s
n
He says when he
aive r e s u sci tati on and h e j
w a s s o m e b o d y t r y i n g to
-- - _
-m *<= assess me nt of the
successful.
That was Mr. r : r o u ^ s a-«e
because
situation but it might help you a
Qn z h e s i de c:
although the only visual evi de n «
jo r ;
^
the pitch, the verbal or
were actually
s u m m a r i s e d tor you m
actually very much nearer t ne
a t t e s t i n g to do something actually v
y
scene* of the incident itselrThe
can
say
sad
can
thins
is
possibly
chat
it
was
di *in:i.sh t h e
unsuccessful^
pa,n
and
a n d ^ t l ^ i n£
nothin:
^
.
t „.
v e r y s i n c e r a * y m p i ; h y ts
all of you at thi s
loss.
*
fl3 I h a v e
i n d i c a t e d to y ou
/-x take
r Alee
are go in g-r r
to
H
L. H a r p h a m Lt d
that
is
We are nuc g o m a any
8
/r r ^ L )
, 1i ^he
iC'Snce —2
r nou
[
D .I ■ MTCHA5L LAYTON
will r i s e f o r a m o m e n t or t wo w h i c h is our n o * ; ^ e e a r c
n r . Fraser- will e x p l a i n to y o u t he a r r a n g e m e n t s w i . h r g
to y o u s pe akin g to the P a t h o l o g i s t . T h a n k y o u .or be
g
here .
Hr-
HR. rRASER:
say something.
and Mrs.
T o o t l e would
just
like to
find -out for me what
it is?
HR. FRASER:
Sir, Hr- and H r s . T o otl e si
excress t h e i r gratitud e to e v e r y b o d y who h e i ped Pet
dayThe y r ec og ni se that ever y b o d y aid e ver yt hi n, tl
the
THE CORONER:
B
Can you just
V
= ° “ id
“ •
unfortunaisly succsaaiul.
tried
their
very
Tney r
.
: h « ” «.ryboay
3
best.
THE CORONER:
Hr. and Mrs- Tootle, thank you y«ry
much.
On behalf of these pe op le I h ea r that oovio , ^ w ‘^
pleasu re be cause although I r e c o g n i s e and
J R e ­
tu rn ed out to be unsuccessful , it do.-n'■*
that peoole did try.
Thank you.
It i* a °°^ 0 1 Y
mention it and it is much a p p r e c i a t e d by me ce-t«*.. y(Short Ad iournrnent )
D
•SHE CORONER:
Can we deal wit h just one small
cn
the case of Peter Francis T ootl e w h e r e I m i s l e a d in-pec.or
Layton.
D E TE CTI VE
INSPECTOR M I C H A EL L A Y T O N ^ — R e c a 1^-C
Further bv THE CORONE.^:
Q.
Inspector Layton,
id enti fi ca ti on at
Q.
I think
gro un d?
this is to do w l C £ c £ J" v J° '~ 'l ^ _ s i _.
1522 on MAP 7.-’ - A-Th-t
- o.
I put it to you it was at the Spion Kop
- A- That is right, s ii , y >--=>•
Q. Where as the evi de nc e is that he ^ i s .
wi thin the terr ac es ? - A- That is ao so
q.
A-
.
Just s ho w us, so
the Jury «r. n' «
If I c a n j u * t ~ s y ' ~
s --“ .
/-=••>
that
(m o v e d t o p l a n )
photographic evidence relating
a b s o l u t e l y ri ght a n d we r e f e r r e d
*
o
to
the
p ~
N o .3 w h i c h w a s
officer
a;
in this posi ti on here (j n a i c a t y m
ref ere nce t o \ h e video
such we indicated the rightworkin-- in
ide nt if ic at io n he is act ua ll y re ei re<
pit ch
Enc losu re No. 3 and not a c t u a l l y at this <=
.although he d o e s n ’t actually -=-21- himoi.1
He d o e s n ' t see h i m s e l f or P e t e r but he just
v i d e o a n d said, "That is w h e r e I w a s . T ha t
H
J. L. H a r p h a m Ltd
it? - A- Yes-
d at
- -
the
irht , is;
the CORONER:
wanted
to
MR.
make
sure
FRASER:
lnau«t
we
Yes,
THE CORONER:
fTh*
”
Is that s a t i s f a c t o r y ,
got
it
Hr.
Fraser?
right.
sir-
Thank you,
Mr-
Fraser-
into rh^ d ^ r h of P* t e r F r s n c l s To o t j i
unt i 1 a dare to be t ixeg.
KEVIN DANIEL WILLIAMS
Kevin Daniel Williams the son
of the Applicants James
Stephen and Anne Williams was born on 27th May,
1973,
and was 15 years old when he died at Hillsborough
football ground on 15th April,
2.
1989.
He went to the stadium with friends but became
separated from all but one, Andr ew Duncan.
Together
they took up positions in enclosure 4 at 1.30 p.m.,
but some time before 2.45 p.m»
they mo ve d into
enclosure 3.
3.
During the course of Kevin's mini inquest on 2nd May,
1990,
the following evidence was put before the jury through
the witnesses Detective Sergeant John Killoch,
Dr. Da vi d Slater, Detective Inspector Michael Layton,
and And re w Duncan:-
Andrew Duncan lost sight of Kevin
Williams immediately after the first surge in
enclosure 3.
At about 3.28 p.m.,
P.C. Michael Craighill
went into enclosure 3 and carried Kevin onto the pitch
where he attempted unsuccessfully to resuscitate him.
Derek Bruder,
an off duty Police Constable saw Kevin
lying on the pitch near the Spion Kop, North stand of the
ground.
He stated that Kevin was having convulsions.
Mr. Bruder,
on seeing Kevin went on to the pitch
where he gave mouth to mouth resuscitation and an
ambulanceman carried out cardiac massage.
They were
later joined by an ambulance woman who took over from
Mr. Bruder.
After a short time the St. Johns Ambulanceman
S-t-atPr) -f-hat- Tfpvi n
r)<=ar).
Some time later special Constable Debra Martin assisted
in carrying Kevin from the pitch to the temporary
mortuary.
She claimed that when they reached the
mortuary he stopped breathing.
She then gave him
mouth to mouth resuscitation and did some heart massage,
after which he opened his eyes,
then died.
said the word "mum" and
At 4.06 p.m. Dr. Curpen examined Kevin and
certified him dead.
Dr. David Slater,
stated in evidence that Kevin died of
traumatic asphyxia.
His case was one of the worst of
those he dealt with from the Hillsborough incident.
In
his opinion Kevin would have fallen unconscious within
3 to 5 seconds of being crushed.
He stated that persons
suffering from asphyxia can have fits.
the view,
however,
He was not of
as SC Martin had suggested,
Kevin could have spoken.
that
The autopsy showed that Kevin
had four fractures of his voice box and irreversible
brain damage,
both of which he believed,
own have prohibited communication.
would on their
Any sound that might
have emerged he put down to the expulsion of air from
Kevin's stomach but stated that this would not explain
the opening of Kevin's eyes.
He believed that because
of the seriousness of Kevin's case,
he would have suffered
irrecoverable brain damage and brain death within 3 to 6
minutes.
- 3 -
6
.
The mini inquest into Kevin was then adjourned until
a date to be fixed.
7.
On 3rd May,
1990,
an officer from the West Midlands
Police Force, visited the Applicants at their home.
The officer stated that Mr. Bruder had now changed his
statement as he realised he must have been mistaken.
Mr. Bruder was now saying that there was no vomit near
to Kevin that it could have been mucous.
Mr. Bruder
was also saying that Kevin wasn't convulsing when he
attended him,
that it must have been body twitches.
The police officer told Kevin's parents that it would
be better if the family did not speak to Mr. Bruder.
He said that Special Constable Martin was still
sticking to her original statement but that she was
young and inexperienced and that she had undergone a
traumatic experience.
In the circumstances,
her statement would be discounted.
he said
He then stated
that there would be another inquest into Kevin the
following day but that the Applicants need not attend,
as the purpose of the inquest was to prove to the jury
that Kevin could not have been alive.
On 4th May,
1990,
the coroner returned to Kevin's mini
inquest and further evidence was put to the jury by
Sergeant John Killoch,
Inspector Matthew Robert Sawers,
Dr. David Slater and Doctor Ernest John Wallace Gumpert,
- 4 -
which, when taken together produced the following account
of events:
When Mr. bruder made his first statement he
stated that he came across Kevin at the Spion Kop end
having convulsions.
This happened after 3.32.
He also
said he could feel a pulse.
Mr. Bruder gave mouth to mouth resuscitation
and an ambulanceman carried out cardiac massage.
minutes they swapped roles.
After 7
About 6 minutes later an
ambulancewoman took over from Mr. Bruder.
Whilst
Mr. Bruder was attempting to resuscitate Kevin he observed
an ambulance entering the stadium.
He asked the St. Johns
Ambulance colleague who was assisting him to stop the
ambulance as he was considering utilising it.
During resuscitation efforts he no ti ce d Kevin's face
going grey and withdrawn.
In his evidence Inspector Matthew Robert Sawers of the
West Midlands Police confirmed that he had visited
m r . Bruder the previous day.
He stated that Mr. Bruder
on reflection thought that the word
not applicable,
'convulsions'
was
that twitching was a more appropriate
term to describe Kevin's condition and that if he had
seen any part of the body move,
it was the head.
He
reported that Mr. Bruder said that he may well have been
mistaken about feeling a pulse.
He added that,
contrast to his original statement,
in
he could no longer
say that he definitely saw Kevin's skin colour change
- 5 -
from normal to grey
but that the fluid he saw coming from Kevin's
mouth might have been spittle or phlegm.
Mr. Bruder
had confirmed that he attempted to resuscitate Kevin
for a period of time of between 10 and 15 minutes and
that the ambulance he saw was definitely entering the
stadium and not exiting.
In his further evidence Dr.
Slater stated that Kevin
wo ul d have suffered irrecoverable brain damage and
death within 3 to 6 minutes,
Mr. Bruder reached him,
that is, by the time
and that although he was brain
dead his heart may have gone on beating for a short
while longer,
and his nerves may have lived on thus
causing the twitching.
time of the crushing,
He brain had died near to the
but his whole body died at the
time that P.C. Bruder was with him and saw him turn
grey.
11
.
Dr. Ernest Gumpert was of the view that Kevin was
probably dead before he was even removed from enclosure 4,
in the sense that he was brain dead and was going to die.
He also thought it conceivable that his heart continued
to operate for a time as did his peripheral nervous
system.
But after Kevin had suffered brain death the
only way to keep him alive would have been by artificial
means.
On 15th December,
1991,
the Applicant Ann'Williams met
with mr. Bruder.
A note of this meeting is exhibited
appended hereto.
at Page
From those notes
it would appear that Mr. Bruder refutes the interpretation
placed by D.I.
Robert Sawers upon the statement made by
Mr. Bruder on 3rd May,
1990.
From November 1991 the Applicants made repeated requests
to South Yorkshire Police to release copies of the statements
made by Special Constable Martin and Mr. Bruder.
The Applicants eventually received the said statements
from the Coroner's office on 19th February,
1992.
In
relation to Mr. B r u d e r 's initial statement made on 2 7th
April,
1989,
the following matter caused grave concern
to the Applicants
(a)
Mr. Bruder describes seeing a police cordon in front
of the North stand.
Kevin was lying on the ground
behind the police cordon having convulsions.
None
of the police officers left the cordon to assist
people who were lying on the pitch.
(b)
(See Page
....).
Shortly after Mr. Bruder began resuscitation attempts
on Kevin an ambulance entered the ground and drove
towards the Lapping Lane end.
man to try and stop it.
He told the St. Johns
He tried to flage it down
but it continued on as if it had been ordered not
to stop.
(See Page
....).
- 7 Details of the aforementioned matters were not referred
to in the police summary of evidence presented at the
inquest.
The Applicants feel that such omissions
of
illustrate the shortcomings^presenting evidence in
summary form.
A copy of Mr. B r u d e r 's first statement
and the West Midland's Police Summary of Evidence is
annexed hereto.
•
In relation to m r . B r u d e r 's second statement made on
14
3rd May,
1990, he states in the first paragraph thereof
that he had "been asked to think about a number of points
which are raised in the statement I made nearly a
fortnight after the Hillsborough Stadium disaster".
See Page
remark,
....hereof).
In the Applicants'
view, this
taken together with the notes of the meeting held
with Mr. Bruder on 15th December,
1991,
indicate that
improper pressure was indeed exerted upon M r . Bruder
to retract or qualify in part his previous statement.
Further,
since receiving the copy statements the
Applicants have viewed a BBC video of events as they
unfolded on the day of the d i s a s t e r .
It is evident from
the video that a SYMAS Ambulance entered the Spion Kop
end of the pitch at 3.36 p.m.
at which time it has been
established that Mr. Bruder was attempting to resuscitate
Kevin.
The Applicants are concerned that despite its
availability this evidence was not put before the jury.
Rather, Mr. Bruder was asked to consider whether the
ambulance he had originally referred to as entering the
stadium was in fact exiting.
\
-
15.
8
-
At the same time as efforts were being made to
secure copies of witness statements attempts were made to
contact Special Constable Martin.
On 20th February 1992
the Applicant Ann Williams received a phone call from
the Special Constable which culminated in a meeting
at the Applicants home on 22nd February 1992.
At that
meeting Special Constable Martin confirmed the contents
of her first statement made on 8th May 1989 wherein she
described the events set out in paragraph 4 hereof.
She stated that this statement was made up from notes which
she had made in her pocketbook immediately after the disaster
She explained that her later statement dated 17th March
1990 was compiled by an officer from the West Midlands
Police Force who visi ted her at her home.
This officer
tried to convince Special Constable Martin that her
original statement was untrue.
The Special Constable
signed the statement prepared by this officer without
reading i t .
She was unable to read it due to the state
of distress brought on by the officer's behaviour.
She
signed the statement because of the pressure exerted by the
officer and because she wanted to put Hillsborough behind
her.
Special Constable Martin has now signed a statement,
the presence of a solicitor,
in
confirming the truth of her
original statement dated 8th May 1989,
and explaining the
circumstances relating to the compilation of the later
statement dated 17th March 1990.
A copy of this statement is appended hereto at Page
.......
The Applicants firmly believe that the statement dated
17th March 1990 led to the undermining of Special
Constable Martin's statement at the mini inquest on 2nd
May 1990
(see in particular page 7, para D.E. of transcript
p r o c e e d i n g s ).
Subsequent to the me eting with Special Constable Martin
the Applicants sought the advice of their general
practitioner as to the contents of Kevin's autopsy report.
In his view the injuries to Kevins larynx would not have
preve nt ed him from speaking.
is appended hereto at page
A copy of this opinion
.......
Now in receipt of most of the evidence relating to
Kevin's death,
the Applicants contend that the inquest
proceedings into Kevin's death and the result and verdict
of accidental death are highly unsatisfactory by reason
of the following matters
(a)
The jury never heard from Mr.Bruder himself,
nor did they hear from Special Constable
Debra Martin.
The jury were merely presented
with excerpts from their respective statements.
The Applicants contend that the evidence
relating to Kevin was presented to the jury
in a confusing and incoherent fashion.
(b)
They are par ticulary concerned at the inactivity
of the police officers in the cordon whilst
Kevin was convulsincr and the unsuccessful attempt
-
1 0
-
to flag down an ambulance.
In their view both
these matters indicate a lack of response on the
part of the emergency s e r v i c e s .
(c)
Notwithstanding the evidence of Dr.David Slater
and Dr.Ernest Gumpert they believe that Kevin
was alive for some time after 3.32 and hence
for some time after the 3.15 p.m,
cut off time.
This belief is heightened by a recent article in
the British Medical
This article
Journal dated 30th November 1991.
states that the accident and emergency
departments of the Northern General and Royal
Hallamshire Hospitals,
Sheffield,
were never
formally told to implement the major disaster
plan.
Further,
the article states that most of
the seriously injured arrived at hospital between
3.30 p.m.
and 4.00 p.m.
Nine of those injured were
convulsing upon admission.
A further 6 were confused
upon arrival and then began having severe convulsions.
It is known that some of these people survived with
no long term physical effects.
(d)
The further evidence which has come to light since
the inquest indicates in particular a suppression
of evidence,
irregularity of proceedings and
discovery of new evidence.
19.
The Applicants submit that in the light of these matters
and had Mr.Bruder and Debra Martin been called as
witnesses there may have been sufficient evidence for
the jury to conclude that Kevin's death was due to or
aggravated by lack of care.
M E E T I N G BETWEEN ANNS WILLIAMS AND P.C. BRUDER 15TH DECEMBER,
P.C. Bruder
1991
made his original statement
approximately ten
days after the disaster.
At that time he asked the West Midlands Police for the name
of
the boy
Williams).
he had
attempted to
(i.e.
Kevin
This was refused.
A t the meeting wi t h P.C.
stated that
Ke v i n
resuscitate
he came
was either
Bruder on 15th December,
across Kevin
convulsing or
on the
pitch and
twitching.
pu l s e and there was vomit in Kevin's mouth.
1991, he
that
Kevin had
a
As he tried to
resuscitate Kevin an ambulance approached going towards the
Leppings
Lane end
of
the
ground.
ambulance to stop in order to put
He
shouted for
the
Kevin in it, but it went
straight past.
On 3rd May,
1990, P.C. Bruder was
Wes t Midlands Police Officer
his statement.
stated that
He
who asked him to
was asked if
Kevin was
visited in his home by a
he was mistaken
convulsing and had
Brude r stated that he was not mistaken.
ANNAAJ
'reconsider'
a pulse.
w he n he
P.C.
N.B.
It
was cniy at this
P.C.
Bruder learnt
for
time
the
(i.e. 3rd May,
1990)
that
first time the
name of
the
West Midlands
Officer
was
p e r s o n he had cried to help.
At
the
same
time
as
interviewing h im in his
and tried to
been
homs, the Coroner rang P.C. Bruder
persuade h i m that the facts
w e r e incorrect in
have
the
particular that the ambulance
driving onto
dri vin g off it.
of his statement
the
Again,
pitch
but might
P.C. Bruder refused
he had been m is t a k e n and
could not
have
been
to admit that
was adamant that the ambulance
had
b e e n driving onto the pitch.
The
West
Midlands
Officer
approximately 10.00 a.m.
P.C.
Bruder
told the
was
with
P.C.
Bruder
from
- 4.00 p.m. on 3rd May.
Officer that he
didn't want
to see
Kevin's parents but if they wished to meet with him then he
w o u l d be
prepared to meet
W est Midlands
same day
them anywhere.
Officer visited
he informed them
Mr. and
(N . B .
Wh e n the
Mrs. Williams
that P.C. Bruder would
the
not see
them).
P.C. Bruder
stated the
O fficer visiting h im
reasons behind
the West
whe n he stated "when he
Midlands
came down to
see me it was wit h a brief - to get me to change my mind."
ANNAAJ
- 3 -
In response to whet her or not
another statement,
P.C. Bruder
prepared to
stand up
convulsing,
that there
A s k e d whether
he would be prepared to make
in Court
was
replied that
and state
he wo uld
that Kevin
be
was
a pulse
or not Kevin was
P.C. Bruder replied "there was a
alive when he got
to him,
pulse and if that means he
was alive then he was alive."
W h e n P.C.
dead.
Bruder left
Kevin he was certain
He
then went home.
all the clothes he was wearing on that day.
he has
never re ceived any
was
He destroyed
He stated that
counselling and has
the disaster "in his own way."
ANNAAJ
that he
dealt with
DECEASED REFERENCE NUMBER :£L---------S
I
WEST MIDLANDS POLICE
I
A report into the death of:
|
NAME:
WILLIAMS, Kevin Daniel
AGE: 15 years
DATE OF BIRTH:
27 May 1973
ADDRESS:
OCCUPATION:
Schoolboy
STATUS:
Single
NEXT OF KIN:
James Stephen WILLIAMS
RELATIONSHIP:
Father
DATE OF "BIRTH:
18 November 1948
OCCUPATION:
Civil Engineer
*
ADDRESS:
GENERAL PRACTITIONER:
Dr S J CROSBY,
Merseyside
DOCTOR PRONOUNCING LIFE EXTINCT: Dr CURPEN
DATE, TIME AND PLACE:
15 April 1989, 1606 hours at the Temporary
Mortuary in the gymnasium at Hillsborough Stadium.
PATHOLOGIST:
Dr SLATER
STATED CAUSE OF DEATH:
Traumatic Asphyxia
BLOOD ALCOHOL ANALYSIS BY DR FORREST - RESULT:
56 mg/100 ml
IDENTIFICATION EVIDENCE:
On the morning of Sunday 16 April 1989,
James Stephen WILLIAMS identified the body of his step son, Kevin Daniel
WILLIAMS, to PC 1269 GLAVE in the Temporary Mortuary at Hillsborough Stadium.
CIRCUMSTANCES
At about 0700 hours on Saturday, 15 April
1989, Mr James Stephen WILLIAMS saw his son,
Kevin Daniel WILLIAMS, deceased, leave the
family home with the intention of travelling
to Sheffield.
He was to travel by train with
a number of his friends to watch the F.A. Cup
Semi Final football match at Hillsborough
Stadium.
Kevin Daniel WILLIAMS had a ticket
for the match.
Andrew DUNCAN travelled to Sheffield with
Kevin Daniel WILLIAMS, Thomas James NICKSON
and Gregory FAGEN by train arriving at
Sheffield at about 1040 hours.
left the others at the station.
Gregory FAGEN
The other
three youths caught a bus from the station to
Hillsborough Stadium where Thomas NICKSON
left them.
Andrew DUNCAN entered the stadium with Kevin
Daniel WILLIAMS at about 1330 hours via the
Leppings Lane turnstiles.
They initially
stood together in Pen 4 but after a short
time moved into Pen 3. At about 144o hours
Andrew DUNCAN saw other friends on the
terraces including Anthony Maxwell GRIER and
Stuart THOMPSON (Deceased Reference Number
At about 1455 hours Andrew DUNCAN was still
with Kevin WILLIAMS and although the crowd in
the pen was tightly packed he was not too
concerned at that time.
As the match started
he was pushed forwards down the terrace and
did not see Kevin Daniel WILLIAMS again.
Following the severe crushing in.the West
Stand terracing Police Constable 1790 Michael
John CRAIGHILL went into Pen 3 and assisted a
number of casualties.
Police Constable
CRAIGHILL assisted to carry a youth, he now
believes to be Kevin Daniel WILLIAMS, from
the gate in the perimeter fencing of Pen 3
onto the pitch.
The officer attempted
resuscitation but without success.
Derek William BRUDER is a Police Constable
with Merseyside Police and was at the match
as a spectator in the North Stand.
He
recalls seeing a person lying on the pitch
near the Spion Kop/North Stand having
convulsions.
Mr BRUDER went onto the pitch
and gave mouth to mouth resuscitation aided
by a St Johns Ambulanceman who carried out
cardiac massage.
Mr BRUDER recalls that a
friend of the casualty was with him on the
pitch.
Resuscitation was continued and they
were joined by a St Jonns Ambulance woman who
took over from Mr BRUDER.
After a short time
the St Johns Ambulanceman said that the
casualty was dead.
Mr BRUDER then left the
scene.
Neither of the St Johns Ambulance personnel
or the 'friend' of the casualty have been
identified. The person Mr BRUDER tried to
resuscitate is now known to be Kevin Daniel
WILLIAMS.
Special Constable 221 Debra Jane MARTIN went
onto the pitch to assist and helped to carry
several deceased and also many injured to the
gymnasium.
She assisted to carry one young
boy, now known to be Kevin Daniel WILLIAMS,
into the gymnasium and remained with him.
At 1606 hours Doctor Naderassen Carpoosamv
CURPEN examined Kevin Daniel WILLIAMS in the
gymnasium which had been established as a
temporary mortuary and certified life
extinct.
Special Constable MARTIN later escorted the
body of Kevin Daniel WILLIAMS to the Medico
Legal Centre and confirmed the identification
by Reference Number to Detective Constable
638 Simon WEIGOLD.
4.
11
On Sunday, 16 April 1989 Mr James Stephen
WILLIAMS identified the body of his son to
Police Constable 1269 Scott 6LAVE.
12.
On Sunday, 16 April 1989 following
identification by Detective Constable
WEIGOLD, Doctor David SLATER carried out an
autopsy and submitted a report giving cause
of death.
BLOOD ETHANOL ANALYSIS
13.
Evidence is included regarding the analysis
of the blood sample from the deceased where
the presence of ethanol was detected.
The
witnesses proving continuity of the blood
sample are Detective Constable 1076 David
Michael 6REEN, Detective Sergeant 2616 John
Albert TURNER and Detective Sergeant 1098
James Norman FLETCHER.
Doctor Alexander
Robert FORREST carried out the analysis.
14.
Found in the personal effects of Kevin Daniel
WILLIAMS was a ticket counterfoil which
confirms his entry to the stadium via a
turnstile.
VISUAL EVIDENCE
15.
An examination of video film and photographic
evidence has been made by Police Inspector
LAYTON and Kevin Daniel WILLIAMS has been
identified in Pen 3. being carried across the
pitch and at the Spion Kop end of the pitch.
Photograph Reference DAC 3/1 shows Kevin
Daniel WILLIAMS apparently unconscious near
the perimeter fencing in Pen 3.
Video
Reference MAP 7. 1528:33:22 shows him being
removed from the terraces via Gate 3.
Police Constable CRAIGHILL has signed a Plan
of the pitch showing where he first came into
contact with Kevin WILLIAMS and where he laid
him on the ground.
The officer identified
'himself on Video Reference MAP 7. 1528:43:24
carrying a youth now known to be Keith
WILLIAMS from gate 3 and onto the pitch. The
officer did not know the identity of the
youth and first believed it to be another
deceased.
Photographs Reference PR5/32 and PR5/33 timed
at 1532 hours, show Kevin WILLIAMS being
carried across the pitch on a temporary
stretcher by a number of spectators and two
police officers.
Police Constable 437 Garrv
HAYES has confirmed his identification on the
photographs.
The officer assisted to carry
two deceased persons on temporary stretchers
but could not recall any further details. He
did not know the identity of the persons he
carried, he merely assisted to carry the
temporary stretcher.
6.
A number of photographs including Photograph
Reference TT1/30. show Kevin WILLIAMS
being given mouth to mouth on the pitch by Mr
BRUDER who has confirmed this identification.
The parents of Kevin Daniel WILLIAMS have
viewed visual evidence and confirm the
identifications of their son.
CONTINUITY CHART
This has been prepared and is included with
this file to provide an overall picture of
the evidence.
HER M A J E S T Y ’S C O R O N E R FOR SOU TH YORKSHIR E
' (WES T D I S T R I C T )
IN QU E S T S IN T O THE D E A T H S OF THE
V I C T I M S O F T H E H I L L S B O R O U G H F OOTB ALL
STADIUM DISASTER
O N T H E 15TH APRIL,
INQ UES T
1989
INTO THE DEA TH OF
KEVIN DANIEL WILLIAMS
Before
S.L.
POPPER.
LL.B,
B.MED.Sci,
B M , B S . MRCGP
(Hsr Majesty's C o r o n e r )
At
The M e d i c o - L e g a l Centre.
W a t e r y Street,
Sheffield.
On
2nd M a y 1990
T R A N S C R I P T OF P R O C E E D I N G S
From the Notes of J.L. Harpham, Ltd.,
O f f i c i a l S h or th and Writers.
55. Q u e e n Street, S h e f f i e l d SI 2DX
lUUi
INDEX
DR. DAVID NEIL SLATER - Called
Ey THE CORONER
•.
••
DETECTIVE SERGEANT JOHN KILLOCH
Ey THE CORONER
.•
Called
....................
DR. DAVID NEIL SLATER - Recalled
00 CO
Ey THE CORONER ..
....
Cr oss-ex am in ed by HR- F R A S E R .........
DETECTIVE INSPECTOR MICHAEL LAYTON - Called
Ey THE COR ON ER .............................
Cr o s s - Exam ine d by MR. LII'lE..........
-■
C r o s s - Ex amin ed by MR. C A T C H P O L E ..........
--oo--oo
1008
\
r>na Mav 1990
TNQUEST INTO TH E DEATH OF KEVIN DANIEL WILLIAMS
B
D
MR. FRASER:
Sir, you will now hear evidence
to Kevin Daniel Williams.
Kevin's mum and dad are in
with the social w ork er from Merseyside who has been
assist in g them.
The so li citors for Kevin's mum
dad are
memb er s of my G r o u p and I therefore appear in tl.e usual
guise as their agent to the Steering CommitteeTHE CORONER:
Good morning, Mr. and Mrs- WilliamsBefore we begin I am going to explain to you the genera
format of the Inquest because you weren t here a lortnigh
ago, were you, and even if you were you might have
forgottenWe will start in a moment or two by m e reading
to you what was said on 18th April 1989 which i» when I
opened the Inquest in this very room.
Then if there are any
am endme nt s which need to be made, if we have got some ot the
facts wrong, we will sort that out.
I will then tell you
what the blood alcohol levels were, as measured by
Dr. Forrest, and then we will turn to Dr. Slater, who is.
He will give us
Pathologist si tting up there behind youthe pathological evidence.
I think I can safely say that
if, after this Inquest over, you feel you would like to talk
t o D r . Slater private ly he is quite happy to do that if it
would be-of any help to you.
When Dr. Slater has finished
pr epared
a nummary
the West Mi dlands Police Officers have prep
ar ed a
for me and he will deal with that and tell me about it.
Then we will hear from Inspector Layton, another We»t
Midlands Police Officer, who will deal with the visua
evidence.
He will first of all tell me all about the pla
and so on and that is sometimes a bit c on fu si ng ^ ec a^ ®
there are a lot of references given but when he has t i n ^ h e
talking about it he comes over and shows us on these d g
plans so that all of us, that is me, you, the Jury and
everybody else can follow it.
Then when that is done we
conclude and take no further evidenc e at this stage.
»
that reasonably clear?
I like to tell you so that you know
what to expect.
Otherwise you d o n 11 know what is coming.
This then is the resumed Inquest which was opened on
18th April 1989 and on that occasion Neil Anthony Parkin,
Acting Coroner' s Officer, said:
"The body which is the subject of this Inquest has been
identified.to PC 1269 Glave of the South Yorkshire
Police as that of Kevin Daniel Williams by James
Stephen Williams, his father.
He was 15 years of age
having b een born on 27th Way 1973_at So u t h p o r t ^
^
i a s Sf schoo lbo y by occupation.
He diid at Hills bo ro ug h
Football Grou nd following an incident there on
1009
nR. DAVID NEIL SLATER
.Saturday, 15th April 1989.
PC Glave caused the body to
be removed to the Medico L e g a l Centre and there he
identified it to Detective Constable Simon Weigola who
subsequ en tl y identified the same body to Dr. slaterIt is the family wish that the body should be
cremated."
I adjourne d the Inquest at that point.
I wrote to you
shortly afterw ard s and you, Mr. Williams, very kindly signed
it on 1st May 1989 and I checked with you the details and
you confirmed the name, that we had got it right, date ot
birth 27.5.73, that is right, isn't it, and the place o ^
birth which was Southport wasn't it?
We typed it into the
wrong spot in your case but you spotted that.
Dr. Forrest did the alcohol levels for many of the
people who died, including Kevin, and the level in respect
of Kevin was 56 milligrammes per 100 mils.
DR.
DAVID NEIL SLATER ~ Called
Bv THE C O R O N E R :
Q. Dr. Slater. .- A. Sir, my name is Dr. David Neil Slater.
I
am a Consultant Histopathologist and a Fellow of the Royal
College of Pathologists.
THE CORONER:
Before I go o n , Mr.
true dad of this ladMR.
WILLIAMS:
Williams,
you are
Stepfather.
THE CORONER:
Thank you very much.
You are mum, yesMr. Fraser, so that we get the record right.
Is this an
informal or a proper adoption because obviously the lad
carries the same surname?
MR. FRASER:
twelve years plus.
THE C O R O N E R :
There is no formal ado pt io n but
it is a
Pardon?
MR. FRASER:
There has been no formal adop ti on by
Mr. Williams as such but the re lat io ns hi p is more than
twelve ye ar s old.
Q
T H E CORONER:
I am very sorry, Dr. Slater, to ha^ e
Just remind us of your name because I have
forgotten whfere.we were up to?
Just s t a r t again?
• y
name is Dr. David Neil Slater, Consultant H i s t o p a t h o l o g i s t ,
i n t e r r u p t e d you.
sir.
Q. Dr. S l a t e r , i n the usual way you are satisfied t h a t the
evidence you are going to give me in this case rela
1010
DR.
DAVID NEIL SLATER
r
51
Ke vin Daniel Williams who was also identified as No.
that right? - A. That is correct, sir.
Q.
you are
Identification was done by Inspector Timms so far as
concerned:' - A- That was the initial ident ificat ion.
doubt
Q. But there is no
A. N o .
B
D
is
in your m i n d about
the identity;
Q.
A.
There were various marks on the body i t s e i r to
Sir, Kevin was clearly labelled both by number and
Q.
Dr. Slater, would you be kind enough then to take me through
the post mo rtem? - A. My exa mination of Kevin showed tha
the main finding was that of asphyxia.
This opinion
formed through the extensive bl ue ne ss on the face an
pp
part o f the chest.
In addition there were small
haemorrhages in both the face and internal organs including
the brain, heart and lungs.
This asphyxia had clearly
resulted f r o m compression of the neck and chest and this
opinion was support ed by the presence of three small
scratches over the left side of the neck and also over the
front of the voice box.
This had also resulted in four
fractures to the small bones in the actual voice box.
in
ad dition there was evidence of b ruisi ng to the lungs, again
supporting compre ss io n of the chest.
y
My autopsy showed that Kevin was a normally developed,
fit
healthy, young male with no evidence of any natural
disease which could have contrib ut ed towards death and 1
was my opinion that Kevin had a normal life expectancy,
terms of the mode of death the co mpression of the neck or
chest has occurred here and un con sci ousn ess occurs very
rapidly
certainly within a few seconds, a nd there is one
reported case of it occurring a p p a ren tly instantaneous y.
Fo ll ow in g un co nsciousness then there is no discomtort an
pain.
Death then occurs after appr ox ima te ly three to five
minutes, sir.
Q. So be cause when we say asphyxia peop le think of agony for
ages and ages.
What you are s ayi ng is that the person
him self would very rapidly not know any th in g J t ua11
what was hap pening? - A. I should say the word
asphyxia
is
unfor tu na te in that scie ntifically it partly includes simply
that there is not enough oxygen in the blood.
It doesn
imply actual suffocation and prolong ed death.
Q. Did you say there were four fractures to the voice box? A. Yes, there are two bones in the voice box, as you know, sir,
a n d ' both these showed two fractures each.
Q. Now the reason why I asked you was this, and I want to P u *
this to you bec ause I would like to get your view on it, one
Offic er will be dealing with the value of this evidence
H
1011
DR.
r
DAVID NEIL SLATER
moment bat she says that at a point when this lad was in the
gymnasium, in other words he had already been moved across
the pitch, she says she hel pe d him into the gym from the
pitch, presum ab ly she carried him.
He stopped breathing.
She gave him the kiss of life, did some heart massage, he
opened h-is eyes said a word and died.
Now in the light of
your pathological findings, is that in fact a possibility,
do you think? - A. Well, sir, I was aware of this statement
and therefore I have clearly given this matter co nsiderable
thought, sir.
I think there are several comments to make
but the mo de ra te ly large number of autopsies I did from this
incident, sir, this was certain ly the most severe case of
traumatic as phyxia that I actually dealt withThis was
both in terms of blueness of the face and also the area of
pallor of whiteness around the mouthSir, it was a very
very severe form of asphyxia and I do not think that
unconsciou sn es s would have been qu icker than ’•hree oi five
seconds.
I have no reason to alter what I have already said
on that a s p e c t .
B
The other very significant thing about this, and it alsc
supports the severity of this case, is that again of the
autopsies I did approximately 15 per cent had some sort of
fracture to the voice box, the larynx.
This case was highly
unusual in that in fact it had four fractures to the larynx.
It was by far the most severe case of voice box fractures.
Not only does this indicate the severity of the traumatic
asphyxia at the time but it also in fact makes it virtually
impossible for the person to have spoken by virtue of the
fact that there were fractures to the voice box, sir.
So
all I can say, sir, that sc ien tifically and medically I find
that inconceivable that the person could have spoken.
D
Q. The other thing I notice is that you show in this pa rt icular
case extensive congestion of the cerebral veins and
cereb al lu m and cortical coning and if a person speaks his
neurons are working, aren't they? - A. That is right.
Q- That ev idence would indicate there had been extensive brain
damage and he couldn't really communicate.
Would that be
right?
I don't want to put words in your mouth but I want
to be sure about that? - A. The coning indicates the
severity of the asphyxia and again that would have resulted
in irreversible brain damage
which again would totally
prohibit any form of communication.
Q.
I have thought about this comment as w e l l , of course, and
there are several exp lanations (1) that it didn't occur and
that the ob serv er is mistaken but ano th er possibility that
has oc curred to me and I want to put it to you and please
disagree if it is not either
right or you don't accept it;
it is possible,
is it not, that if a person having died is
moved air or stomach contents might be expelled and might
make a sound as it escapes, so to speak?
Is that a
H
1012
P. S.
JOHN ktlloch.
p o ss ibi lity ? - A- It is an interesting comment, sir, because
it is a p o s s i b i l i t y 1 c o n sid ere d also m y self and that is
cer ta in ly an e x p l a n a t i o n to the noise which could have been
made which may ha ve mim ic ke d the wor d "mum" but it would not
e x p la in the o p e n i n g of the eyes, sir.
No.
- A- Eut
it w o u l d exp lain the noise.
MR. FRASER:
much, Dr. Slater,
explanation.
No questions, sir, but thank you very
for that s ym pat heti c and detailed
THE CORONER:
Any other q u es tio ns for Dr. Slater?
Thank you very much, Dr. Slater.
We spent a lot of time
t hi nkin g about thi s sentence beca us e it w a s difficult.
I
didn't think it was possible from what I knew of the
e vi de nc e but, on the other hand, we didn't want you to f ® ® 1
that we w e r e r ‘* te lli ng you what w^« in the statements.
We
felt it was b et ter for you to hear it and have it explained
r a t h e r than for us to keep it under wraps, so to speak, and
you might poss ibl y find out some oth er time.
I hope I have
taken the right decision.
I don't know.
The only person
who knows that is you.
We did spend a lot of time thinking
about it won d e r i n g what to do for the best.
POT.ICE SERGEANT JOHN KlLLOCH.
Cal led
Bv THE C O R O N E R :
Yes. - A. Polic e Sergeant John Killoch\, sir, of the West
Midla nds Police.
1 have previously''taken the Oath.
Co ul d you then please, if you would, ta ke me through che
st a t eme nt? - A. At 0700 hours on Saturday, 15th April 1939,
Mr. James S t e phe n W illia ms saw his son, Kev in Daniel^
Williams, leave the family home with the intention of
tr avell in g to Sheffield.
He was to travel by train with a
number of friends to watch the Semi Final football match at
Hi llsb o r o u g h Stadium.
Ke vi n had a ticket for the match.
Andrew D unca n travelled to S he f f i e l d with Kevin, Thom as
James N i c k s o n and Gr egory Fagen.
T h e y t ra v e l l e d by train
a rr iv in g at S h ef fiel d at 1040 hours.
G r e g ory Fage n left the
others at the station.
The other three youth s caught a bus
from the st ati on to H ills bo ro ug h S t a d i u m whe re Thomas
Nic kson left them.
Andrew Duncan entered the s t a diu m with Kevi n at about
1330 hours via the Leppi ng s Lane turnstiles.
They initia
y
stood t oget her in Enclosure 4 but s h o rtl y a f t e r they moved
to Enclosur e 3.
At about 1445 hours A n d r e w Duncan saw other
friends on the terraces, including A n t h o n y Maxwell Grier an
Stuart Thompson.
Stuart, of course, als o lost his lite at
Hillsborough.
5
<30 I
1013
p. S.
JOHN
KILLOCH
At about 1455 hours Andrew Du nc an was still with Kevin
and al tho ugh the crowd in the enc los ure was tightly packed
he was not too c onc ern ed at that stage.
As the match
sta rted he was p u shed forward do wn the terrace and did not
see Kevi n again.
Fo l lowi ng the severe cr us hin g in the West Stand
t e rr aci ng Police Constable Michael John Craighill went into
E n cl osu re 3 a n d ass ist ed a number of casualties.
Police
Cons tabl e Craighill assisted to carry a youth, he now ^
belie ve s to be Kevin, from the gate in the perimeter tence
of Enclo su re 3 and on to the pitch.
The Offi cer attempted
r e s u sc ita tion but without success.
Derek W i l l iam Bruder, an off- du ty Police Constable from
the Me rseys id e Police who was a sp ectat or at the match,
recalls seein g a person lying on the pitch ne ar the Spion
K op/ No rt h Stand of the ground.
The per son
as having
convulsions.
Mr- Bruder went on to the pitch and gave mouth
to mouth re su sc ita tio n aided by a St. Johns Amb ulanceman wio
carri ed out ca rd iac massage.
Mr. Bru der rec al ls that a
friend of the casualty was with him on the pitchRe sus cit atio n was continued and they were joined by a bt,
Johns A m b u l a nc ewom an who took over from Mr. cruder.
Alter a
short time the St. Johns Amb u lan cema n said that the casualty
was dead.
Mr. Brude r then left the scene.
Neit he r of the St. Johns Am bu la nc e personnel or the
friend of the casualty have bee n identified.
The person
Mr. Bruder tried to resuscitate is now known to be Kevin.
Special Cons ta bl e Debra Mar tin went on to the pitch to
assist and she hel pe d to carry several dec e a s e d persons and
many injured pe rsons to the gymnasium.
S h e ass ist ed to
carry one youth who she now knows to be Ke vin into the
gyrnnas iurn where she
remained with himAt 1606 hours Dr- Curpen exa mi ne d Kev in in the
gymn asiu m which had been estab li sh ed as a tempora ry
mortuary.
Dr. Cu rp en certified life extinct.
Special Con sta bl e Martin later es cort ed Kevin's body to
the Medico Legal Centre and she con firm ed the identl icatlon
by r ef er en ce nu mb er to DC Weigold.
t
On Sunday, 16th April 1989, Mr. Jam es Stephen Williams
identified the body of his son to
Police Cons ta bl e Scott
Glave.
On Sunday, loth April, following id en tification by
Detect iv e Co ns t abl e Weigold, Dr- David S la ter carried out an
autopsy and sub mit ted a report giving the cause of death.
1014
p.
c
JOH N .KILLO.CH
Evidence is included regard ing the analys is of a blood
sample taken from Kev in where the pre se nc e of ethanol was
detected.
The wi tn ess es pr ov in g con t i n u i t y of the blood
sample are De te c tiv e Constable Green, Dete ct iv e Sergeant
Turn er and D et ect ive Sergeant Fletcher.
Dr. Alexander
Robert Forrest ca rr ied out the analysis.
Foun d in K e v i n ' s personal eff e cts was a ticket
counte rf oi l whi ch is consistent with his entry to the
s t a di um via a turnstile.
That con c l u d e s my evidence, sirThere is visual evidence.
B
I think I am right in saying, am I not, that Mr. Bruder (I
am looking at page 47) identifies Kevi n from clothing, is
that right? - A. He has been shown p h o t o gra phs which show
K ev in which Mr. L ayto n will deal with later and one of the
p h o t o g raph s I be lieve does show Mr. B r u d e r actually giving
first aid.
QA.
50
there
is no doubt about
it that Mr.
Br ud er was involved?
No
Q. His personal recoll ect ion isn't as s t r o n g ? - A- No, but what
he does recollect is corrobo ra te d by the visual evidence.
D
Q.
We have already m en ti on ed the evi den ce of Special Constable
Mart in who said about the lad speaking.
In no way do I want
to run poor Special Constable Martin d o w n becau se she had a
very hard day but it is right she was obvi ou sl y from her
st ateme nt s very distr ess ed ? - A. I also wouldn't want to
crit ic is e WPC Mar tin in any way but I have interviewed her
twice, sir, and she was par tic ular ly upset as indeed many
people were but it affected her part i c u l a r l y badly the
even ts of that day.
THE CORONER:
Well,
conclusion.
Mr. Fraser.
I won't ask you to draw a
MR. FRASER:
The re is a ma tt er ari sin g out of what the
Offi ce r says whi ch may perhaps leave a doubt in Kevin s
parents' minds.
Can I ask you to ask Dr. Slater to deal
with the point that was made in p a ragr aph six of the
summary, sir?
THE CORONER:
MR- FRASER
Dr.
Yes. sir-
Yes, I will do that
THE CORONER:
Slater to come down in a moment
MR. FRASER:
THE CORONER:
H
About the c o n v u l s i o n s ?
Thank you,
I will ask
sir.
Is there an ythi ng else you want to ask?
1015
DR. DAVID NEIL SLATER
D . I . MICHAEL LAYTON
MR. FRASER:
THE CORONER:
No,
thank you,
sir.
I will recall Dr. Slater.
DR. DAVID NEIL SLATER - Recalled
Bv THE C O R O N E R :
Q. Dr. Slater, the point that is being made, of course, you
have got to remember that Mr. Bruder was at the Spion Kop
end, the bottom end and not the top, and he says, “ I saw
this man lying on the floor havi ng convulsions".
Ca n you
help us about that? What do es that add or not to your
pathological op in io n? - A. It is obviously very distressing.
Unfor tu na te ly when people have not got enough o xyg en in the
brain, as I said in my earlier evidence, which is really
what the word "asphyxia" means, individuals can in fact have
fits.
This is one of the me ch anisms that leads towards
death and makes the asphyxia worse.
This does, however,
only occur when the individual is totally unconsciousIt
does not mean there will 'be any pain or discomfort.
The
person will not know they are fitting and actually I have to
accept that some individuals do have convulsions and it is
one of the mechanisntys leading to death in traumatic
asphyxia, sir.
Q. Does it make you feel the other evidence about the lad
breathing and speaking either more or less likely because
obviously this would be much closer in time to Special
Constable Ma rtin's evidence than what had happened on the
terrace? - A. Yes.
For somebody to have convulsions, this
would imply that the amount of asphyxia is such that there
must be virtually irreversible brain damage present and
again this would fully support the concept that the evidence
of opening eyes and speaking is not really conceivable, sir.
THE CORONER:
Does that help, Mr. Fraser.
C ro ss-Ex am in ed bv MR.
FRASER:
MR. FRASER:
I am sure it does, Dr- Slater.
It is
difficult to find the phrase to sum the situation up.
Kevin
at that stage w as beyond help.
He was as good as d ead ? - A.
Yes, that is right, absolutely.
Q. And would feel not hing and know nothing? - A. Absolutely.
He would know nothing.
DETE CT IV E
INSPECTOR MICHAEL LAYTON - Called
Bv THE C O R O N E R ;
Q.
Inspector Layton. - A. Sir, Michael Layton, Detective
Inspector in the J e s t Midlands Police.
1016
D . I ■ M I C H A E L LA Y T O N
an examination has been made of video f i In and
.1 r
photographic evidence and Kevin has been i d e n t u i e a in
E n c l o s u r e No- 3, also, sir, being carried acroas
the pitch
and at.-the Spion Kop end of the ground-
B
On a pho tograph r e f e r e n c e d DAC3/I Kevin is shown
apparently unc onscious near the perimeter fencing in
Enclosure No- 3On a BBC video tape, referenced aAP 7
timed at 1528:33:22 this shows him being removed from the
terraces via Gate No- 3.
PC Craighill has signed a plan of the pitch showing
where he first came into contact with Kevin and where in
fact he laid him on the ground and that plan, sir
if
referenced M J C 2 - The Officer has identified himselt on
video
again a BBC video tape, MAP 7, timed at 15f S : 4 ^ 4
carrying a youth who he knows to be Kevin - that i ^
error there
It says Keith in the summary but it should be
Kevin - from Gate 3 and on to the pitchThe Oirlicer
l
not know the identity of the youth and at first in tac
believed it to be another of the deceased but that has been
clarified.
D
E
Photograph referenced PR5/32 and PR5/33 which are both
timed at 1532 show Kevin being carried across the pitch on a
temporary stret ch er by a number of spectators and two Police
Officers.
PC Hayes has confirmed his identification on
those photographs.
T h e Of ficer assisted to carry t w o people
on temporary stretchers, both of whom were deceased, but
couldn't recall any other details and he didn't know the
identity of the per so ns he carried.
He m e r e l y t as it were,
assisted in carrying.
We have mentioned that before.
It is
not aii unusual feature that people's r e c o l l e c t i o n s weren t
exactA number of photographs, including a photograph
referenced TT1/30 show Kevin being given mouth to mouth
resuscitation on the pitch by PC Bruder who contirmed his
identification.
Sir, you mentioned this Officer earlier.
In fact, it is true to say Mr- and Mrs. Williams have
previously seen visual evidence.
They have in fact seen
some of that visual evidence again today and I think
arn
right in saying they have confirmed that Kevin is shown on
that photograph so, as it were, PC Bruder is confirmed as
having given mouth to mouth resuscitat ion to Kevin.
Q. The reason I ask ed is because it refers to a friend and
there doesn't see m to be any other evidence of that.
A. No, that is right;
It is true to say the initial
identification was from cl othing but it has subsequently
been confirmedDir, can I re fe r you to a plan which has been given the
reference MWJL40 wh ic h is a plan of the terraces.
H
1017
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n .I . M I C H A E L LAYTON
Yes,
C 2 0 - And NWJL41
which is a plan of the pitch.
MJC2 are they the same markings? - A. I would say, sir, that
in fact although there are two ma rkings the reference to MAP
7 on the previous plan actually would deal with PC Craighill
on that occasion.
So MWJL41 we make C 2 0 2 . Let us i n c l u d e that one as well
MJC2 will be C 2 0 3 . - A. Which is PC C r a i g h i l l ' s p l a n .
(moved to p l a n ) Sir, if we can deal with the plan MWJL40,
which is the plan of the terraces, the first photograph
DAC3/1 referred to in this sumrnary indicates the position
here (indicat i ng) and this indicates Enclosure No- 3 and it
is at this point here (indicat i n g ) that Kevin is shown quite
close to the perime ter fence.
the second identification, MAP 7, the BBC tape, refers
to the identification by PC Craighill and the point at which
we see Kevin is ap pr ox im at el y here ( indicat ing) and it if
prior to his removal via Gate 3.
Then, sir, in respect of PC Cra ig hil l' s plan, MJC2, it
is a terrace plan he refers to but he act ua ll y indicates a.
position here (indi cat i n g) in front of Gate 3 and a further
position which is shown just off the plan but it is here.
It is just on to the pitchIt is d iagrarnmat ic ? - A'. Yes.
Certai nl y the second location can't be taken as giving us
any sense of distance? - A- No, but factually the next plan
will do that.
I think, sir, just to correct myself I should
have been pointing there.
Yes. - A. Sir, in respect of M W J L 4 1 , the video reference on
BBC tape, MAP 7, indicates a position here C indi cat ing.)
which accords with PC Craigh il l' s recollection.
There is
also photographic identification on PR5/32 which is where
Kevin is being ca rr ie d across the pitch and the location
re ferred to is there (i n d icat ing ) Rem ind me
do we know the time for that one? - A- Yes, 1
think it is 1532, sirYes, 1532.
A further photograph,
sir, TT1/30, which I think refers to PC B r u d e r , the location
of that is ap pro xi mat el y this position here ( indi cat- i n & )
which is towards the Spion Kop end of the pitch.
THE CORONER:
MR- FRASER:
Mr.
Fraser-
No questions.
1018
Cr oss -Examined -by MR- L I K E :
Q. Was che photograph with the reference DAC3/1 a timed
pho tog ra ph ? - A. No, sir
Cr oss- Ex am in ed bv MR.
B
D
CATCHFOLE:
Q- Andrew Duncan, did he show any visual evidence or did he
* - last
’saw Kevin, when they
give a plan showing where he
Can you just give
parted co mpany? - A- 1 don't believe so
me a moment?
The answer is we don't have a plan from
Duncan.
fir
THE CORONER:
If I can help you a little bit on that
one, what Andrew Dun ca n says is, "We stood up and were
standing about two to two and a qu arter y a r d s from the
peri me te r fence around the pitchWe were waiting for t e
game to start.
At about 1445 or so a gr ou p of friends were
standing behind me, Stuart Thompson and Tony Grier.
I wa&
st and in g with Ke vin Williams".
Then he describes the people
coming out and he says, "When the game kicked off I was
pushed forward down the terrace about two y a r d s . ^ After this
push I lost Kevin and did not see him again".
His final
remark is that he saw Kevin for the last time on the terrace
just before the crush started.
"The last time I saw Kevin
was on the terrace just before the crush started.
After
this I did not see him again".
That is his statement
just
that we know what it is which one we are ta lking about
dated 17.5.89.
Any th ing else, Mr- Fraser, you want to ask/
bo
MR-
E
FRASER:
No
sir
THE CORONER:
Mr- and Mrs. Williams, that is the
evidence we are going to take.
As I said to you in the
middle of the
heari ng we spent quite a lot of time wondering
what we should do for
the best.
Obviously we knew Kevin
lost his life and we were worried about upsetting you in
Court but I think on balance we have done the right thing
because you have heard within the limits of what we are
doing and s u m m a r isi ng the evidence what happened and what
went on.
Fortunately, Dr. Slater has been able to be here
and he has been
able to give you his opinion as to what
^
happen ed in his
view and what in his view is possible and i
think I am sure
that will help you - not to come to terms
with the loss
of your son but it is very difficult to come
to terms with that loss at all but just to appre ci at e in the
stress situa ti on in which people found them se lv es
rec oll ec ti on s tend some ti me s to be mistaken and indeed there
are lots of mis take n recollections not only in re lation to
Kevin but also in relation to many of the other people o
which we have heard.
That is not at all un common and occurs
in normal fatal incidents as wellIt is exc eedingly
difficult when you are suddenly confronted with a situation
to then recount exactly what happened.
H
1019
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B
I realise Kevin was a young boy, just fifteen, which ii
very very young of course and I would like you ’to know how
ver.v sorry we are that he should have lost his life at such
an early age in this tragedy.
The Jury have had to deal
with many cases but today, at this moment, we are just
dealing with yours and so far as we are able we w o u l d like
you to know we are conscious of t h a t . Thank you for being
here .
Ladies and gentlemen, we rise for a moment or two and
then we proceed to deal with our next Inquest.
(The Inauest into the death of Kevin Daniel— Williams
was adjourne d until a date to be fixed)
D
H
oB
1020
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HER M A J E S T Y ’S CORONER FOR SOUTH YORKSHIRE
(WEST DISTRICT)
INQUESTS INTO THE DEATHS OF THE
VICTIMS OF THE HILLSBOROUGH FOOTBALL
STADIUM DISASTER
ON THE 15TH APRIL. 1989
INQUEST INTO THE DEATH OF
KEVIN DANIEL WILLIAMS
(Further)
Before
DR. S.L.
POPPER,
LL.B,
B .M E D .S c i , BM. B S , MRCGP
(Her Majesty's Coroner)
At
The Medico-Legal Centre,
Watery Street,
Sheff i e l d .
On
4th May 1990
TRANSCRIPT OF PROCEEDINGS
From the Notes of J.L. Harpham, Ltd.,
Official Shorthand Writers,
55. Queen Street. S
SI 2DX
1021
'T
C"
INDEX
Pa%e
1.
OPENR- 5 BY THE CORONER
SERGEA MT JOHN KILLOCH
Recalled
2
Bjy THE CORONER
.
INSPEC TOR MATTHEW ROBERT SAWERS Called
5.
G y THE CORONER
DR. DA \ I I 0 SLATER Recalled
10
B|y THE CORONER
ross-Examined by MR. LIMB
DR
.
13.
.WEST JOHN WALLACE GUMPERT Sworn
15.
18.
19.
By THE CORONER
Cross-Examined by MR. LIMB
Further by THE CORONER
E
F
1022
H
( S
/
o
)
Friday, 4t'n May, 1990
FURTHER EVIDENCE IN
THE INQUEST INTO THE DEATH'OF
KEVIN DANIEL WILLIAMS
THE CORONER:
Mow you may remember on Wednesday I
kept you late.
I said I had to go out and do a little
bit of thinking, and that is what we are going to deal
with this afternoon.
What we were thinking about was that one of the
inquests which we had done related to Kevin Daniel
Williams.
I will remind you of this inquest.
This
was the case of another young man, in fact he was only
15.
The problem in that case was that the evidence
was difficult to unravel as to when he died and what
had happened when he was being taken across the pitch
and had he said something in the temporary mortuary and
so on
After the inquest was concluded my attention was
drawn by some of my legal colleagues, and very
rightlybecause they were realised it was a sensitive
problem and did not want to upset the family, so they
brought it to my attention privately first.
The point
which they were bringing to my attention was that one
of the witnesses appeared to say that when he came to
this young man at the Spion Kop end, more or less, of
the ground, he had convulsions and he also said he
could feel a pulse.
We knew from the visual evidence
- we are going to repeat all the relevant evidence in a
moment - we knew that he was being taken across the
pitch and we had a timing at 1532.
Assuming that was
right, this convulsion or whatever it was, was
happening after that point of time.
The question was:
what on earth was going on?
I agreed that this was a valid point. I think
we
were so concerned about the event which happened after
that, namely, what happened in the gymnasium, did he
speak or did he not speak - this was the lad with the
fractured voice box - that we may not have put quite
enough concentration and thought into the earlier
evidence, but we are going to do it now.
We are going
to sort it out so that we know, as far as we are able,
so that we understand, if we can, what happened.
I think if Sergeant Killoch could come back.
1
sF.RC KANT JOHN KILLOCH. R e c all ed
By THE CORONER:
THIS WITNESS:
Sergeant John
West Midlands Police.
Killocb
from the
Sergeant Killoch, if you read - we are not ^oing Jo
read the whole summary again because we don t need to
but I think paragraph 5 which is where somebody starts
describing helping him from the terraces. - A.
Following the severe crushing in the West Stand
terracing Police Constable Michael John Craighill went
into enclosure 3 and assisted a number of casualties.
Police Constable Craighill assisted to carry a young
rnan he now believes to be Kevin Daniel Williams from
the gate in the perimeter fencing of enclosure 3 and on
to the pitch.
The officer attempted resuscitation but without
success.
Derek William Bruder is a Police Constable with
Merseyside Police who was off-duty at the match
day.
He was a spectator in the North Stand.
recalls seeing a person lying on the pitch n££r
Soion ICop and North Standing and describes that
as having convulsion^.
the
that
He
th£
person
Mr. Bruder went on to the pitch and gave mouth to mouth
resuscitation, aided by a St. John's Ambulanceman who
carried out cardiac massage.
Mr. Bruder recalls that
a frieod of the casualty was with him on the pitch.
Resuscitation was conci-nuecf and cney were joined by a
St. John's Ambulancewoman who took over from Mr. Bruder
and after a short time by a St. John s Ambulanceman.
The St. John's Ambulanceman said the casualty was dead
and Mr. Bruder then left the scene.
Neither of the St. John's Ambulance personnel or the
friend of the casualty have been identified.
The person Mr. Bruder tried to resuscitate is known to
be Kevin Daniel Williams and there is visual evidence
to show that, sir.
). Then the next paragraph deals with the lady police
officer.
Just read that next paragraph as well. - a .
Special Constable Debra Jane Martin went on to the
pitch to assist and helped to carry several deceased
and many injured to the gymnasium.
She assisted to
carry one young boy, now known to be kevin, into the
gymnasium and she remained with him.
-
2
-
1 02 4
A([.
Now what she said we are not going to deal with because
that was satisfactorily explained.
What we are
interested in is that bit which has been read.
If we
turn to page 41, I think I arn right in saying that what
Mr. Hruder says - he says he saw a person about a
quarter of the pitch length away from the Spion Kop? A. l'es.
®f . He was lying on the ground or thereabouts? - A. That is
correct, sir.
He says he can remember this because he recollects an
ambulance going past which locates it in his mind and
in fact he tried to flag it down? - A. Yes.
Then he says:
"I saw this man lying on the floor having
convulsions."
- A. That is his exact wording.
Then if we turn over the page and pick out the bits
that are relevant.
He says he went down and he went
up to this man:
D
"...and then went to the man having convulsions."
- A. Yes, sir.
Then he says:
"I was joined by a St. John's Ambulanceman.
- A. Yes.
"That chap said, 'You do mouth to mouth and I will
do heart massage'"
- A. That is correct.
(&. He goes on to say:
"I then took his pulse in his neck.
a slight pulse."
- A. Y e s , sir. *
I could feel
.
He then tried to resuscitate him, mouth to mouth, and
undressed him so he could do it more conveniently
probably. - A. Yes.
0. Then he says:
H
J . L. H a r p h a m Ltd
"We continued to work on the man but after about
five minutes he went grey and his face was
withdrawn."
A
- A. That is right, sir.
B
Me also noticed there was something unusual about his
rib cage:
"As I did heart massage his ribs were unnaturally
prominent."
- A. Yes.
J. -Then eventually another St. John's Ambulance person
came and he left the man? - A. That is right.
}. This whole thing took quite a few minutes? - A. Yes,
obviously the officer had no conception of time.
D ).
Can you remind me about the visual evidence?
It is
just to make sure I have got it rignt that there is
visual evidence, both of Mr. Bruder.•• ~ A. One
photographic print was mentioned, sir, and was given
the reference number TT.1/30.
That is a photograph
which shows Kevin lying on the pitch.
The person has
been identified by Kevin's parents.
Shown about to
give mouth to mouth resuscitation of Kevin is a man who
has been identified as Police Constable Bruder.
PC
Bruder has identified himself on that photograph.
5. Then there is another timed print, is it PR.5/32 or
PR.5/33, showing Kevin being carried across, paragraph
18? - A. There are two photographs, sir:
PR.5/A/32,
which is timed at 1532 and PR.5/A/33.
That is also
timed at 1532.
THE CORONER:
Inspector Layton, just show us
where those photographs are.
INSPECTOR LAYTON:
Yes, sir.
They are referred
to in the plan MWJL.42.
PR.5/32 is approximately at
this Dosition here on the pitch.
That is the timed
photograph, sir.
TT.130 is not timed, but I believe
it is somewhere in this area h e r e .
From recollection
I think I did that actually from what Mr. Bruder says
in his statement, about the positioning on the pitch.
H
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1026
THE CORONER:
Now Inspector Sawers went to see
Mr. Bruder because we wanted to be sure we had the
facts.
INSPECTOR MATTHEW ROBERT SAWERS Called
By THE CORONER:
B
THE WITNESS:
Matthew Robert Sawers, Inspector,
West Midlands Police.
I believe you went to see him yesterday.7 - A. Yes, sir.
In fact it was Mr. Bruder's day off but he very
willingly gave his time? - A. He did.
D
Now can you summarise for me what he says? - A. Yes,
sir.
He starts off by referring and identifying his
two previous
statements to us, sir, the first of which
was approximately a fortnight afJtjsr the disaster
itself, and ci aciuohci statement in August of last year
was a very short statement in which he merely
identifies himself on the photographs that you have
heard reference to, sir.
He goes on to say that I had shown him a number of
documents and plans, from which he was able to refresh
his memory.
He refers to the fact he had made some
notes on the
day after the disaster but that they did
not refer specifically to his dealings with this
casualty.
He refers, sir, to joining Merseyside Constabulary in
1987 and receiving basic first-aid instruction during
his initial training.
That was both in theory and
practical application.
He refers, sir, following the
incident and his dealings with this youth, to feeling
he was inadequately trained in his own confidence,
although it is also true to say that he is absolutely
satisfied that the first aid he rendered on the day was
the very best he could do and he felt he could do no
more.
He goes on to say as a result of feeling
depressed about the incident he applied of his own
volition for further first-aid training within
Merseyside Police.
Indeed, he attended a full week,
Monday to Friday course, leading to a further
qualification and much greater confidence in his own
ability.
However, with the benefit of that training,
sir, he is able to reflect on his actions of the day
and he is still absolutely satisfied that the first aid
he rendered in terms of mouth to mouth and heart
massage were correct and he could have done no more for
Kevin.
H
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1027
He goes on then, sir, to deal with specific matters
that I referred him to in his original statement.
Specifically, sir, from the transcript and police file
he deals with page 41 of the police file statements,
which is naee 6 of his original statement in April last
year.
He reters and confirms seeing Kevin a quarter
of the length of the pitch.from the Spion Kop end of
the ground.
He refers to his being on the floor and
clarifies that as on the grass surface of the pitch.
He has given very careful consideration, sir, to the
expression that he used of having convulsions and in
the light of his further training and what he now knows
and thinks about the incident was that "convulsions"
was not the word that was applicable to these
circumstances.
He refers specifically to having seen
epileptic fits and says that what he originally
described as a convulsion was not anything like an
epileptic fit.
He goes on to say later, sir, that if
there was a part of the body that he saw move it was
his head and that the word that he best thinks
describes this movement is that of a twitch.
He refers to comments he made originally about
approaching the body, the body that was convulsing.
Having specifically considered it again, sir, he does
say that the body was not convulsing as he approached
it.
He referred originally, sir, to feeling for a
carotid pulse and originally he thought he had detected
a slight pulse.
On reflection, sir, he feels he would
be much more skilful if he were required to perform
this action again and he cannot discount the
possibility that he did not feel immediately in the
right place for the carotid artery.
He certainly felt
in the neck region where he
thought he would find the
artery but he cannot say he would have gone to it
directly.
I put to him, sir, the specific point I believe Or.
Slater made in his evidence
about this inquest a couple
of days ago and PC Bruder specifically discounts having
felt for the carotid artery with his thumb.
He refers
to the first two fingers of his left hand.
fie says in dealing with the carotid pulse that
he may
have touched other areas around the neck region,
including the Adam's apple and that whatever h£ felt
there he cannot be categoric it was a pulse.
He feels
he may well be mistaken in that matter, sir.
Later in his statement of April last year, sir, he
referred to the face of Kevin Williams going grey and
being withdrawn.
He wanted you to know, sir, that he
cannot specifically say he saw the face change from a
1028
normal pallor, or colour, to grey.
He mentioned it in
his statement, sir, in the sequence that it occurred to
him that he was now noticing that he was grey.
He may
have been grey as he approached him before he mentioned
it, or it may have occurred as he noticed it.
B
D
He referred in his original statement to the original
resuscitation attempts whereby he gave mouth to mouth
resuscitation and the St. John's Ambulanceman commenced
heart compressions.
His original thought, sir, was
that that was for approximately seven minutes and, give
or take, he is happy with that time and thinks it is
reasonably accurate.
He then later referred to
swopping over with the St. John's Ambulanceman and PC
Derek Bruder was then involved in external heart
compressions and this was when he noticed the unusual
rib cage and he had earlier referred, sir, to
unbuttoning his shirt, I believe.
He referred to
unzipping his trousers [~ "
"
I have put to him the apparent difficulties in the time
sequence of the action that he describes near the Spion
Kop end of the ground and his specific reference to am
ambulance and asking the St. Jphn's Ambulance colleague
whp was assisting nim and who hjts nuc been identified,
fco stop tne aifouianuc because he was considering
utilising it, sir.
I have drawn his attention to the problems in relation
to the known timing of ambulances arriving on the
pitch, both of St. John's and of the South Yorkshire
Metropolitan Ambulance Service and I have drawn his
attention to the qpp^rent discrepancy in relation to
the time shown on photographs PR.5/A.32 and 3, sir.
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1029
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A ). The point is that the ambulances were known to arrive
at about 1515 and 1517 or thereabouts? - A. Yes, sir.
. And the photograph, PR.5/A/32 and so on, is timed at
1532? - A. That is correct, sir.
. We are saying he was dealing with this young boy after
that? - A. That is correct.
. In fact I put the wrong times to you.
It is 1515 on
the pitch for the St. John's Ambulance and 1520 for the
first South Yorkshire... - A. That is correct, sir,
irrespective of which...
D
E
*
F
. It is still earlier... - A. It is still earlier than
1532, sir, and that point has been put specifically to
Hr. Bruder and try as he may he is simply ur. ible to
reconcile those differences.
I have put to him, sir,
was it for instance a question of one of those
ambulances actually exiting the stadium across the
pitch rather than entering the stadium.
He has
considered that point and try as he may his
recollection is still of it being an ambulance that
entered the stadium.
He refers then to being joined by the woman St. John s
Ambulance Officer, who he refers to pushing him out of
the way to become involved as a trained first aider and
recollects this was approximately six minutes after he
changed places with the male ambulance officer#
for
that reason, with the original seven minutes mouth to
mouth resuscitation, PC Bruder feels that that total of
thirteen minutes he could amend to a period of time of
between ten and fifteen minutes of sustained attempts
to resuscitate Kevin.
It was at this point, sir, that after approximately two
minutes of the involvement of the woman St. John s
Ambulance Officer, that the male St. John's Ambulance
Officer stood up and said, "He's gone."
He referred
to the expression being completely grey and would seek
to reaffirm that choice of words as his description of
Kevin at that particular moment in time.
He says,
sir, and I quote:
"There is absolutely no doubt in my mind, both now
and with the benefit of further training, that
then at the moment the youth I had tried to save
was dead, certainly dead, and beyond any further
help.
I and St. John's Ambulance personnel would
not have stopped if there had been any glimmer of
hope at all.
There was none."
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8
1030
He refers to the personal description of Kevin again,
sir, and refers to the fact he is r.bsolutely satisfied
it was Kevin Williams that he was attempting to
resuscitate.
THE CORONER:
I just want to make it crystal
clear that there is no suggestion in any of this of any
criticism of PC Bruder*
I think he did absolutely
valiantly and did his best.
Not only did he do his
best on the day, he is doing his best today as well,
through Inspector Sawers, to try and help us understand
what he remembers and I want that clearly understood by
everybody.
I don't want you to think w e are knocking
him.
We are not.
All I am trying to do is finding out
what happened.
Mr. Fraser, any questions of this o f f i c e r o n this
part?
I had Detter tell you who else I am going to be
calling.
Dr. Slater and Dr. Gurnpert, whom I will tell
you about when he comes.
He is a neuro physiologist,
a clinician, and an expert on this sort of thing.
MR. FRASER:
No, sir, I have no specific
questions, save to say that I understand, Officer, you
have spoken to Mr. and Mrs. Williams, having spoken to
the officer?
I rise because I appear for Mr. and Mrs.
Williams and obviously have their interests at heart.
THE WITNESS:
I did go and. visit Mr. and Mrs.
Williams, sir, yesterday evening, having seen PC Bruder
and I have outlined briefly to them the contents of PC
Bruder's further thoughts and recollections for Kevin
on the day.
MR. FRASER:
Sir, I understand they are
appreciative, both of the efforts the officer has made
and of his visit and they have no questions.
They
have decided not to come today, sir, for reasons which
I am sure you will understand but they are fully aware
of exactly what is going on on their behalf.
THE CORONER:
questions?
MR. LIMB:
Thank you.
Have you got any
No, thank you.
MR. CATCHPOLE:
No, thank you, sir.
THE CORONER:
When we have heard the rest of the
evidence I am quite prepared to recall any of these
officers, or, indeed, any of these witnesses because I
want us to understand it.
Dr. Slater.
1031
DR. DAVID SLATER Recalled
A
Bv THE CORONER:
3. Dr. Slater, you have, of course, already dealt with
this case a couple of days ago.
If I remember rightly
you said, among other things, that (a) this lad had a
broken voice box.
It was broken in four places.
Also (b) he was, of all the cases you dealt with,
perhaps the most asphyxiated, if one can judge that by
cyanosis and so on.
Would that be a correct
^
recollection? - A. That is absolutely correct, sir.
Ot
all the cases I dealt with Kevin showed really the
worst injuries to the neck in that there were four
fractures to the voice box.
In addition there were
three very large scratches; to the neck.
In addition
to cne normal signs ot asphyxia, the blueness and the
hemorrhages which were v e r y marked, there is no doubt
this was a very, very severe case of asphyxia and
probably the worst one I dealt with, sir.
B
D
E
-Q. We established to everybody's satisfaction what had
happened in the gymnasium and the account, we dealt
with that as to whether this lad could have spoken and
so on, so we don't need to be concerned about that.
What we are interested in this afternoon is the
evidence relating to Mr. Bruder.
I will also remind
you that in general that what has been said is that a
person becomes unconscious in an asphyxial situation
within anything from zero to twenty to thirty seconds.
There is a slight variation amongst pathologists, but
quickly.
Then that death usual supervenes within four
to six minutes or thereabouts.
The problem is, as you
have already heard, that whichever way you look at it,
Mr. Bruder was dealing with this young man quite a few
minutes after he had been taken out from the Leppings
Lane terraces.
In the light of the evidence can you help us as to
you think was going on on? - A. Yes, sir.
I will dea
with this in three general areas and then Dr. Gumpert
certainly will come and enlarge on these and help us
out further.
Firstly, and I apologise if this is an emotive area, I
think I need just to spend thirty seconds in explaining
what death is. - - Death is a sequence of events.
It is
not one set event and the sequence I will put to you is
an individual becoming unconscious;
whilst they are
unconscious they quickly lose all sensation of pain and
discomfort;
then there is a period of various tissues
in the body which are susceptible to a lack of oxygen,
dying.
The most important one of these is, of course,
the brain, and after about three to six minutes the
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1032
B
brain undergoes irreversible brain damage.
There is
then a point which we call brain death.
This is a
difficult concept, but by this I am implying that the
brain is irreversibly damaged.
The brain is no longer
able to control respiration and in fact that person,
for effective purposes, is dead, irreversibly.
That
is a medico legal definition, #t least one medico legal
definition, of death.
The problem now comes that I have not mentioned other
tissues in the body.
For example, the heart, a very
emotive organ.
When somebody is brain dead it is
quite possible that the heart is still alive and still
beating and this can go on for a few minutes or longer,
perhaps even half an hour.
C
D
E
Then we come to the point where the brain is dead, not
controlling respiration, and finally the heart stops
and that is really the point of whole body death and
that is really what the lay person understands by
death.
A doctor going up, putting the stethoscope on
the chest, no heart beat, no respiration, then that
person is unequivocally dead.
I hasten to add there that although the person is truly
medico legally dead, in fact even then there are
tissues in the body that are still alive.^
The skin is
still living.
The kidneys are still living.
This is
how we can then transplant them.
In fact it is an
emotive area and although that person is dead, there
are still tissues living.
It then takes another six
to twelve hours for all the tissues in the body to die.
Really, when we use the word "death" we have to be
very, very careful we are not talking about one set
event at one point in time.
We are talking about a
whole continuum of events that go on.
F
I mentioned that some tissues do not die as rapidly as
the brain and this includes both nerves and muscle.
In fact one can have a situation of somebody being
brain dead but the muscles and the nerves in what we
call the peripheral nervous system - not the brain are still living and in fact these can occasionally
function in some way.
Sir, that is a -general comment on death.
In relation to the Hillsborough incident, the sequence
that myself has given, and although I have not heard
the other pathologists I understand they have given a
very similar sequence of events, has been a rapid loss
of consciousness, perhaps five to ten seconds.
I
understand I have been the nearest by quoting a paper
H
1033
A
where unconsciousness can be instantaneous.
the rapid loss of consciousness.
That is
As soon as that person becomes unconscious I have said
several times that pain modalities, discomfort, again
disappear very, very quickly, perhaps within a second
or five seconds.
B
In very general terms, certainly myself - and I have
tried to keep it general - I then said that death - and
I have used the word very broadly, as you will
appreciate in iny previous evidence - that death occurs
five, ten perhaps fifteen minutes after.
I purposely
kept that very open because human beings are very
variable.
You cannot say that somebody is going to
die in fifteen minutes, and not in fifteen minutes.
C
I am trying to put the concept that although I have
talked about averages, very occasionally you are going
to have additional extremes.
I think K e v i n w a s one of
these extremes that did not fall into this five, ten or
fifteen minute sequence of somatic death, whole body
death, but in fact this was extended.
D
Having said that, Kevin had extremely severe asphyxia.
I have no doubt in my own mind that he had suffered
irrecoverable brain damage and death within the three
to six minutes that I said.
Therefore, I am quite
confident at that cime cnat Kevin was dead and there is
nothing that anybody on this earth could have done for
him after that time, including PC Bruder and any
ambulance people who arrived.
E
Again, you will appreciate from what I have said to you
that although Kevin was brain dead I have not said that
other tissues in the body may not have been living the heart, muscles, nerves.
In fact I know DrGi'mi>ert will explain in a minutfi that in fact there are
mechanisms whereby wTien aomeDody is brain dead in fact
the muscles in the body can twitch.
This will come as
a surprise, and I apologise if it is emotive, this can
even happen to somebody who hasn't got a head.
That
person is clearly dead, they haven't got a head, but
those persons can actually have twitches in their^
muscles.
This is what happened to Kevin.
He died
early - brain death - but unfortunately in this
particular instance we are talking about an extreme^
case where perhaps the heart beating went on for a bit
longer and we noticed these twitches, at least PC.
Bruder noticed these twitches in the body.
F
G
I
I feel this is what happened in the case of Kevin.
1034
From the description - in fact it is only fair to say
yon also had a word with PC Bruder because you were
concerned, you wanted to be quite sure that you
understood his evidence personally, so to speak? - A.
Yes, sir.
In the light of what you heard and what we have heard
now, do you feel that this lad died, if you like, in
the totality sense, I don't meant that- his skin was
dead, but in lay terms at the point in time when Mr.
Bruder was with him? - A. Yes, sir, I am quite
confident of that.
When one speaks to lay people who
have experienced people dying, a word which is
recurrent in these descriptions of death is the way
that individuals turn grey.
In fact I was very
impressed by the content in PC Bruder's statement of
the word "grey", recurring several times.
To me as a
doctor that implied that that was the point of whole
body death.
In fact I feel that it was probably
around that time that Kevin's whole body died.
His
brain had died twenty/twenty five minutes before that
at the time of the crusning, but his whole body died at
the time PC Bruder was with him.
We have mentioned these twitches and I think sometimes
they are referred to as spinal reflexes? - A. that is
correct, sir.
THE CORONER:
clear?
Now, Mr. Fraser, is that reasonably
MR. FRASER:
Even to me, sir, thank you, and I am
sure it will be clear to the family.
THE CORONER:
Any questions?
Cross-Examined by MR. LIMB:
Doctor, it is an emotive subject.
I remember in your
evidence about Kevin you described death in terms of a
process rather than as a moment? - A. Yes.
I would like to ask you a few questions about the
process following unconsciousness.
As I understand
it, in the cases of these victims, unconsciousness has
come ten to twenty seconds after compression of the
chest? - A. Yes«Tnat is as a result of oxygen to blood mix leading to
unconsciousness? - A. Yes.
There are various...
We
are now not talking about the actual cause of death,
but mechanisms.
One very profound view that has been
put forward of crush asphyxia, traumatic asphyxia, it
is not simply only the reduction of oxygen going to the
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1035
brain, but the fact that in fact there cannot be
circulation through the brain.
The pressure from the
chest is reflected up into the brain so in fact
effectively the cerebral circulation stops, so it comes
up against a dead end and it cannot circulate round.
But, yes, your concept then is right.
Following unconsciousness, that is to say, twenty
seconds^ say, after the start of the crush becoming^
is the body capable of facial expressions or
uoes it have a neutral expression? - A. First of all
the word "unconscious" itself is a very vague term, as
you probably appreciate.
There are varying degrees of
unconsciousness - superficial unconsciousness, perhaps
a sort of sleeping...
You are unconscious, really,
vfhen you are sleeping, and then, of course,
unconsciousness becomes deeper and deeper and deeper.
The deeper bit is when one truly loses pain sensations
and in fact in this particular instance having spoken
both to Dr. Gumpert and, indeed, a consultant
anaesthetist, everybody I have spoken to is confident
that pain modalities have disappeared very quickly,
perhaps within one or two seconds, five seconds is the
longest I have heard somebody express.
As I understand your evidence, following that short
period of five, ten, twenty seconds at the most, there
is profound unconsciousness rather than, say, the
unconsciousness of sleep.
Is the face then of the
unconscious person, the profoundly unconscious person,
capable of expression of any sort, or is there a
neutral expression? - A. I think I prefer to leave that
to Dr. Gumpert because you are into a clinical^area
there of what we call reflexes.
I am not trying to
avoid the question.
I think he will be able to give
you a very expert professional witness reply to that.
Would that be reasonable to you?
MR. LIMB:
Certainly.
matter with Mr. Gumpert?
Sir, may I pursue that
THE CORONER:
Certainly.
I want to be as
helpful as I can.
It is a difficult subject and in a
sense we are slotting it into the inquest. of^this poor
boy, but it is a more general topic and it wilij^ot
c u m s e , apply in a sense to everybodyt but t don t see
how we can avoid doing it.
Please do pursue it with
Dr. Gumpert.
Thank you, Dr. Slater.
1036
A
DR. ERNEST JOHN WALLACE GUMPERT Sworn
Bv THE CORONER:
Dr. Gumpert, could you first of all give us your
Q. names,
qualifications a n d appointment? - A . Ernest John
B
Wallace Gumpert.
I am a Bachelor of Medicine of the
University at Cambridge, Bachelor of Surgery of the
University of Cambridge.
A Member of the Royal
College of Surgeons and a Fellow of the Royal College
of Physicians of London.
I am consulting clinical
neuro physiologist and consulting n e u r o l o g i s t to the
Sheffield Area Health Authority, Teaching.
Gumpert, although you are a Sheffield
Q. Dr.
professionally, I dragged you bacK crom Cambridge
today? - A. Yes, sir.
D
E
I very much appreciate the
o. Where I tracked you down!
fact you dropped all your other arrangements in order
to be here.
Thank you very much.
Dr. Guinpert, you,
of course, had nothing whatever to do with this ^a s e *
I think you dealt with quite a lot of the injured
following Hillsborough ana inueea you may well know one
or two people I will be referring to later, but this
particular case was not one you came across.
You have
heard the evidence which has been put regarding this^
young man.
What I would like you to do now is to give
us a short explanation, as you see death, in the rirst
instance and then we will try and relate it to this
young man and particularly Mr. Bruder s evrdence
relating to him. - A. In about 1979 or 1980 when it
became possible to carry out renal transplantations or
kidney transplantations, it became very important that
the supply of kidneys of people who had died acutely,
usually in accidents, could be increased because the
life of a patient who has had a kidney transplant is
completely different to the life of a patient
to have dialysis three times a week.
They can go back
to normal life.
A hypothesis of brain death was then discussed, agreed
and published.
This consisted of certain examinations
of the back part of the brain, the part we call the
brain stem.
If you imagine the brain as being like
walnut, and it is., it is like having a c a r r o t stuck
underneath the walnut, and it is the carrot that
matters.
This is where blood pressure, pulse,
respiration and a whole variety of other functions are
controlled.
Once this part of the brain is dead, and
this death occurs, as you heard from Dr. Slater, in
between four and six minutes after deprivation of
oxygen, then the person is going to die.
They can be
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1037
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kept alive by artificial means and some of you may
remember the case in America which was kept alive for
thirteen and a half years.
Some of us were concerned that the guidelines that were
drawn up were not strict enough and that there was no
call for them to be repeated after a passage of time.
Perhaps unwisely we said this and this resulted in a
BBC "Panorama" programme one night at ten o clock when
the medical profession for once actually debated it,
<;ight of us.
As a result of that debate the
regulations were hardened.
They had to be carried out
by senior people who were used to doing it and they had
to be repeated.
A satisfactory outcome from my
personal point of view, although I don't know whether
the anguish was worth it really.
B
As a consequence of that I suppose in the next three
years I had to go through this rather unpleasant
procedure many times.
It was part of m y professional
duty but still to this day I cannot certify someone
dead without being disturbed by it still.
From this I suppose I have gained a great deal of
experience of brain death and brain damage. ^ It seems
clear to me, sir, in this case that poor Kevin was
grobablv dead before he was .got out of. thfi area in
yjiich he was standing.
I would agree with Dr. Slater.
I would think consciousness was lost probably within
ten seconds.
I would say loss of pain would be almost
instantaneous - not quite, but almost.
D
I cannot explain the.Liverpool Police Constable s term
"convulsion"
because to me
a
convulsion
is a f major ,
L .U I I V
w
w — - - - ----------------------------epileptic attack and he has quite clearly said he does
not mean that, so I don't know what he does mean.
I
think it would be wrong for me to try and guess what he
means.
I think we could accept that he does not mean
any significant movement.
Unfortunately, after people are brain stem dead, they
can twitch and very unnerving it is too.
1S
really due to a spinal reflex.
What we think happens
in anoxia - lack of oxygen - is that the brain stem
dies first.
The cortex, that is the thinking part of
the brain, your walnut, probably goes on quite ^ “l t .
longer and the-peripheral nervous system probably quite
a bit long still and I think that is the explanation of
what has been described by the Liverpool officer.
Q.
H
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I know the Liverpool officer in his supplemental
statement when he was discussing the question of a
pulse says he may have been mistaken, but let us
hypothesise that in fact he wasn't and he had felt a
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1038
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T)
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pulse when he approached this young man on the pitch,
would that fit in with your understanding...
Is that
a possibility? - A. It la a possibility, sir.
I would
like just to observe that feeling the carotid pulse is
quite difficult in somebody who has got a low blood
pressure, as would have been here.
In fact it can be
so difficult it is impossible and you have to put an
electrocardiogram on to know whether the heart has
stopped or not.
I would also like to say something about resuscitation.
I was very fortunate when I qualified that I became
house surgeon of a famous heart surgeon called Lord
Brock at Guy's Hospital.
That was in the days when we
did open cardiac massage.
In other words, if somebody
died you opened their chest and you massaged their
heart between your hands.
A terrifying experience.
It was while I was working for him that one day three
of us were doing it one morning, that he stopped it,
and that was the start of external cardiac massage.
Even to somebody like me who has been doing it f°r
twenty-five years, it is still very difficult.
The
last time I tried to do it I failed completely.
Even
to a trained person it is difficult.
Indeed, when
junior doctors are examined for this now, as they are,
a significant number fail rather than pass.
It is
quite difficult and for the lay person it must be
incredibly difficult.
0. You heard Dr. Slater's account of death, shall we say.
Would you go along with that? - A. I thought it was
eloquent.
I felt quite nervous!
Q. You mentioned this point about unconsciousness and the
loss of pain and I think you distinguish slightly
there.
Can you give me any idea that if a person
becomes unconscious, can he feel pain, and for how long
can he feel pain, in your judgment? - A. Again, Dr.
Slater put it very clearly.
You all read in the
newspapers about patients - particularly when they have
had caesarean sections, the ladies as usual - being ^
able to tell what the doctors were talking about during
the operation.
Again I have experienced this at first
hand when I was doing heart surgery because then it was
often very important not to depress the state of
^
consciousness too far because things were pretty tricky
anyhow-.
When- we. used to resuscitate the patients we
used to give them an electric shock.
Lord Brock used
to always shout, "Give it two fast ones."
The patient
would then ask you the following morning two fast ones
were.
Then you would ask, "Did you hear anything
else?" and they didn't, so it is all very much a
question of degree.
H
1039
“ ’^
1
I think slipping from slight unconsciousness to deep
unconsciousness in this circumstance, one, because of
the compression and two because of the asphyxia and^
three because as Dr. Slater again explained everything
is shoved up into the head and so there is nothing
moving around, it would have been very quick, almost as
quick as a rabbit punch I would have thought.
B
THE CORONER:
MR. FRASER:
Mr. Fraser?
No questions,
sir.
Cross-Examined by MR. LIMB:
D
Q. Dr. Guinpert you have spoken in terms of passing in a
very quick space of time from slight unconsciousness to
deep unconsciousness.
Following deep unconsciousness,
do the eyelids remain open or are they closed? - A.
Either may occur.
There is no particular rule.
The
thing we all see on the cinema of the person going to
close the dead person's eyes.
I don't think I have
had to do that more than two or three times in my life.
Most of the people I have seen die have died with their
eyes shut.
Q. Deep unconsciousness is associated with no longer
feeling any pain or discomfort.
Is then the face of
the person who is profoundly unconscious capable of ^
grimaces or expressions which might be taken as showingpain or discomfort? - A. Not in my view, sir.
E Q.
Is it in fact capable of any facial expression? - A.
Not in my view.
0. Following profound unconsciousness, is it right that
the face will become discoloured towards the next stage
of the sequence of events, namely, brain damage and
thereafter brain death?
THE CORONER:
Could you repeat that question?
MR. LIMB:
I am referring back to the process, or
the sequences of events as outlined by Dr. Slater,
Firstly, unconsciousness, thereafter brain damage and
thereafter again brain death.
The nature of my
inquiry was as to whether following profound
unconsciousness^ although there may be no outward
expressions there is this change that the face becomes
discoloured?
THE CORONER:
HR. LIMB:
H
I I
H v n K a m f t rt
The greyness you are driving at?
Sir,
that is right.
- 18 -
1040
THE WITNESS:
Are you asking tne to say when I
think the greyness came on or just the way it changed.I
cannot tell you when it came on.
I think probably jj.t
came on during the unconscious stage and I don t think
the Face would change when the moment of death came,
total somatic death, I d o n ’t think there would be any
change.
B o.
MR. LIMB:
Doctor, I am asking whether it happens
following the entry into unconsciousness towards the
next stage in the sequence, namely, brain damage? - A.
I don't think there is a change of facial expression at
the time of brain damage necessarily.
This change of
expression will be a gradually evolving process from
the minute the crush started.
MR. LIMB:
Thank you, sir.
________
Sir, you cannot tell by looking at
THE WITNESS:
person
that
they
are
dead or unconscious, at least I
a
n't.
You
can
by
feeling
them but you can t by
can't.
looking at them.
Further bv THE CORONER:
D
0. If a person has been, shall we say, somatically dead
for long enough, would you accept or would you agree
that sometimes the face goes paler? - A. Oh, it goes
paler, and becomes rigid and takes on a stare.
Yes,
that is quite different.
E
THE CORONER:
Anything else you wanted to ask on
that?
MR. LIMB:
No, thank you, sir.
MR. CATCHPOLE:
THE CORONER:
ask Dr. Slater?
No questions, sir.
Is there anything else we want to
(No)
Ladies and gentlemen, I will give you a chance.
It is emotive but it is also v ery interesting.
Is
there anything else while we have two experts here?
You have understood it as far as one is able to
understand it?
THE FOREMAN:'
Yes.
THE CORONER:
Dr. Gumpert and Dr. Slater, may I
say to both of you, you have done remarkably well in
explaining what is clearly a very (a) emotive and (b;^
difficult subject, succinctly and clearly to all of us
and I very much appreciate your help.
Dr. Slater has
H
J . L. H a r p h a m Ltd
- 19 -
1041
A
had to come as well, but not quite so far, and I am
very grateful to you for taking the trouble and the
time to come and I am sure it will be of benefit not
just to Kevin's family, but to other people who of
course are involved in this tragedy as well.
Thank
you very much indeed.
_
®
MR. FRASER:
Sir, I will certainly make sure that
Kevin's family have the opportunity to see the
transcript of what the doctors have said and I am sure
they will feel some benefit from that when they feel
able to look at it.
Thank you, sir.
c
D
E
F
G
H
J . L. H a r p h a m Ltd
1042
ANDREW DUNCAN Sworn
Bv THE CORONER:
Q. You are Andrew Duncan? - A. Yes.
Q.
Q.
You too
are
a Liverpool supporter? - A. Yes.
I think
you came to
the match with several of your
friends including Kevin Williams? - A. Yes.
Q. You came by train, is that right? - A. Yes.
Q.
Did you
come to the
main station in Sheffield
come on the special train? - A. The main train.
ordid yo
Q. What time did you get to Sheffield? - A. About half past
ten.
Q. When you got off the train were you steered towards
•coaches? - A. Yes.
Q. Were you wearing regalia?
Could they tell you were a
football supporter? - A. No.
Q. Just ordinary clothing? - A, Yes.
Q. How come you were steered towards the coaches to take you
to the ground?
Did you ask or did they just say,
Young
man, are you going to the match?11
What happened?
A.
There were people getting off the train who obviously
weren't going to the match*
If you were like a lad they
asked, they said, "Are you going to the match?
If you
said, "Yes*', they said, "Go that way."
Q.
Did they check your tickets or anything at all that
can remember? - A. No. The train tickets?
Q.
No, the match ticket? - A. Oh, no.
you
Q. So you then got on to the coach? - A. Yes.
Q. That brought you to Hillsborough? - A. Yes.
Q.
Q.
You got to the ground at about 11.30? - A. Yes.
Did you go straight in or did you do a bit of shopping?
A. Well, the ground wasn't open so we walked round for a
bit.
We went to the shops and just walked round until
about half past one.
Q. That was you and Kevin? - A. Yes.
Q. Both of you had tickets, I take it? - A. Yes.
i ■
i
Q. I think you entered about half past one? - A. Yes.
B
Q. Were you searched when you went in? - A. Yes.
Q. And on the other side of the turnstiles as well? - A.
Yes.
Q. You had no difficulty getting through, I take it? - A.
No.
Q. Then I think you went and bought yourself a cup of coffee
inside? - A. Yes.
Q. You saw the tunnel and you went down it?
- A. Yes.
Q. Had you been to the ground before? - A. No.
Q. Were there people going down the tunnel at that time
already or... - A. There were a few, but there wasn t
many people.
Q-
It wasn't too bad anyway? - A. No.
Q. You came out of the tunnel and you entered the terracing?
- A. Yes.
Did you go left or right, can you remember? - A. At first
we went left and then we decided to go to the right.
Q« You just thought that would be better? - A.
i e s.
Q. There wasn't any other reason for changing at that point?
- A. No.
Do you know what time it was when you got into the right
hand pen? - A. Probably about twenty-five to two/twenty
to two.
How would you describe it at that time? - A. Well, it was
pretty empty because we actually sat down on tne
terracing.
Q. With the passage of time of course it started filling up?
- A. Yes.
Q.
You were standing fairly near to the perimeter fence, is
that right? - A. Yes.
Q. Fairly near to the front?
In line with the goal, or a
bit further? - A. Just right of the goal.
A. DUNCAN
You were lust talking and waiting for the x.atch to start?
- A- Yes.'
At that scaga I taka it nothing concerned you,_ apart from
the fact that Liverpool shouldn't lose? - A. Yes.
It happened that you actually saw two of your friends,
Stuart Thompson and Tony Grier, is that right? - A. Yes.
I know what time you said in your statement, but do you
remember about what time you saw them? -A. Well, it was
pretty full then so we didn't speak to them, we just saw
them.
They were further up.
They were behind you, were they? - A. Yes.
when you saw them can you remember Tony climbing up on to
a barrier? - A. M o .
You don't remember that? - A. No.
It doesn't matter, you may not have been watching him at
that particular moment.
Do you remember a beach ball
being knocked about? - A. Yes.
Was that at about the same time as you saw Tony or was it
earlier or later? - A. I can't remember.
Can you remember the players coming on to the pitch,
pre kick-off? - A. Yes.
Were you still in the same position? - A. Yes.
At that point, what was it like? - A. Just like a normal
game, really.
A bit of pushing and that but not bad.
Nothing that concerned you at that stage? - A. No.
You of course were excited, the match was going to oeg-n
soon, you hoped.
Did you see the kick-off? - A. They
were about to kick-off - I didn't actually see it because
of people pushing about.
You were sort of moving round
everywhere.
So when the players came out pre kick-off, it was
like a normal match as far as you were concerned. - A.
Yes.
Just before kick-off something had happened.
Tell me
what had happened in that period between the players
coming out and kick-off? - A. Well, there was a bit of
_
pushing and moving round and that, then I don t know.
I
just don't remember actually seeing any of the game, so 1
obviously can't remember seeing the kick-off.
A. DUNCAN
You say you don't, remember the game at all? - A. Not
reallv.
When the slavers tame cut
Kevin still with you? - A. Yes.
vou ao rememoer, was
What happened to Kevin?
When did you last catch a
glimpse of him? - A. .Well, there was a big push forward
and he went off to the right a bit.
He said something,
"It's a bit packed, isn't it?"
Then I didn't see nim
after that.
Are you saying you felt a big push then? - A. Yes.
Where did that push take you?
Did it leave you.in the
position that you were in, but more squashed, or did it
move you? - A. It moved you forward and you were
squashed, but normally what would happen is it would go
back.
You know, people would push back.
That's what didn't happen? - A. No.
We have tended to use the word "surge", but you can use
"push", it doesn't matter.
How many of these pushes did
you feel, just the one or more than one? - A. Well, there
was the first one and then it didn't move back andthen
another one came, a bigger one.
There was a bigger one after the first one.
Did the
first one move back or not? - A. It did slightly.
It
eased off slightly.
Not as much as you would expect? - A. No.
Then the second one was much stronger? - A. Yes.
But you don't know what was happening with the game.
No
You were fairly near the front. Had you seen
which is in the fence? - A. Yes.
- A.
the gate
You had seen that.
Could you see what happened to that
gate? - A. Well, there were people shouting for tne
Police or stewards or whatever on the other side^or tne
fence, for them to open it because they were. getting
crushed.
No-one opened it and then I think some_o. tne
crowd who were in front of it started pushing on it to
get it open and it came open.
Then a few Policemen ran
over and shut it again and were leaning on it.
After
about five minutes or so - I think they got it locked
again, and then after about five minutes or so one or
them opened it.
45
A. DUNCAN
B
Q. So you wera saying this happened.
Did this happen
after kick-off cr just at kick-off cr iefcra kickoff? - A. It was aftar the kick-off.
Q. You think it was aftar? - A. Yes.
Q. You are saying it was opened by some fans who pushed
it open? - A. Yes.
Q.
Did you see any of them run on to the field? - A. A
few ran out and then when the Police had seen them
run out they ran over and shut it, leaned against it.
Q. Did they get them back in, can you ramember? - A.
They tried to.
I.am not sure whether they ran off in
another direction, I am not sure.
Q. I cannot hear you? - A. I am not sure whether they
ran off in a different direction or the Police could
not get them.
Q. We have heard from several young men who were
standing at the gate and who ran out into the field.
What I am trying to find out is what you remember.
You remember this happening.
You remember the gate
being shut? - A. Yes.
Q. How confident are you about your timings? - A. I
could not really tell you.
I am not tco c a r t a m .
Q.
Do you know how long the match
to end? - A.I did not know at
heard since.
played frcm c e g m n i n g
the time.
I have
Q. Pardon? - A. I have heard sinca but I d i d n ’t knew at
the time.
Q. What I am trying to find out is whether you ara
saying the gate was shut for the whole of the
duration of the match because the match only played
for five minutes? - A. I do not think sc.
Q. Did you see a Police Officer open the cata or was it
the fans that opened it the second time z z a z you
noticed? - A. I could not really be certain.
I- was
either a Policeman or am ambulanceman, I thank,
one
of the St. John Ambulance or what have you.
Q. You were standing in the crowd and there was a man in
front of you who was not very well, is that righ .
A. Yes.
q
. Somebody shouted to you and said,
him", is that right? - A. Yes.
<
ftz
s
)
"Try and revive
Q. Z c ycu rameraber whether tjia match was still in
prcgrass at that point? - A. Nc, I couldn't see on to
the pitch.
Q. In fact, this man told you to bite his ear, did he
not? - A. Yes.
His friend was standing outside the
fencing and told me to bite him.
Q. He told ycu to do that? - A. Yes.
Q. How did you get out? - A. I was there for a bit and
eventually I suppose I got on to my side.
Q. I am sorry? - A. I got sort cf sidewards cn a bit sc
that I could get a bit of air and then scmecne pulled
me over the fencing.
Q. Somebody pulled you over the fence? - A. Yes.
Q. Eventually another friend told you that Stuart was
missing, did he not? - A. Yes.
Q. Unfortunately your friend Kevin also lost his life? A. Yes.
Q. I want you to show us on a plan where you were? - A.
Y e s . (witness marked the p l a n )
MR. BEECHEY:
Q.
C.457, sir.
THE CORONER:
Did you notice the barrier at ail
behind you? You have put your cross frcm near the
barrier.
Do you remember that barrier at all? - A.
No.
Q. You do not remember anything about it? - A. Not whi - 2
the crush was on I d i d n 't .
Cross-Stt*fflingri bv MR. PAYN5
Q. Have you followed the team to other grounds? - A.
Yes.
Q. How long have you been doing that? - A. Actually that
was the first away game I went to and since then I
have been going now and again.
Q. -This was the first time you had been to an away
match? - A. Yes.
Q. At this particular Semi Pinal? ~ A. Yes.
A. DUNCAN
Cross-Examined bv MR. ISAACS
Andraw, ycu rold the Ccrcner that you recall tie
players coming out and at that point it was just like
a normal game? - A. Yes.
There was pushing but it was not that bad? - A. Yes.
You get pushing behind the goal in a normal g a m e A. Yes.
And surging, as you have told us, with people coming
down and people going back up again? - A. Yes.
You said that you started to feel, and I am
paraphrasing now I think the impression you 9^v® anctall'me if I am wrong about this or if I am right.
It started to get bad when this first big surge came
just when they were about to kick off? - A. Yes.
I wanted to ask you about that because you were asked
by the Coroner whether you actually saw the kick-of^
and you said you had not.
By that you meant you did
not actually see someone kicking the ball?
You did
not see Rush kicking the ball? - A. No.
When you say they were just about to kick off, do you
mean they were standing in the centre circle ready wC
kick off? ~ A. Yes.
In the centre circle ready to kick off.- ~ A. Yas.
They were getting into position to kick o f z ,
they? - A. Yes.
were
THE CORONER:
Mr. Manning, shall we adjourn new?
Did you say, yes or no, Mr. Manning?
MR. MANNING:
I think we can finish this
witness. Shall we try?
THE CORONER:
It is easier for him but I do not
want anybody to feel rushed.
MR. MANNING:
better.
THE CORONER:
I actually think it would be
Go bead, Mr. Manning.
^ ^ s - E x a m ined bv MR. MANNING
I iust want to go further in time just a little bit
than the gentleman next to me had done.
push came, of course, that was when
A. DUNCAN
ycu and Xsvin talked, when he had been pushed off to
the
and tia. is when he said or you said, I sun
net sura, "It is a bit packed, isn't it?"? - A. Yes,
he said it.
It was him who said it and you agreed with him at
that time? - A. Yes.
The first time you had the push it eased back a bit.
The second time it did not ease back at all? - A.
Yes.
MR. XING:
Do I understand the evidence of
Andrew correctly that he lost two friends?
THE CORONER:- Two.
He went with Kevin Williams
whem he lost and he knew Stuart Thompson.
MR. KING:
I do not think it will serve any
purpose to question him.
THE CORONER:
Yes.
MR. KING:
I just want to say to Andrew, thank
you for coming, because I suspect it is difficult for
you to relive it.
LUNCHEON ADJOURNMENT
Elbozi- Lane, Formby L 3 7 4A IF
Teleohone:(0704S) 78661
Fax:(07048) 32488
6 March 1992
To whom it may concern
Dear Sir/Madam
Re Mrs Anne Williams,
I have been asked by my patient, Mrs Anne Williams, to
give my opinion concerning the death of her son Kevin at
the Hillsbrough disaster in 1989.
I can confirm that I
have read the report of the autopsy dated 16 April 1989
and have counselled Mrs Williams regularly since that date.
Mrs Williams has been able to interview witnesses at the scene
of Kevin’s death only two weeks ago and was able to discuss with
a Mrs Deborah Martin in detail the final few minutes of Kevin's
life.
I have been asked to give my opinion on whether or not
Kevin was able to utter the word "Mum" following attempted
resuscitation by Mrs Martin of Kevin.
It is my opinion that fron
the given information from Mrs Williams and the detailed report of
the autopsy, it would not be impossible for Kevin to have utterec the
word "Mum" and I have informed Mrs Williams accordingly.
Yours faithfully
"Dr
Roger Parker
• Forbes Innes
Patricia Gibson • Sieve Crosby • G raham A U z l t w u
STATION
IAl^E :
DEREK WILLIAM
BRUDER
ADDRESS:-'.
MERSEYSIDE POLICE, ' F \ DIVISION,
HALEWOCD PSTN, LIVERPCCL.
^ 2 / DATE DF BIRTH: C Z
XCUPATICN:
POL PC7808 F DIVISION
vho states: - This statement consisting of 012 pages, each signed
:y me, is true to the best of my knowledge and belief and I make
Lt knowing that if it is tendered in evidence I shall be liable to
prosecution if I have wilfully stated in it anything which I know
2 0 be false or do not believe to be true.
ZIAIED: 270489
D W
<SIGNED)^ .
I am a serving Police Officer with Merseyside Police, on Saturday 15th
April 1989 (150489) I was off duty and went to support Liverpool in
the match against Nottingham Forest at Hillsborough Football Ground.
I want to the game in my own car with my friend
Liverpool.
He had bought our tickets for seats in the
North Stand for #14.00, fron Liverpool football club supporters club I
think.
We drove to the ground via Huddersfield where I dropped my sister off
at Polytechnic and then carried on to Hillsborough.
O n the way to the
ground there was a short delay at the Manchester Interchange on the
M62 with roadworks.
Aftar we arrived at Sheffield I vent w ________________ -°
stcre on the continuation of Halifax Foad.
GatewaY
This being ware v s parked
the car at about l.lOpn (1310).
At the Gateway store there were
between 200-300 Liverpool fans.
We stayed with them and were allowed
into the store in small numbers to buy drinks.
1 bought
four cans of lager between us and then went outside and sat on a
grass verge together with the other 200-300 fans and we drank two cans
3;
each.
2
DEREK WILLIAM
BRUDER
The group of fans was well behaved and I didn't see any
-drunkeness.
We were supervised by a Merseyside and South Yorkshire'
Folice Officer who were sat on two horses outside the Ccmet
Superstore.
Whilst I was sat on this verge everyone was happy and amenable and at
one point I saw a uniform Superintendent and Chief Inspector WALK past
us.
Between 1.45pn and 2pn (1345) (1400) the two mounted police
officers
came over and told us it was getting on and time to make our
way to the ground.
The whole crowd moved on without any problems at
all. I renenber it was the Merseyside Officer who actually spoke to
the crowd.
Wte walked to the ground and when we got into Leppings lane itself it
was packed with people even half a mile from the ground itself.
Because of the crowd my friend asked a policeman for directions to
the ground, he was manning a junction either two or three roads up
from the ground off Leppings Lane.
He then directed us to go back the
wav we had cate and round to the Spion Kop end. .I didn't think that
was right but followed his directions and walked back the way we had
core and to the Spion Kop.
This was about 2.20pn (1420).
We then went to the Spion Kcp but three quarters of the way round on
walked back.
The time was getting on now and the walk round was long because a lot
of the connecting roads between Leppings Lane and Penis tone Read were
blocked by Police.
Because of the time I approached a police officer
on one of the barriers and he alleged us to take this short cut when I
explained what had happened and shewed him my police warrant card.
arrived back at Leppings Lane at 2.30pn (1430).
We
W h e n ----------1
arrived back at the turnstiles there were no queues whatsoever and a
DEREK WILLIAM
J
large mass of people all trying to get through the turr^tiles and into
the ground.
It had reached the point of every man for thenselves in
order to get to the turnstiles.
I made for and entered the far left hand side turnstile of turnstiles
1-15.
There was no police officer by my turnstile.
riant I saw a number of police officers on horses.
Cver to my far
I could not see
any police officers on foot but could not say whether this was
because there were none or they were blocked from my view by the
crowd.
Outside the ground my friend had both our tickets and to try and stay^
toeether I had hold of his jeans, •However, the pushing of the
pecpie was that much that we were pushed apart and separated.
Onca we were apart I decided to make for the turnstile on my own.
had got in before me and once I reached the turnstile he handed
ny ticket out to me and I was allowed inside.
I handed my ticket into
the turnstile operator and retained the stub of the ticket.
I had difficulty in finding the entry point only by the misdirection
of the police officer, but once I got back into Leppings Lane, I found
the turnstile but had difficulties getting in because of the sheer
nuiccer of people.
At the tine of my entry I saw no gates open other
than the turnstiles.
I did not see any of the gates cpen.
As I was trying to get to the turnstiles I saw about five or six
teenagers climb over a concertina gate inmediately to the left of the
turnstiles. After the first five or six went over I saw a number of
others climb to the top of this gate but then drop back into the crcvri
outside as if there was someone in authority on the inside telling
them to get back.
Onca |
11 had got into the ground I saw a police sergeant and
four constables imnediately behind the concertina gate where I had
DEREK WILLIAM
4
BFL-E”
ae^ - \ the teenagers climb over.
I approached
the sergeant and said
Scir= > th ing along the lines of "I am a Police Officer frcm Merseyside,
theres a huge crowd outside and they're pushing to get in, can you do
sarsthing about it or get something done?”.
At this time, I was with
but I did not produce my warrant card or formally identify
mysslf. He ^
no reply to me and by this time it was close to
kicic off time so I left it at that.
Onca inside the ground I saw no direction signs to my seat in the
North stand and had difficulty in finding it because the sections of
seating were given letters of the alphabet, however, the letters did
not follow alphabetical order ie ABFDGCM, though I can't remember the
exact order.
I entered the North Stand through a tunnel, there was no crowd within
this tunnel and no problems at all.
I saw no Police within the
tunnel and only a few stewards right at the beginning.
Once inside the ground I saw no alcohol being drunk at all.
I
took my seat along with
the pitch.
just as the two teams came out onto
This was about 2.57 pm (1457).
Once through the
tunnel and up the stairs, I went to the section of my seats where two
stewards directed us to our particular seats.
entrance to this section of seating.
These were right by the
People continued to enter after
me and after about ten minutes between ten and twenty people arrived
at this entrance and didn't appear to have tickets for this stand.
I
actually saw two people holding tickets which were for the West
Stand.
This was after the incident in pens 3 and 4 and people had
started to come cut onto the pitch.
Everyone started to discuss what
was going on and these trwo men said that they should be in those pens
and shewed the tickets which were complete without the counterfoil
being removed.
3 fl
DEREK WILLIAM
-
J
bfc -eh
r s-cceriencsd no personal crowd crush within the ground only that
cut
side which was about 2.45 pm (1445).
s t i r z e
I did not see any crowd
within the ground and was not injured.
At about the time these men had appeared at the entrance to my section
of seating which was three quarters of the way along the North Stand
nearest to the Spion Kop about ten rows from the front, I saw people
climbing over the fences fran pens three and four of the Leppings Lane
stand fran kick off but initially they were directed behind hoardings
and sat near to the pitch.
I could not see whether they were directed
by stewards or Police.
Aftar about five minutes a Police officer ran on to the pitch and
stepped the g a m s .
People then began to climb over the front fencing
onto the pitch at will and I could also see people pulled up into the
seating area above.
At no point did I see any gates opened to allow
escape fran the pens.
Onca play had been stopped the Nottingham Forest fans in the Spion Kop
j^ecan to taunt the Liverpool Supporters.
A fan then ran onto the pitch and then ran up to the Spion Kop and
began shouting and making 'V' signs with two fingers at the Forest
supporters. Myself and other fans in the North stand began to shout
telling him to go away because we could see there was something wrong
in the Leppings Lane end.
This man who was in his early twenties with
long hair and a black capped sleeve T shirt was then turned back by
either stewards or Police and ran back towards Leppings Lane but was
detained by Police before he got back.
Another older man then ran up to the Spion Kcp and then began to wave
his hands at the Forest fans.
Ke wasn't taunting, he was signalling
for then to calm down and trying to tell them there was something
wrong. Shortly after this the Police formed a cordon across the
2
U L k
DEREK WILLIAM
■--av line* I'm not sure if this was after the first or second man.
ha
par-le in the Leppings Lane end then ripped down advertising hoardings
and began to carry people on them up towards the c o m e r formed by the
cpion Kcp and the North Stand.
I could see that sane of then were
presumed dead as they had coats over their faces and one man in
particular had a jumper pulled back to cover his face.
These people
wera then rolled onto the pitch and the carriers went back for more
pecole or bodies.
The police then fonred a further cordon in front of the North stand.
Around the sane time a number of people wearing tracksuit trousers arfd
sweatshirts came fran the direction of the players tunnel and went to
the Spion Kop end.
They then pulled down more hoardings here and went
to help carry more people up fran Leppings Lane.
A number of people were also carried up to the c o m e r in front of me
bodily.
There were a large number of people in this c o m e r either
laid out behind the police on the pitch or sitting with their heads in
their hands.
I did not see any of the Police in the cordon in front of the North
Stand break ranks to assist these people.
/I saw one person on the pitch about a quarter of the pitch length away
frcm the Spion Kcp about twenty feet from the hoardings in front of
the North stand.
will
I distinctly remember this because later on as I
describe an ambulance drove directly past us and a St John's
Ambulance
ma n
who
wa s with me tried to flag it down but it carried on.
I am not sure if this man had been carried on a hoarding or by his
friand who was with him.
I
saw this man lying on the floor having
convulsions.
the Police cordon in front of the fterth Stand appeared unconcerned and
'smarmy', this agitated the supporters in the stand who were shouting
^r-i
DEREK WILLIAM
BPtOER
for then to go and help the people on the pitch.
None of the Police
officers left the cordon.
j W2S V B r y dose to the pitch so I went down the aisle, over a snail’
five foot wall with hoardings on, I walked through the cordon without
being challenged at all and then v^nt to the man having convulsions.
Almost iirmediately I was joined by a St John's Ambulance man.
I
identified, myself to the St Johns man as an off duty Police Officer.
He then said to me - You do mouth to mouth and I'll do heart massage".
I then took his pulse in his neck.
I could feel a slight pulse.
I
then carmenced mouth to mouth resuscitation and the St John's man
started heart massage.
shirt.
I undid two buttons on the top of the man's
If I remember rightly the bottom of the shirt appeared
ripped.
we zontinued to work on the man tat after about five minutes he Mint
grey and his face was withdrawn.
As I had approached the man his head
had ncved as if he was being sick.
When I got to him I cleared his
mouth and the back of his threat|
pefore cc^encing .rcuth to
mouth resuscitation.
S t i r about
five minutes when the man vent grey,
After about seven minutes I swapped places with the St John's
Ambulance man and he cotmenced mouth to mouth and I heart massage.
As
I did heart massage his ribs were unnaturally praninent in the whole
of his rib cage even though he was only thinly built.
His stanach
was depressed and abnormally lower than his ribcage.
Aftar a short tii« I undid the button on his trousers and riEE*d open
the zip.
I then continued heart massage.
Shortly afterwards an ambulance entered the ground.
It appeared
DEREK WILLIAM
0
a Haalth Authority ambulance as opposed to St Johns.
drive dcwn towards Leppings Lane.
try and step it.
It began to
I then told-the St John's man to
He tried to flag it dcwn but it continued on as if
it had been ordered not to stop in the top c o m e r but to go to the
Leppings Lane end.
The St John's man then rejoined me and continued to give mouth to
mouth resuscitation.
Shortly after this we were joined by one of the men I described
earlier in the tracksuit trousers and I think green sweatshirt.
He
askad me if I was all right and knew what I was doing.
**
I said "I'm an off duty bobby, i'm all right", with that he left as if
to go scnewhere where he could be of more use with other injured
persons.
Shortly after this man, which must have been about six minutes since I
had changed places with the St Johns man, a female St Johns Ambulance
officer came over and pushed me out of the way and took over fran me.
I then steed up and watched as she was obviously better trained in
First Aid than me.
I then steed by the injured man together with his friend who had been
there all along, telling us to keep going and not to let his mate die.
Within two minutes of this, the St Johns Ambulance man told the Su
Johns Ambulance weman, "He's gene", and stood up.
I looked at the
man's friend who was standing by his head, he was completely grey.
By this tine, I felt ill myself and just turned away as there was
nothing else I could do.
I would describethe man who died as:- between 17 and
20 years of age,
approx 5'8 - 5'9tall, short sandy or reddish coloured hair, slim
build, no facialhair, white eurcpean, I could see no cuts or
abrasions cn him.
I seen to
remember freckles
on hischeeks, but I
m
DEREK WILLIAM
gpl'OEF-
I
--------
3
•■---- ’------- ^-i I'm almost: positive it was
--------------------------- 1
no c surs i
freckles. As I said previously he had an unusually prominent rib cage
anc depressed stomach.
He was wearing a light, possibly white button up shirt, light grey or
beige cotton trousers, j
boxer shorts.
I noticed no
jewellery or footwear.
His friend I would describe as 21 or 22 years of age, dark brown hair,
shortish hair, about 5'9 tall.
I cannot rananber much of his clothing
but he appeared quite plump with a slight beer belly.
He had no
fac ial hair nor glasses.
The St John's man was in uniform, the only thing I can remenber was
that he had dark hair and was thirty plus years of age.
The St John's woman was in uniform again very slimly built and no
older than 18 years of age/
After the St John's man had said the man was dead I'd seen enough,
I felt ill and had to get out of the ground.
I knew]
stayed where he was because he knows no First Aid.
wall where I had climbed in.
would have
I went over to the
As I got there I saw a photographer
kneeling dcwn with an orange tabard he was taking photographs of the
injured and dying.
A fen who was already on the pitch went over to him and said "Fuck
off, you're taking pictures of my injured mates”.
The photographer carried on taking pictures so the fan started pushing
him.
The photographer stood up and the fan then pushed him back to
the wall and tried to take the camera from him.
and smashed into the wall.
The camera then swung
I then climbed over the wall using the
photographers case as a step.
I then rejoined
He said to me "Cane on we're going", and we both then left.
say what time this was.
I cannot
DEREX WILLIAM
■LU
BPC~£B
Whilst at Hillsborough the only criminal offences were of a minor
public order nature ie, the fans climbing over the gates etc.
After
the disaster within the stand, I saw a number of instances such as
the photographer's camera and sausage rolls thrown at the cordon in
frcnt of the North Stand and one old man who threw a cup of tea at an
officer in the cordon.
This was caused purely by agitation amongst the crowd by the apparent
callousness of the photographer and apparent inactivity of the police
with regard to the injured and dying.
I witnessed no serious offences.
There were a number of factors which I believe contributed to the
number of deaths and injuries.
Outside the ground there appeared to be a lack of co-ordination
between the mounted and foot police officers.
The approach roads to
the ground were well manned with Police officers at junctions and
outside pubs and off licences.
However, I made a caiment about being
misdirected by the police officer to another officer and he said it
was understandable because a let of the officers were drafted in fran
outside stations and had poor local knowledge of the area.
This may
have contributed to the build up outside the ground which caused the
initial crush outside.
Inside the ground once the disaster had occurred there appeared a lack
of ro-ordination between senior police officers and lewer ranks on the
pitch.
The actual scale of the incident wasn't appreciated
imrediately which resulted in a delay in the response and personnel
beina despatched to deal with it.
From my own personal experience I and most Police officers have only
basic First Aid knowledge.
When I administered first aid to the man
felt totally inadequate on reflection.
However with that particular
DEREK WILLIAM
bfi^ er
man,
11
I don't think more knowledge would have helped but it might have
in others.
I would also like to add that though the Police in the cordon did not
assist the injured and dying I saw a number of other officers who did.
In oarticular two small policewomen who tried to help a very large man
but couldn't carry him until helped by fans.
D W BRUDER SIQIEU
t , T A K E N
PLACE:
DATE:
TIME:
WITNESS TO SIGNATURE:
OFFICERS SIGNATURE:
D
270489
V G A1 A
West Midlands Police
(Amended 10.
STATEM ENT OF W ITNESS
( C . J . ACE 1 9 6 7 , j . 9 ; H.C. Ae= 1980, * . 1 0 2 ; M.C. R u l e * 19 8 1 , s . 70)
Derek William BRUDER
Name
Agc
2"
C '- s )
D a te o fE ird i
Occupation
Police Officer (Merseyside Police)
H ome or business address
Merseyside Police
and telephone aumDer
'F' Division
Halewocd Police Sts.cion
Liverpool
(05^ 709 6010)
This statement, consistingof sever.page (s) each *signed by m e, is true to the best o f m y knowledge an d b eiief
and I m ake it knowing that, i f it is tendered in evidence, I snail be liable to p r o s e c u tio n if I have w ilfully stated
in it anything which I know to be false or do n o t beiieve to be true.
Dated the
Signed
3rd day of
May
.
1990
D Bruder
Signature w itnessed by
M Sawers
Officers N am e
M R Sawers
R ank Inspector
No
3A^1
Further to my previous statements of 27 April 19S9 and 17 August: 1969, I
have been asked to think abcut a number of the points which are raised in
the statement I made nearly a fortnight'after the Hillsborough Stadium
disaster on 15 April 1969-
Before clarifying a number of these points I would point out that I have
today been shewn a number cf photographs, plans and documents by Inspector
SAWERS cf West Midlands Police which I have used to re'fresh my memory.
I-s
also fair to say that my first statement (27.4.89) was the first occasion
that involvement with the disaster was set dcwn in any detail, in writing,
although I did make some brief nctes myself on Sunday,
16 April 1969-
1
retain these in my possession and wculd say that they do not relate to my
dealings with any deceased casualty that day.
Signed
Signature w itnessed by
D Bruder
* Delete as applicable
\
y
M Sawers Inspector
dvco<.
iv h u ic i/iv iO
(Amended 9*31)
4- w i J O w
STATEMENT OF W ITNESS
( C . J . A c t 1 9 6 7 ,a . 9 ; M.C. Ac= 1980^ 3 . 1 0 2 ; M.C. fculea 1981, r . 7 0 )
DEREK WILLIAM ERUDER
Continuation of statem ent or
(2 )
I am a single man and joined Merseyside Police on 27 October 198, .
Dur...*
initial training at Bruche District Training Centre, Wcrringtcn, I receive
basic first aid resuscitation in both theoretical and practical
a n o U cation.
I obtained a pass and was issued with an identifying carc
qualifying me for, I think, 2 or 3 years.
On 15 April 1989 I had receive;
no further instruction or refresher training in basic first aid.
^c-e/e.
as a direct result of the situation I found myself in on the day cf^ the
disaster I personally felt inadequately equipped in either theory-cr
practise of
first aid.
I am absolutely satisfied that the first aic I
rendered in
terms of mouth to mouth resuscitation and heart massage were
correct and that I could have done no more, but, nevertheless,
i fe_.
-
didn't know enough and regretted not having taken that aspect cf initial
traning seriously enough.
For these reasons, I applied on my own initiative for further :irst a,a
training in the form of a one week full time course _e^c_n£
qualification as a first aic public orae.
the course m
,
i,,r ve-r
June las*- /e— »
-—
r-ar'm
a - ....
w r c v’ means I new nave a
*• -*
ar*
public order deployments to treat casuai--.es e . , . -
t undertook
s^ec.a-r-~_
n z
mercers w-
^ ®
public or police officers as injuries occur.
As a result of that course, I feel confident and a.— ., ae—
-
deal with injured people whether these injuries be miner cr life
threatening-
It
also c o m m a s
.,
that, i..
mv actions were n g n t
-
cn .
•<a* ‘■'"cuz" unsuccessful, were proper
day and my attempts'at resuscitao.cn, a_-..oue.administered.
2 T
signed
D Bruder
SignagewSwssedby
M Sawers Inspector
STATEMENT OF W ITNESS
( C . J . A c t 1 9 6 7 ,s . 9 ; M.C. Ae= 1980, a . 102; M.C. R u l e s 1 9 8 1 , r . 7 0 )
ConunuationoT
statement of.
DE?.T \ W I L I A M 3EUBER (3)
I will now deal with a number cf specific points from my original statemer.o
(27.4.S9) using the page numcers of that statement.
I understand tha.* the
numbers I will use in brackets are these of the file of statements
contained in respect of Kevin Daniel WILLIAMS,
prepared by West Midlands
Police under the deceased reference number 51 .
On Pace 6 (File page 41 ) I first refer to the youth I new know to be Kevin
Daniel WILLIAMS lying a 1/4 length of the pitch from the Spion K o p ;
I
refer to him being "on the fleer", meaning the pitch s u n ace, and "having
convulsions".-
I have thought accut this carefully today and with the added
benefit of my training I can say that this was not a process that lasted
for any time.
for example.
It certianly wasn't anything similar to an epileptic fit,
It was an impression that I had which I originally associate-
with the lad vomitting.
I will say that I did net see the casualty vomit
nor did I see any sick on the body or grassed area around him.
I will
correct further references to vcmit as they occur in my original. Soaoement.
Cr. pase 7 (42) I describe approaching the body.
He was net convulsing as I
did so (line
I refer to feeling for a carotid pulse in the neck and said originally t..a~
I thought I could detect a slignt pulse, however, I new fee^ tna~ I
to correct this.
I felt for the pulse with my first two fingers or my l e . -
hand, I believe, to the carotid artery.
I cannot say absolutely that I
felt for the pulse before I started acuth to mcuth or at-er, ncr inde_whether I did both simultaneously.
Signed
D Bruder
ac_-
Whilst I wculd new have much mcr-
Signaturewitnessed by
M Sawers Inspector
WG 4 1 3
West Midlands Police
(SO 5 2 2 )
(Amended. 9.31)
STATEMENT OF W ITNESS
( C . J . A c; 1 9 6 7 ,a . 9 ; “ .C . Ac: 1980, a . 102; U.C . R u l a s 1981, r . 7 0 )
Continuation of s ta te m e n t
of
DERE-<
w I L — ..-iM
sRUDER (A)
skill, cn the day I cannot say with absolute certainty that I went
accurately straight to the carotid artery.
For all those reasons, I can say that I felt for a pulse in xfce reg-cn cf
the carotid artery, but I may have also touched the area of the "Acams
Apple" or felt something in the neck region which I originally thoug..t Wa~
a pulse but may have been mistaken.
I refer to the face going "grey" and "his face was withdrawn".
I cannot
say specifically that this was a cSar.ge from normal pallor to grey, or wha:
I now know to be cynosls or blueness.
I mentioned It in the sequence of
wrien X became awsps or i ^ *
I refer tc approaching the lad and having the impression that his head
acvec and associating this with his being sick.
I an newabsolutely
satisfied that he was not sick, or certainly I did not see vcmitting or
vcnit.
The acvemer.t of the head, if thats what it was, I would s a y
best described as C-L
—
Us
I refer tc clearing his mouth before resuscitation, by tnat I me^n t- so.j
checked that his airway was clear before expressing air into his mcutn.
There was a fluid of some description out I ac-ep^ . __d
y
>-.*
have been spittle cr phlegm.
D Bruder
aJJHTa.—
»y ■
M Sawera Inspector
(So ZZ2)
WC 415
(A saodad 9 .3 1 )
West Midlands Police
STA TEM EN T OF W ITNESS
(C.J. ACC 1.67,..., M.C. AC, 19S0.
Continuation of
r
.
statement of
«-C*
lM1’ r-/0’
DEHEX WILLIAM BRUDER ( 5 )
s minutes and a very distinctive
to the man going grey ai ,er <*ccu, „ o -
.
..
T *,. w a c acairi net vcait but its true to say
sne1! coming from his mcu^...... —
.
3 c i f- caused me
I can still rememcer iw new a
-V-veandfeel
.*«=—
sickaysei:.
•
the St John ambulanceman did
T pafgn to performing mouth to aouta w m . s . wae
.
..
..-nils: this is purely recollection
heart compression for aocut T m--*u^_.
I believe it to be reasonably, accurate.
^
i
-« T rer'or' to feeling
St Johnsambulancemen
I re.
wi*-i tw e
Having changed places wi-ii t.e
i .k r-.ee and abdomen.
what I thought was an usual r_
A photograpn I have
shown at post mortem appears to support this.
•
*-ue l a d .s trousers at this point
and in my second
I refer to unzipping ^he lac s «.* ~u
..n <rv' ~ have seen m
tr“ striked boxer snorts «n_c.. - na
rachs (Ref No TT1/31 and m / 2 2 )
Dhotogr*:
.
of the arrival on
I have been shewn documents which purport „
pitchof the
-
-
. • -...ral anr the 2hC sE“u-“ w
, _ .- h ,,-! =rr= (St Johns imcuiai.c-.
1st omcui^.c. u . o
\
t h-ve considered this information
(be*-.* W e 1stSWAS
antuiar.ee!.
J. «*'• e-
_ ____ar,d a w 1C.17.0S;
(referred to as MAP 1 1t-1^--- a-a Hu““
'
.
0 -c— e"3 Ci:s PH5/A/32 and PR5/A/., w m c n pu. ,c.
p..c— »- -r
■
, ___ - 'c-^or
c a m e - on a
--
_
incomparison
w^-..
=-rw kUe casuai-/ ae— s
—nn^P^SuST.Q
ar 1=
>2 and wr.icn x unce.s— .u
al
*- •—"^
.vi’id be beicre x
«CU*U
w
E ’-cur.d.
him a*- the Scicn .scp. end or t..e gsaw and assisted i-- r-~ -<
■—
Trsrector
c ic r .a tu r e witnessed try
West Midlands Police
(Amended 9.81^
STATEMENT OF WITNESS
( C . J . Acc 1 9 6 7 , 3 . 9 ; M.C. A c i 1980,, s . 102; M.C. R u la « 1981, r . 7 0 )
Continuation of statem ent of
DEREK WILLIAM BRUDER
(6)
I canncz reconcile the-time sequences and I am still sure that I aid see an
ambulance, distinguish in my own mind that it was not of St Johns but
Health Authority and that I told the St Johns man with me to stop the
ambulance.
I have considered that what I referred to may have been this
ambulance exiting from the stadium but I don't think it was.
My
recollection is still that it was entering the stadium.
I refer to being joined by a woman St Johns Ambulance Officer who pushed me
out of the way.
I recollected this to have been about 6 minutes after I
had changed places with the male St Johns Officer.
That makes a total,
from recollection, of 13 minutes joint resuscitation with the St Johns
male.
I would standby these estimates only in as much as I feel we
attempted resuscitation for between 10 and 15 minutes. Within a further two
minutes of both St Johns people working together the man declared "He's
gene" and steed up.
I referred to and re-affirm that he was "completely
grey" and there is absolutely no doubt in my mind, both new with the
benefit of further training, and then at that moment,
that the youth I haa
tried to save was dead; certainly dead and beyond any further neip.
I and
the St Johns personnel would not have stopped if there nad been any
glimmer cf hope at ail - there was none.
I describe the bcdy of the youth on p. 8 and 9 (^3 i
and believe tne
distinguishing features I referred to 12 months ago are plain to see cn
photographs.
D Bruder
Signed
.
Signature witnessed by
M Sawers Inspector
WC 413 (SO C22)
(Aaanded 9.8 1)
W est Midlands Police
STA TEM EN T OF WITNESS
( C . J . Acs 1 9 6 7 ,s . 9 ; M.C. Ac= 1980, » .1 0 2 ; M.C. R u le* 1 9 8 1 , r . 7 0 )
Continuation of statement of
DEREK WILLIAM 3RUDER ('
I have seen injuries shewn on photographs ox’ the neck area, however, I did
net see them or notice them on the day.
D Bruder
M Sawers Insoector
& f7
Signed
D Bruder
Signature witnessed by
M Savers InspSC-Or
®*E: ' ■ ■ martini
ADDRESS :•
AGE / CATS OF EIS22i:|---
26091963
CC'^jrAITICN: FCL S'———1
r-v^ «*=r<=s*- This statement consisting of 0 0 4 pages,_each signed
S' mo is t-ue to the best of my knowledge and belier and I »f»®
krcwing that if it is tendered in evidence I snail be li^xe to
if I have wilfully stated in it anyth^g which I knew
to"fce false or do not believe to be true.
„„
DATED: 080589
®
D J MARTIN (SIGNED)
I a.u Debra Jane MARTIN and I live at the above address. I am
/
I am also a Special Police
single.
Constable number 221 based at WXDSEATS (E2 Sub-divisicn) of South
Yorkshire Police.
Cn Saturday 15 April 1989 (150489) I paraded for duty at 9.00am
(0900) at HILLSSCRCUGi Football stadium where there was a briefing
all officers involved in the semi-final between LIVERPOOL and
NCinNG-IAM FOREST.
The briefing was at 9.45am (0945).
At 10.20am (1020) I returned to the gym at the football ground for a
separate briefing for special constables.
At 10.35am (1035) I left HTLLSECFCUGi stadium to patrol HERRIES PCAD
SOUTH to step the parking of cars by fans cn the hard shoulders.
did this with S.C.206 EAKER.
I
We continued to patrol KERRIES PCAD
SOUTH, which is a very long road, until about l.lQon (1310) that
aftamocn.
At this time «e had orders to go to EETJZSICHE RD to cover
traffic outside the main entrance gates for the NOTTS FOREST f-ns.
At this point I saw about 6 ticket touts.
and money changing hands.
I saw then selling tickets
I also saw numerous fans both Liverpool
for
MAPriN
DEBRA
JANE
fans and Notts Forest, who were obviously drunk, although at this
stage they were behaving reasonably.
At about 2 .45pm (1445) I started to make my way to the LEPPING3 LM®.
)
entrance, as I passed what I think is the main entrance to the SPICN^
KDF, the turnstiles were shut dcv/n.
At about 2.50pn (1450) there was trouble at these turnstiles wnen the
Notts Forest fans, realising they v*=re being locked out, were trying
any way they could to get in, this included paying money to the
turnstiles stewards and trying to buy tickets fran the touts.
The
crowd became very abusive and angry and I had to assist in the
removal of fans frcm the ground, . I was on the read side and the
police inside were passing fans back out over the turnstiles and
there was a very large number of fans trying to get in still, so much
that mounted officers and their horses were being pushed up against
the wall.
The next thing I kne* is a large blue gate was opened and
a large majority of the crowd pushed their way into the ground.
I
found myself being carried along with the crc**i unable to resist.
A
mounted officer grabbed my collar but had to let go, because he would
have been pulled fran his horse.
I got pushed to the floor, but I
managed to get back to my feet by pulling myself up a man's back.
I
then rem-mber opening my eyes and finding myself inside the ground,
at the bcttan of theJpion Kcpand_the_aates had been shut behind---me.
I asked the steward on the gate to let me out, but at first he
refused, it was only when a ireunted officer, the same one who had
triad to help me a few manents earlier, put his horse up against the
gata, he opened it a short way and let me out.
Onca outside I found myself surrounded by drunken fans, screaming
abuse, and the area covered by police.
An officer used my radio to
try and call for back up but to no avail because the channel was
,aFnN
DEBRA
fu11 of static.
My radio was handed back to me and I ran to the
Le e ?i-ngs Lane end of the ground-
rusnina to that end of the ground.
Ambulances and police cars were
When I got to the Loppings Lane
enc of the ground I saw a vast crowd outside the turnstiles trying
to get in, it must have been about four times larger than the crcwd
I lsf* at the other end, so that would mean the crowd at the Spion
Kcp end numbered about 1000 plus and I would estimate about 4000
outside Leppings Lane end.
I can't really remsnber how, but sanehcw I got inside the ground,
|
through the large blue gate which was open, and I ended up on the
j .
pitch.
I did not go through the tunnel.
Onca on the pitch I saw a lot of people who were obviously injured
and I can renanber a man caning up to me shouting, "THERE'S TWO DEAD
YOU BASTARD".
I then saw people who appeared to be dead.
People
vers screaming and shouting and ambulances were driving onto the pitch.
I assisted other police officers with dead and injured people and
helped to take them on stretchers to the gym, and I can remember
seeing officers fran E2 (WXDSEATS) everywhere.
I tcck about 6 dead to the gym, as well as many injured and whilst I
was trying to revive a young boy I renenber something hitting me on
the back of my head, but I didn't really notice until much later when
I fcund a large swelling.
I could see many bodies being put on the
pitrh, sane of then appeared to be dying.
I lost count of the number
of bodies I helped carry into the gym.
I halted carry a young toy into the gym frcm the pitch nearby.
Ke
steeped breathing so I gave hi* the kiss of life, and heart passage
and a doctor also helped-
He started breathing and opened his eyes,
his only word was "M31' and then he died.
.At 4.06pm (1606) Dr CURPEN certified death and I stayed with him.
I
mafi in
debra
jane
would describe him as white male, 5'6-5'7, 14-15 yrs, slim build and
brc*n hair, with a cut under his chin.
_______ ____________
there were no other marks on the body.
He was wearing a white
shirt, green sweat shirt, beige trousers, white socks, white Feeboks
and ^
boxer shorts. He had a gold metal chain with a
gold horn, a bus ticket, a train ticket and an entrance ticket.
had no identification or money.
He
I later found cut the number given
to this boy was 51.
I stayed with the body and at 5.20am (0520) Sunday 16 April
(160489) an ambulance arrived and I went with the bccy together with .
DC PONT and GRIFFITHS to the Medico Legal Centre, WATER LANE,
Sheffield.
I stayed with the body until he was stripped and details
tak=n fran me.
I finally went off duty at 6.30 (0630) on Sunday
16 April 1989 (160489).
At about 6.30pn (1830) Monday 8 May 1989 (080589) I saw PC's MORGAN
and GODWIN fran West Midlands Police at my hone.
PC ? shewed to me a
partially completed report of death form that I identified as being
the form- I filled in whilst in charge of the body, details of name
and other personal details are missing because there had been no
identification made by the time I went hone.
form relates to body 51.
All I can say is this
I new knew this is Kevin David WILLIAMS,
:
•
*______________
b. 27.5.73 (27051973) o f ________________________________________
mar ti n
DEBRA JANE
D J MARTIN SIGNED
statement
TAKEN
-PLACE:
TIME:
•7ITNESS TO SIGNATURE:
OFFICERS SI3©TURE:
DATE:
080539
STATION
NAME:
DE5FA JANE
MARTIN
ADDRESS;
2F BIRTH:
POL SC221
CCCUFATICN:
Who states:- This statement consisting of 005 paces,_each signed
by me is true to the best of my knowledge and belief and I make
it kncwino that if it is tendered in evidence I shall be liable to
prosecution if I have wilfully stated in it anything which I know
to be false or do not belie/e to be true.
DAIED: 170290
D J
(SISJED)
Further to iny previous statements I would like to add the following,
Cn Saturday 15th April 1989 (150489) I worked in the capacity of
Special Constable at the F.A. Semi-Final football match between
Liverpool F.C. and Nottingham Forest F.C. which was being played at
the Hillsborough Stadium, Sheffield.
My recollection of the events of that day are vague and confused.
As a result of the disaster I was prescribed medication by my Doctor
to assist me to sleep.
I was really upset by the whole incident and
was cn medication for about a week.
The result being that I was in a
state of what I can only describe as seni-conscicusness.
I felt like
a 'Zombie.'
As a result of this I feel that my memory, my recollection of that day
is ocssibly inaccurate. I am unsure of what time I arrived at the
Lee pines Lane entrance to the ground or even how I came to be cn the
pitch but I did.
Ev time I get onto the pitch it sesned to be mass confusion, there
wera police officers and supporters all over the place.
I could see
pec ole who appeared to be injured and possibly dead, lying on the
L.
' f h i e
i f
c t a t c ^ c i x i
E x h i b i t
'd a - ti- d
- D
T r n
3
r ^ b r ^ r c j
..yp
DEBRA JANE
i was in a state of shock. I didn't knew what to do but my
pit-*'1*
cural instinct was to help these people in the best way that I could.
I can't describe
t o you in any detail my exact movements over the next
half an hour or so.
I knew that I approached several people lying on
the pitch and assisted if possible.
I did not give any of these
people nouth-to-mouth or heart massage.
I dacided that there were enough people dealing with the situation
at the Lepuings Lane end of the ground and made my way to the Spion
Kop end of the ground.
I could see that bodies were being carried from the Lappings I*me end^
0
to the Spion Kcp end of the ground and then being placed on the pitch.
I assisted to carry a number of dead and injured people fran the Spicn
Kop end of the pitch, into the gymnasium where a temporary mortuary
had been set up.
I was talking to sane of these people, contorting
them and trying to reassure then.
I am unable to describe any of
these people in the detail.
By this time I really «as in a stats of shock, I couldn't believe what
I was seeing.
I seened to be on autonatic pilot.
y g s -ry C O n f U S S d 3 T ld d l S tO x .
My memories are
•
I can recall carrying a youth who I new know to be, Kevin Daniel
WILLIAMS fran the pitch to the gymnasium.
I assisted in carrying.
He was the last person that
I first saw Kevin WILLIAMS lying on the pitch
near to the goal area at the Spion Kop end of the ground.
At that
stage he wasn't on a hoarding or a stretcher.
I renetiber that there were several people around where he was lying.
I can't recall anyone giving him mouth to mouth.
With the help of
othar people, who I can't recall, Ifevin WILLIAMS was placed onto a
hoarding and carried into the gymnasium.
Saneone instructed me to
stay with the body.
(£
&
£
)
£ didn't knew what to do.
I didn't want to believe the boy was dead.
I didn't knew if he was dead or not but I decided that I had got to
attanpt to revive him.
I started to give him mcuth-to-mouth but
sciracne, I don't knew who, touched me on the shoulder and told me he
was dead.
By this time my head had gone, I wasn't aware of what I was
doing or what was really happening.
At 16.06 hours (1606) Doctor CURPEN examined Kevin WILLIAMS and
certified him dead.
I rananber a detective officer, DC Paul M3NFREDI helping me to
corolete the GEN 18 form (sudden death form).
-
I stayed with the body until the -early hours of Sunday 16th April
(160489) when I escorted Kevin WILLIAMS, who at this stage had not
been identified, to the Medico legal Centre.
I identified the body by the number allocated, which in the case was
Number 51.
I had no further dealings with Kevin WILLIAMS.
This statement is irade to the best of my recollection and I believe it
to be the truth.
However, under the circumstances I cannot be
positive that the details are accurate.
I have been quite badly
affacted by the whole incident and I am trying to erase it fran my
merory.
I have marked on a plan of the pitch (Reference D.J.M.l) the
approximate location where I first came into contact with the
decaased, Kevin Daniel WILLIAMS.
D J Martin
PkpriN
DEBRA
JANE
D J MARTIN SIGNED
^rEYTEMEOT TAKEN
FLACE:
TIME:
DATE:
170390
WITNESS TO SIGNATURE:
WPS 7844 AFPLETCN
OFFICERS SIGNATURE:
JULIE AFPLETCN
r
o?
6
7
'I f l-
SENT BY:
//
! I w||Vnt'
IdS
'; i :
’
U ' *Jk
•
nnn^uTu
26QS89
Surname
PH I L L I
.Forenames
GLYN
Age
J-Q 5
-Date of birth
-
" J "se:
Address
Occupation
MEDICAL PRACTITIONER
Telephone
IC
Build
Height
““
Hair colour
ir type
Complexion
• * yes
F ac ial hair
Glasses
Accent
‘J* *
Num ber of Pages
Da t e d
G P h i l l i p * Signe-
1505S9
I am Dr G l y n M ic hael P H I L L I P S of C
a fully q u a l i f i e d medical pra ctitioner hav ing qua lifie d
f r o m Leeds U n i v e r s i t y in June 1980-
My q u a l i f i c a t i o n s are M.S. Ch.8
M . R . C . G . P . D.R.C.O.G.
••
I a r r i v e d in S h e f f i e l d at about 8.0 0 pm (1400) on Sat urday ,
April 1989 (130489) w i t h my brother a n d two friends.
15th
We par ked abou
half to t h r e e - q u a r t e r s a mile f r o m the ground and t h e n w a l k e d to the
L e p p i n g s L N end of the ground.'
I not i c e d that the pubs w e r e open
w i t h fans- relaxing outside w i t h drinks.
’
The pubs all s e e m e d to have
b e e n o p e n on the route from the m o t o r w a y to the ground.
I
s p e c i f i c a l l y remember thinking that this wo u l d not have b e e n the cas
in S c o t l a n d whe re I now live a n d work,
G>
iiu- 4-S* i
i UUUliHlY 51 WHAMBtKS"*
U91
'USZlSSlW
9
KftUfc
S771
At ab o u t
10 pm (141Q) we arr ived at the ground.
2*
l o o s e l y c o n g r e g a t e d and moving' freely about.
M a n y fan* were
The tur nstil es were
qui te quiet w i t h app r o x i m a t e l y ten to f if teen people in each q u e u e d
M y cerrier bag was sea rched by a Pol icema n.
Onc e inside the
^
t u r n s t i l e it was aga in easy V c ^ o v e abo.ut fre ely and my y o u n g broth.,
bought a programme.
My carrier bag was s e a r c h e d aga in by a _P o l i c e * *
inside the turnstile.
I visited the Gents and then we made our way
to the t e r r a c i n g - the c e n t r e 'section.
Wal king thr o u g h the tunnel t
the t e r r a c i n g was not difficult, there was no pushing or crowding at
that stage.
On reaching the terrace we found that it wa* alr eady
quits full.
We dec ided to move to the right (looking at the pitch)
away from the tunnel.
Two of US rea ched the point stout ten yar ds f r o m th. pit ch fence and
r e a l i s e d we were sep arate d from the other two.
On seeing them highe
up «. m a d . our way up to the crowd to J o i n t h e m about f i f t e e n to
t w e n t y yar d, a w a y from th. perimeter fence a n d five yard, f r o m th.
fence s e p a r a t i n g the centre end side sec tions of the ter racing.
B e t w e e n 2 . 2 0 pm (1420) and 3.00 pm (1500) we g r a d u a l l y became more
and mor e t ig htly packed.
the A n f i e l d Kop.
It
Much more so than even in a tight crowd on
became «o .tight that o c c a . i o n a l l y .urges of
pus hing and pressure did not act u a l l y cause a ny m o v e m e n t of note.
O c c a s i o n a l groan, of pain were heard.
1 s p e c i f i c a l l y m e n t i o n e d to m
f r i e n d " I f s so tight in here.that we are not e v e n s u r g i n g at all,
just o s c i l l a t i n g more or less on the spot."
I n o t i c e d that despite this increase in pressure in the centre
section,
fans on the other side of the fence <ie. in the side seclic
to our right) were moving about fre ely end that sec t i o n did not
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051 225 2135!# 6
S771
a p p e a r to be filling at all•
I
looked
t
up. from time to time to the front of the sta nd above and
b e h i n d us - there was a Police Sergeant there
o b s e r v i n g the
*,,,
^
t e r r a c i n g but not really doihjj^much.
A few p o l i c e m e n on the pitch side of the perimeter fence d id not seer
to have n o t i c e d <1> how t i g h t ‘we were packed and (2) that the side
s e c t i o n was n o t i c e a b l y more empty.
Fans
t-egan to express their dis comfo rt by criticis ing the
ground. I
brought no response in terms of a c t i o n from the police.
I v a g u e l y remember a tannoy a n n o u n c e m e n t asking us to mo^e dovnn to
the front - there were i r o n i c ‘jeers from the crowd in res ponse to
this.
The game started.
I didn't feel any surge in terms of m o v e m e n t -
just a n o t h e r noticeab le increase in the by now a b n o r m a l level of bed
p re ssure all round.
"Get back, get back."
People stood on barriers in front and sho uted
This was impossible,
s t a t i o n a r y by the pressure from front, sides
we were all pinned
and back.
P o l i c e m e n at the perimeter fence at last seemed.; to not ice
the
problem.
to pull a
fan out.
,The gate was opened;
A pol icema n trie'* in v a i n
I could not see the game w h i c h had s t a r e d nev er m i n d what
v,as h a p p e n i n g on the
ter racing below us.
The p o l i c e m a n looked very
w o r r i e d a n d see med to shout into his radio as
a n d my right.
I got
stop it" - I a s s u m e d
he l oc ked to his left
the i m p ressi on he was saying "St op it, stop it,
he meant the match.
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UMAMt Jt KS- *
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PAG E
S771
i
Of the six min utes of the mat ch (I heard later it was six minutes) I
rem ember less than twenty seconds.
I was so intent and occ upied
our s a f e t y that wat ching the mat ch was impossible.
b 'y~
I t r i e d to kee^
an eye on my you ng brother w$#£ was pressed fi r m l y a g a i n s t the side
fence a few yards away.
Ha seemed okay but I couldn't get near him
anyway.
Fans s e e m e d to spill over the front perimeter fences but they were
w a l k i n g a n d running although obv iously shaken.
The m a t c h sto p p e d and many police arr ived at the per imeter fence.
Fans next to the side fence had begun to climb over in small numbers
to reach the side sec tion of terracing.
A very d i s t r a u g h t young fnan
on the oth er side of the fence (he had pr e v i o u s l y been in the centre
section) s h o u t e d "Get over the fence - they're g et ting s q u a s h e d at
the bot t o m . "
One by one fans climbed over. I f ol lowed my brother over and by then
I saw the first of the injured or dead being lifted out at the
front.
I i m m e d iat ely heeded for the pitch gate.
At the gate there
were t,W o or three policemen inside the terrace a n d one or two on the •
tra cksid e.
I s ho uted "I'm e doctor,
let me on the pitch.
I was
j
pushed a w * y as a body was passed t hr ough (having been l if ted over the!
;
side fence and carried to the gate in the side s e c t i o n whe re I by
the n was situated).
me as 1 leapt up.
heavy blow.
j
i
I put my foot on the wall a n d a p o l i c e m a n calico]
j
My head struck the crossbar of the gate w i t h a
j
A d r e n a l i n coursing through m y body r e n d e r e d the blow
f
v i r t u a l l y painless but I feIt. jujusteady for a few seconds.
vJ
<£>
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S771
-
I mad e my w a y on to the pitch a n d reached a body near the goal line.
....
S o m e b o d y was crouched over it.
pulse,
the answers were no.
pul seles s.
*
I asked is he breathing, has he
I saw he was cya nosed a n d was
I knelt next to iji| ‘Vhumpsd and thu mped his chest herd
three times.
I commenced m o u t h to mou th r e s u s c i t a t i o n a n d i n s t r u c t # ’,
the m a n next to me te give cardiac massage in the ratio 3-1.
I made
a conscious d ec ision "This man was one of the first out. therefore,
i
_
give him a decent chance at c a r d i opu lmona ry r e s u s c i t a t i o n . "
As we c o n t inue d to give CPR I sho uted to nearby p o l i c e m e n te find
o u t if we could get a D e f i b r i 1 lator and some oxygen.
We c o n t i n u e d ,
w i t h CPR and I d i s c o v e r e d my ass istan t was a male nurse.
We wer e by now s u r round ed by mil ling figures in black - pol ic e m e n anpolicewo men.
A distraught teenage fan came over and put his face up
to that of the body and ye l l e d words like "Come on mate* don t die,
you can't die, you're a Liv erpoo l fan."
I was tol d that there was- n-
D e f i b r i l l a t o r but I was given an oxygen cylinder a n d i n f o r m e d that i
was s w i t c h e d on.
I pulled the flimsy ven ti m a s k off the tube and put
the open tube in my own mouth to enrich the o x y g e n in the air I was
giv ing to the patient.
We c o n t inue d wit h CPR.
tube.
I soon realised nothing was coming out of
th
The valve was turned on and I looked at the gau ge w h i c h
s h o w e d an empty tank.
I d i s c arde d the tube.
P e o p l e kept coming up a n d sho uting adv ice a n d I kept i n f o r m i n g them
that I was a doctor and knew what I was doing.
no-
4-92
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S771
A g e n t l e m a n w i t h a blazer end tie indicated he was a doc tor and gave
t
*
*
encouragement.
^
"
T e n m i n u t e s passed.
The patient seemed to have lost some of his
cyanosis but he was still puljsjless.
more."
^
At ten min utes I said "Five
By now there was a cac ophony of sound aro und me and- from the
ter racin g.
I could not
However, as I was s u r r o u n d e d by people m a i n l y standing,
see any thing that "was hap pening at the front of the
centre section.
A dis traug ht
young fan *.vas m a k i n g it d i f f i c u l t for
me to con c e n t r a t e and I asked a pol icema n to "Get rid of him."
He
ge n t l y e s c o r t e d the fan away.
At about f i f t e e n m in utes I was about to say to a p o l i c e m a n to cover
the bod y w h e n his heart sprang to life a n d he d e v e l o p e d a good
pulse.
He was still not breathing so I c o n t i n u e d to v e n t i l a t e him.
A p o l i c e m a n a s k e d if I n ee ded a stretcher a nd I said yes.
a r r i v e d and
we lifted the m an bn to it.
One
We lifted and s t a r t e d
tow ards the a m b u l a n c e w h i c h had a r r i v e d be h i n d the
goal.
As I s t o o d up I saw for the first time some s u g g e s t i o n of the scale
of the casualti es.
t e n bodies.
To get to the a m b u l a n c e we had to s t e p over about
The y m o s t l y looked like you ng men, some h ad their heads
c o v e r e d w i t h P o l i c e raincoats.
We had to sto p every few paces so Z could give the pat ient a breath
1
into his lungs.
As we lifted him into the a m b u l a n c e 1 s aw the bodies
of two y o u n g m e n a l r e a d y in there.
I c o n t inue d to v e n t i l a t e him witfr
m o u t h to m o u t h r e s u s c i t a t i o n ajnd. h« began to m a k e his o wn bre athing
efforts.
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S774
It 1.
impossib le to , K ? r s „
w o r d s w i l l do but it
senses
my t h o u # M l „
th4t
no
iifcV a Chaotic n i g h t m a r e o v .r lo a d i. n g a l l «
.
I told th. a m b u l a n c e M n
a n d ; ^ police . . r g . a n t that th, m a n
s e r i o u s l y ill a nd M , M
* hospital "Now.-
he cou ldn't get out.
Y,
Th. w b u L n c . i i > s . i d "
Thi. add ed to th, f r u s t r a t i o n - not h.l p.d
by . y tho ughts that in vie,. o> th, l.ngth of tim. h, w „
it w o u l d pro bably b, Kin*.,. if h, di,d.
I
puU.W..,
an, l u r . n ,
h. v,
fc„ n
s e v e r l y b r a i n dam aged by that time.
I l.ft h im lying on hi, .id. bre athin g on his own and , m d
a
p o l l . . m a n to try to get him to hospital as , o o n as possibl*.
I would
30
to see if I c o u i d htl|) s o m , b(Jiy e l j ,_
u
I said
tMmtd ^
tin., that th, perimeter fence was obs c u r e d by p o l i c . m . n a nd s e e
fan-
tr y i n g tc get people out of the terraces.
1 s e a r c h e d for s o m e b o d y needing h e l p .
I
stopped
a g r o u p of fans
l if ting a body on a m a k e s h i f t stretcher, some of them s. e m e d to b,
tryin, to do CPR.
I s aw that It was a boy a g e d abo ut 14.
th.m that if th.y w a n t e d to
give
hlm
.
I said to
th.y s h o u l d .top and
do the r e s u s c i t a t i o n properly.
T h . y put him d o w n and J started mou th to m o u t h - f i l l i n g hi, lung,
w i t h air.
A g i r l n . x t to m. did th. heart
m a „ a g .
he was obv io u s l y d e a d so we sto p p e d w i t h i n
■about 6 Q seconds.
l o o k e d d e s p e r a t e l y for som e b o d y not dead but s e r i o u s l y ill w h o neec
help.
I
c ou ld not find a n y b o d y in that c a t e g o r y in the goal ar.a.
r .•
Q
•
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S 771
T h e y „ r.
U » e nd
,11
8i t h s r d „ «
, k,y „ u h
^
>
thr.. or four grouTi of people .» th, o t h , r , n,
Pit ch gi v i n g CPR.
I ran to th. other end.
Th. f t r , t b o d y I c m .
to ^.s ^ m ' a n abo ut 2 5 y „ r, o l d _
*" « < • » “
• sk.d "Has
h.
" * « »
-Mrt « .
a pal ..," she s.id
"I
„ dark
trying to , t » . h t . CPR.
d o n ’t think ..."
I started
g i v i n g h im m o u t h to m o u t h «
ft. did Ih. cardiac mas sag,.
s ho rt -while *. s wa pped ov.r.
Opp o s i t e me hi, fr i e n d ! „
*>* 3 i d ' hi"'Self W i t h ° ‘'*rwh«lming g r i . f
s n o u t i n g „ rd. H k .
After a
bro ther?)
di,tr.„.
H.
"Como on. y » u T . not d..d" and l oo king ,t m, and
s h o u t i n g "Keep going, .don't
st0Pt
d o n ,t l t o p ...
I . a i d to th. girl qui etly "He •. gone."
o b v i o u s l y v . r y . « d l y "I kno„."
des p a i r .
lh#
she r e p U > d £s l m l y ^
His friend (brother, ,,as so m u c h in
A n o t h e r you ng doctor took my place doing hea rt mas s a g e .
I,
w-as h o p e l e s s .
I w.nt to the other t«. or three bodies.
People w t r . ,jolna v8ry g00t
c a r d i o p u l m o n a r y r e s u s c i t a t i o n but it « ,
o b v i o u s i y too lat. for them.
I ..id to a p h o t o g r a p h e r that I nopsd that the paper, W er. goi ng to
"Hammer this g r o u n d for what hap p e n e d today."
abo ut th. a b s e n c e of equipment.
telling
1
them
not
I ,0 ld them m y nam. a,
T h . y look a p h o t o g r a p h d . s p i l , „ . ■
to.
went t o t h e . i d . o f t h . p i t c h ( . p p o . i t . t h . p l a y . r s t u n n e l ) and . . .
q u i t , a few p e o p l e propped up a g a i n s t , h. hoardi ng w i t h som.body
h e l p i n g them a l l .
«ny h . l p .
I s h o u t e d t h a t I w „ a d o c t o r and di d anybody n e . c
AH I heard i n r .pl x
(I)
„a, lh. t th. y
okiy_
^
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; doughty st chambers-
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S771 '
onl y people I had seen carried up the fi e l d were dead
10
I headed
\
i
back to the L e p p i n g s LN end.
passed t h r o u g h the line of pol icemen
.across the e n t r a n c e (what were they doing,
I thought - not muchl').’*-
As 1 wen t t h r o u g h I ask ed f o u r or five of them if they could tell t^e
w h e r e there mig ht be injured'jjfople I could help.
The general reply
was that the y c o u l d n ’t and that they were sorry.
I am f a i r l y sure that I went liack into the goal a r e a at the Lep p i n g s
L N end.
I have to admit that by now I w as angry, c on fused s l i g h t l y
a n d f e e l i n g quite helpless.
a doctor,
I did d e f i n i t e l y ask a p o l i c e w o m a n "I ar
can you tell me where the inj ured m a y have been t a k e n so I
might h e l p ? "
No she could not.
The re did not seem to be muc h I could do at that end.
lying d o w n w i t h people helping said they were okay.
a n y b o d y s e r i o u s l y ill needing help.
Some people
I could not f i m
Just dead or s e e m i n g l y minor
injuries a nd sh a k e n people.
I he a d e d tow a r d s the other end again.
"
Quite a few people a s k e d me
*1
how I was — 1 r e m e m b e r e d my head and my face was now cov ered in
blood.
I kept saying " I ’m okay" but I really d i d n ’t feel okay.
I a k s e d the police aga in where I sho uld go*
j
T h e y did not know.
9 y now the c o m b i n a t i o n of having been in the crush, trying te do
r e s u s c i t a t i o n on hopeless cases, trying to find others to help, the
a b s o l u t e c a c o p h o n y and confusion, the lack of in f o r m a t i o n f r o m the
police
a n d the bang on my head became too much.
at the
w a y we had been
Pol ice,
1
treated.
felt c o m p e l l e d
I felt ver y a n g r y
I knew who was to blame — the
to tell some sen ior L i v e r p o o l foo tball
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club o f f i c i a l not to lei them blame the fans for this.
I went up the players' tunnel saying "I'm a doctor.
s o m e b o d y in a u t h o r i t y from LFC."
line.
O u t s i d e the changing
I nee d to s ee1*'--
The se words opened the police
it
w m
Ay
v e r y confused., Lets of men
in suits, bl-asers and ties.
I saw J i m m y H I L L (BSC) and forced him te listen to my a c c o u n t of wha
hap pened *
He looked pale and very concerned.
y o u come a n d say that on the air?"
took
me
a
down
my
n a me.
few
y ar ds to the laundry.
He
T h e n a m a n sai d "Will
I sai d "Why?" but a g r e e d to.
Ha
He put hea dphon es on and wrote
sho u t e d into a m i c r o p h o n e "Tell Peter to hand over
to me n o w !"
Next he was t al king and introducing me, and then sho ved the big
m i c r o p h o n e up to my face.
s t a r t e d talking.
disgrace."
I felt awful, a n g r y and upset but I just
The last words I said were " I t ’s an a b s o l u t e
I meant the way we were a l l o w e d to get so t i g h t l y packed
and on the pitch the total lack or o r g a n i s a t i o n and e q u i p m e n t after •
d i s a s t e r struck.
deed.
I said on the air that I had seen eight to ten
In re t r o s p e c t I had pro bably s e e n abo ut fif t e e n so I thought
p r o b a b l y tw e n t y to thirty were dead ove r a l l .
thank you in a very sombre voice.
The radio m e n said
I s a i d "Was that going out live."
He sai d thank you a g a i n and shook my hand.
I wen t out and saw K e n n y DALGLISH.
I t o l d him wha t had h a p p e n e d and
that he must not let the fans get the blame.
g r o u n d ( H i l l sbo rough ) was "Shit."
I told him that, the
He t o l d me that L FC wer e pot happ;
about the g r o u n d being used but these t h i n g s were out of their
control.
He was very shaken.,
.— —
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A l i n e s m a n or the referee s h o w e d me into their room to get cleaned
up.
I did this and ins pecte d the split in my s c a l p - it needed
or three sti tches but that could '.vait I thought.
U i& ~
I rem e m b e r
i- j
a p o l o g i s i n g for getting bloocj^ri/a towe-l - how ridiculous)
I wen t bac k on the pitch.
All the bodies had gone.
on the t e r r a c e up to my brother and friends,
I cl i m b e d back
I saw p o l i c e m e n in the
now a l m o s t emp ty centre s ec tion collecting bel ongin gs.
lads w h a t had h a p p e n e d on the pitch.
I told the
All of a s u d d e n for the first
time I felt a searing pain in my head and said " G o d / my h e a d hurts."
At no time at H i l l s b o r o u g h did I realise people had d i e d in the
tun nel.
At no time did I see any thing to s u b s t a n t i a t e claims that
p o l i c e m e n wer e a s s a u l t e d or bodies were looted.
fans t r y i n g to save lives hopelessly.
I saw brave young
I saw brave lads o rg anise
t h e m s e l v e s to make mak es h i f t stretchers to carry the dead.
some p o l i c e d e s p e r a t e l y trying to save lives.
I saw
I also saw some polict
s t a n d i n g idly - not knowing what was happening or m a k i n g any attempt,
to f i n d o u t .
I did not see at any time any fan (whether before or aft er the brief
game) m i s b e h a v e d e l i b e r a t e l y in any way.
A f t e r the game had been a b a n d o n e d we left the g r o u n d via the centre
s e c t i o n on the tunnel.
R e m e m b e r i n g the fan we had r e s u s c i t a t e d I
gave a p o l i c e m a n my name and address.
I felt it ver y u n l i k e l y that
he w o u l d have s u r v i v e d and rec oncil ed my s e l f by the fact that if he
h ad he w o u l d have been brain damaged.
’* %
O
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G P hi llip* SIGNAC
STATEMENT TAKEN
PLACE:
TIME:
WITNESS T O SIGNATURE!
OFFICERS SIGNATURE:
END OF REPORT
ft
t
•
DATE:
Hillsborough, 15th April 1989
Dr John Ashton
I
am
a medical
practitioner
and
senior
lecturer
in
Community
(Public)
On Saturday 15th April I went to
Health
the FA Cup semi-final match at Sheffield with other members of my family.
This year we travelled by way of the M62 and Ml because for the same event
last year we had travelled on the direct route through the peak district
and there had been very bad build-ups of traffic on the way home.
We left
Liverpool at about 10.15 am and arrived in Sheffield at about 12.15 - 12.30
pm.
We had a meal at a pub some distance from the ground and afterwards
walked perhaps 2 miles to the match.
of Liverpool supporters came in.
While we were at the pub a coach-load
They were boisterous but well behaved and
there was good humour between them and the local people who were eating in
the dining area.
We arrived at the Leppings Lane end of the ground at around 2.30 - 2.35 pm
It was
We
had
immediately apparent that it was going to be difficult to get in.
four
tickets
Leppings Lane
terrace.
this year because
together
for
row
2
of
the
West
Stand,
above
the
I had been particularly relieved to obtain seats
at last year's
game
in the
semi-final we were
in the
terrace itself (in the right hand corner behind the goal) and it had been
terribly crowded and unpleasant.
On Saturday we found that outside the ground there were a large number of
supporters trying to get in to a small number of turnstiles a&d .that there
was
very,
little^ police presence.
I saw no stewards outside the ground.
There appeared to have been no attempt to marshal the supporters into lines
in advance of our approaching the turnstile areas.
We
managed
unpleasant.
to
get
nearer
to
the
turnstiles
but
the
crush was
I heard a police officer telling the supporters
their own fault for coming late.
1
becoming
that it was
I decided_that X did not
want to go
on because it
was so unpleasant,
said
worse
that
going
it
would
only
get
and
he
was
in.
and they stayed where they were as
I withdrew to the wrought-iron fence.
After a few minutes I thought I would try again.
I could not see my family
and assumed that they had managed to get through the turnstiles.
approached again it was now much worse and again I withdrew.
When I
I was aware
of an officer trying to close one of the wrought iron gates, but he had no
chance on
his own.
I noticed that there was now
a police landrover in the
lane just
outside the gates and my instincts and experience of 30 years as
a Liverpool supporter told me that things were going badly wrong.
I went
to the police landrover and obtained the attention of one of the officers.
I said to him,
control,
"you've got to get a grip of this
there
unresponsive.
is
going
be a
tragedy."
it is out of
He
bemused
seemed
and
People were closing in around the landrover and I withdrew
to the other side of the
again.
to
situation,
road to see if it would ease off and
I could try
The time now must have been 2.45 - 2.50.
After a few minutes
I suddenly realised that everybody had gone in and I
was able to walk up to the turnstiles and gain admission without difficulty
after tendering my ticket.
Once inside the turnstile it was at first unclear where I should go.
were
no
stewards
in
sight
and
the
section
labelling
was
Thecfi
confusing.
I
realised where the entrance was to the West Stand and went to get in after
buying a programme.
At this stage I had no idea that things had actually
now deteriorated to the extent that they had done.
It must have been just
after 3.00 pm.
When I went to the gate into the West Stand there were a few other people
in the process of getting in and two policemen were checking their tickets.
I then became aware of a man crying and beseeching the police.
kids dying in there," he said,
"you've got to do something."
have come out of the terraced area.
They checked my ticket and let me in.
"There are
He seemed to
The police were unresponsive to him.
Once
insijJe the stand area I
turned up the stairs,
fere
that M
alright.
now worried to check
As I got to the top of the
stairs it was difficult tomake progress because there were so many people
in the aisle.
At the top
of the stairs I could begin to see why.
Many
people were being pulled up out of the terrace and into the front of the
s tand.
I could neither
to make my
able to do
I got
attempt to get down to row 2 nor see the boys. I decided
way along the adjacent row.
this without difficulty.
some
way along
it -I looked
Everybody was helpful and
I was
It must have been about row 20.
When
down to see
if I could see the
boys.
I was able to make my way down
to them over the seats.
When I reached them I could see that there were a large number of people on
the pitch,
people
trying to get out of the terrace on to the pitch and
people were continuing to come up in to the stand.
There seemed to be few
St. Johns Ambulance people attending the people who were lying around the
pitch and I could see people lying on the pitch unattended.
There was a
large line of police officers across the pitch at the centre circle.
The
tannoy told the supporters who were on the pitch to get off it.
The pressure was bad where we were so I made my way back some rows with
stayed where he was to help pull people up from the
terrace.
happening
When
on
we
got
further
the pitch;
back
we
had
it seemed incredible.
a
clear
The
view
of
what
was
time must have been
about 3.15 pm.
The overwhelming impression was of a large and growing number of casualties
and not much response.
The supporters were now impatient and angry at the
slowness of the response to the emergencies.
There appeared to be only one
or two stretchers on the pitch and one ambulance was making its way around
from the
far corner.
The
supporters were chanting for assistance
brought to the injured who were lying on the pitch.
to be
The next thing was
that many of the supporters who were on the pitch began to tear down the
advertising boards
and organise
themselves
into stretcher parties.
This
all happened very quickly.
I heard
the
tannoy
appeal
for
doctors
to help.
I could
see
that
the
situation was really bad and could count six people who appeared to be dead
near the goal mouth.
I made sure that
~
were safe with
and that I knew where they were and made my way out down the back of
the Leppings Lane Stand.
On
the
stairs
injuries
a policeman was
attending
somebody who was
injured.
The
did not appear to be critical so I asked the policeman where I
should report to help.
He did not know.
I went back into the stand and
brought the boys out and down the stairs to place them somewhere safe and
in sight.
to.
I then tried to find somebody in charge to tell me who to report
I asked several officers, but none of them knew.
There were people
lying everywhere in the yard area between the Stand and the turnstiles.
I
asked the officer who was in charge and he indicated a senior officer.
I
approached this officer and told him that I was a doctor and asked him who
was in charge of emergencies and where I should report.
know and that he had just arrived.
By this stage I realised that there was
no organised response and I was angry.
but he did not appear to have one.
Inspector Grace.
He said he did not
I asked the officer for his number
I asked for his name.
He said he was
I left him and went to see what I could do.
All around were people either dead or unconscious, or seriously hurt.
supporters were fantastic.
resuscitate people.
could.
The
They were all helping each other and trying to
Individual police officers were also doing what they
At no time did I see anybody attack a police officer, nor did I see
anybody who was drunk.
I came to the conclusion that somebody needed to take an overview of the
situationand began to go round all the casualties to appraise them.
did not seem to be any St. Johns Ambulance workers around at all.
There
I became
aware that some casualties were being taken out into Leppings Lane itself
and I went out there.
about 3.30 - 3.35 pm.
There was one ambulance.
The time must have been
The policy were beginning to put people into the ambulance and I realised
that a system of prioritising by triage was needed.
around
and
either
attending them.
who
were
checked
people
myself
or
So I did this.
asked
the
person
I went
who
was
There were two or three other health workers in evidence
assessing,
resuscitating
and
doing
what
they
could.
There
appeared to be no medical or emergency equipment.
The
dead were
taken to one side and I allocated the other casualties
category one or category two.
I told the police who should be despatched
by ambulance next and who could wait.
They
took my
instructions
to
The officers were mostly very good.
and acted on
there was a steady flow of ambulances.
them immediately.
By
this
time
It must have been 3.45 or 3.50.
I
became aware of a local general practitioner who had arrived at the scene.
Over
the
next
half
an
hour
we
worked
together
casualties and despatching them in the ambulances.
as
a
team,
sorting
the
An anaesthetist arrived
from somewhere and fire-engines came with resuscitation equipment, but all
of this was
really
too late.
casualties had gone
injuries,
By 4.25 pm it was all over.
The serious
to hospital and what remained were people with minor
shock and distress and a line of dead people.
I went to check
that my family was alright and when I came back a police officer asked me
to certify the deaths.
A general practitioner had already started this at
one end of the row of bodies.
I started at the other.
I think the time
was 4.27 or 4.29 and I think
I certified five or six dead.
whom could be identified from
documents on
During this whole period the
public were fantastic,
angry.
the end a group of young men came past
dead,
On one occasion
and
one
of
them
at
expressed his
anger
Only one of
his body.
although
at police
who
shocked and
were
standing
there.
I told him to "cool it", that it was not helpful and he stopped.
saw
other
no
episodes
like
this
at
all,
although
atmosphere of anger at what had been happening.
there
was
the
a
I
general,
I remember thinking how
restrained everybody was.
It must have been about 4.30
else
for
me
Lere
to
do
behind
alright with
- 4.35.
Leppings
Carl
and
There did not seem to be anything
Lane.
I
then made
checked
my way
that-------------to
the
gymnasium
around th£ side of the ground to see if I could be of any help there.
I
had become aware that other casualties had been taken to the gymnasium.
At first I had difficulty finding it as nobody could give me directions.
When I arrived there I went in and found that it was all over.
At one end
there were tables (I think three) which must have been used for processing
details of the injured.
There were now no
casualties in this area.
•near end of the gym were rows of bodies.
display
of
photographs
and
At the
On my way past I noticed a large
information
on
the
wall
of
the
gym
showing
Liverpool supporters who were thought to be pickpockets, etc.
I left
the gym and returned round to the Leppings Lane end to check my
family again.
gym
to
see
emergency
They were alright.
if
there
response,
would
so
all
be
I thought that I should go back to the
a debriefing
four
of
us
of people
went
round.
involved
This
in the
time
it was
difficult to get near the gym because there was a large cordon of police
around it.
I spoke to an officer and he let us through when he knew I was
a doctor and I left
the
gym.
This
control on
time
the door.
behind them and went to
it was very difficult
to get in.
There wastight
I explained why I wanted to go in and was allowed to
enter.
I asked
about
a debriefing but nobody could help.
helping were being cleared out of the
called
all
briefing.
the
officers
together
at
gym.
one
I don't know what it was about.
Those who had been
Just then a senior officer
end
of
the hall
for
a police
I left.
On our way back to Leppings Lane we encountered a police officer who
great distress and being comforted by another.
comfort him as well.
that
I put my arm around him to
He was sobbing uncontrollably and saying that now the
police would get the blame.
felt
was in
Another officer was angry and fold me that he
they had been let down by
the .senior officers.
He said that
nobody nad taken charge and that when senior officers had come they had
been of little use and just got in the way.
,,
A returned to the car to drive home.
left the ground and returned
We
We must have
left the ground by about 5 o clock,
x would like to say that I have been
over 30 years and that I “ 'f M l 1
club supporters.
Before the mate ^cm
the crowd mood was buoyant
^
^
^
^
and generally good humou
. ^
attitude of .tad has been cultivated which regard,
-
—
-
football supporters .
^
*
i:r
—
-
response by the police to what was happening.
x
z
t
l
z
—
It
the tragedy for crowd trouble.
lt to know how many lives might have been saved if the
It is difficult
.ffective
but in my opinion on this
emergency response had been more effective,
occasion it was woefully inadequate.
dr
J R ASHTON
Wednesday 19 April 1989
JRA/SMC/s tatement
<S>
HILLSBOROUGH DISASTER
A pp e nd i x 1:
Eyewitness Accounts
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I arrived at the approach
Stadium at lh.25 hours.
a young man of 17.
Address:
I
I
to the Leppings Hoad end of the Hillsborough
I was accompanied by cy 27 year old son and
*e all had a valid ground ticket.
The immediate
approach to the turnstiles, a distance of some 70 yards, was full of
a jostling crowd of ticket holders tiying to make their way to the
turnstiles.
There was no semblence of orderly cueues, with some kind
of order trying to be maintained by three mounted police officers.
Despite the lack of organisation and frustration the mood of the fans
remained reasonably co -operative.
To emphasise this, one of the horses
was very close to me and accidentally almost knocked my spectacles off.
The officer apologised and we e.changed smiles and I stroked the horse's
nose.
The nearer one got to the actual turnstiles tne pushing and crushing
became severe.
After approximately ten minutes all three of -us were
literally catapulted through the turnstiles.
Over the last ten yards
one had no control whatsoever over car movements.
Once through the turnstile all three of ny party came together.
son
attempted to remonstrate with a police officer regarding the lack of
organisation on the approach to the turnstile.
ne was warned by a
steward standing alongside the officer to keep ouiet "because other fans
who had made similar protests had been forcicly
"ejected from the ground.
'We then moved away and vent to use the toilet situated in front of us
under the stand.
As we came out of the toilet we were directly facing
the rear of the turnstile area and were immediately aware of the
opening of one of the gates alongside the turnstiles.
just after I h . h O hours.
The time was now
Anticipating the ensuing rush I took
my
companions to the right, aiming to take our place high up on the terracing
to the left of the Lepping Road Stand facing the playing area.
The
previous y e a r ’s experience had alerted me that this was a sensible area
to stand, both from a safety viewpoint and it also provided an excellent
view.
I have a vivid mental picture, as we hurried past the now
infamous tunnel leading to the ill-fated sections, of turning my head
and noticing there vas nobody to be seen, either spectator or official.
The high up area we entered was very full, but with no crash.
positioned ourselves within feet of the "blue boards.
We
Looking down from
my high vantage spot I could see the two middle Dens immediately "behind
the goal were .jammed to caDacity with a seething mass of people.
surprise, the pens on the left and right were half empty.
To my
The area on
the far ri^it around the electronic scoreboard was also half empty.
The time of this observation was 14.50 hrs.
Ifor attention then became diverted when the Liverpool 'team took to the
field, followed a couple of minutes later by the opposition.
At the same
time I was conscious of a few people entering our section behind and
alongside me.
There was no large influx just before the kick-off where
I was standing.
The
° had b°sn in progress for some five minutes witn Liverpool p.essing
home an attack at the far end, with a c o m e r followed by a shot which hit
the woodwork.
I believe this shot to be significant because it meant
a tremendous surge down the Dens behind the LiverD 0 0 l goal to try and see
what was happening.
football match.
This is the normal reaction on the terracing at any
From my vantage point I was then immediately aware
of fans trying to come over the metal fence behind the goal.
Some had
been successful and were being led down the touchline by the police.
Others
were being stopped climbing out of the pens despite their obvious protests.
At the same time a senior police officer ran from behind the Liverpool goal
and approached the referee.
teams off the pitch.
escape from the pens.
He immediately stopped the game taking both
By this time a few more fans had managed to
One fan on the field of Dlay appeared to be
pleading whilst he was being forcibly led to the side of the playing area.
Behind the goal the two Dens were a seething mass of people with little
or no movement either backwards or forwards.
passed from the back of the Dens to the front.
A few people were being
The front of the pens
next to the fence seemed to "be flat without the usual bobbing heads.
Within two minutes of the teams leaving the field I realised something was
. very wrong.
On reflection I have come to the conclusion that my alarm was
confirmed due to a combination of medical experience combined with an
intimate knowledge of years of attendance at football matches on the
terracing.
I quickly realised that help would be required on the pitch.
I informed my
son what I was doing and because I was so close to the entrance to the
terracing I had entered I quickly made my way down the stairs to find a
Steward to get me to the side of the pitch.
I quickly found a Steward who
^^.ccepted what I was telling him and he took me through a tunnel under the main
stand where a Police Officer again accepted my explanation of being a trained
nurse and let me on to the pitch.
I raced to the area immediately behind the goal net.
The narrow gate belonging
to the pen behind the net was open with police officers trying to pull flaying
bodies through the narrow opening.
Other officers appeared to be trying to
instruct the fans to push tack ir. the pens.
through the gate.
of.
I helped officers pull people
We were pull ins any part of their body we could get hold
On reflection I realise now because their bodies were level with the
bottom of the gate that they must have beer, lying on top of people because
^ ^ . h e gap between the bottom of the gate to the floor of the terracing was some
three feet.
The first casualties I helped pull through the gate were conscious, but very
shocked.
I attended to them at the back of the goalmouth on the netting.
Their recovery was comparatively quick and simple were moved away from the
immediate area.
unconscious bodies.
Very quickly I was aware that we were pulling out
I can next recall working on a young man who once he
was conscious seemed to have chest injuries.
I looked around the goalmouth
for a stretcher or something to remove him to a place for him to get treatment.
The scene around me remained completely chaotic with everyone trying to do
their own thing, fans and police all mingling together.
I eventually found
' a stretcher lying on the pitch with which I quickly returned to the injured man.
I literally ordered three police officers to help me lift the patient on to the
stretcher.
$y this time he was complaining about the pain in his chest.
quickly made our way to the c o m e r of the field between the m a m
We
stand and the
Kop and took the young man behind the stand to the St. J o h n ’s Ambulance room.
I then ran back on to the field to the goalmouth.
In that short interval of
time & lot more bodies were lying behind the goal.
People of all descriptions
were attempting mouth to mouth resuscitation ar.d cardiac massage.
(
On the right
iand side of the goal net a young girl was being worked on by a man who stated
was a surgeon.
I moved to the body next in line and worked with a young
police officer until the patient appeared to be starting to come round.
I
then moved on to the next person who was lying unconscious and unattended in
the goalmouth.
I was working alone in this instance giving both mouth to mouth
and cardiac massage, an impossible and hopeless situation.
vomiting to complicate the issue.
The patient started
I was conscious of an elderly w m t e haired
St. John’s Ambulance man working alongside me.
I requested some swabs to clear
an airway, all that was forthcoming was a dry sponge.
By this time it was
after 15.30 hours and we still had no equipment of any sort to work with.
It
^^.s just after that that I was conscious of the first ambulances beginning to
make their way on to the pitch.
Eventually I realised that I had lost the
battle for this young m a n ’s life.
unattended bodies.
I looked around but I could not see anymore
By that time our ranks had been swelled by ambulance crews
and firemen with some oxygen.
I next left the field making my way behind the main stand to the gymnasium wnere
I understood some of the injured were being taken.
of chaos.
Again I found another scene
The only entrance to the gym was a door of similar dimensions
to that found in any household room.
St. John’s Ambulance Room.
The space was becoming jammed full of people
with comparatively minor injuries.
people presumed dead.
Directly outside this door was the
The area was also rapidly filling with
I next assisted police to make some sort of pathway to the door of the gym "byhelping and organising the movement of "both the prospectuve dead and the
seriously injured.
Inside the gymnasium the space was roughly divided
into two, half for the dead and the rest for the living, with tables set up
to interview the relatives.
I began to work with the injured in the
gymnasium at around 15*55 hours.
I was conscious of around three doctors in
attendance, but when I arrived there there was still no medical equipment of
any sort.
One doctor shouted across the gym for some drags to treat an
injured fan who was in obvious pain.
There was nothing available so I
volunteered to go to the St. J o h n ’s Ambulance room.
the?/- were not allowed to carry any drugs.
I was informed that
I rushed back to the gym asking
^some Senior Police Officer on.the-way if they could obtain some equipment
for" us.
Quickly three small plastic boxes arrived with medical equipment
plus an emergency case with drugs in it.
items of equipment to the doctors present.
a dozen injured in the area.
I began passing out the meagre
There were still only roughly
I prepared ten intravenous lines ready for the
Medical Officer to set up, and we commandeered police officers to hold the
I.V. packs because we had no stands to attach them to.
3y then some
semblance of order was being maintained in the part of the gymnasium given
over to the injured.
with the
fthree
The other side of the gymnasium was rapidl;/- filling
dead.
One of the doctors present had taken one of the
stethoscopes available to enable him to declare them clinically dead.
I next tidied up the medical equipment as most of the injured were being
rapidly removed to hospital.
I then began to realise the full extent of
the disaster for there were already over fifty bodies lying on the floor,
fty final act in this carnage was to comfort and stay with the husband of the
young girl whom I had seen attended to behind the goal.
At least I knew
she had had the best of attention that had been available in the
circumstances.
I stayed with him whilst he gave the necessary details
to the police, and then a local vicar took over from me.
When I left the gymnasium, to my amazement it was. still only 16.45 hours.
The longest hour and a half of my life.
PERSONAL OBSERVATIONS
1.
Comparison of the organisation with the previous year.
The previous year I arrived at the same area of admission at 14*50 hours
with my daughter.
Before we reached the turnstiles at Leppings Lane
we had to go through a police filter system, whereby it was ascertained
that we did have the appropriate match tickets.
This year no such system was set up.
2.
^
3oth years I was delayed because of travelling difficulties.
The
appropriate Authorities had decided to initiate roadworks on the Mo2
to commence around a week before each game.
Surely tne matches could
have been taken into consideration when setting up these roadworks.
3.
When we cane through the turnstiles for the 1988 game we were met by a
line of stewards and police officers who gently but flroly prevented us
from entering the tunnel to the middle sections.
It had been decided
that these sections were already full to capacity.
This year no such precaution was in operation.
4.
I can understand the Police Officers at the turnstiles wishing to open
the gates to relieve pressure and avoid injury to life or limb, out
in these davs of ultra m o d e m and sophisticated personal communications
surely it could have been done in conjunction with i,heir central police
control area at the side of the electronic scoreboard.
5.
Very recent national publicity has assured us that surveillance cameras
at football grounds means that any problems can be dealt with within
two minutes of their occurrence.
Surely with the police central control post with all its battery of
T.V. monitors available, they should have been able to ascertain the
need "to close "the middle sections when "they became full.
6.
Observing from the outside it appears to have taken far too long
for the authorities to decide that it was not a security problem and
that the fans genuinely needed help.
VJorking with
etnd alongside
the individual police officers in the immediate disaster area, I
have tremendous praise and admiration for their efforts.
Overall
at the scene, however, there appeared to be a lack of co-ordination
and genuine leadership.
"5'or an extremelv long time we were without any form of medical
equipment of any description.
X still cannot understand why tne
local Health Authority’s Major Medical Disaster Team was not called
upon.
I understand that all Health Authorities in this country
have a major disaster policy.
It is impossible to accurately
estimate the difference, this would have made m
saving life.
I do, however, believe that the Liverpool fans should have been
given the chance.
SENT BY:
•
n o - 4-92 ; 9=34
; doughty st chambers^
051 225 2135;# 2
»
TEL: ______________
12th February, 1991
Dear Dr. Popper.
At the mini inquests we attempted to ask a series of questions concerning
the aftermath at Hillsborough, we were left with the impression that the
luestions would be dealt with at a later stage.
However since then you have ruled that it 1s not necessary to proceed after
15.15pm and it now appears that our questions will not be addressed, you
did say that in an Ideal world everyone would have ended up in hospital and
you suggested that we were naive 1n thinking that the medical response was
Inadequate, that sort of answer is not conducive to the facts as shown In
the video, and reports from Medical Personnel who were trying valiantly to
assist the injured.
The video shows 1t took till at least 15.35pm before all the casualties
were removed from the pens, a fairly lengthy delay which obviously did
nothing to help their chances of survival.
Reports and recommendations from the Medical Personnel (please find
enclosed) certainly imply that in their opinion, the response left a lot to
^be desired.
He also know of people who were removed in an unconscious state, a prime
example being Mr. Edward Spearritt who according to Mr. Spearritt was not
admitted to hospital until 17.00 hours and who subsequently recovered, that
it was possible for people 1n the crush who suffered severe Injury to
survive with a reasonable amount of aftercare.
At the very least this raises questions 1n the eyes of the families that
the inefficiency of the major incident response could have contributed to
the number of deaths occurring at Hillsborough and therefore we considerthat this should have been part of your enquiries into the reason for the
deaths.
You have promised to look into individual questions of concern, therefore
1t would not take a great deal of your time to enquire into this matter.
/
n o - 4-92 ; 9:34
SENT BY
; doughty st chambers-*
22b
Page 2
He would suggest the two most qualified Medical Personnel niamely Dr. John
Ashton and Or. Glynn Phillips be called to give evidence at your Inquests,
so they can be questioned as to their medical opinion of whether the
response contributed at all to the amount of fatalities.
He think you realise the seriousness which we place on this matter, and we
feel that if you fall to address this situation, that this failure will
obviously form part of a case for judicial review no matter what verdict 1s
reached.
Trusting you will give this matter your earnest consideration.
Yours sincerely
L. & D.M. Jones
LDMJ/CD
21351#
3
OFFICE OF H.M. CORONER FOR
SOUTH YORKSHIRE
(West District)
MEDICO-LEGAL CENTRE,
WATERY STREET
SHEFFIELD
S 3 7ET
STEFAN L POPPER, LLB.. B.MED.Sd.. 8.M., B.S.. M.R.C.G.P.
CORONER
Telephone SHEFFIELD (0742) 738721
Our Ref:
.19..February
^g 9.1.
SLP/LL
Your Ref: LDMJ/CD
Mr L & D M Jones
Dear Mr Jones
Thank you for your letter dated 12 February 1991, the contents of
which I have noted and have read with care.
Whilst I would not for one moment question the seriousness with which
you view the points raised, I do not think that it is either right
or appropriate for me to enter into a dialogue with you regarding
the issue which you have raised.
However, in order to avoid any possible misunderstanding, I do have
to say that it is not my intention to call either Dr Ashton or
Dr Phillips.
I have also read your penultimate paragraph. Whether or not you
apply for a judicial review is a matter entirely for you and/or your
advisors arid I do not think that I should comment on this either.
Yours siycfcerely
J T p p T y
H M Caronar/^
^ t ' : t~ 1
16.
dull
II
IM PO R TAN T
erpool
"
ft,.•J®,",°u®
‘ 1 rfi ° m 4 AuHusl 1900 '.he
Hospl.al i new ni.irnDer vdil be._
L*
Royal
TEL: 051-706 2000 (all depts.)
or
lor r°r.e?,s,4?. Pathology
direct on
031— 706 !*3 ? 1
-^
!-C! nurr.i'jr;■ i a b o v e
prsveni sw itchboard ccn o e stic ''.
iTH.
TEL: 051 — 709 0141 EXT. 2800
TELEX NO: 627095 UNILPL Q
FAX: 061 708 6502
JOT STREET
JB/SA
11th March,
1991
Humphreys,
Brian Thompson & Partners,
Solicitors,
5th Floor,
Richmond House,
R^fcord Place,
-L^erpool,
M r.
M.
' ^ 9SW
Dear Mr. Humphreys,
Re: Hillsborough Disaster, April
1 98 9
nn , ThS"k you for sending me the relevant documents in this matter
comprising th*
of the bodv I T l }":tlr , ” POrt 0f Pr0f'SSOr
- w o t of
in the earlv oart of'thf0?'"
tran3crlPt of Part of the medical evidence given
early part of the Inquest, at Sheffield,
in April,
1990.
Hillsborough1nl n ^ e n .a n y .of the vldeo evidence of the events which took place at
taller
\ ?
y 10 question> although I did, like millions of others see
in anawirnto ouestiotran6mlt,
teJ °C th® day °f th$ dlsastei'- The comments I make are
H i ^ b o r o m t h v i c t i n ^ h*1*?
Leslie Jones, father of Richard Jones, one of the
rough victims, when he spoke to me by telephone last week:-
’■
JeSrdln»ytie
T Z T l f ^ 0," * Or °Sh'r “lth «•«*>«= *> Th*
M » conclusions
garcung the cause of death, in the case of Richard Jones.
post-mortem
consequentre *XaCtly those one would e*Pect-in someone who has died from asphyxia
l o ^ i o p T H UPK° c™ pression of the chest and Professor Usher's conclusions a r e ’
forenftln
+ objective.
I might add that Professor Usher is a very exjer^n"ed
forensic pathologist, of international high repute.
experien-ed
2‘
adult ?oidieii ? ° M « b^ *1 ? ta^ 63<aCtly h°W l0ng U w i l 1 tak« * healfchy young
bv r p u h M
r
e
being severely crushed, thereby producing asphyxia
estimate that"r
^
mOVemont' but 1 would concur with Professor Usher's
estimate that consciousness would be lost after 30 seconds cf significant
j;estriction of chest movement and that death would M c u r after four
to six minutes of significant continuous restriction of chest movement
^
the~?atal^dav~'
would be dead'bv ^ 06
well be that 1
3-06
or *h.««. ^ . . rKI- n l
om
p.m
J'®s|;rlctlon of chest movement began at 3.00 p.m. on
* rea50nable t 0 conclude that a person so affected
an.d unquestionably so by 3-15 p.m.
However, it may
? fr ?aSe’
ln “ any cases, significant restriction
the restriction of r'hLflf-*
S ° f
1 SeVeral minutes a f t * ~ -00 p.m. and that
were so and
m °vement was not continuous, but intermittent.
If that
>
d there is reason to b e l a y s that it was (see Professor Usher’s
datfl tn
0
K. Humphreys
-
2
*.
11th March,
S T S V T tato * “ •
been placed in the correct position
fearea consequence, an inaderuaf«
1991
“
such a Do s i t i o ^
pOSltion' or wno> having
position was not maintained, a
state of unconsciousness, with death l l l n t T i i ™ 11 ^
produ<3ed a Prolonged
than 3.15 p.tn.
’
* d6* th event^ l y occurring at a much later time
Tours sincerely.
^
/
James Burns,
Lee Pathologist.
S
HER MAJESTY’S CORONER Irnp «^.T„ Yn m .-„Tnr
(WEST DISTRTPTl
—
INQUESTS INTO THE DEATHS OF THE
VICTIMS OF THE HILLSBOROUGH FOOTBALL
STADIUM DISASTER
ON THE 15TH APRIL, 1989
Before
S.L. POPPER, LL.B, B.MED.Sci, BM, BS. MRCGP
(Her Majesty’s Cornnpri
At
The Town Hail,
Sheffield.
On
Monday, 19th Noveaber, 1990.
TRANSCRIPT OF PROCEED
Fro« the Notes of J.L. Harpha«. Ltd.,
,, Official Shorthand Writers,
Queen Street, Sheffield Si 2DX
INDEX TO T R A N S C R I P T
OPENING STATEMENT BY THE CORONER
APPEARANCES
LEGAL SUBMISSIONS
STATEMENT BY THE CORONER
SUBMISSION BY MR. ISAACS
STATEMENT BY THE CORONER TO THE JURY
S. BROWN Sworn
By The Coroner
M. LAYTON Sworn
By The Coroner
Cross-Examined
Cross-Examined
Cross-Examined
Cross-Examined
LEGAL SUBMISSIONS
by
by
by
by
Mr. Payne
Mr. Isaacs
Mr. King
Mrs. McBrien
3
MR.
CALLAGHAN:
Sir, you know the representation on
previous occasions and I should say it is my intention to stay
only for today and in the case of one or two witnesses. I
will not take any major part in the Inquiry.
THE CORONER:
I have got no particular objection to
you being here.
I thought you probably would not be here
continuously but I wanted to be sure about that.
Perhaps
the best thing would be if we started with you really and
if we started with appropriate legal submissions.
It may
be easiest if we start with Mr.. King and then we will move
across the table, so to speak.
MR. KING:
Sir, my primary legal submission is
directed to your preliminary ruling on the last occasion
that this Inquest should be concerned only with events up
to about 3.15 pm.
As I understand your ruling, sir, it
was designed to ensure that this Inquest would only be
concerned with events leading to the crushing on the
terraces and the first arrival of an ambulance.
As you know, sir, the families whom I represent are
very anxious that this Inquest should deal with what to
them is a very major issue, as to how their loved ones came
by their deaths, namely how the services and the rescue
services, and those attending with the emergency, coped
with it immediately after people were brought off the
terraces because death was not certified in many, if not
most, cases until after 4 pm.
Sir, I do not know if you
have had an opportunity to read these.
I did ask those
instructing me to send to you statements from each of the
families whom I represent setting out a number of
individual questions directed to their own Inquest but also
incorporating in their individual cases why they were
anxious to learn of what happened between the time there
was a first sighting of any loved one being brought off the
terracing and the pronouncement of death.
I do not know
if you had an opportunity to read them.
THE CORONER:
I have briefly because these did not
arrive until Friday afternoon but I have looked at them.
MR. KING:
What I would like to do is take you
through some individual examples in order to persuade you
that this is a question which ought to be gone into at this
particular Inquest.
I do not know whether that is a
format you want to follow or whether you want first to hear
some other representatives as to their attitude to my
submission.
I am happy to go into considerable detail
about it.
THE CORONER:
There are several points which have
occurred to me and the first point I would like you to deal
with is this; you were not present but you will be aware
that in April/May this year we sat for two-and-a-half weeks
approximately and we dealt with the 95 deceased and we
dealt with three issues which Coroners deal with; who the
deceased was, when he/she died and where he/she died.
I
specifically excluded from discussion at that time the
question of how he or she died because as you will
recollect the DPP was still actively considering the matter
and we did not want to trammel his investigation but, on
the other hand, I felt it was right we should allow people
to hear what we could deal with.
I will raise the second point at the same time because
it may be easier for you to deal with the two things
together.
At those hearings we dealt in considerable
detail, in fact infinitely more detail than we would
normally deal with in an Inquest, with events after the
pathological cause of death and I did it because I realised
that the families were desperately anxious to know what had
happened immediately after the incident.
My question to
you is - and I think this is what we need to deal with and
get right - bearing in mind we have only dealt with the
question of who, when and where and that we have done it in
considerably greater detail than one would normally expect
to do, why is it necessary to review that very activity
again which I think is what you are really asking me to do?
MR. KING:
Sir, as I understand the individual
Inquests there was not an enquiry into, in the individual
cases, the impact of the organisation rescue on the
survival or otherwise of the particular loved one.
All
that was done when
one looks at those Inquests was to
identify the time of a first sighting,that is to say,
somebody who seemed to be unconscious, and of a time when
effort was made to resuscitate in any given case and then
death was certified.
In many of the cases there was a
large gap of time after 3.15 pm when it was not
investigated at the individual Inquests the nature of the
services available to deal with those being brought off and
if I can just give
one or two examples of that, you have
examples of people
who are brought off at 1522 and it is
said that there was an effort to resuscitate by a lay
individual and then that particular lay individual is not
heard of again, or the officer is not, and it is said that
the given loved one arrives at the temporary mortuary.
There has been no investigation directed to thealobal
organisation_of what happgngd immediately after they were
brought off ,the t*»rrsres._ certainly I have ueen through
the” inaj.vxduax transcripts and there does not seem to be
any evidence directed to that issue and those witnesses who
were called could not deal with those issues, sir.
s
THE CORONER:
Are you suggesting that the cause of
death in respect of these individuals is not in fact the
pathological cause of death which we have been given but due
to a novus actus in effect by person or persons whose
evidence you have not yet heard?
MR. KING:
Certainly the families, and I put it as
openly as this, sir, and putting it bluntly, cards on the
table, are not convinced at all that had there been a far
more sensible, logical organisation of the rescue services,
of the major disaster team being brought in, of proper
,
medical equipment being available, of proper triage being
‘
carried out, that those measures, had they been there, in
several cases, would not have resulted in the survival of
their loved ones.
They cannot - obviously they were not
there - produce through me concrete evidence of that at this
stage but at every stage of an Inquiry into this disaster,
and this certainly is true even in the Taylor Inquiry, that
particular aspect of the disaster has never properly been
gone into.
Again putting it very simply to you, sir, most of the
families I represent feel there has been a complete blanket
(not a deliberate blanket) been held down over what happened
after they were brought off the terraces and before
individuals were certified dead and there has been no effort
made systematically to analyse what was the organisation at
the time for the rescue, what might have been, and what could
have made a difference.
A very simple example again is that
I am instructed there is evidence of Dr. Gumpert given at the
Inquest that without an electrocardiogram we can never be
sure whether or not there is a pulse and when dealing with
individual loved ones taken off the terraces and simply dealt
with by lay people, the absence of such sort of equipment
means that one would never know whether or not that
individual was alive or dead at that stage.
It is a
matter - and I do not mean this pejoratively - which is swept
under the carpet as if to say, "All we are interested in is
the immediate crushing leading to those being brought off the
terraces".
I cannot put it any more firmly than that, sir.
THE CORONER:
You have put it very plainlyand I
appreciate it.
I will give a ruling on your application in
a few moments but do you want to develop it further?
Obviously I want an opportunity to hear from your colleagues. '
MR. KING:
were supplied?
Have you the individual statements which
THE CORONER:
I do have those in front of me.
I would
not want to go through all of them but if you wish to pick
one or two as examples I am prepared to listen to you and
indeed it also makes it easier for everybody else.
MR. KING:
Sir, if you were to turn to No. 11 to start
with, which is the submissions to you of the Jones family,
Richard Jones, I do not know whether you have been given one
or two documents.
I have two documents in relation to Mr.
Jones one headed "Dear Miss Steel” and one headed "Dear Mr.
King".
THE CORONER:
No. 11, did you say?
MR. KING:
Yes, sir.
I beg your pardon, sir, it is
No. 10.
Sir, if you look ---THE CORONER:
Mr. King, may I just stop you for one
moment because something has occurred to me, and I have been
reminded, which I ought to say to the Press before we go
further?
The session this morning is being heard without
the Jury and the reason we have not got the Jury is because
we are dealing with legal points.
That means no doubt that
you can report we are in session but you should not actually
report what is being said.
You will no doubt be familiar
with the provisions of Subsection 2 of Section 4 of the
Contempt of Court Act and I say you must not report what we
are discussing.
If we had wanted the Jury to hear we would
have had them present but we do not wish them to hear at thii
stage.
You may, when we have finished the Inquest, if you
still feel it is a reportable and interesting aspect then,
course, that is a different matter but for the moment please
do not report the content of the legal matters we are
discussing.
Mr. King, I am sorry to interrupt you, would
you continue?
o j
MR. KING:
Sir, the document I am looking at and I
appreciate those alongside me are not looking at any document
but it is just to help you is one headed to myself, "Dear Mr.
King".
THE CORONER:
I have a document headed "Dear Miss
Steel" dated 22nd October.
MR. KING:
Sir, this is dated 7th November.
THE CORONER:
not in front of me.
I have not got it I am afraid.
It is
MR. KING:
Iapologise for that and I will take you
through, if I may, through five points which are raised by
Mr. and Mrs. Jones.
Sir, they make the basic point that th«
report into the death of their loved one,' Richard, was
certified at 1600 hours in the temporary mortuary and,
therefore, so far as the family are concerned, so far as
evidence is concerned, they presume, as they say they must b<
entitled to, up to that time the evidence of death is not
clear as having already occurred.
w ^ Po^nt N o * 2 > air., is extracted from the evidence given
by Dr. Gumpert at theInquest already held here and in fact
it was evidence given
on the occasion of Kevin Tyrrell
and
1S a quotation from his evidence which you may
r6Call •
"I would like to observe that feeling the carotid pulse
is quite difficult in someone who has a low blood
pressure as would have been here.
In fact it can be so
difficult it is impossible and you have to have an
electrocardiogram on to know whether the heart has
stopped or not;"
Then there is the statement of Mr. Eccleston, which is
certainly a statement in the large bundle of statements given
to the West Midlands Police, and indeed Mr. Eccleston gave
evidence to the Taylor Inquiry in which he says this:
/"For an extremely long.
8
B
"tor an e x t r e m e l y long time we were wit hout an/ form
of m e d i c a l e q u i p m e n t of any des c r i p t i o n .
I still
ca n n o t u n d e r s t a n d wiy the locaL h e a l t h a u t h o rit y's
m a j o r m e d i c a l d i s a s t e r 'team were not c a l l e d upon.
I
u n d e r s t a n d that all h e a l t h a u t h o r i t i e s in this
c o j n t r y hav e a m a j o r d i s a s t e r policy.
It is
i m p o s s i b l e a c c u r a t e l y to e s t i m a t e the d i f f e r e n c e this
would have m a d e in sa v i n g life.
I do, however,
bel ieve that the L i v e r p o o l fans should have been
given tne c ha nce".
And the q u e s t i o n rai sed by Mr. and Mrs. Jones is this,
sir:
tnere w a s a m a j o r i nc ident vehicle.
Why <*as it not
cal led? Lac k of e q u i p m e n t u n d o u b t e d l y res ulted in deaths.
Sir, I pause there.
Of course, Mr. and Mrs. Jones
w e r e not there and of c o u r s e they are n o t experts, but you
will .see, sir, from the b a s i s of that e v i d e n c e they are
firmly of the b e l i e f that one ca n n o t just ignore an
inquiry, an inquest, into that aspect.
r\
Sir, n u m b e r 4 point m a d e by Mr. and Mrs. Jones comes
from the s t a t e m e n t made, a g a i n in the large bundle, sir,
from Dr. G l y n n P h i l lips , p a r t i c u l a r l y w h e r e he says that
a ft er 3.15 p.m. he gav e m o u t h to mou t r e s u s c i t a t i o n to a
m an for 15 min u t e s , and jus t as he
giv ing up the heart
sprang to life, and a f t e r that the m a n started b r e a t h i n g
on his own. We k n o w that this does not prove this man
lived, or if he did he m a y have bee n brain dam aged, but
the point we are t ry ing to put across to the c o r o n e r is
that after 3.15 p.m. not all the pe o p l e w ho were later
c e r t i f i e d dea d wer e n e c e s s a r i l y dead.
Sir, f i n a l l y Mr. and Mrs. Jo n e s d i r e c t your a t t e n t i o n
to the long s t a t e m e n t w h i c h I a.“ sura you have seen, sir,
of Or. Joh n A s n t o n in w h i c h tnere is a series of rea soned
c ri t i c a l c o m m e n t s on the d i s o r g a n i s a t i o n of the m e d i c a l
and the res cue a t t e m p t s , ho n e s t and in good faith tnough
they were, a f t e r the p e o p l e were br o u g h t off the terraces.
Sir, that is Mr. and Mrs. J o n e s in tnose c o m m e n t s and
in the short letter, sir, w h i c h you have, w h i c h you have
al r e a d y r e f e r r e d me to, sir, they e m p h a s i s e an issue as to
the failure to i m p l e m e n t triage a f t e r the d i s a s t e r
happened, again, c o n c e n t r a t i n g on what Dr. G u m p e r t has
said as to the fact that wit h o u t an e l e c t r o - c a r d i o g r a m it
is not pos s i b l e to k n o w w h e t h e r a hea rt has stoppped.
Sir, c a n -I
m o v e on from Mr. and Mrs. Jones' c o m m e n t
andd just giv e you one or two mor e e xa mples - I a p p r e c i a t e
thaat in m a n y ways it is r e p e t i t i o u s but it is m a k i n g the
po int - to n u m b e r 14, sir, w h i c h is in the cas e of Williar
Roy Pemberton.
T H E COR ONER;
And this one is a d d r e s s e d to you,
(
H
£
)
9
HR. K I N G :
Sir, it is not o f t e n that i n s t r u c t i o n s to
C ou n s e l are giv en in a d v a n c e to the Tribunal, and I
suspect, sir, that it is not a wis e mov e in m o s t cases.
T H E COtvONER:
You are p r o b a b l y right.
MR. KING:
Sir, it was an eff ort in tne rel ative ly
short time since we wer e b e f o r e you to put b e f o r e you the
var i o u s m a t t e r s w h i c h the fam ilies wi s h e d to place be f o r e
you and it was felt this was the eas i e s t way to do so,
sir.
•
Sir, if I can then turn to Mr. Pemberton, you will
see that he mak es the f o l l o w i n g points:
tne report into
the d e a t h of his loved one Roy that life a g a i n in his case
vas pr o n o u n c e d ext inct at 16.00 hours nours, and ag a i n in
tne a b s e n c e of m e d i c a l e v i d e n c e to the contrary, the
family can only assume that t.neir loved one was alive
until that hour, and sir, if you then go to p a r a g r a p h 3
that d o c u m e n t you will see there is a ref erence to tne
s t a t e m e n t of Mr. Sa x t o n of the St. J o h n s A m b u l a n c e
Service, b ec ause he refers to tae r e s u s c i t a t i o n of a you ng
man at 15.50 hours, i n d i c a t i n g in the h e a r t - f e l t v i e « of
Mr. Pemberton, as w i t h a ll the o t h e r families, that d e a t h
mus t have o c c u r r e d a f t e r 3.15 p.m.
Ag a i n he refers you, sir, in p a r a g r a p h 4, to tne
s t a t e m e n t of Dr. Byrne w h e n he quo tes tnat he was
a p p r o a c n e d by a senior Po l i c e O f f i c e r and as k e d to start
c e r t i f y i n g the dead as there may be some still alive, and
.sir, again, the point has been m a d e that as we only '<now
for cer t a i n that d e a t h was at 4 o'clock, to ign ore these
c o n c e r n s as to the a d e q u a c y of the a t t e n t i o n s and the
rescue eff orts a f t e r 3 . 1 5 is to not i n v e s t i g a t e wha t c o u l d
well have b#»en a m a j o r r e a s o n for why som ebody d i e d and
d id not survive.
T he final point on Mr. Pem berto n, sir, in p a r a g r a p h
7, is the q u e s t i o n he asks: why was it that the very
s e r i o u s l y ill and dying, and those w ho a p p e a r e d to be
dead, w e r e not taken to the h o s p i t a l in the ver y first
a v a i l a b l e amb ulanc e, and ne rai ses h i m s e l f the issue as to
why the se r i o u s a c c i d e n t r e s p o n s e veh icle was not cal led
out to the stadium, as he u n d e r s t a n d s to be the case.
Sir, if I can then d e a l w i t h per h a p s one e x a m p l e of
m in utiae , of detail, if one turns to the cas es of the
Hicks sisters, of V i c t o r i a and S a r a h Hicks, sir, w n i c n is
at num bers 7 and 3 in y o u r list, sir, you w i l l not ice the
c a s e of Victoria, that on .the face of tne sum m a r y w n i c h
was
pro d u c e d at the I n q u e s t pri or to today, there was a
gap
in time. There is a g a p in time
between 15.21, w h i c h
^was the time whe n Police C o n s t a b l e M c G u i n n e s s rescued
'Victoria from a pile of those w ho u n f o r t u n a t e l y had
fallen, and 15.23 when Mr. T u r n e r was seen h e l p i n g
fict oria out ont o the pitch.
(£)
H i c k s has drawn to your attention, sir, that he
a
H Wn
tne a t t e n t i °n of this Inquest the evi d e n c e of
a gentleman, a Mr. Taylor, w h o s e e v i d e n c e is that he was
" r e ^ u e d ^ h v p C? a C M r ^ r & V i c t o r i a w a s after she had been
miniitae h X ’j
M c G u i nne ss, and that for some six
man did not - £
bit as Mr H
i j
n 0 t ’ 10
reS'JScitate because the poor
i
r
t0*0'
a ?d one can understand that,
S says, those six minutes could have been
r ec eived
sur vival of his loved one Victoria, had she
r _c eived ttie pro per attentio n.
*S juSt arl e x a m p l e of matters which, in Mr.
Hicks
s s u b m i s s i o n to you, th r o u g h me, ought to be
investigated.
5
Sir, if one turns to S a r a h Hic ks at number 8, again
m ^S
tim ings we know that at 6-m inute spast-3 a Miss M c C a f f e r y sees Sarah, who clearly has
^ ! . r n !hand we know at 2 1 - m i n u t e s - p a s t - 3 , helps the fallen
b et apan
? nt°
P i t c h* Again, the time gap there
it
n r ^ n! - ^ i ast
and 2 1 -m i n u tes-past-3. We know
2 ' 20-p.ast-4 that Dr. Bull examined Sarah
i? icS f
2er d e a t h > and we kn ow from the sum mary that
5
SOiUe time b e tween 15.38 and 15.50 an
u n i d e n t i f i e d m e m b e r of the m e d i c a l
team stated in his view
that Sarah was at that time bey ond help.
tie
t im; s » s i 5» §° b e yond 3.15 and they again
Hmfc
n f e?c:ln
s u b m i s s i o n of the families for
s a f t e r 3.15 to be t h o r o u g h l y investigated.
f l r * those a r : Just four exa m p l e s but, sir, if you
r ad tne pap ers w h i c h I u n d e r s t a n d and I am sure you have
they express the flavour of all the other submissions
that, in fact, we can not k n o w that a cut
off point at this
stage is the right cut off poi nt at 3.15 and it is
premature, sir, so to do, in my s u b m i s s i o n to you. That
is how I put it.
T
£ ° * 0 N E * ; .,,rhank you very m u c h indeed, Mr. King,
ioi nr? ‘^ at\ we will n ow do is to giv e the rest of you an
o p p o r t u n i t y to m a k e points.
I think we ought to start
w h a ? Jjr s * '*c 8 r l e n.
I think y ou w o u l d probably sup port
M r S ^ en I
* ^
is there anythin8 in a d d i t i o n to
*hat Mr. K i n g has said that you feel you would like to
* / ,<TBri!n C3n f *** lf ^
3re m0re
comfortable sitting down - indeed, that *oas for all of
a r ? m j re c o m f o r t a b I e ’sit t i n l d o w n ^ s i T d o i n .
don t min d - it does not m a k e any difference.
I know
,your lfiS al c o l l e a g u e s s i t t i n g around you are used
to s ta nding so they will tend to rise, but you do what is
comforta ble.
Mrs. McBrien, is there any thing you want to
aad r.o what Mr. King has told me?
Mr
.M c B R I f5J:
No,
I go a l o n g w i t h eve rythi ng that
rfr. King has said, thank you.
11
THE COR ONER:
Tf T qtarf
n ..
d o w n the row, is tnat s a t i s f a c t a L ^ F ^ 60 and work
way
ladies? It Is e a s i e r f t c m e .
Y
^ - g e n t l e m e n and
MISS HAN P T O N :
THE COR ONER:
I have no sub missi ons, thank you.
Mr. Hale?
•
n 3
you wil 1 have t0 r es trict the ar=as in^n
w m c h you are prepa.red to en q u i r e further and further
top of tie e n q u i r i e s m a d e b y t n e T a y l o r R e
t
’ °n
S o f f ®lraPl l £ y i n « m a t t e r s a little, but I t h i n k ’it i s' v e r t
1 known by e v e r y o n e c o n c e r n e d that the Police f->r
example, have a d m i t t e d n e U i e » n c e
T h l - l
fc „ ’
r
about that at all.
T h e r A a ^ I n JfciJ “ c L d ? ^ *
seems t o ^ i V ^ r
ev e ryone 's time
be6n j ° i n -d in th2f", so it therefore
W 3 s t e ? f your tiraa and a was te of
that In .nindf
Mndsijht,
■In m i ™ ? C0*0Hra‘
s e r v i c e s "b u t ’ t
»o I am sure you will bear
Hntch one in ^a c t i - u l a c have you ; ot
?**? “ aS ?u l U d down ° v * c
one lt-
: l u t “ i r i ni s
v erdict of'misadventure^ “
rescue
d° Ubt lnStrUCt the J “ / »« a
j o i n=^ bosyond
e j o n d that, and I wou
f° rld
!J I hop
arae s uthat
r i ’ nM
is nl2
s e e tah-«
ing
5 uil'g m
w as te
t(l3ir M m e
K..I- *-_'
K
£
r--r-c
E
=
-
m i s a d v e n t u r e , a nd I w o u l d m e r e l y ' m e n ^ o n tliau
nut
l?° kins
raatter^for ray l e f r n e l T f r i ^ r M r ^ K i ^ V t ? n t i r e l >' a
r e p r e s e n t s 43 fam ' i i o o
•*
•
^ see that ne
the same.
T h e r e was a p r o b l e m ^ t ^ h ^ T a J l o r L q S i r ^ i h e n
c
12
A
B
the Police wer e r e p r e s e n t e d by one r e p r e s e n t a t i v e and it
s u b s e q u e n t l y t r a n s p i r e d that it could well have been
b et ter if there had been s e p a r a t e r e p r e s e n t a t i o n over
c e r t a i n aspects. Hap pily, tnose aspects have not
m a t e r i a l i s e d and no real har m was done.
I w o u l d like to see an end to this Inquest when it is
o v e r and I w o u l d not want s o m e b o d y com ing bac k aga in and
a s k i n g for it to be r e - o p e n e d and started all over again
bec ause of lack of r e p r e s e n t a t i o n se p a r a t e l y by some
p e o p l e W'io may be a l l e g e d to have played a part in tie
deatns.
D
/That is a m a t t e r w h i c h my learned friend
H
13
That is a matter which my learned friend lh i i t
understand. I merely mention it nou 2! -i? J
am sure< fully
mentioned with hindsight afterwarHc
not said that it is
great deal of diffiriSSe b e t S e S S There may* indeed, be a
responsibility on the part of som<= ® r®®ponsibility or lack of
separate repreSe n t « L n wou!d fn n o ? L ? c?r,“h° dled’
because it may be that one family would lake . n ' t n ® ^ re<!'Jirec
against another. Again I e Iv p
frT
?
legation
saying that any such person exists but ifP<t’ ^
1 am not
someone who died had come at t-h<=
? I * Were shown *hat
deal of alcohol i n s ^ r ^ / a n d " ^ ^ ^ ^ r i ^ ^ * ,r“ t
rs:
A
'
£
A
r
s
s
J
s
r
,
s
£
“
s
S
M
'
5 1 - -
coupirs^iSSTi^lS.niS ?£?•■ ,yS! n
hire m
*ntioned a
“
™ u rd —
t M s Stase as to what verdict if anj f h e ^ y 1"*0
loads of statements
I
f
5 advanta®e of having seen
taught me in mulh l i m p L ? I n q S e s ^ s ^ h a n ^ M i ^
*?perlence
g»s:r^.2S=rtrLSrSr-s Sir
have h ^ i ' t ^ e J L S S ^ ^ S ? *nS“ r bUt t0 “a“
*
U s t e n ^ aEh\ CJarifiCatlon for everybody?8 I So“ ntenS ?o yOU
thj
°.W
said, which is the reason why we are her<=»
5«s S Kbri^ Sly' 1 have read statements andT h a ^ e
to r
«
A.M;. ■
r un
2S^:
£
o ? t ? h r ^ p ? : i^ 0 td
h^
d° -
he
w
% i s
got
1 “ » • * * inore than that.
,
the relative
14
A
B
C
D
i
As a comment on what Mr. King has said, strictly it appears
to us that he is saying that there is the possibility, to put it
in a legal term, of a novus actus, i.e. something which
intervened after the crushing and before the deaths, which caused
or contributed to the deaths of at least some of the people, and
the response of the Chief Constable to that submission, if I put
it correctly, is that we can quite see that is something which
people would wish to see investigated on the question of how it
came about. I only make that comment in an endeavour to be
helpful, but the position of the Chief Constable is that he has
no submissions one way or the other.
May I just say while I am on my feet with regard to what Mr!
Hale has just said, as a matter of fact it is not correct that
the Police have admitted negligence. It is well known and has
been well publicised that what has happened is that the Police
have agreed to make payments to those people who were injured anc
to the dependents of those who died, and that such payments are
in the process of being made.
Also there has been a civil actior
in respect of apportionment of liability in respect of those
matters.
THE CORONER:
Thank you very much, indeed. I accept
entirely what you say and in a sense I accept what Mr. Manning
says as well. It is not really relevant to my proceedings
whether or not negligence has been admitted or not admitted. It
is neither here nor there. So I did not comment on it, but I
appreciate what you have said.
MR. ISAACS:
I think, sir, in fact, that is Mr. Hale.
Manning sits to my left.
E
THE CORONER:
of you.
I beg your pardon.
Mr.
Forgive me, please, both
MR. ISAACS:
Sir, I have no submissions. It is entirely a
matter for you having regard to the breadth or depth which you
consider appropriate for this particular Inquest.
F
MR. MANNING:
Sir, I have exactly similar comments as far
as my client is concerned.
MISS SINCLAIR:
I have no submissions on this matter, sir.
MR. CATCHPOLE:
I add to that. The matter is entirely for
you. You are the best person, having read all the evidence, to
make that judgment, and no doubt that was the reason we had, as
you have already pointed out, sir, a fairly detailed
investigation into the earlier Inquests.
G
I
1
MR. CALLAGHAN:
Sir, this is not an application of which I
have had previous notice, and which in the circumstances of the
application is some surprise to me. All I think I should, sir,
is this is not the time and place for some sort of Public Inquiry
into the activities of the Ambulance Service and the Emergency
Services, and it is not appropriate to bring such a matter into
15
the srena
obviously
as a sort of side wind.
a matter for you.
Beyond that, sir, it is
MISS ADDELMANN:
Sir, I have no observations or submissions
about the point, and Ican do no better than echo those remarks
made by my learned friend, Mr. Catchpole.
MR. RUSSELL:
I too endorse those remarks. None of us
other than my learned friend. Mr. King, has seen the original
statements, and so are being invited to comment upon a course in
the dark because we have not seen the nature of an example of the
material he now seeks to rely upon. I recognise it is a matter
for you, and if you decide I d6n't take a stance one way or the
other.
THE CORONER:
Shall I then deal with this point? Is there
anybody else wants to say anything on this issue? Mr. King?
MR. KING:
Sir, only to emphasise that it is not a side
wind which I am embarking on. I am seeking to address causes,
contributory causes to the deaths, and I am concentrating on
that, and it is in that context I have invited the Court to look
beyond 3.15, and certainly we are dealing with it from the point
of view of possibilities of novus actus, yes, I accept that.
THE CORONER:
I have listened hopefully with attention, anc
perhaps I ought to say this to you, Mr. Russell, before I go on.
I know you have not had the advantage of seeing the letter, but
it is only fair to say Mr. King in his summary of the points as
far as I can see summarised the points which his clients were
making entirely fairly. There is nothing extra in the letter, sc
to speak, except connecting words, basically. That is for your
reassurance, if I can put it like that.
Throughout, and in fact almost from the word "go” on the
15th April, 1989, when I first learned about this incident, one
of the underlying criteria which I tried to apply in thinking
how to set about dealing with the Inquests was to as far as
possible treat the Inquests as if they were completely
standard, if I can put it like that - it is a horrible word but completely normal Inquests. The fact that it was national
news, that it was 95 young people, that it created a terrible
amount of anxiety, pain and so on, in some ways is unique
because of the numbers, but each individual death I dealt with
families are in exactly the same situation, and I tried to
think and I still try to think, what and how would I set about
if I had had a road traffic incident or a works accident as
opposed to an incident in a football stadium. I have thought
back on many occasions to say a road traffic incident where
somebody might have suffered a serious head injury. That
person may well have been at the road side for X number of
minutes while one was waiting for the ambulance services to
attend. They may then have been taken by an ambulance to a
hospital. They may have gone into the resuscitation room.
They may have been worked on by the doctors. They may have gone
into hospital and they may have then died two, three days, may
be longer after the incident. Or alternatively, you could have
/
/here by chance the road traffic incident occurs on
/a doctor happens to be. He walks up to the
/ks and says, "I am sorry, the injury is so severe
yerson is dead". Or you could have a situation where
/has this road traffic incident and is taken into
Ad is certified dead on arrival.
zione of those instances would I as a matter of routine
/dence of what happened after the incident ;itself was
,ed, and indeed, the pathologists in the example which i
sed would have given as cause of death serious head injury,
istance, or multiple injuries with fracture of the skull, 01
hing of jhat nature. It seems to me that the fact that the
jn may survive an injury for a number of minutes or hours or
i days, isnot the question which I as Coroner have to
£ider. M^task is to establish who the person was - I am
f r y to repet this
- where he died, when he died and how he
&d.It isjrom my
understanding of the pathological evidence,
»he overwheling pathological evidence is and was that the people
ilied as a reflit of crushing or traumatic asphyxia. Different
fwords were usd, but the sense was always the same. The
underlying ppblem which these poor men and women were subjected
/* to was an iroility to breathe.
/
That d<S not mean to say that some of them did not in fact
respire for^period of time dr even have a heart beat
thereafter, t the damage was done, and indeed, both Dr.
Gumpert, Dr later. Prof. Usher, who dealt with this question ir
an overall nt of view, all in fact said, as I understand theii
tly the same.
evidence.
One
because
points, Mr. King, which you have made is that
_
r
With
tne greate respe
r iiiiiiiniiiiniiii rnrriii i "reasonabl Ls a very
would take ^[ndeed, if you think about it
I am sure
you would ,Bee with me, if a body were to be found in a
macerated S t e one would call a doctor who would
certify de$, but it would be a little bit illogical to
hat particular body was actually alive
until thatioint.
±
The isue of death certification and the timing of it is
is tht3n.’>ecause one wants to have if possible certainty. ThathinS- Secondly, the conventional way of
so h,,;ShilS a Person is definite dead is that a medical man say.' ■
so a n
todraw tl}e c°nclusion that until a medical man has said
raaintainSOn *S a^ive
in my view an impossible proposition to
/I do understand the anxiety.
I do understand the anxiety which a lot of the families
nave about this issue, but as I have already said the
overwhelming medical evidence, the pathological evidence
and that is the crucial one I am interested in, is the *
damage that caused the death was done due to the crushing.
Now I picked the arrival, of the first ambulanp-g not
because there is anything magical about that but because
when we look at the videos we can actually see that and it
is aajcgnvenient marker? that is all.
If the first
ambulance had arrived at 3.30 I would have picked that time.
It is simply intended as a marker, but, and this is an
important point, I considered the medical evidence. The
medical evidence was that once - I am not quoting verbatim but the sense of what Professor Usher said, .and, indeed, the
Ot h e r s as wel l
nro'iwimrrmin«A.» i■'
Now I felt that the evidence which I had heard and in
the light of what I had read that
the
assume six minutes past, at
that is tj
before, but let us
oTKe r~wor3 s’^"what’’5'
2Ii>Jam**!ry1 ng^*'*say”*ls
1 have already indicated that at the - I will call them
the interim inquests if I may just for the sake of a name >r,»
lat sense n>rolce my own rule straight away because I said
I wanted to treat this matter as if it were a completely
standard normal road traffic incident, if you like.
I
didn t, I gave a great deal of information for various
reasons which I don*t need to go into now.
As an aside I can assure you that within the limits of
our ability the summaries and the evidence which was given
was an accurate reflection of what people said and if there
wa? f faP»
instance, as has been suggested in some cases
which is unexplained |
e wh l c n w e n a ve put under the curtaILn,
but because we'didn't know of it or couldn't find it or it
doesn t exist. The truth of the matter, of course, is that
people weren t being watched individually continuously by
somebody else
fortuitous as
witnesses who
who remembers
recording what was happening.
It is entirely
to whether or not there is a witness or
happens (a) to have been with a person, (b)
who he is and (c) has some idea of the timing.
Some of you who were there will remember that in some
cases we had a great deal of evidence with regard to what
had happened post-crush, shall I say, and in others we had
next to nothing because it is very sad particularly for
those families where we have got so little to share with
them, but we are living in the real world and in some cases
there was overwhelming - for instance, there were dozens of
photographs as you know - some of the people were all over
the newspapers and in others we could not find any.
It
can't be helped, it is just one of those things.
Bearing in mind that IjiltfrTirt1 1"*“i*‘v<"
pi-auestion;of^hoy. and I do intend to deal with it
reasonably comprehensively, I have to remember two things:
that my powers are limited.
I don't have an open ended
authority to carry out an investigation.
The Rules and the
Act, indeed, are quite clear as to the limits of what the
coronal inquiry should be.
I admit that the word ’’how" is
a little bit flexible and assuming we call all those
witnesses on that preliminary list which I have circulated I
hope you will agree that I have been reasonably flexible
with that word, but nevertheless I do have to draw a line.
Indeed, this was done in other inquests.
If you think back
to the Zeebrugge inquest, for instance. The learned Coroner
there drew a line.
He was judicially reviewed on where he
drew it and in that particular case the Divisional Court or
the Court of Appeal, I can't remember now, clearly said that
a line has to be drawn and in the Zeebrugge case they agreed
it was right.
I am doing my best.
I am trying to draw a
line as well.
If you think of the other major disasters where
inquests have already taken place, you will find that lines
were drawn there as well and I think you will find that the
line with regard to the question which we are now thinking
about was very, very much tighter than what we have already
done.
In answer to your submission, I still consider that as
a general proposition we are going to accept - I am going to
take these inquests and deal with the question of how on the
basis of what happened to about 3.15 or thereabouts.
I
have explained it to you so I am not going to repeat it and
I base it mainly upon the pathological medical evidence.
Having said that, I think it is probably right to say
because we will be calling witnesses it may be that w m esftf
TjflftfWijfrhitnp
ic.h.^o
~to >a;*min o r1
v m s t cay^owntfthat^alih.
!
. 1 have also got to say, it is only right, that wha
understand it, e-outside-m p ’autbortey^tid^S^H^.
I also
seem to recollect, although Lord Justice Taylor s Inquiry
isn t - as I have already said to you at the business
meeting, I don't really want to spend too much time on it but I do recollect that the emergency services were very
well represented at that Inquiry and, indeed, a lot of
discussion, from my reading of the transcripts, did deal
with the issues of the medical response.
Whether or not that was satisfactory, whether Lord
Justice Taylor should have done more, whether somebody else
should look into that when we have finished that is nothing
to do with me.
However, as far as I am concerned, my
intention is to stick with what I gave you as my initial
preliminary intention.
I have, of course, already looked through the documents
which you sent me and insofar as in one or two instances
witnesses are mentioned, if I think, and, indeed, I have
thought that one or two of these in fact I think three at
the moment, you have got a point.
It would perhaps be
advantageous to.call those persons and we are making
appropriate arrangements.
Please don't think that I have
said, Good grief, fifty pages, I am not dealing with that,"
I have already spent quite a bit of time thinking about it
and I will hopefully have another look.
If I were - which
is highly unlikely - in any particular instance to feel we
ought to go a little bit further down that line because
there is a specific point to be made in any particular
instance, then I will if I think it necessary, tell you.
However, I think it is unlikely from what I have seen and
what I have read and for the reasons which I have given you.
MR. KING:
Sir, thank you for that
20
MR. KING:
Thank you for that.
Can I raise a
separate matter, sir, which is not connected with the issue
of cut off but is connected with the issue of 50 pages
which you have referred to?
THE CORONER:
I was not saying that as a criticism.
MR. KING:
Not at all, sir.
One only has to state
the number of families whom I represent to know that.
Sir, a number of the families have raised specific
questions relating to the summaries which were put before
you in their individual Inquests.
I just give one
example, sir; in the case of No. 13, Jonathan Owens, you
will note they have a particular concern as to the timing
when their son came to the ground and a particular concern
to the fact that the summary suggests he joined the crowd
at twenty to three when, in fact, they point out to you
that the positive video evidence shows they were standing,
not having joined the crowd at all, round about ten to or
eight minutes to three.
I put that as an example.
Are you willing, sir, to go through those individual
questions - not now - and indicate at some stage, perhaps
even in writing to us, whether or not you would be prepared
to reopen those individual Inquests to deal with those may be small points in the whole but to the individual
families - important points of factual errors which seem, to,
have crept in by reference to positive evidence whicn can
now be laid before you?
THE CORONER:
My recollection of the papers is that
they affected very few or where I feel it is justified.
I
think those two things go together.
As I say, I have not
had sufficient time to study it in detail but if I were to
think there was a genuine error and that that error was
actually relevant - the incident which you have given me
indicates with respect to the family it is an anxiety to
them - but the crucial point is not whether he was standing
in a crowd or whether he was standing aside but where was
he or at least at what time was he still outside the
ground?
One has to ask the question, does it actually get
us any further forward?
MR. KING:
May I just interpose to say that the
example I gave was directed as much to the timings outside
the ground in fact.
THE CORONER:
If we have made a mistake, and we will
be checking that...
MR. KING:
I am obliged.
21
THE CORONER:
When points have been made of actual
error we have been trying to check.
If we agree with
them, as Mr. Fraser and some of the others will remember,
we have made from time to time a<| hoc amendments when
points of error were pointed out to us.
I am not averse
to that, not in principle anyway, and if it helps somebody
by clarifying something then I will be pleased to do so but
I would not want necessarily to spend endless time on
clarifying minutiae which, in the final analysis, do not
matter so far as the Jury are concerned.
I am sure you
accept that.
MR. KING:
I understand that, sir, but I am sure when
families are supplied with an "agreed" summary and they see
matters which are of great concern to them which appear to
be incorrect then obviously they are desirous that that
should be rectified as quickly as possible.
THE CORONER:
comments on that?
I take it none of you have any adverse
MR. KING:
What I am going to suggest is that those
instructing me extract from those documents which do
confuse two issues, those which are directed specifically
to individual questions and they can be then sent to you in
a more orderly manner which enables us the more quickly to
obtain help from you.
THE CORONER:
That would be very helpful indeed
because then we would really know what we are looking at
and what we have got to concentrate on.
MR. KING:
THE CORONER:
anybody?
MR.
going to
with Mr.
run down
Yes, sir.
Are there any other comments from
ISAACS:
Yes, sir.
I just wondered how we are
deal with these matters.
I know that you started
King and I thought probably what you would do is
the line so to speak.
THE CORONER:
Yes, we will do that.
any submissions to make?
Have you got
MISS HAMPTON:
I have no submissions raised by Mr.
King, though he has raised one particular matter which
concerns the City Council with regard to the agreed summary
of facts.
They have been through the proposed summary
prepared for today's hearing and there are one or two
matters, they have instructed me on, which concerns them,
sir.
' THE CORONER:
I think I will be able to short circuit
this submission. You will recollect, ladies and gentlemen,
at the business meeting a suggestion was made that we
should try and extract various paragraphs out of Lord
Justice Taylor’s Report as an agreed statement.
I was not
particularly enamoured of the view and for some reason
which at the moment I cannot account for I forgot to
mention at the meeting that we were actually in the process
of preparing what we thought was an actual noncontroversial, entirely neutral, account of various
activities which we hoped it.would be possible to put to
the Jury so that they had an underlying base on which one
could build the edifice, so to speak.
In the events which have happened, we have heard from
most of you, if not all, but whilst quite a lot of you have
actually come back and said that you are reasonably happy
with the summary there have been quite a number of you who
have had substantial points of criticism to make with
regard to the content.
Unfortunately some of these points
- and I do not think I am criticising anybody and I am not
going to name any names either - were not made until Friday
or even later.
When I say Friday, I mean Friday late
afternoon.
I have come to the conclusion that we are not
going to use these summaries at all.
We will build, if
that is the right word, what we need as we go along.
I mention that now, and I will mention it when the
Jury are here, but what we are going to do is that we have
got some two dozen slides which we are going to show.
They are shots of the ground from the air and so on in
order to give the Jury some idea of what we are talking
about and then we will just build the evidence on it as far
as is necessary for the purposes of the Inquest.
I think
that probably deals with your point.
I know that many of
you thought it was a jolly good idea but in the event it
has not worked out.
I thought it was a jolly good idea as
well which is why I intended to do it but I would rather
not.
Some of the points which were made, I could see what
was being said and some were very good, but I would rather
not have anything which people were not entirely happy on.
Some of you might feel you have been pushed because you
have been asked to agree to something.
If you are not
happy with the evidence, that is another matter altogether.
I take no responsibility for what the witnesses say.
We
have to accept the evidence that is given.
Are there any
other submissions you want to make, Miss Hampton?
MISS HAMPTON:
THE CORONER:
No, thank you, sir.
Mr. Hale, what about you?
C ? ^ s e ». js .Rule 22 Of the Coroners Rules of
198-4, dealing with self-incrimination, sub-Rule 1 - and
tnis is the matter that I referred to:
"No witness at an inquest shall be obliged to answer
any question tending to incriminate nirnself."
And then Section 14 of the Civil Evidence Act, which in my
submission is to the same effect but I refer to it for the
sake of completeness.
That is the Civil Evidence Act of
l“o o , sub-section 1:
II
*
The right of a person in any legal proceedings,
other than criminal proceedings, to refuse to answer
any question or produce any document or thing if to
do so would tend to expose that person to proceedings
for an offence or for the recovery of a penalty, (a)
shall apply only as regards criminal offences under
the law of any part of the United Kingdom, and the
penalties provided for by such law and (b; shall
include a like right to refuse to answer any question
or produce any document or thing if to do so would
tend to expose the husband or wife of that person to
proceedings for any such criminal offence or for the
recovery of any such penalties."
I mention sub-section (b) only because it is there not
because, of course, it is in any way relevant to this
case.
_ s°, sir, that is the position.
Mr. Duckinfield, as
with any witness before you and before the Jury, has that
privilege not to answer any question which may tend to
incriminate him.
So, sir, what does that mean?
Could I
then ask you to turn to the bundle?
My submission is that
tnere are two cases, one in the Court of Appeal one in the
House of Lords which followed, in which the House of Lords
confirmed the decision of the Court of Appeal, which eiv^s
you a great deal of guidance as to v.iat constitutes a
risk, a^tendency, of incrimination.
The first one is that
in tne Court of Appeal, the case of Re Westinghouse
Llcictric Corporation Uranium Contract Litigation MDL
uocket ^o. 235 (,N o . 2 ) , reported in tne third volume of
the All tnqland Reports of 1977 at page 717, and I would
ask you at this stage, sir, to find that, which is at
folder 6.
Sir, the fact, of that case are wholly different to
the facts of this, but of course it is the statement of
principle, th| ratio of the case to which I wish to refer.
‘
. ay
f l rst of all read that part of the preamble to the
hea d n o t e :
Evidence - Privilege - Incrimination of witness or
spouse - Belief that evidence would expose witness to
proceedings for offence or recovery of penalty -
/
Reasonable ground for belief - Sufficient to show
real and appreciable risk that proceedings would be
taken or increase of an existing risk of proceeding:;
•
• •
and then it goes on to deal with discovery of documents,
production of documents and I don*t weary you with that
now, sir.
Sir, I don *t think it will be helpful to you or to
taose who are listening to this submission to deal with
the facts of that cas , oth^r than to say that it was
action involving an American corporation against RTZ, Rio
Tinto Zinc Corporation Limited, and there was an
application for discovery of documents which Rio Tinto
Zinc did not wish to produce because they said that to
produce those documents would give rise to the possibility
that they may well face prosecution or a penalty within
European Community law, but I now deal with what was held,
and this, sir, is at page 718, and these are the
statements of general principle wnich in my submission
apply to the giving of evidence in any Court, and
tnerefore before you, sir.
THE COKONER:
May I just stop you - the page numbers
are missing off mine.
MR. ISAACS:
a*- ter toe first.
It is the second page - the next paze
I do apologise, sir.
it
Held - A witness was protected from incriminating
himself by the production of documents ...."
and, it therefore follows,
to any question -
by the giving of any answer
"... if he could satisfy the court that there was
reasonable ground to believe that production of the
documents would furnish evidence against him which
would be used in proceedings for a penalty ...."
- and agair;, that was, of course, relevant to that case,
but it applies to proceedings for a criminal offence, and
indeed it could be said, having regard to the wide ambit
or trie Coroners Rules, for example proceedings in relation
to disciplinary matters, wnich of course you, sir, know
tlr. Duckinfleld along with others still faces.
"Reasonable ground for the belief might appear from
tne.circumstances of the case or from matters put
forward by the witness himself, but the witness was
required to show only that tnere was a real and
appreciable risk, or an increase of an existing risk,
that proceedings would be taken against him for an
existing penalty offence, and not that proceedings
were likely to be or would probably be taken*11
1
uolnti ««rt^hv ih'
Ue g° t
gh the reports, that one of the
5Ss ?ha? "U=Yl
r
obJec'ed to the claim to the privilege
and so you are not goinE°toamalr£lnuiSsion fireadV know about this
shall see sir. I hope,*ho„ both
'’the"*
a°Po?n? t h « dL d « i e n W ie?ethat proposltl° " ’ b—
e that mi*ht b
you t o ^ u r n ^ o 1^ ^ ^ ' VOU don-t have page numbers could I ask
of the
l
f °Ver: pags 721 • the right-hand side
t j n
j
judgment which was that of the Master of the Rolls
Lord Denning.
It is the right-hand side of the page and he
deals with the common law as to self-incrimination, ’l ask you tc
look first of all at between D-E:
y
"Today We are not dealing with a party to a cause we
are dealing with a witness. At common law, when a
witness is being examined in the witness box or is
subpoenaed to produce documents to the court then,
quite understandably, he may have something he
wishes to keep secret to himself so that his
neighbours or his competitors should not get to
know of it; something which he might reasonably
believe he ought not to be compelled to disclose.
Not, at any rate, if it exposes him to risk of
some ill befalling him. The common law does in
some circumstances cast its protection over him.
It adopts the maxim nemo tenetur seipsum prodere.
No ;one is bound to furnish evidence against
himself. It says:
'If a witness claims the
protection of the court, on the ground that the
answer would tend to incriminate himself and there
appears reasonable ground to believe that it would
do so, he is not compellable to answer".
Then there is some reference by the Master of the Rolls to a
?hlc!> 1 sha11 n°t weary you with, because
they are all dealt with in the judgment itself and the statements
or principle in the judgment.
Could you go down to H on that same page:
"But if it appears to the judge that, by being
compelled to answer, a witness may" (I stress the "may*
sir) "may be furnishing evidence against himself, whicf
could" (I stress the "could" sir) "be used against him
in criminal proceedings or in proceedings for a
penalty, then his objection should be upheld.
There is the further point: once it appears that a
witness is f»t risk, then 'great latitude should be
allowed to him in judging for himself of the effect of
any particular question': see R. v. Boyes".
30
l i n e ^ s i ? * y°U tC Pay
partlcular attention to the next few
"It
may only be one link in he chain, or only
corroborative of existing material, but still he i=
bound to answer if he believes on reasonable grounc
that it could be used against him. it is not neces
tor him to show that proceedings are likely to be t
against him, or could probably be taken against him
It may be improbable that they will be taken but
nevertheless, if there is some risk of their being
taken, a real and appreciable risk as distinct from
remote or insubstantial risk, then he should not be
made to answer or to disclose the documents".
I stop/there for my purposes in relation to this authority
least in the judgment of Lord Denning.
a
Could I then ask you to turn over to the next page. We i
move to the judgment of Lord Justice Roskill, which is pages
a5
* k 25,page
and at
1ask
sic
of the
D. you to look at Page 725, theright-hand
"It has long been a rule of English law, as Lord
Denning MR has pointed out, that a person cannot
be required to answer questions or produce documents
which may lead to his being, if I may be forgiven a
colloquialism, ’convicted out of his own mouth*. Tt
is a long line of authorities dealing with this topi
of which the earliest cited to us was R . v . Boves. a
decision of the Court of the Queen’s Bench subsequen
expressly approved by this court in Re Reynolds
Bgrte Reynolds. Those two cases, and there are othe
to the same effect, show clearly that a mere asserti
of a claim for privilege on the ground of an alleged
risk of self-incrimination is not enough to enable t
privilege to be successfully claimed. Nor, of cours
will the court uphold such a claim for privilege whe
it is made in bad faith.”
ft^P*Jhere for a moment’ sir. An example of that would
has forni ! ^ e ar? reported cases to this effect, where a man
?! example, given a statement to the Police. He goes int.
k ™ " itness box as a prosecution witness.
May be because he h.
n n I ^ f i VenK munity he says*
do not wish to answer these
questions because the answers may incriminate me” , when in fac^
he does not wish to protect himself but what he is trying to dc
is to protect another by not giving that evidence, for example
no?Vh^Uf ®“pl°yer or a friend, in those circumstances he woul<
not b2SUphefd
falth bUt In bad faith and the privuege
At F:
The first question which a court must ask itself is
whether the facts proved in evidence disclose the
commission of an offence, in some cases a criminal
31
offence. The first question here is whether those
facts disclose that there is a liability on Rio Tinto
for what counsel for Rio Tinto called ’a penalty
What, then is the degree of risk of penalty proceeding.'
following? It seems to me that once a party to legal
proceedings who is resisting production of documents
can show facts which establish the existence of a
penalty offence (or in other cases the commission of a
criminal offence) the courts should be slow to deprive
that party of his privilege against self-incrimination
which the common law now for some three centuries, and
s 14 of the Civil Evidence Act 1968 today, accords him
In the absence of bad faith, to say that there is no
risk of proceedings may in all but the plainest cases
involve a court claiming for itself a degree of
prescient foresight to which it would not be wise to
pretend for it its forecast were wrong and if
proceedings and penalties were to follow, damage will
or at least may be done by an erroneous decision of th«
court which it would not be easy thereafter to undo or
redress.”
I ask you to turn over the page again to what would be 726. the
left-hand side of the page at D. Again, after a review of the
authorities, Lord Justice Roskill says:
"It cannot, I think, be right in these cases for
the court to attempt a quantitative assessment of
the probability one way or the other of the risk
of proceedings ultimately being taken, and then
to seek to draw the line one way where the
Probabilities in the view of the court are
thought to be more or less evenly balanced and
the other where the balance is more disparate.
It is not for the court to resolve problems of
this kind by calculating odds. I think that the
right question to ask is that posed by Shaw LJ; can
exposure to the risk of penalties (or in other cases t<
the risk of prosecution for a criminal offence) be
regarded as so far beyond the bounds of reason as to b.
no more than a fanciful possibility?”
In fact, later on Lord Justice Shaw said exactly that.
Could I ask you to turn from that case to part 7 of the
folder you have been handed, because the case ended up in the
House of Lords, where as I say the Court of Appeal’s view was
upheld, as were the dicta of the Master of the Rolls and the
learned Lord Justices. It is interesting to note when the House
of Lords dealt with the case what was said in relation to this
question of the information already being in the possession of,
let us call them in the context of this case, the prosecuting
authorities.
I anticipate you are lacking in numbers again. If
I could ask you to turn over the first page and go to the second
This would be page 437 on the right-hand side, sir, dealing with
32
that part of the case as to what was held by their Lordships.. I
would draw your attention to (ii) starting with "The RTZ
companies".
"(ii) The RTZ companies were entitled to claim the
privilege from the production of documents given by s
14(1) of the 1968 Act notwithstanding that the
commission had knowledge of the cartel and had not
taken any action in respect of it, for if the documents
were produced under the letters rogatory the RTZ
companies would be exposed to a greater risk of
proceedings being brought against them by the
commission for recovery of a fine than they were
exposed to at present, since production of the
documents might authenticate and support the existing
information in the hands of the commission and afford
conclusive proof of a breach by the RTZ companies of
the prohibition against cartels, and might cause the
commission to decide to take action against the RTZ
companies” .
So, sir, we have there the House of Lords dealing with the point
that may be raised in this case as to the decision that has been
taken by the Director in this case, but who knows what will
happen in the future.
Could you then turn four pages on to what would be page 445
between B-C, still the speech of Lord Wilberforce. He says at C
”1 base that conclusion in part on evidence which was
before and considered by the High Court and the Court
of Appeal and in part on the proposition that the
tendency to expose to a penalty would be increased if
the documents in question were to be validated and
connected with the RTZ companies by sworn evidence,
as opposed to being, as they are now, pieces of paper
found in a file".
Sir, it won’t have escaped you the difference between, albeit th<
evidence that was given before Lord Justice Taylor was all taken
down, it was not evidence that was given on oath, but of course
the evidence before you would be given on oath.
Then, sir, could you turn another six pages, pages 456 and
457. "To give any evidence” . This is the speech of Viscount
Dilhorne, between G-H, and you appreciate, sir, I am only pickin.
those parts which are germane to this matter:
’’Secondly, it was argued that the discovery of the
document would not in the circumstances tend to expose
the RTZ companies to such proceedings". (That is for a
penalty) "It was said that as the commission had
knowledge from the ’Friends of the Earth' documents fo
a considerable time of the existence of the cartel and
had taken no action, there was no real risk of such
proceedings if the documents in the possession of the
RTZ companies were disclosed".
Then he deals with the arguments and reference to certain
authority.
If you could move to page 457, the right-hand side, between
C-D, and he refers to what was said by Lord Denning in the Court
of Appeal to which I have just referred you, he says:
"With these observations I respectfully agree. It was
suggested that the reasoning in the Triplex case had
reduced the burden which formerly lay on a person
claiming privilege but I do not think that that is the
case. In his judgment du Parq LJ reviewed the earlier
cases and based his conclusions on them. Lord Denning
MR contrasted a real and appreciable risk with a remote
or insubstantial one, and once it appears that the risl
is not fanciful, then it follows that it is real. If
it is real, then there must be a reasonable ground to
apprehend danger, and, if there is, great -latitude is
to be allowed to the witness and to a person required
to produce documents.
If the RTZ companies are compelled to produce the
documents which they were asked to produce, I
cannot reach the conclusion that it would be
fanciful to suppose that that would expose them to
no greater risk than at present of proceedings for
the recovery of a penalty being brought against
them. The documents might well authenticate and
support the information now in the hands of the
commission” .
So what the learned Law Lord is saying, sir, in my submission,
that even though the Commission nad evidence before it which thei^
had decided to take no action on, the production of these
documents, the production of additional information, may well be
sufficient to cause them to take a different view.
There is just one further part I would ask vou to look at,
and that is in the speech of Lord Diplock. Page 465 on the
right-hand side of a page which begins, "The privilege claimed b:
the RTZ companies". Could you go to the right-hand side, sir, a*
B:
"I do not think that your Lordships are entitled to
dismiss as fanciful the risk that if the documents
relating to the cartel were produced at the trial in
the Virginia proceedings and came, as they then would,
into the public domain, the resulting publicity in thi:
sensitive political field might result in pressure on
the commission to take against the RTZ companies
speedier and severer action than they might otherwise
have done” .
Sir, having regard to both past and recent events, some events s-
s“ Lr:r£r?H;ss:"
'
/So, sir, that is the law
zr™
misunderstood the situation so far as the Director's
decision was concerned.
At that stage they indicated that
Mr. Duckenfield would then be prepared to make a statement,
or might be prepared to make a statement, for the purposes
of the disciplinary proceedings.
They received bv letter
of the 6th September, 1990, this reply:
"You are correct when you say that the DPP has decided
that there is insufficient evidence to prosecute your
client for any criminal offence arising out of the
Hillsborough tragedy.
It is also correct to say that
the disciplinary issues now have to be considered by
South Yorkshire Police in consultation with the Police
Complaints Authority.
I believe you are also aware
there are outstanding civil actions being brought by
various parties with an interest in the matter and that
there are ninety-five Coroner's inquests to be
reconvened.
I am aware that at the interview on the 3rd of July,
1990, your client intimated that once the DPP had made
his decision in respect of the criminal issues he would
consider being interviewed in respect of any
disciplinary matters.
If that is still his wish then
I am ready to conduct that interview, but it must be
understood that the disciplinary matters are very
closely related to the criminal issues so any interview
would have to be conducted under a Police and Criminal
Evidence Act caution and the transcript of the
questions and answers would have to be sent to the DPP
for further consideration of the criminal matters.
That is the position in respect of any new or
additional evidence which comes to light, forexample,
that which may arise out of the civil actions or the
Coroner s inquests*
It is not for me to advise you or
your client as to how you, or he, should proceed, but
it seems to me that you should be aware of the
foregoing information.”
Sir, one could not have a clearer statement, in my
submission, of it being said that anything that is said by
any witness in these proceedings, but my concern is Chief
Superintendent Duckenfield, who after all is the only police
officer in this matter who was suspended and remains
suspended as a result of this tragedy, that anything that is
said by him will, as a matter of course, be sent to the
Director and, who knows, it may be that the Director on
receiving such information will reconsider his decision.
In my submission it cannot be said that the risk
Superintendent Duckenf ield is a fanciful one as
likelihood of proceedings taking place.
Indeed, one
that only a matter of days ago, and I ask you to look
to
to the
knows
at
something I mentioned earlier, and this is at section 3 of
the bundle:
"Mr. Duckenfield, as with some other Officers, still
has hanging over his head the disciplinary proceedings
pursuant to the making of complaints under Regulation 7
of the Police Disciplinary Regulations of 1985.”
Though documents have been served on him pursuant to
Regulation 7 dealing with those matters.
Of course, anything he says..
offence had been committed and that for other
verdicts (except an open verdict) they had to be
satisfied on the balance of probabilities.
Furthermore, when directing a jury on
manslaughter comprising unlawful killing alleged
to have occurred because of neglect on the part
of police, the coroner was required to direct the
jury on four matters..."
I pause there.
My submission is this, against the
background of the submission I have already made, namely
that any question which Mr.'Duckenfield was asked would
have the tendency to incriminate that in relation to those
four matters that the Divisional Court referred to, if any
question is asked of Mr. Duckenfield which touches upon any
of these four matters, or of any of the four ingredients of
the first matter to which the Divisional Court refers,
there will be a tendency to incriminate him in the very
nature of the question itself because these are questions
which would be directed to the possible commission of a
criminal offence.
Those matters are these:
" — firstly that they had to be satisfied, on the
evidence, of four ingredients, namely (a) that
the police were under a duty to have regard to
the health and welfare of the deceased..."
So any question to Mr. Duckenfield as to his duty in
relation to the spectators at Hillsborough, or those who
tragically died, would require an answer which would have a
tendency to incriminate. It continues:
"...(b) that in the circumstances there was a
failure to do what should have been done for the
health and welfare of the deceased..."
So any question asked of Mr. Duckenfield as to what he did
or did not do that day which touched upon the health and
welfare of the deceased would be a question which would
require an answer which would tend to incriminate him. It
goes on:
"...(c) that the failure amounted to a
substantial cause of death..."
So any question asked of him - of course this is only a
privilege of self-incrimination - as to causation between
what he did and any death or deaths, or the deaths of those
who died in general terms, would be a question which would
tend to incriminate, that is, the answer would tend to
incriminate and:
on that particular question Mr. Duckenfield or perhaps
myself saying, "Sir, I object to answering that question.
1 rely on privilege".
The risk of prejudice so far as the
Jury is then concerned is overwhelming both in so far as
Mr. Duckenfield is concerned and indeed the position so far
as the South Yorkshire Police themselves as a body are
concerned (and here I intrude a little on to Mr. Payne's
territory).
One can perhaps, no matter how carefully you are
directing, see the difficulty that would be in the mind of
the Jury if to every question the position of privilege is
claimed. They would be bound to think, "What has this man
got to hide?" You, sir, know and my learned colleagues and
I know, that such a privilege is said not to be taken
against a man but lay people and lawyers are quite
different and there comes a time when they say to
themselves, "There is something funny here. We are not
being told the whole truth and whatever".
My concern is
that even in the asking of a question that may be
disallowed by you there will be sufficient in the question
to prejudice the Jury against either Mr. Duckenfield or
others.
I come back to the point I made earlier about the line
being drawn.
Everything at the moment is above the line.
I am concerned there should be nothing below the line which
may prejudice Mr. Duckenfield.
May I go back to the
analogy you drew as to the straightforward case of the
reckless driver and the fatality?
I anticipate that it would be your practice - let us
say no PACE interview had taken place - that the driver had
relied upon his right not to answer any questions, as has
taken place in this case so far Mr. Duckenfield was
concerned, and you would not in those circumstances with
the driver facing the possibility of prosecution say to the
driver, "You must answer these questions as to what you did
and what you thought" etc. You would not expect the driver
to answer those questions in those circumstances. Mr.
Duckenfield is in exactly the same position.
It may be said that Mr. Duckenfield is such an
important participant in the events of that day that
without him what is the point of going on at all but in my
submission that would be misconceived because the privilege
is only against self-incrimination. There are many, many
people, both police officers and civilians who can give
evidence as to the facts and the factual decisions that Mr.
Duckenfield took on that day and so the Jury will not in
any way be deprived of the opportunity of hearing about
what happened. They would just be deprived of not being
told by Mr. Duckenfield.
I come back again to the point that I made at the
outset.
Whilst this is a high profile Inquest, it is
important not to disregard the rights of any individual who
has interests of his own and important interests which are
affected by the law.
I finally say this - and I know I have been on my feet
for quite some time and I do not want to weary you
further - that if it be felt necessary by you, and both you
and I know, sir, that there are no PACE statements or
interviews by Mr. Duckenfield, that the Jury must hear
something about what Mr. Duckenfield said about the day
then, sir, upon instructions - and it is only on this basis
that I put this - I have no complaint with what Mr.
Duckenfield said to the Taylor Inquiry going before the
Jury. I say that because that is all above the line as
opposed to anything new below the line.
That has already been considered by the Director and
my concern is that there is something else. It may be
said, "We can ask him the same questions and if the
Director has already considered those matters, well then,
frankly what has he got to worry about?" Sir, the asking
of the question (a) is unlikely to be in the same terms and
(b) the answer is unlikely to be in the same terras and it
does not have to be an answer which is an admission of any
offence.
It only has to be, on the authorities, a step
possibly towards this, and again, sir, you have the dicta
where that is made abundantly clear.
I fear, and I know you are mindful of this, sir, that
this is really the last opportunity for the families (and
one can understand their concern and I do not criticise
them at all) through my learned friend, Mr. King, or Mr.
Hytner who may well be brought in, as Mr. King mentioned on
the last occasion to, cross-examine Mr. Duckenfield or
other witnesses, to produce extra evidence to get that
which they have, which we see, been pressing for. It is in
those circumstances that seeking to protect Mr.
Duckenfield's interests, to be fair to him whilst being
fair to others, and being mindful of the restricted area of
Inquests as this is not a Public Inquiry, this is not the
Spanish Inquisition, this is not the Star Chamber, not only
should be the questions which he is to be asked that he
should not be obliged to give evidence at all. Those are
my submissions, sir.
THE CORONER:
Can I just make two small points before
I call anybody else? Perhaps it was my fault, I do not
recollect, but if I instanced an RTA where the driver was
reckless then I made a mistake because if a driver had been
reckless he would have been charged with causing death by
reckless driving and under Section 16 of the Coroner's Act
I would have had to adjourn it sine die. The point I was
trying to make was that under normal circumstances it was
the ordinary driver.
MR. ISAACS:
Let us say, it is probably my fault,
careless driving or driving without due care.
THE CORONER:
It makes no difference to the argument
but I just wanted to be clear that we were talking about
the same thing.
I
MR. ISAACS:
It is important. The seriousness of the
crime is neither here nor there.
It is a privilege, as you
and I know, against self-incrimination in any offence.
I
am obliged to you, sir.
THE CORONER:
It is 1236 and in twenty minutes we
will be rising because at two o'clock we are starting with
the Jury. Can you indicate whether any of you feel you
wish to address me on the point which Mr. Isaacs has made?
What you are saying is that there is clear authority that a
person does not have to answer questions which tend to
incriminate him, to use the text of the rule, and you cited
the rule plus several cases. Do any of you feel you want
to address me on the point which Mr. Isaacs has made? As I
understand it, what you are saying is that there is clear
authority for saying that a person does not have to answer
a question which may tend to incriminate him and you cited
the rule plus several cases. It is exceedingly difficult
to formulate questions where people are in danger of
prosecution which are meaningful and in the circumstances
what is the point of getting the man or the witness to come
into the box at all? You are not suggesting that a PACE
statement, if there is one, or anybody else should be
excluded?
MR. ISAACS:
No, sir, not at all.
THE CORONER:
Have I summarised very, very briefly
the heart of your submission?
MR. ISAACS:
Indeed you have, sir. To call him in
those circumstances would only serve to disadvantage him as
well as others in addition to the prejudice which would be
caused. You have summarised it absolutely correctly.
THE CORONER:
The fourth point you have made is that
the damage of refusing to answer the questions is out of
proportion to the benefit of having him here as a witness?
MR. ISAACS:
There is no benefit in having him here
because any question he is asked is bound to have the
tendency to incriminate him on the basis of the principles
I have put before you.
'
THE CORONER:
I look to Mr. King, first of all
because he is the most likely person to address me on the
issues. Are you likely to address me on this?
MR. KING: Sir, I would wish to. There are two
matters. One I would wish to hear if anybody else has
anything to say in support and, secondly, in the light of
what has just fallen from my learned friend's lips as to
the use of the transcript I Vould like to take certain
instructions from those whom I represent.
THE CORONER:
Mr. Isaacs, it seems to me that it
would be wise, before I give a ruling on your submission,
to allow other people to have their say so that I can hear
different points of view and secondly, it gives me a chance
to think about it as well. If you do not think it rude,
what I intend to do is not proceed with the point at this
stage because we cannot deal with the submissions on what
is quite an important point actually in twenty minutes and
we will deal with it either at four this afternoon, subject
to your agreement, when the Jury go or if it is more
convenient to you we can deal with it at four tomorrow or
any other day.
/Mr. Duckenfield is not going.
Hr. Duckenfield is not going to be called in the immediate
future, so in that sense it is not urgent that we have eot
to have a ruling this morning.
HR. ISAACS:
Sir, save for this, that I am afraid and you may have gleaned this from some of tne newspapers,
I think - that I will not have the privilege of being
before you on most days during this Inquest.
THE CORONER:
I had not appreciated that.
9
HR. ISAACS:
You had not, sir, but no, I arc afraid
that is the position.
Without going into any details I am
afraid that the cost of representation would be so great,
and there is no sufficient funds for him at the present
time. The Police Authority have unfortunately failed to
agree that he or others in a similar position should have
their representation paid for, so I am afraid that he will
not be represented during the course of this inquest, sir,
other than on the days when, if you do decide that he
should be called, he is actually giving evidence.
THE CORONER:
And presumably on the days when any
statement *• in fact, I think there is one,
it is not very
long but I think there is one - were to be dealt with?
MR. ISAACS:
That may or may not be the case, sir,
but one can understand the difficulties.
May I say this,
in relation to what you said just a moment ago, and this
perhaps is a little special pleading? You said a moment
ago you did not want to be rude - I think I can speak on
behalf of all my learned friends, it is a long time since
we have been before a tribunal wiich is so courteous and
we are very grateful to you for that. We are not perhaps
used to being treated so well.
THE CORONER:
MR. ISAACS:
yes.
Will you be here this afternoon?
I shall be here this afternoon, sir.
'■
THE CORONER:
In that case shall we deal with it
this afternoon?
Is that agreeable to all of you? I know
it makes it a longer day but I did say at our business
meeting that the lawyers nave to put up with the strain.
I don t like to subject my jury to too heavy pressure,
because it is not fair on them, but we have just got to
put up with it, so to speak.
Is that agreeable to
everybody? Good.
Is there any other --- perhaps you could outline the
nature of your submissions, so I know what we have got in
sfore, so to speak.
MR. MANNING:
The first thing I am going to do, if I
may, is to pay tribute to the way in which my learned
' Z ....
iuc matter Detore vou, and the
second thing I am not going to do is to repeat it. It
does not get stronger or better by repetition.
Vou know that
I represent Superintendent Hurray. He
nas made a statement under the Police and Criminal
Eyidence Act. * expect that in one form or another that
will be brought before this hearing at some stage, and
having done tnat I find myself adopting, and .li the more
so, the views thathave been canvassed before you.
At*the end of tnis hearing the verdict will be one
for the Jury and as learned as we hope we may be in the
ways in which a Coroner's Inquest is to proceed, the fact
of the matter is that the probability is that most of the
people wio will be on the Jury have never been on any
jury, and I shall certainly be surprised if they have ever
been on a Coroner's Jury. With tne best directions in the
world, tha fact of the matter, as we know from juries and
experience, is that some people can take one \.’hat seems to
be minor and inconsequential point and make that the
deciding and turning factor upon which everything else
falls.
It is impossible, in the words that have been read to
you by my learned friend, for it to be conceivable that a
Jury will not in its mind's eye say, "What on earth is
2>oing on here under this rule against selfincrimination?", and "Why are we not being allowed to see
the person?” , and therefore there is damage beyond measure
in even going to that stage which suggests that a person
snould be called into a witness box, give their name and
address, and somebody, whether it is you or whether it is
the witness or the lawyer for that witness, referring to
the Rule, and w.iether then the Jury is asked to retire,
tne fact of the matter is they have got the whiff of
something and when they have got that scent the brain
begins to run wild and we can have no control over what
part that is likely to play in the ultimate decision
making process.
Therefore, in adopting tne legal submissions and in
not seeking to put them before you over and over again, I
have to say that considering what questions may be raised,
and considering those criteria which have been put before
you as to the sorts of questions which clearly have to be
in the mind, and have to be enquired into, if those are
the questions which normally would be asked and there is
t?ie Rule and the law, and that is what we, and you, sir,
are here to uphold, the law, if the law says that a person
s.iould not be put in that position, categorically should
not, then it seems to me, with respect, that you should
therefore make a ruling that you are not going to have tne
witness put into it, and you can make whatever explanation
you want, because you can simply read the law to the Jury
50
and, make them clear that they should dismiss that from
their minds.
B
THE CO k OWE;::
Mr. King, I will skip you, if I may not out of discourtesy.
MISS SINCLAIR:
Sir, I do not adopt the submissions
made by my learned friend, Mr. Isaacs, and indeed, I have
no other submissions to make at this stage.
* THE
CORONER:
MISS SINCLAIR:
You do not?
I do not.
HR. CAICHt’OLE:
Sir, can I say* on behalf of tne
Officers of Sheffield Wednesday Football Club, that we
came nere prepared and expecting to see every witness
called to give evidence, subject to the normal rules, and
indeed, as I hope has been made clear, we are anxious to
help throughout.
I would like, however, to reserve my
position in the light of any ruling you may make.
If the
senior Police Officers are not going to be giving evidence
at this inquiry naturally that is something I would like
to have the opportunity of discussing with my clients.
I
cannot predict what the outcome will be of that, and if
necessary I will make an application at a later stage.
At
present I have no observations actually on the
applications made by my learned friends.
MRS. McBRIEN:
Sir, I would personally be very
pleased if Mr# Duckenfield would appear in this Court so
that I can put questions to him directly.
As he was t*he
main participant in the disaster I was looking forward to
raeeting Mr. Duckenfield so that I would be able to meet
him face to face.
That is all.
MR. CALLAGHAN:
Sir, I have no observations to make.
ADD LEMAN:
Sir, as you are aware I represent
the Police Federation and the ruling that you are about to
make clearly will have a generalised application and apply
to certain witnesses whom I represent.
Sir, in short, at
tnis stage I would wish to say that in principle I also
echo and adopt those submissions whicn have been made by
my learned friend, Mr. Isaacs.
Clearly individual
decisions are going to have to be made by certain
individuals, dependent upon your ruling.
I
\\
...." S * 1 WKUJd
sir» in particular, is that in ray
.respectful submission it would indeed be preferable for
such individuals not to give evidence at all if that
yOU5 de^ ision» rather than running tne risk of
Rowing the seeds of prejudice in the Jury's minds in the
^aacs
mS
described by my learned friend Mr.
\oquently.
Manning, If I may say so, so
13
, For ray p art I would submit th a t i t must be rioh* t-h**
tn ere i s very l i t t l e indeed which cJuld S e ' a s k l d
sue!! a
w i t n e s s , th e answer t o which would not have a tenHpnru
i!'?ri"i"al,i
Sir> 1 w o n '‘ reP sat all the submissions
which have been made by ray learned friend but I would
specifically wish to reinforce those particular ones.
‘°
_
MR. RUSS&LL:
Sir, as you will recall I represent
Superintendent Greenwood and I would endorse what has been
said principally by my learned friend, Mr. Isaacs. Sir,
it may be that you would prefer me to add my two penny
wortrh to thosa arguments at 4 o'clock.
t *u.T2E„C0?0W?R.
s
depends now long you will be. Yes,
I think tnat mignt be wiser because I don't want to rush
you. Is anybody at this end going to want to ....
MISS HAMPTON:
I have no submissions.
1 u i U say that in Principle I would
support Mr. Isaacs because his arguments are so very
and based on precedent. Whether I avail
mys.lf of tnem will be a different matter. Mr. Marshall
choice?
t0 §1Ve evidence but that» of course, will be his
fhfl?\fAYK£S ,.Sir» the Position of the Chief Constable
is that he supports the position taken by individual
Officers, and accordingly, therefore, supports the
submissions made by Mr. Isaacs.
» .THJ CORONER:
Very well. We will leave this
e n a b U SMr" K ? n ? \ at thif#istafe » in order to particularly
wants to net
consider it and to put anything he
May I just ask whether you will have any oth^r leoal
! S ? Sl? ? L r hiSo
toaay?
u
l i l t r
—
which need to be made
Pleasc don t think tnat I wish to stifle vou in
So? thGooWd°!d -
1 im Just tryln« “
tne l e ^ a ^ r e p r e s e n t a t i v e s ^ r ^ c o n c e r n e d ^ t h e r e I s ^ u H e V
s?el!
^ 1SuCal Jed, the S4te and 1 think it’has got
steel doors - tne key to it is under the control of the
beConeiU|i?r ty ond 5rf®ngeraents have been made for it to
tbetween 9 and 10 and A and 5, so that if
you wish
y?U
“ you can deposit any of your
f " ?ls §oes for y°u as well, of course, Mrs.
i «rien “ in that room, but you cannot assume that tha
local authority will take responsibility for them. The
5* U n d e r *he ^ h a r A e 1of one chip Sith a iey and
so to L e a k " a?ouSd o i ' J t h but y ° u haYe to a c c e p t the r i s k ,
whieh A
S
e
tried to pr^vide? US6
U
ls a faiilit>'
, Secondly, those of you who were here for Lord Justice
Taylor s Inquiry, we have been provided with the big rooms
on tne other side of the main staircase - one is called
the Mandela Room, the other I have forgotten the name of.
The Mandela Room has been laid out with a big screen like
this,-so if taere is an overflow or somebody wants to know
what is going on but does not want to be in the Court,
they can go and watch and near.
As I understand it, if we
use, for example, a video, you will see tne video but you
will not be able to see the Court, because we have only
got one camera.
In the normal course of events you will
be' able to see and near what* is going on in Court but in
certain circumstances you may have a slightly limited
recording, because of the facilities - we have had to draw
the line somewhere.
The other room has been laid out and is intended
really mainly for the families, if they want to withdraw
and sit and be quiet.
That is one half of it and in the
other half we have built small partitions, cubicles, so if
any of you wish to speak to your clients you have got a
measure of privacy but they are not soundproof, so you
have to judge how good they are and whether you want to
use them.
They are there for your use if you wish.
At the bask of the hall Ithink there is
restaurants, which has not been putup by me,
want to go and look and see what is what and
go - and no doubt there are dozens of otners
are rignt in the centre of town so it should
difficult to eat and have refreshments.
a
list of
so if you
where you can
as well - we
not be too
We have had quite a long session.
I hope you will
forgive me, but I wanted to get on with it. We are going
to rise.
Is there anything - yes, Mrs. McErien?
MRS. McBRIEN:
I just wanted to say something
relating to the other matter earlier in the day.
I was
wondering if the time limits could be extended, in the
individual inquests, the time limit of 3.15 for the day in
question could be extended for individual inquests but not
apply to the generic inquest?
^THE C0.10HER:
The answer to that is that I took Mr.
King s submission to incorporate that point and I have
said what I want and am not going to change my mind on it.
I am going to stick to what I have said, 3.15 or
thereabouts, so I am not extending it but-we did say that
if there are any specific errors which you were going to
bring to my attention in the summaries, that I would
consider it, and that would apply, to you as well, of
course, as far as your boy is concerned.
MRS. McBRIEN:
Thank you.
town so there are plenty of facilities, including a restaurant
upstairs.
So we are going to say to you, fend for yourselvesand my Jury Officers will sort out the financial reimbursement
There are rules and limits, but they will have told you that.
I:
they have not, ask, so that you know how much you can spend
without being out of pocket.
It is adequate, you will find.
One advantage of giving you sandwiches, was that we had vou
nicely segregated from everybody else, and we won’t have that if
we allow you to run free, but after all. you go home in the
evenings as well; don’t you, so I ca n ’t see any good reason why
you should not do whatever you wish, but please remember the rul<
is no discussion with anybody about the case.
It is very
difficult, but you must follow it. particularly in a building
like this where you can see there are quite a lot of people here
I have met quite a lot of these people and I still do n ’t
recognise most of them, and so it is very easy if you start
talking to strangers you may find you are talking to people who
you in no circumstances you should have opened your mouth to. S<
d o n ’t talk to anybody. So will you please do that for me?
If you find I am going on for too long, because we won't be
rising quite as frequently as we did at the Medico Legal Centre
because it is slightly different now, but if you think I am goin;
on too long you are near enough now to attract my attention and
to say, ’’Can we stop and have a cup of coffee” , or something, an<
of course, if any of you need to stop because you are not feelin;
well or because you were indisposed in some way then obviously
you must let me know.
It is exceedingly important that vou are
all here, because if we are not we have to stop* We have no
control over Our lives completely, but unless there is a really
compelling reason why you cannot be here please be here.
It doe.
not actually inconvenience ne, because if I am not here I am
doing something else, but it inconveniences everybody else,
because- we would have to adjourn it until we are back again, so
to speak, as a group.
I think that is all I need to say on domestic natters.. May
I ask, were any of you in Court this morning, because somebody
suggested that you were? None of you were in Court? That is
good, because we did not want you in Court. That is right, none
of you, members of the Jury, were in Court in the morning? That
is important, because if we have legal submissions and I ask you
to go out you must stay out.
It may be when it is all over and
we have finished I will explain to you why we do that, but I
d o n ’t think I will do it now because we have not got much time,
and it can wait, I am sure.
I am not going to tell you the potential verdicts which you
will have to consider because we
are going to hearthe evidence,
find when we have heard the evidence I am going to sum it up,
hopefully, and I will direct you with regard to the law and
anything else I need to tell you, and then you will retire and
tak§“your time and so o n .
I do want to draw one or two rules to your attention,
because it is exceedingly important that you should understand i
now and that everybody else should understand it. This is not
actually a rule but it is a general point. We are doing
Inquests. There are 95 of them but we are doing them together.
This is not a trial. Nobody is accused of anything in my Court.
It is not a Public Inquiry, so we don’t roam beyond my brief. I
is not adversarial in the sense that the parties can introduce
their own witnesses and put them up to me to listen to and then
make a judgment. I introduce the witnesses. That is not to say
that if parties want to draw my attention to a particular witnes
or witnesses whom they would like me to consider, they can do
that and have done because a lot of water has flowed under the
bridge since we last met, but in the final analysis it is my
decision whom we call, rightly or wrongly, and it is an
inquisition.
The next thing to understand, and this is very, very
important, is that this is an inquisition not on behalf of the
relatives, not on behalf of the South Yorkshire Police, not on
behalf of the club, not on behalf of Eastwoods, not on behalf of
the supporters generally. It is an Inquiry by me, and if you
like because I am called Her Majesty’s Coroner you may take it i*
is on behalf of the State or Her Majesty the Queen. So it is
important to understand that, and I have to keep on reminding
myself of this as well, because otherwise we get misled into
thinking we are doing this for others, and of course you realise
and I am conscious and so are you and everyone else, of the
families, so it is important that the evidence which we call
should seek to be intelligible and relevant and answers as far a:
one can some of the things which concern and worry them. It is
very important to know that this is not done because they are
bereaved people. It is because somebody has died and the Act
says that when that happens the Coroner should hold an
inquisition either on his own or with a jury. Well, we are with
a jury, of course.
I
have already indicated to you the ove***1! limitations o
an Inquest, so i am not going to repeat that, but there is
another very important corollary to this, and that is Rule 22.
am going to read this rule to you because you have got to
understand it, because it may be relevant at some point. It
won’t be relevant today, but I want to get it right at this
stage. What it says is:
"(1) No witness at an Inquest shall be obliged to
answer any question tending to incriminate himself.
(2) Where it appears to the Coroner that the witness
has been asked such a question the Coroner shall infon
the witness that he may refuse to answer".
Now, this is a fundamental principle of Coronal Inquisitions, an*
it may well be a fundamental principle in a load of other courts
but I am not interested in what happens elsewhere. I am
interested here. An important thing to understand is that if
somebody exercises their right it is a right. It is not that
they may or may not. They have a right .not to answer questions
which may incriminate them. You must not draw inferences from
57
the exercise of their rights.
✓
That does not mean to say that you may not hear evidence
from other people which may tend to incriminate them. That is
not the point, but you cannot expect somebody to stand up and
say, "I did it". It happens in TV series, but it does not happer
generally speaking in real life, but it is part and parcel of the
overall structure of Coronal jurisdiction, and it is designed (a)
to protect the individual or individuals who may be involved, anc
(b) to ensure that if it were to be that some other proceedings
were to take place in some other court we have not muddied the
water.
/So there is actually a dual
' MRS. McBRIEN:
Sir, and members of the Jury, I am
Joan McBrien and I appear on behalf of our family in this
matter.
MR. CALLAGHAN:
Andrew Callaghan, solicitor, on
behalf of the Ambulance Service.
MISS ADDELMANN:
My name is Andrea Addelmann of
Counsel.
I am instructed fry Russell, Jones and Walker
and I represent the Police Federation.
MR. RUSSELL:
I am Christopher Russell.
I am a
barrister.
I am instructed by solicitors called Barlow,
Lyde and Gilbert and I represent the interests of
Superintendent Greenwood.
THE CORONER:
You might ask, having told you all
about this inquisitorial system and how I do it all:
what are they doing here?
The answer is that the rules
which I have already referred to permit interested
parties to be present, obviously.
The rules permit them
to ask questions which is why Mrs. McBrien is there, and
the rules also provide that people can be represented by
their legal representatives and that is why they are
here.
Of course, if it is correct and opportune they will
ask questions of the witnesses and within the limits
which I have outlined to you they will be permitted to do
so.
Now without any further ado, all I will say is that
these inquests are concerned with a disaster vhich
happened at a football stadium known as Hillsborough
Football Stadium, on the 15th of April, 1990.
You will
learn as we go along more details about it.
Now I think the first thing is we will call Steven
Brown.
STEVEN BROWN Sworn
Bv THE CORONER:
Can you give me your full name? - A. I am Police
Constable Steven Brown of the Vest Midlands Police.
Is it right, Mr. Brown, that you have with you some
overhead photographs of various scenes? - A. Yes, sir.
These are photographs mainly of the stadium.and its
surrounds? - A. Yes.
60
A
S. BROWN
THE CORONER:
Ladiesand gentlemen, I hope
got good eyesight, the model is over there:
11
you have
Q. These photographs, most of
them were taken after the
incident?
In fact all of
them were taken after the
incident? - A. Most of them, yes, sir.
Q. Can you put them up one at a time and we will number
them.
Let's put the first one up.
We are going to
give these all "C" numbers in our usual way.
This is
C.249.
That is what? - A. Aerial photograph of the
ground, sir.
Q. Can you put the next one up?
This will be C.250. - A.
This is a photograph of the south stand and the Spion
Kop.
Q. Can you point on the model?
OK.
Next one.
What is
this? - A. This is a photograph, sir, of the north stand.
(C.251)
D
Q. It is taken across the Leppings Lane terraces, is that
right? - A. That is correct, sir.
THE CORONER:
Ladies and gentlemen of the jury, in
. football parlance, apparently, the stand is a place where
you sit and the terrace is the place where you stand:
Q. Yes, next please.
What is that?
(C.252) - A. It is a
photograph, sir of the west terrace and west stand.
Q« (C.253) - A. This is a photograph of the perimeter gates
at Leppings Lane end of the ground.
Q« Some of the perimeter gates.
In fact it is a photograph
in two bits, in effect? - A. That is correct, sir.
Q« Can you put the second one up as well?
(C.254).
The
next one please.
This is another aerial view.
That
gives a better impression of the Leppings Lane end? - A.
Yes, sir.
(C.255).
Next please.
This is very similar to one you
have already seen, but what are we intending to see on
this one? - A. Sir, this shows the turnstiles 1 to 16.
Q» Turnstiles 1 to 16?
(C.256).
shows the turnstiles A to G.
Q* (*G%257).
This i§ what? - A. This
Can you see the A to G on there?
There are
the big "Bs" and then underneath it there are the
letters, A, B, C, D, E, F, G.
Next. - A. This shows
the courtyard area beyond the perimeter gates and also
Til
61
S. BROWN
t)\e metal perimeter wall and turnstiles which have the
letters A, C, B, from left to right.
B
Q. Can you point to
and B.
the A, C andB? - A. A here, sir.
C
Q. That is how the turnstiles were numbered.
That was
C.258.
What is this? - A. Sir, this is gate B.
Q. (C.259)
THE CORONER:
Are you sure, Mr. Jones?
turnstiles 1 to.16?
What is
OCC JONES:
C.256.
Two photographs, sir, C.255
and C.256. Turnstiles A to G, C.257.
Courtyard and
metal wall C.258 and C.259 is gate B. We have missing
turnstiles A, C and B.
THE CORONER:
j\
No, we had that.
Q. Can you put that back?
That is turnstiles...
What is
that? - A. That is turnstiles A, C and B, sir, also the
courtyard and the metal wall.
Q. I see, these are bracketed.
Nov put gate B up again,
please.
That is one of the exit gates. (C.259).
What
is that? - A. That shows gate C to the left of the wall.
Q. Can you point at it? - A. Yes, sir.
Q. (C.260). - A. Sir, this photograph shows the gate locks
and the observation panel in the gate.
Q. The observation panel is that little square thing? - A.
Yes.
Q.
(C.261). - A. Sir, this shows a view of the concourse
beyond the turnstiles and a hole in the wall which leads
round to the north-west terrace.
Q. (C.262). - A. This shows the tunnel leading to enclosures
3 and 4 and also shows the standing sign and the letters
B and A above the tunnel.
Q. This is behind the turnstiles... - A. Leading from the
concourse into the enclosures.
Q.
Down towards the terracing.
photograph shows th<% standing
eight of the photograph.
(C.263) - A. This
sign on a pillar at the far
Q. Can you again point to it up there please?
If you had
followed that you would have finished up in enclosure 1.
v.
TT
S. BROWN
(C,264). - A. This shows a double gate at the end of the
concourse end of the tunnel.
Q. (C.265). - A. This shows the gates at the terrace end of
the tunnel and the radial fence which separates the two
enclosures.
Q. End on, of course, the radial fence? - A. Yes.
Q. (C.266).
This photograph was obviously taken very soon
after the incident.
What is it? - A. This shows the
gates at the rear of the enclosures giving access to all
of the enclosures in the Leppings Lane terraces.
Q. Can you point where they are?
I can see them because I
know where they are.
(C.267).
Just point to the
tunnel exit.
Yes. - A. This photograph shows the
barriers in enclosures 3 and 4.
Q« (C.268) Could you point out which is enclosure 3 and
which is enclosure 4? - A. This is enclosure 3 and
enclosure 4.
Q. It is just an overview. - A. This photograph shows the
perimeter fences separating the terraces from the pitch.
Q* (C.269).
The people on that photograph had nothing to
do with it*
It just happens that they were there. - A.
This shows the top of those fences where the wire bends
inwards towards the enclosures.
Q* (C.270). - This shows the radial fences separating the
enclosures in the Leppings Lane terraces.
Q* (C.271). • A« This shows the police control box and the
electric clock and display board above it.
Q. Just show us where the clock is. - A. This is the
electric clock.
Q« Switched off* - A. Switched off, and the display board
here.
Q* The police control box is that building with the word
Skips" written on it, or that structure? - A. Yes, sir.
Q. (C.272). - A. Finally, sir, this is an internal view of
the police control box.
Q. That will be C.273.
—~
THE CORONER:
Any questions of this Officer?
63
S. BROWN
MRS. McBRIEN:
Sir, have you a photograph of the
area past gate C, the no man's land area, where people
were not supposed to go but they went for safety reasons,
I think?
Have you any photographs where they could have
gone in that passageway?
THE CORONER:
I know what Mrs. McBrien is after.
We will have a look and see whether we have got a
photograph of that area.
It is in fact on the aerial
shots if you look.
We will see whether we have got one
which might show that area for you.
MRS. McBRIEN:
Thank you, sir.
THE CORONER:
Thank you, Officer.
PC Brown will
be back probably tomorrow morning with the videos.
Next Michael Layton if he is here.
You are sworn
actually, Mr. Layton so you don't need to be sworn again.
Ladies and gentlemen, witnesses who have already
been sworn I can see no advantage in re-swearing. Are
you happy with that or did you wish to hear him sworn?
I cannot see any point in it.
MICHAEL LAYTON Called
By THE CORONER
THE WITNESS:
Sir, Michael Layton, Detective
Inspector, collar number 9364 of the West
H a v 8U? M 0 b e T
tW! ^
th e
l9“
? f A p r il> 1989 and th e 9 th o f
sSDirii*iJn of this
? J ? * particular
POnffbl? on team
8 full-tlra«
supervision
of officers.
»HchPm « ^ . f U?C w ? ,\ Y a V
for the
he “ U a t l o n «<i examination of
latterly for the Coroner's inquests.
M. LAYTON
✓
number of agencies.
This material which varied both in
content, quality of picture and evidential value was
viewed by members of the team, copied and scheduled.
Each film and photograph were given a unique reference
number.
The schedules prepared were in themselves a
precis of the events shown on film.
Ultimately, sir, a composite film was prepared in
conjunction with the Treasury Solicitor's Department,
which was shown at Lord Justice Taylor's Inquiry.
This
film was designed to show what was felt to be the most
important scenes and sequence of events.
Sir, that film was given the reference number MRE.2.
Q. Is that the one that I... - A. That is the composite
film, sir.
Q. The compilation? - A..The compilation, sir, yes.
Q. I think it is right - you have said it but I just want
you to confirm it - this wasn't prepared solely by the
West Midlands, it was done in conjunction with the
Treasury Solicitors? - A. That is absolutely correct,
sir.
Q. They had. somebody there who was looking? - A. Physically
present, yes, sir.
Likewise photographic material was obtained from various
sources which was examined and scheduled in the same
manner.
Continuity in respect of all this material is
not necessarily complete since the person handing over
the material to the police is not necessarily the person
originating that material.
In an effort to analyse...
65
M LAYTON
In an effort to analyse the contents of the visual evidence
for the purposes of the Inquest some of the material has
been grouped into a number of key areas. As such the
sequence of events as referred to here in this statement do
not run in strictly chronological form, rather it deals
with a number of specific points.
First of all, sir, having regard to the movements of
people at the Leppings Lane end of the ground I can make
the following observations with regard to the visual
evidence. On a video film reference TB2 which was filmed
on the South Yorkshire Police CCTV system using an operator
set database, in other words, this shows the date and time
on which the film was recorded, this camera has Dan
facilities.
It should be noted that videos RJH1 and RJH2 have no
such time clock arid these relate to Sheffield Wednesday
Football Club's own video system, in order to try to
establish the times of events shown on these tapes a
comparison was made from events that occurred on the RJH2
tape which are also shown on the video referenced TB2 taken
from almost identical positions and which show almost
identical footage.
To be specific at 14:47:38 hours on the tape referenced
TB2 a youth is seen to jump from the roof of Turnstiles A
to G into the concourse area. This same scene can be seen
on the tape referenced RJH2. On the tape referenced TB2
again at 14:52:30 hours a youth is seen standing against a
wall near to Gate C with his arm raised and an identical
scene is shown on the tape reference RJH2. The timings of
other events as they appear on RJH2 can then be calculated
using what is called a real time counter on a video player
from either side of these fixed points.
THE CORONER:
Just pause for a minute.
Have you understood what he is saying?
(To the Jury)
Q. What you are saying is that two of these tapes did not
have a time clock on them? - A. That is right, yes.
Q. An operator one?
-
A.
Yes, that is right.
Q. Then you try to match scenes which were identical and
once you had got a time for that scene* you could
. calculate backwards and forwards? - A. Yes, that
is right, sir, using a real time counter-.
Q* “Please carry on? - A. By using this method of
calculation it is estimated that the tape, referenced
M LAYTON
RJH2, would have been switched on at about 12:56
hours. The same will apply for all the tapes given
the reference RJH because I understand they were all
switched on at the same time by PC 1421 Guest of the
South Yorkshire Police who I believe has since
retired.
On a video tape referenced TB2 at 12:00:48 hours,
supporters are shown arriving in a slow trickle and
entering the ground at the Leppings Lane end. At
13:40 hours on the same video a steady flow of
supporters are seen entering the ground and at
13:56:33 hours on the same tape the volume of
supporters has increased. At 14:35:30 hours there is
a very dense crowd in the courtyard and the perimeter
gate area. A view of the courtyard is also shown on
the BBC tape which has been given the reference
number Map 9. This is a digital reference of 0602
and the estimated time of that is at 14:35 hours.
Q. Can you just pause there for a moment?
-
A.
Yes.
THE CORONER:
Members of the Jury, are you happy with
that? I just wanted to be sure that we know what we are
talking about.
Q. I want to turn to the digital reference now?
Yes, sir.
-
A.
Q. The advantage of having the digital reference is that
you can find the frame, the scene on the tape, but it
does not tell you anything about times, is that
right?
A. At a period of time which in fact i have covered at
the bottom of this page but it does not show an
actual time.
Q. Carry on? — A. Again on Map 9, digital reference
0842 a crowd is gathered in the Leppings Lane end and
the courtyard is full. At a digital reference of
0906 Superintendent Marshall is shown amongst the
crowd. At a digital reference of 1034 youths are
shown climbing over a metal ribbed gate o n t o the
roof of Turnstile 16. Between a digital reference Of
1212 and 1239 Superintendent Marshall is shown
outside the gates in Leppings Lane, the whole area of
which is heavily congested. With regard to the tape
reference Map 9, as I have said, there is an operator
set digital database on the film. In the initial
vtages only an estimated time can be worked out on
the basis that the BBC cameraman, Ian Young, states
M LAYTON
that filming took place outside the ground at the
Leppings Lane end between 14:35 hours and 14:50 hours
and indeed there are also apparent breaks in the
filming.
In respect of subsequent filming inside the
ground it is accurately timed and time based between
15:03:30 and 15:16:58.
On a video tape referenced RJH2 at an estimated
time of 14:46 hours a number of youths are seen to
climb on to the roofs of Turnstiles A to G from
outside prior to dropping into the stadium. On a
video tape TB2 at 14:55:21, supporters are shown in
the concourse area moving towards the tunnel. A
number of these changed direction towards a gap in
the wall which gives access to the north side of the
ground.
On video tape RJH2 which gives an estimated time
of 15:05 hours, the turnstile area and outside
courtyards are clear of incoming supporters. An
Officer in a flat cap and two Police Constables are
seen to run from outside Gate C along the perimeter
drive towards the south stand. Seconds afterwards a
Police Constable runs through Gate C towards the west
stand closely followed from all the Officers in the
turnstile area.
Sir, in respect of vehicle movement at 14:08:20
hours on a video tape reference TB1, a South
Yorkshire Police video,traffic flowed quite freely
and continued to do so until 14:33:08 where it c m i be
seen that no traffic is able to flow due to
pedestrian congestion in Leppings Lane. At 14:33:27
on the tape TBl a bus and two cars are seen moving
slowly through the crowd in the roadway.
At 14:35:56 hours on TB2 another bus moves
through the crowd and at 14:36:24 a car. At 14:41:15
a coach moves through the crowd and at 14:45:01 what
looks like a white roofed vehicle is seen arriving in
Leppings Lane immediately behind a bus from the
direction of Penistone Road. At 14:45:03 this bus
passes another one coming in the opposite direction
but the white roofed vehicle remains stationary in
the crowd. Sir, from research of the'written
evidence 1 believe in fact this vehicle was a Police
Landrover being driven by PC 1863 Buxton of the South
Yorkshire Police.
THE CORONER:
He will be called in due course.
M LAYTON
Please continue. - a . No further vehicles apart
from this one are seen until at 14:55:35 hours a bus
and a car are seen and a further vehicle at 14:57:25
hours. These latter two vehicles come to a halt in
Leppings Lane and remain stationary. In the tape
RJH2 the vehicle believed to be the Police Landrover
drove through the courtyard area passed Gate C on the
perimeter drive at an estimated time of 15:06:49
hours.
In relation to the perimeter gate which
separates the turnstile area from Leppings Lane I can
make the following observation with regard to the
visual evidence. At 14:35:22 hours on a video tape
referenced TB2 the perimeter gates are open giving
access to turnstiles and the area near to Gate C.
Can you point to which perimeter gates we are talking
about on the screen? Can you find the overhead and
put that up too? - A. Yes.
At 14:40:26 hours on
the same video all the perimeter gates appear closed.
At 14:52:57 on TB2 people can be seen to be climbing
over the closed perimeter gates. At 14:53:40 hours
this second gate from the left as you look at the
screen opens and supporters enter the turnstile area
in front of Turnstiles A to G.
I realise this is not the video you are referring to
as this is a still but is that the gate we are
talking about can you remember? - A. Yes, looking
®t it from the opposite direction the video camera is
there.
From the inside out and so it is the one that is on
the right on this photograph? - A. That is right,
sir, yes.
You heard the question from Mrs. McBrien about the
sterile area, is that the area where the van is
parked? ** A. I believe it is slightly further in
than where the van is parked.
Further in towards the ground are you saying? - A.
(to the Court Officer) If you could just perhaps
indicate Gate C for me I believe that 'the sterile
area was more or less to the far side of that gate.
MR. HALE:
It is clear on the model, sir.
M LAYTON
THE CORONER:
Could you please continue? I am
sorry to have interrupted you. - A. At 14:53:44
hours the left hand perimeter gates are open. At
14:55:17 hours the right hand perimeter gates canbe
seen open. At 14:56:32 hours the area in front of A
to G up to the perimeter gates appear clearer and
Police Officers can be seen holding the crowd back to
the roadside of the perimeter gates. At 15:02:11
hours there is a close up view of the perimeter gate
area which shows that they are open and relatively
clear with supporters entering the ground.
Four photographs taken by Michael Warburton Lee
of the South Yorkshire Police show sane damage to a
retaining bolt of the second set of perimeter gates
as you look from the groundside towards Leppings
Lane. These photographs are referenced as DPP190.
There is no acetate available at the moment for you
to view.
In respect of visual evidence relating to
mounted Officers at the Leppings Lane end of the
ground the video tapes that cover this area are South
Yorkshire Police CCTV and on tape referenced TB2,
also Sheffield Wednesday Football Club's CCTV on a
tape referenced RJH2 and a BBC TV outside broadcast
on a tape referenced Map 9.
At a digital reference of 0602, estimated time
14:35 on video Map 9« two mounted Officers can be
seen directly in front of Turnstiles A to 6 near to
Gate P.
Pause again. Have we got the acetate plan of the
ground and if so put it up please? Carry on reading
but start again with "mounted Officers"? - A. At a
digital reference of 0602, estimated time 14:35 on
video Map 9, two mounted Officers can be seen
directly in front of Turnstiles A to G near to Gate
B. At 14:35:22 hours on video reference TB2 two
mounted Officers can be seen apparently talking to
supporters in front of Turnstiles A to G.
Between digital references 0839 to 0847 on a
video Map 9, nine mounted Officers can be seen in the
courtyard area from the outer perimeter gates to the
Turnstiles A to G. At 14:38:08 on video reference
TB2 a mounted Officer can be seen attempting to ease
the crowd back from Turnstiles and Gate C. At an
"estimated time of 14:48:23 on video reference RJH2 a
mounted Officer can be seen blocking the entry of
M LAYTON
supporters through Gate C. This can also be seen at
14:48:26 hours on vide reference TB2.
At 14:49 hours on video referenced TB2 a mounted
officer can be seen outside Gate C controlling the
crowd. At 14:51:50 hours four mounted Officers can
be seen outside Gate C. At 14:53 hours four mounted
Officers can be seen controlling the crowd in the
area of Gate C. At 14:53:32 hours two mounted
Officers can be seen supervising the flow of
supporters through Gate C.
In order to try and analyse the visual evidence
available in respect of the opening of the concertina
gates referred to as A, B and C, it is necessary to
refer to three video tapes. Video tapes referenced
RJH2 and RJH1 are black and white video, of poor
quality and with no sound. RJH2 refers to a fixed
site camera which overlooks the rear of Turnstiles A
to G and the concourse area. RJH1 is also part of
the system and covers the area of Gate A and the
concourse area. The particular reference to the
concertina Gate C # sir, it is apparent from visual
evidence on the day in question it was regularly
being used as an entrance and exit point for a number
of reasons i.e. the ejection of supports and tb?
"
movement of Police personnel.
Being more specific on a tape referenced TB2
timed at 14:39:31 hours a boy is carried through Gate
C by Police Officers. The gate appears to be closed
at 14:40:45 hours. On a video tape referenced RJH2
with an estimated time of 14:48:04 hours Gate C was
opened to eject a support.
/At this stage
t
At this s t a g e a l a r ^ e number of s u p p o r t e r s rushed
n r o u g h i.ie gat e into t=ie c o n c o u r s e arsa.
On the same tape, at an estimated time of 14:48:31
nours Gate C is closed. On the same tape at an
estimated time of 14:52:00 hours Gate C is again
?? €a*lafiSe ,1umber of supporters entered
through it itit > th* ground. At 14:57:40 hours, as
snown on the tape referenced TB2, Gate C is closed.
?4 .^q^ioif0rtta>% refe5 e9 ced RJH2 at a" estimated time of
I I1*- nours G ate C is again nnenod, with supporters
entering the ground.
In respect of cite A on S' video
tape referenced T62 it is apparently open at 14:58:09
nours witn supporters entering via it. At a time
estimated at 14:58 tne same cene is snown on the video
1
K -H ** 0n video tape referenced TB2 at
14.58.23 a line or Police are shown supervising the
supporters tn-*ough Gate A.
T.iere is no clear evidence, sir,-of o w nings in
relation to Gate B. The video tape from the camera
tnis arsa is one of two that were found to
be missing wnen tney were originally taken possession
feel it is important to point out in respect of
J estimated timings, given that where seconds are
indicated there are always likely to be slight
t26Se are dependent on the individual's
interpretation of a particular sequence of film.
toek i ^ " i f f ti!ai 0C??frf? i;sid? the ground leading up
to kick-off and until the football match was stopped,
t
o c e t h ^ °with
« ^ s individual
fy^?B?^te}evision
and a
IBain
recording,
together
recordings
from
separate
-amera angles, was sup tiled to the Inquirv, as
previously referred to.
chichi
raaln 5efordin8» referenced Hap 1,
«,™ I
?BC tape, and in particular the movements of
supporters In enclosures 3 and 4 of the Leppings Lane
1 4 ^ « ? A ? ra^
f° make the following observations. At
J
€
a stron8 surge of people along the
Hid in g fence between Enclosures 3 and 4. At 14*40«0Q
a youtn in a re<! top is seen standing on top of a
EPc3osure
At. the same time a beach ball
is bei jg push d arou id by the crowd in the same
enclosure.
ll?UrS there is a furth«r surge of people in
At 14-Ao N a 2
8 the i^i?in8 fence with Enclosure 3.
At 14.40:34 hours a youth in a blue top is seen on top
^5f a barrier in Enclosure 3, near to the dividing fence
of Enclosure 4. At 14:45:41 hours a youth in a white
top is seen dancing on a barrier in Enclosure 3.
At 14:40:29 hours Join Motson, a BBC commentator, makes
'1 4 ^ 7 * ^ ahout the emptiness of Enclosure <i. At
o n ' a b f r r i e ^ i n 3 *'7 0 ? 111 in f b r ?wn t o * is seen sta n d i n g
top, as
r n c l o 5 ure 3 and the y o u t h in the whi te
14t^7:46 uours?
f?oo°
M f * r M d t0' iS pulled off at
h0“rs a hole develops in the crowd in
?h- 3
Pe°Ple appear to be looking down at ‘:ie
u p A t 1 4 . 5 S . 5 ? ° - W h 0 Had fall6n ° Ver are * een to § e ‘
1 ’J V
nours tnere is considerable crowd
” “
‘r » t I5 ?;',re 3,but S t i U «> apparent probl.o.
!:r kn® e nt r the enclosure. At 24:55:49 nours a
cncio>urJn
from tae direction of the tunnel, into
F n r \^:Urt% 3 and *. takas .>lace. In respect if
in *°ed'a-e of^Enr?"6 lS f 1™ * th* dlvldlnS fence, and
«c ! i E"closure 4 the surge is down and to the
^ t as you look at ths screen.
At 15:07:.'>9 hours ....
ecu--?*'' S?ii°NEi?S. You are talking about the vidao, of
*,.Ca y°“ Just turn round, and wien you say to
1-ft
on .tbe Plfln u would be towards the
look*at it c?3-1
rig?i»uin En^ o s u r e 4? - A. As you
° e 1 “ ft I k
t W ° Uld h t t 0 the r i " h t * l t is to
.on tne screen?
’ yeS> but 10 the rl«ht « Voi look
-*e’o*'ie£ *nHrishl ‘ > V ' ; , Cr ‘ \ * 5 arc lookln8 at it from
Ij,
u f
,7
At 15:07:09 hours supporters are
I in-o
PUJ
!T Up trom th'2 rear of Enclosures 3and
a .2 - ? £
area above* At 15:07.15 nours a
if
I
:e takes place in Enclosure 3, from th» left
of cjntr. t° tn* right.front as viewed on tne screen.
Vorkshlre1Polic»'cCT5fCr^nw?dJ
BL' w;,ich
a*sin
So«be
n
xsnire rolice CCTV, at 14:59:04
hours* is
Gate
4 ~an
seen open, and at 14:59:20 hours Gate 3 ian Je se^n
*■
hSUrS GaJe 1 w.
as °Pene^ to allow supporters
tae track area into tie enclosure*
Fron a photograph taken by South Yorkshire Police at a
time snown at 15:03 Cate 3 can be seen open.
Pnotograph referenc d PR1/10A specifically refers. At
o > e n raa n d n O W n / S 1 5 I !04 ;}ours G a t e 4 can still be seen
o p e n a nd p n o t o g r a p h r e f e r e n c e d PR1 / 2 2 A s p e c i f i c a l l y
refers, again taken by South Yorkshire .Police.
I have been unable to establish, sir, any visual
evi fence to suggest that these perimeter gates were
T O * thfj*? thf'e Par.
ticu1^
It fhoufd be
bf
&
J5 tines- snown on these photographs was set
own
div4d u U caraera operator by reference to his
own .atch. Tney were not synchronised, nor were they -
73
P r J / i a «h » .1 tt??r woffs., tho p h o t o g r a p h referenced
? * tlme of 1 5 : 0 1 > -whilst a c l o c k on the
p h o t o ^ . a p h in tne g r o u d shows 15:00 so there is a
. ♦ n a t i o n , sir.
B
Q.
S°At!.l? L J 0<ld ne?n that either ha'is a minute fast or
*lST? m i n u t e slow, or >oth of t iem could be
A. Tnat-is ri?,ht, sir.
Having viewed tha mail
C °^ ing r e fere nced ?,*P 1 I a.u abl e to cive tne
f o l l o w i n g i n f o r m a t i o n in rel ation to events on th«
>itch.
u; , n J
Q.
^ V ? ’ar'' tn the l5BC f.
i lns» the Ha,! Is and 9s, I
‘ 16•c°n,Putfr set the times, is that right? - A.
„
s » except for tho outside. We are
Jtisfied that ts-ie ti es inside would have been
correct.
tu
Q.
we are no« setting to, on Map 1, thes?
would be a c c ua t e as far as you can tell? - A, Yes,
foil . p H
Liv®rP°o1 teafn was announced,
14.51:47 by the Nottingham Forest team.
Th^se annou c.meats caused obvious excitement amongst
tu
D
'
at
f **jverp°o1 taam came onto the pitch
at 14.54.0> hour;-:, followed by the Nottingham Forest
«ef!!ha
f i/ o oc TJie two teams were joined on t:ie
pitch at 14:.57:25 nours by the referee and linesmen.
Tie toss-up took ..lace at a time shown as 14:57:48
lt shoul?,be noted at this point, sir, that
* *e
-tabase actually stopped counting for a short
perio .. I don t know wiat the explanation for that is
kicke
Sff J P u J f o o . 8 ' 14!58‘43 :iours- and
”atch
At 1^:00:32 a corner kick to Nottingham Forest was
the nof th west corner-of the pilch. At
L ; ; : , , 2 UrSo ?,la^ e S1,00*1 of supporters are seen
being led by Police .rom tne direction of Enclosures 3
a.jd 4 t,wards tae Mort-i Stand. At 15:00:43 hours
•upporters are seen climbing over tae perimeter fence
5‘*°m Enclosure 4 to th.- pitch side. At 15:00:50 hours
t :e corner kick to Nottingham Forest was taken from the
norti west corner. At 15:04:09 hours Gate 3 is open,
supporters are s'iown climbing from Enclosure 3 into
Enclosure 4 via the dividing fence, and people leaning
in "Jver tne peri iter fence in an apparent effort to
reach peo .le i*: tha enclosures.
Pilay ~°nlinuc<J and at 15:04:52 hours a Peter Beardsley
sh t hit tho crossbar of the Nottingham’Forest goal.
Shortly afterw:rds, at 15:05:24 nours, Superintendent
Gree.iwooH ran ont th» pitch towards tha referee and
: ~'-e match vas stopped. •
On video tape referenced Map 5, which is again BBC TV
coverage, but from a separate camera anp.le,
H
Su ,ar ntend nt Murray can be seen on tha football
pitch, gesturing to Liverpool supporters at a time
refere.jci-d 15:05:36 hours.
?itt2rrfsard !°ighe rescue operation, visually on a Map
1 BBC tape at 15:u7:09 lours supporters can be seen
bii . pulled from th* rear of Enclosures 3 and 4 into
. -e seat2 d area. At 15.08:54 hours Police Officers can
•
at t:iS Per*meter fence motioning towards people
in enclosure 3 to move :>ack from the fence. At
j
i hours is s«?en tha first sighting of a casualty
and this shows him being taken towards t le Spion Kop on
a.i ambul nc st.retchsr.
At 1 :1«):03 nours on Ma,» 9 a South Yorkshire Police
Ins >.ctor is seen and heard to request a serial of
Police Officers. At this point he is on the perimeter
t:vick near to Enclosure 2. At 15:10:24 hours, Map 7,
whi n is also a BBC tape, shows Police Officers placing
a tad:er against tne perimeter fence at the Leppings
La.ni end. At l.;:12:lj hours on Map 1 Chief
Superintendent Ne^bit* is suown on the perimeter track
nrar t j Enclosure 3. At 15:12:50 hours on Map 7
supporters are shown sitting and lying on the pitch at
t‘ie Lepp ngs La;ie end of the ground receiving
attention.
ih fi-st sighting of a casualty leaving the stadium is
s.iown at an estimated time of 15:15:40 hours and is
s h w n on the tape referenc d RJH2, when a casualty is
carried tnrough Gate C by supporters to an ambulance.
At 1 :14:51 hours on Map 1 Superintendent Greenwood can
oe ;seen on the pitch using his personal radio.
•At 1:15:11 hours on Ma » 1 a casualty is seen being
from “ncl°sure 3 into the tunnel by a Police
el y’F fn<* a s,PPort«r. At 15:15:33 hours on Map 9 a
St. John s ambulance is seen arriving on the pitch and
k-i'-g driven towards the Leppings Lane terraces*
Is that 9j or Map 1? - A. Sorry, that is Map 1. At
1 :1>:0 • hours on Map 7 a group of supporters can be
seen pulling down tie peri.nter fence at the front of
Enclosure 4. At l‘.:l:l:12 hour.s on Map 1 a large number
ot Police Officers move from the Kop end of the ground
t wards tae Lepp‘ngs La.ie end. On Map 7 at 15:19:24
supporters are Sitown at Gate 3 being carried out of the
enclosure by Police Officsr-.
On a video referenced TB2 at 15:19:58 hours
Superintend nt Greenwood is seen at the perimeter fence
of tie Leppings Lane terrace, apparently using a
Ixuj :hailer to commu .icate with supporters in Enclosure
3. A second ambulance arrives at the Kop end, this
b -ing a Soutn Yorkshire Metropolitan ambulance, which
is snown at 15:20:41 hours on a video referenced Hap 1.
Evid;nc of the rescue operation, sir, continues for
some time and is snown on video and photo>oraphic
f 06 a^e.
'
Vid:o ev donee was also obtained from the FA C u > semi■ti.^ils 'ield at Hillsborough in 1981 and 198 >. With
regard to tne 198'. serai-zinal, this match was filmed by
Yorkshire Tv. liere is no database on the recording.
However, at a comme.tar/ time, 15:11 p.m., the
comnent:tor remarks about supporters being on the pitch
behind tae goai at the Leppings Lane end, and
supporters can be seen cliabing tae perimeter fence
onto the pitch. Thire th=n follows views of supporters
sitting on i:ie touchline behind the goal, marshalled by
t-i.5 Police.
At half-time th=? s-jpporters on the pitch ran up th-?
;'itch towards tne Spion Kop. The Police cordon is
sub.-eque *tly placed around the pitch and there are no
tur. ler points of interest.
Witn re.»ar t? the semi-final held on 9th April 1988,
* lere is video ^vi.-'ence available from the South
?r<Sn ^ e p? lice CCTV referenced TB5/2 and TB5/3, and
•Iso BBC television referenced JG1 and JG2. The video
tapes are available and show extensive coverage of th<=>
b u i r - u p and match coverage. As a comparison exercise,
a composite video tape was p r e p a r e w h i c h shows crowd
rz.--.es at the Leppings Lane end outside the ground
betw«e ! 14:00 and 15:02 hours on bof» 9th April. 1983
and 15th Aoril, 1989. This, sir, has been -,;iven the
reterenc number SDB1.
fooo t*is v;deo u cai1 *>« seen that at 14:00 hours in
1988 \.ie pe.-i^ieter gates nearest tne River Don are
cJc?.* creating: a sterile area along the side of -the
tur .stiles A-G, towards Gate C, wnereas in 1989 tiese
gates are open and people can be seen moving freelv in
t.iis area. At 14:16 nours in 1988 there is a build up
of supporters in front of turnstiles A-G, and back
along Leppings Lane.
In 1989 the build up is more
severe and the area near to Gate C has become very
crowed.
In 1988 at 14:29 nours the roadway in
Lepp;ngs Lan-:? remai :s relatively clear, although
crow»:d, whereas at 14:30 hours in 1989 the Leppings
Lan-s area has become very congested, with supporters
spilling into the centre of Leppings Lane and blocking
the road.
At 1^:43 hours ir. 1988, although it is very crowded,
traffic is still able to pass and the perimeter gates
are still closed, whereas at 14:46 hours in 1989 th-?
area in Cront of the turnstiles and Lepoines Lane is
t Tally blocker..
At 14:52 hours i 1*188 t*h • area adjacent remains
sterile, whereas at 14:52 hours in 1989 the concertina
Gate C was opened ty allow supporters into the ground.
Air 15:Ul nours in >oth 1988 and 1989 the crowd in
Leppings Lane is ver • similar in size and under
control.
Sir, during th.- course of the preliminary inquests I
:;ave evidence in respoct of locations at which it was
believed that tn^ deceased were either alive or dead or
<oth in Enclosures 3 and 4.
Plans were produced in
respcct of individual deceased.
Subsequently composite
• l m s were prepared of some of t.iese locations, based
on my evidenc , by Miss Da*’n Goodall, senior plan
f!.*3wer of the West tii 'lands Police.
Because of t ie
pr-'ole;ns associate^ wita tr.'i g to put all locations of
eceased on t lese two »lans, tney actually only show
the las* position established alive, and th* first
w lere believed • eceased.
Sir, I pro luce a composite plan referenced DHG9 in
res .ct of t ie 1 -ation of the positions of deceased. .
alive, and a composite plan refere .ced D a GIO where they
were beiieved to be
eceased in the enclosures.
Sir,
th_*re are over eads avai-able of these two plans.
/Q. Yes. - A. There is one point
M. LAYTON
Sir, there are overheads available of these two plans. There
is one point which I need to raise in respect of one of the
plans, sir.
Since the limited Inquests, Mrs. Traynor. mother
of two of the deceased, has viewed visual evidence again. At
the limited Inquest a plan was produced which showed
Christopher in enclosure No. 3 at 14:45, and that location is
reproduced on the plan DRG.9. Since that time Mrs. Traynor
has found Christopher alive at 14:45 outside the ground. So
in fact I would ask you to disregard the one location in
relation to the deceased No. 60 as shown on that plan.
What time was he shown on the plan? Would you repeat the
time? - A. 14:52 outside the ground, sir, and 14:45 was the
original identification by Mrs. Traynor inside the ground.
So what you are saying is Mrs. Traynor has now reidentified
him but alive at an earlier time than she originally thought?
- A. In fact alive at a later time. So in fact, the point I
am making is on the plan 0RG.9 we should disregard the
location shown for that particular location.
We will deal with this again.
THE CORONER:
This, Mr. King, is a typical example of
the corrections one would wish to make with regard to the
summaries. I did not know what Inspector Layton has just tolc
me, but it is clear it needs amendment, and obviously we woulc
want to get that right.
THE WITNESS:
I can tell you the original plan which
was produced at the limited Inquest was given the reference
No. C.140.
THE CORONER:
Before you put that up can we number that
plan of the ground C.274. The plan of the ground is C.274.
Can you put the next one up:
Inspector Layton, which one is this? - A. If we go
chronologically as far as the statement is concerned it shoulc
be the other way round. I don*t think it matters as such.
You mean the deceased first? - A. I am sorry, is this the
first one, sir? This is the deceased alive.
I think we will have the people alive first. - A. This plan
is DRG.9.
That is C.275.
These are the people last seen alive as far a:
you can establish based upon the evidence which you gave at
the interim Inquests? - A. That is correct, sir, and it is
this plan which bears the identification which I have just
referred to in respect of Christopher Traynor.
I— don't suppose you know where he is? - A, It is to the top.
just near to the top.
(Indicated on plan)
Can we get Miss Goodhall to delete it? - A. We can do, sir.
M. LAYTON
And we will then reproduce it as an amended version,
it givei
you a visual impression of where the people were when last
seen alive on the visual evidence. Put the other one up now
please. - A. This plan is DRG.10.
That will be C.276.
THE CORONER;
Members of the Jury, the purpose of this
is just to give you an impression where the people were to
save you looking at 9S individual plans:
That is right, is not it? - A. That is right.
It does not have 95 spots on it because we did not find
everybody on the visual evidence? - A. That is right, sir.
Finally, as I have already stated, the events outlined in thi:
statement are not actually in chronological order, and to
assist with this particular aspect a schedule has been
prepared which has been referenced SB.l, which seeks to place
some of the events into chronological order. I produce that
schedule.
Have we got that on an overhead as well, perchance? - A . I
understand the quality is not....
It is too difficult to read.
MR. KING:
THE CORONER:
will have them.
THE WITNESS;
C.277.
Would it be possible to have photocopies of
We will do that.
Tomorrow morning you
Sir, that completes my evidence.
THE CORONER;
What we are trying to.do with that
schedule is to pick out some of the aajor events. You have
given us an awful lot of detail which is useful, but that
picks out' some of the major events in chronological order as
to the outside of the ground and to the inside? - A. That is
right, sir, and where there is an "E", that is estimated tiae
sir.
THE CORONER:
It is supposed to be an aide memoire so i
somebody says, "What time did that gate open?” , we can tell.
It is difficult to follow because there are so many numbers,
but basically he was telling us events which he and his team
found either on photographs or videos, and relating to variou
things. When you see the schedule it will be shorter. We
will have them available tomorrow morning.
Any questions of Inspector Layton?
M . LAYTON
Cross-Examined bv MR. PAYNE:
You referred at a point about quarter-of-the-way through your
evidence, to a photograph taken by a photographer called
Warburton Lee.
I just did not get the reference. — a . The
reference given is DPP.190
What was that of? - a . It is in relation to damage to a
retaining bolt of the second set of perimeter gates as you
look from the ground side towards Leppings Lane.
THE CORONER:
Can you point? - A. It is the second set
of perimeter gates as you look from the ground side towards
Leppings Lane:
We will put the overhead on. Show us which one it is?
(Indicated) - A. That is right, sir, the second set of
perimeter gates from the ground side towards Leppings Lane.
Exactly where Mr. Brown is pointing.
That is C.254.
Cross-Examined bv MR. ISAACS:
Mr. Layton, could you help me with just a number of matters.
How many people in your team? - A. It varied initially from a
its height I think 12 to as a norm an average of 6.
Let us put to one side for a moment the accumulation of the
evidence.
I am only concerned with the looking at the
evidence, particularly of the video evidence, and you have
told us something of your observations, and when 1 say "you"
mean you and your team, of, for example, outside and then
inside the ground of certain parts of different videos. Coulc
you help me with this against that background. Taking, for
example, what was seen on the videos inside the ground. l o r
example, the BBC film that was being taken, in order to
produce the observations which you have produced how long
approximately would the film have been looked at for? I d o n ’
want it 5 minutes, 10 ninutes. How many hours? - A.
Countless. The process was never ending.
I think it would b
fair to say every time you view a video you see something
else, because there are so many images on the screen that it
is not possible to take them all in at one viewing.
It was a
continual process right up to the time of the limited
Inquests.
Indeed. I have no doubt since then it has continue
as well, albeit on a more limited scale.
So could you help us, have you done any of the watching
yourself? - A. I have done some of it. ’yes.
But are we talking about a video, for example, inside the
ground where you tell us that certain things were taking
place, being watched over 20 hours or 40 hours or 100 hours o
more than that? — A. It would be impossible to put a figure o
it. As I said at the beginning, the initial process after
retrieving the original video tapes, was to copy them.
M. LAYTON
KS^ t iiey wffe c°Pied the copies were viewed and a
wJ}ich is a precis of events shown on the film
From that schedule really the continual
5
? Wfs ’ as Part of our brief, to try to locate
oart o f t h ! ? either outside or inside the ground, and as
part of that process we were continually viewing.
°*
events were occurring, any incidents that occurre
the
7 A' P r i m a r i l y our brief Mas. having scheduled
the tapes, to locate the deceased for the Inquests. There
were other specific areas which were dealt with as the inquir
progressed, but because of our brief to locate deceased it wa
a continuing process.
G. But as you were saying, as well as doing that you would see when I say "you" - you and your team would see different
incidents taking place on virtually each and every occasion
n , i 5 t show
Jhe taPe?
“ A>people.
That i s r i g h t ’
on one video could
numerous
° ne scen e
Q. As opposed to, for example, someone who was looking at that
and £arcel of the events of the day which would
be quite different? - A. I am not sure I follow you.
°‘
^ - cate fxactJy Mhat 1 ®ean. We have on the one hand
Police Officers for the purposes of Lord Justice Taylor’s
Inquiry and for the purposes of this Inquest looking over and
r ideos
taken
ex“ Ple
section of %
thea8#in
ground,
whether
itof
be £or
outside
or »
inside, and
g dlfferent P ^ t o P s or something else in
addition? - a . Yes.
7
Q. On each viewing, and then we have an individual who may be
Hf Jw ^
Veppings Lane end for a f a c t i o n of a second as
ThiL°f.
S even5s? " A. Yes. I accept your point.
ePeJSe.bet,,!“ °Ur trief* whic- -a»'to view the
videos to either obtain evidence or to schedule them so as to
become a sequence of events as to what to what took place,
there is a difference between that and purely viewing it
perhaps on a monitor.
And it required from your point of view repeated lookings at,
if I can use an inelegant phrase, in order to get a complete
~<A *
on Mhat we were seeking to establish.
Certainly in relation to the deceased, yes.
Q. Thank you very much.
Cross-Examined bv MR.
kina-
Q. Arising out of that last question, if ©ne is looking for
precise details, a particular individual, you need to look at
a^video over and over again? - A. Exactly, yes, sir.
Q. If you are looking for a general impression, a build up of
fans, emptiness of a pen, the fullness of a pen the first
time is sufficient for that, is not it? - A. Yes. sir
M . LAYTON
*
Q.
Cross-Examined bv MRS.
M c B R I E N" :
I would like to go back to the point where the fans entei^A
the ground at 2:48 p.m.
Could you read that part out, plgD&e
A. Yes, if you can just bear with me a second, please. QtA
you want the whole section again?
Q. The wording you used? - A. Page 10, I think, sir.
On a v^dgo
tape reference RJH.2 at an estimated time of 1 4 :4 8 :0 4 , Ga|~eC
was opened to eject a supporter.
Is that the bit?
Q.
Yes. - A. Do you want me to go further?
Q.
Yes, just a little. - A. At this stage a large number of
supporters rushed through the gate into the concourse area
Q. Yes, thank you.
It is the part that they rushed in, and i
k,
was established at the preliminary Inquest that the fans W e r e
actually allowed in at that time, as Police Officers there,
mistakenly thought that Gate C had been opened in response.^®
Superintendent Marshall’s request.
THE CORONER:
for you:
Mrs. McBrien,
I will phrase your quest
.
Q. Mrs. McBrien is asking you whether this was the incident c ^
the timing as far as you can establish from the video
evidence, where the gate was opened as a result
of an o rd e r
opposed to not? - A. No, that is not that particular openif\q
of the gate, not the one you refer to.
'
‘ >1
Q.
MRS. McBRIEN:
The transcript of Superintendent
Marsha l l ’s evidence at the Taylor Inquiry....
THE CORONER:
Q.
Mrs. McBrien,
I am sorry:
Inspector Layton, read the whole section through again, or ^
you like specify the openings, because it may assist you.
THE CORONER:
I think you may have your timings wron^
MRS. M c B R I E N :
We brought this point out at the
Preliminary Inquest, and it was altered in the Preliminary
Inquest.
it was altered to ’’allowed” , ’’they were allowed"
"They were allowed in” .
THE WITNESS:
The timing you are referring to is the
occasion on which a person was ejected from the concourse
area via Gate C and out.
Certainly it ‘is apparent when yo\3i
view the video, and that; is why I have differentiated with q &
it were, the official opening when people walked through,
is certainly apparent on the video for this earlier openinq
they did not go in in the same fashion.
^HE CORONER:
This was at 15:52, was not it?
was one opening? - A. That is right, sir.
So 14
M. LAYTON
Q. What time was it closed then? - A. At 14:48:31.
/
Q. How long was it open? It was only open for 27 seconds'? - a
That is right, sir, yes.
Q. And then it was reopened at 14:52.
is right, sir.
Is that right? - a
That
O. And then it stayed open for how long? - A. At 14:57:40 the
gate is shown closed.
Q. That is about 5 minutes? - a . Yes.
distinct openings there.
Q.
We are talking about two
MRS. McBRIEN:
I was firmly under the impression that
fans were encouraged through that gate at that particular
time.
THE CORONER:
We will be hearing evidence.
Inspector
Layton has told you what he has seen on the visual evidence.
He c a n ’t say any more than that.
It may be - it may be;
I
say no more - that some of the other witnesses might be able
to give you some more help on this.
I d o n ’t think Inspector
Layton can.
MRS. McBRIEN:
Thank you very much.
THE CORONER:
When you say, Mrs. McBrien. there was a
correction made at the interim Inquest, are you talking about
the interim Inquest relating to your son?
MRS. MCBRIEN:
Yes.
THE CORONER:
I will have a look at it.
I will check it
and see what is actually said, but not now beczvie I have not
S°t it here.
Any other questions arising out of Inspector
Layton *s evidence?
Tomorrow we will give you a copy of the abbreviated
schedule, and I think everybody will find it is a lot easier
once we have that to look at:
O. Inspector Layton, as always I am exceedingly grateful to you.
Thank you for your help.
The only thing I would ask you is ij
you could arrange to have that plan redrawn with the
amendments, and also let me have a short statement regarding
this matter, and we will either deal with it by way of
documentary evidence or I will have to bring you back,
depending on what I think.
It is a poimt that has got to be
corrected. - a .. I think P.C. Brown should be able to assist,
sir.
THE CORONER:
Ladies and gentlemen, we are aiming
timewise to start at 10, rise about quarter-to-1, 1 o ’clock.
Obviously we c a n ’t be absolutely sure.
We know that from
experience already.
Start again about 2.
It depends what
82
M.
LAYTON
JhlSL
k for *un c h - Then aim to finish about 4 and a
SSi- Jii KSn a i tle bit of flexibility.
You may think
is not too bad, but you will find it is quite sufficient i
Lavtnn^e
ten t0 evidence for five hours.
Inspector
Layton s evidence is interesting but jolly difficult to
follow, not because he is difficult but because of the nura
and maps and goodness knows what.
A lot of the other evid
£
Uil1 h?ar u U 1 ^ easier
follow because they
Pe°Pi*- 1 don-t "ea" he is an extraor“ „ary
'
Ut 11 “l n ^ JUSt pe°ple tellln® “•
lhi -k
Quarter-to-4.
I don't think we will start
i aisn hsw ^ further tonight as far as you are concerned,
also have some more legal submissions to deal with we die
m e J e 1^
Klnl S h* ?° 1 a“ going to rise* You can leave
IlST? °n
e so we can get cracking at 10 tomorrc
lrtS It'th
^ We
1 d ° tomorrow in the morning is we wi3
c
videos* this compilation tape, which is about t
hours,
so we will watch for an hour and then stop and h L e
nS waJch the other half.
Then we have two short
h*df°S *
has two screens.
It compares 1988 with 1989 a
made
a2 d then 1 have had m o t h e r short c o m p U a ? ^
IS
J?81 and 1988• 1 think- ^ i c h shows the events
Me
t h a t ^ u c h b^ttdidfthe words today you would follow the*vide
t ®^ch better tomorrow.
Is that satisfactory to you? I
the afternoon we are starting with some real live witnesses
Can we rise for five minutes or so.
(Short Adjournment)
83
(In the absence of the jury)
THE CORONER:
Yes, Mr. Isaacs?
MR. ISAACS:
Sir, before my learned friend Mr. King
makes such submissions he wishes to make in relation to the
submission that I made this morning, may I just take this
opportunity to draw to your attention the city late edition
of The Star.
If I hand my copy in - you, sir, have not had
the benefit of going out to the local news vendors.
If I
could be handed another copy.
First of all I would ask you to read it. First of all
against the background of the submission that I made this
morning my argument is this that nothing could be more
designed to add fuel to the submission I made than what,
sir, you will now read.
THE CORONER:
Well, Mr. Isaacs, I have to agree with
you that it was an unwise - if the quotation is correct and,
of course, I can't say whether it is or whether it isn't, I
think it was an unwise comment, bearing in mind that we are
sub judice here and it is a matter for this court, or my
jury, if you like, to take decisions on what will happen.
MR. ISAACS:
Sir, that is another aspect of the matter
which perhaps I can refer to in a moment and which I know
others will refer to and that is.the question a3 to whether
The Star, rightly or wrongly, have been party to an attempt
to influence the jury to bring in a certain verdict.
That
is certainly one aspect of the matter.
The aspect I would seek to address you upon in relation
to the contents of this article is this, that clearly,
however you see these inquests, and, of course, you are in
control, those who represent.••
I put it another way. The
families quite clearly see these inquests as an evidence
gathering exercise in order to produce fresh evidence which
will, they hope, enable them to persuade or enable the
Director to take the view that criminal charges should be
preferred.
In my submission, so far as Chief Superintendent
Duckenfield is concerned he should not be put in a position
- should not even be put into the witness box where he could
be put in a position where, by asking him questions which
would then be disallowed, then be disallowed, then be
disallowed in the manner that I referred to this morning, so
as to increase the possibility, probability, what you will,
of the jury returning a verdict of unlawful killing.
In my submission, sir, this article and the contents of
it do add a great deal of fuel to the submission I made and
84
evidence?™ lnherent in
you n w f C0R0NERt
Mr. Duckenfield to give
Tha"1' yo»-
Mr. King, I w i n ilgten t,
»u,ass?!i.:!'unSiassrs*A,
j remi n ™ n gC2eR?NER:
Y°U are qult* rl*ht‘
Thank
for
fri^nIJRM»-RUf^ELL: t Sir* happily in supporting my learned
u ? ^
*saacs I need not rehearse his verv artic.ulAt-a
1 ad0Pt hiS
iZlilll"
- s ^ .“ -SSS2i,r^SJ^.?,S5TStSSS.^'th
e
Fourth
d e c isio n .
T hird, a p r i v a t e p r o s e c u t io n .
d i s c i p l i n a r y p r o c e e d in g s.
~
Ehe, depth and the strength of the feelines flf i k #
and better than ^ l l n t t u d
or infa
^
%
:
g
‘ ■ p r e f e r 8to a5wIl
S
fou rth ,
h?h- r ^ S e r,?ia£ e ^ r 2
ry Pr o c e e d in 8« are concerned, I
o V o V M
JncldHlU a d S t0
you
S K * *
Mentioned^the
5 S S ~ 1
of long-standing’officers" WhlCh
s s n s ^ - o r ^ ^ p S b E s s * ^ . * * 1'*
foT„oo r o ^ ^ ^ ^ « f f i i dl-
*T h L prOCeedl5J8#
them w i l l t o ^ n ^ * ? # t k
_the.e f o ^ ia°!U
U 18n o t m« r e ly In empty
a re on f o o t and what happens to
"hat
Sir, it is important perhaps also to e n v i i am *h» «<.)•
.cope of the offence, and they Sre o f f ^ 2 . r f i S S t t a p S u c e
85
Discipline Regulations 1985, that constitute those
disciplinary proceedings.
Perhaps I could invite you
briefly to consider the nature of the complaints that have
been made against Superintendent Greenwood because in my
submission they show that the wider the scope of the offence
the more difficult it is to conceive questions the answers
to which will not tend to incriminate Superintendent
Greenwood or anyone else in a similar position.
The allegations of complaint come from two
complainants, both of whom I note from the contents of
letters and other documents put before you this morning, are
represented by my learned friend Mr. King.
Mr. Jones Leslie Jones - the father of Richard Jones, makes four
allegations which constitute his complaint against
Superintendent Greenwood and I say at the outset these are
allegations which are, and will be, refuted by
Superintendent Greenwood:
j;
1
"A. You failed to carry out your assigned duty by ‘
placing yourself in a position by the players tunnel.
Using your radio and your eyes you should have been
aware of the dangerous situation and controlled your
officers accordingly.
1
\
,!
B. You failed to give instructions
monitor the pens for over-crowding
crowd safety at your briefings*
]
C. You were totally ineffective in mounting a rescue*
That is, you made no attempt to organise the police
officers in a way which would have helped to bring
about a successful rescue operation*
Si
•
I
I
to your officers to '
in relation to the
D* You failed to send officers to the rear of pens 3
and 4 to relieve pressure when you were in control of
the area*
This was when you knew that gate C was
being opened to allow supporters in*"
Sir, Mr* Trevor Hicks, who also instructs my learned
friend Mr* King, is the other complainant*
He makes three,
perhaps broader, allegations in his complaint:
|
I
-
"1* You failed to prevent a dangerous build-up of
supporters outside the gates*
2* You failed to control the movement of supporters
subsequent to the opening of gate C*.
3* You failed to respond to the developing tragedy and *
were slow to effect a rescue operation."
I say again the totality of each of those allegations
is refuted, but they do serve to show the wide nature of the
position of Superintendent Greenwood and the way in which
his position will have to be protected should he give
evidence.
I just invite you to consider the prejudicial
effect that the constant challenging of questions asked and
the jury being told that the officer need not answer them,
if matters are dealt with on a question at a time basis.
Alternatively, if there is dispute about whether the
answer to a particular question might tend to incriminate
Superintendent Greenwood when such argument, if there is to
be such argument, takes place in the absence of the jury,
the effect and the impression that that will have upon the
members of the jury.
In those circumstances I invite you to adopt the course
that has been suggested by Mr. Isaacs, that these officers,
certainly Superintendent Greenwood, should not be asked to
give evidence at all because of the prejudicial effect of
having to deal with each question on its merits and in
j f^ces where it is difficult to conceive any question
which will not produce that response.
MR. KING:
Sir, the families...
87
<THE CORONER:
Yes, Mr. King.
MR. KING:
The families would have liked each of the
senior Officers to have come to give evidence here
voluntarily. That is what they would have liked. They would
have wished that the truth of the events which led to these
deaths could have come from their lips voluntarily so that
the Jury could hear it. The families are mindful of the law
as much as anybody else and I have advised them what the law
is. They know and appreciate that it is within the right of
any of those senior Officers that if any question is asked
tending to incriminate that he can refuse to give it. To
this extent they are in a dilemma because what they want and
have always wanted, is for this Jury to hear the whole of the
facts. It would be a very unreal world which this Jury would
be living in if they did not hear in some way from the
principal players in these events, by which I mean the senior
One could make trite examples. The one going through mv
mind was hearing Julius Caesar but we did not hear from
Brutus and the whole of the Senate. That is not meant to be
trivial because these are vital witnesses.
£ *ew weeks a9°# sir, I submitted to you matters relating
to the Taylor Inquiry Report and the transcripts. You know
if agreement were possible the families would wish that the
whole of the Taylor Report and the_ whole of the transcripts
should be before the Jury. Indeed, they would wish they
would go there without agreement but again they' accept
advice, as they must, that that is not possible without
agreement. If my learned friend on behalf of Mr. Duckenfield
is saying to this Inquiry he will agree and consent to the -«'f
whole of the transcript of Mr. Duckenfield*s evidence being ~
read out aloud to the Jury so that they can hear it and
assess it then that in fact from the families* point of view,
much as they would like Hr. Duckenfield in the witness box to
be cross-examined, will be far better in the effort they
generally have, not in making noises to the outside world, in
bringing the facts to the attention of this Jury.
Sir, if that is the position, then much as they would
like M r . Duckenfield here, and much as I would say to you
that he ought to come into the witness box and be heard to
say, "I will not answer", if there is that alternative
genuinely being put forward, then I would say on behalf of
the families I represent that that is a course which is, in
fact, preferable as the lesser of two evi’ls from their point
of view. I say that not in any way reflecting on the right
of Mr. Duckenfield to take the stance he has but from the
point of view to prejudice of all the matters being before
the Jury.
88
* •
.
n°^,^now» sir/ what the position is with regard to
£ 1?frs# that is to say Mr. Murray, Mr. Greenwood
5s a11* 1 do not know whether I have the agreement
? L 5 * ose "h° represent those Officers to the transcripts^?
their evidence being read aloud to the Jury. If I do have
LrS U
P?S,
ition wil1 be < ^«erent than if I do
??!»•
might be helpful from my point of view if an
indication could be given in that respect.
m
r « R ^ n * C0RnNER:
that?
y°U W1
Hale is not bere and so he cannot
to resP°nd or take instructions on
4 « ^ ^ MR;.RUSSEL 5 :
£ ir' for
Part I would like to take
instructions and perhaps I could do so overnight.
.
J®* KIN? 1 _ In those circumstances, sir, perhaps it miaht
better if I postpone my final words until I hear what
those instructions are.
haveHL f S ° w S u 1 T°Uld prefer to conclude this now. You
t«
beard what Mr. Isaacs says, if he says no and Mr.
l
l
ESS' I * * '
naY think again but assume for the
moment that everyone will fall in line behind Mr. Isaacs.
MR. KINGs
If everybody falls in line behind Mr. Isaacs
as I say, sir, much as I would prefer a different course - it
tha?S?RS?!!2dS like a bargain b u t i t is not meant to be - if
£
e
* iV ? L h y whic* the families can get facts before
tne Jury it is the means they would adopt.
4-*,,?R:KISAAfS:
IJ,wish to ,Bake one thing very clear, sir. so
that there is no misunderstanding. The offer that I make is
iS
transcript of Mr. Duckenfielj** evidence both
i
were and in cross-examination before Lord
*,Can be read to this Jury as being a report of
evidence he gave on that occasion. So far as my learned
concerned he understood me correctly and I just
well
ensure, sir, that you understood me correctly as
TOE CORONER:
What you are trying to say is that you are
not putting it forward as evidence of the truth of it but
purely of what was said?
NR. ISAACS:^
That is what was said because that is
exactly the point you were making this mornina. as it w@r»
witn** CrimiSaL JUSJiSe Act state®ent when, of course, the'
m i*
asked, "Is that the statement you have
made?" On this occasion he would not be asked this but it
5 L SS
f evidence
2",5iS b*5f1£
z z by
you#i“ Lord
by Justice
SfiXfe was
the
that he
gave
before
iayjior •
\o
MR. KING:
I understand the point my learned friend is
saying on behalf of Mr. Ouckenfield as to the quality of that
evidence but it is certainly evidence which can go before a
Jury otherwise we would have no function, sir. I am not sure
now if I understand the distinction being made.
THE CORONER:
This is the problem.
Mr. Payne.
MR. PAYNE:
Sir, I was rising to make the point which was
mentioned by Mr. Isaacs simply as a matter of clarification.
If this Inquest is to proceed, as has been suggested, then it
should be on the basis that the evidence, and we are only
speaking for the moment about Mr. Duckenfield, that he should
not in fact give evidence but there should be read out at the
Inquest what he said at the Taylor Inquiry, not as his
evidence before you but as a report of what in fact he said
on that previous occasion. That is what Mr. Isaacs said to
you just now and I was rising to ensure that that was what
was being agreed.
THE CORONER:
I have not agreed to anything yet, Mr.
MR. KING:
So far so good. The next question was the ••
purpose for which the Jury could use that evidence and
certainly, sir, as I understand it, it should be capable of
being used as evidence of that which is stated in it, in
other words not as evidence to'you, sir, but as evidence of
what was said on previous occasions. Otherwise it would have
no value. I am not sure if my learned friend is trying to
say, "It can go before the Jury but the Jury must be told
that they cannot put any truth on that which is being
asserted".
HR. PAYNE:
I think Mr. King can be helped by the fact
that the ordinary rules of evidence as we tend to know them
do not apply in these proceedings and certainly for our part
we can see no objection to the Jury being informed that what
was read out was a true report of what was said before the
Taylor Inquiry and the Jury could take it into account in
that context.
THE CORONER:
Can I just put this to you because I think
I can understand the problem but you will appreciate that if
you say to the Jury, "here is a statement which has now been
read. It may or may not be true because we have not asked
Hr. Duckenfield but it is true that he said that because it
is a report of what he said. You, ladies and gentlemen, must
decide whether you believe it or whether you do not". Are
you in effect inviting me to view that statement in that
form? Have I understood you correctly?
Yef' 4.1 think -that is right. What is being
of Shit was said
?*” 5® r?ad OUt as a true account
???!
r
i the Taylor Inquiry and the Jury can take
it xnto account and make what use of it they wish.
K ™ ? : _ 0n that basis I am content as long as my
realises the import of what is being said, it
is not simply a record. It is being put to the Jury as
thev^hink
they cfn assess and «se and, if necessary and
they think fxt, accept as truth.
J
THE CORONER:
I take it what you are saying is that
because thxs statement is in the public domain, so to speak
f ?lready been given - whether it has been giv4n
k j
° Z no* 5 s “either here nor there - it is there for
anybody who wishes to get the transcripts out. That is
really what you are saying, is it not?
concessior^i^id
?e5tainly right and in making that
concession X did it so not because I felt there was anv
weakness xn the submission I originally made to you but in an
he;pful to «"»t the demaids of ySuHir, » S
I?? Perhaps the legitimate demands of my learned
« clients. If I could put it this way, if the offer
c k ! i unaccePtable then it can be withdrawn and I
rest on the submission that I have made which is still a
strong one, in my submission, but I hope to try and assist
the Court by saying that here at least ls L, S c “ nt^i ch
has been given by Hr. Duckenfield, in the circumstances it
JrSt °f ai 1 ' in chief and then under cross-
£ ? * £ £ « £ •
0,8 ttuth
K JNG:
on that basis I am content and would be
content in respect of any other senior Officer who allows his
transcript to go forward in that way.
°*s m s
■\ -
Xehave;*>een able to use the intervening
w
} to Superintendent Hurray who instructs me on
efJS as_^hat
P ut forward by my learned friend, Hr.
so
P ?5 ° f
SuPerintendent Duckenfield, that
so far as his evidence to the Taylor Inquiry is concerned it
may be used in exactly the same way. it was evidence that
was received. He answered questions in chief and in crossreSS ?? J?ni.in det*21 - ***** l t is- It will be received and
read in that way and on the same basis under the same caveat.
T fcT2E-i?°?ONE5 : ^ ? ay 1 put in “y view for what it is worth?
listened with considerable interest to your submission
and I have to agree with you because this is a regular
occurrence in Inquests that whenever you get the situation
<
2
)
91
where a person is potentially liable to be charged with sonu*
offence s lt careless driving or
spSSnl^t
what, it is next to impossible to construct »
exDerlSHee *52 «“ “0t incriminatorY* That has been my
experience and in a sense I am encouraged that that seems to
be your experience as well. I thought it w a s % u s t
in constructing questions. So far as that goes I aaree itre
edingly difficult to formulate questions'which
iy advance the matter if a person is in a situation
where an answer may incriminate him.
°n
.
Secondly, because I realise that that is so, my practice
™ „ al?aYS
to cal1 the driver, or the persoA whole
conduct is being called in question, to ask him thinos like
*s y°ur name?" (which is not I think in«iminStorJ) aAd
PfUSe* . f questions are asked and if they are
?<1 iS pointed out straight away and my
experience generally speaking is that the matter draws to *
close very quickly because people realise there is no point
whoP iSC*e«in9 ' J* d°es have the advantage that the witness
who is a player in whatever it is one is enquiring into is
«'■«
seen to be there and is also given the opportunitv
uS&
M
if
wishes to say something whereas if
opportunity?
y°U
“0t 9ive
witness that
..
Now' of course, you might say to me, "X am tellino von
that we do not want that opportunity, thank you very m2ch".
MR. ISAACS:
That is exactly what I am telling you for
the purposes of this submission.
9 you £or
THE CORONER:
The fact that somebody does not aive
evidence is also prejudicial. In a sense the problem has
been made more difficult from the decision plint o f ^ i e ^
because of the exchange that has just taken place as to what
Taylor^s^Report^nd^r^ir^0 **2*,transcripts of Lord Justice
«
.
Report and Mr* King, who has the primary interest of
a good number of the bereaved, feels that thS^Lght bS 1
ter bet than having somebody say, "I am not answerina
questions
and you obviously feel that as well.
'
I am a little bit concerned about it, in fact, because
quite a bit of the evidence of Chief Superintendent
? £ k?nfJeJd \ S d We * * * * *
him sii^ly because you took
the lead in this matter but it applies to others as well i am
sure, there is quite a lot of his evidence ^ h
is n i t
germane to an Inquest. It will be ever so interesting but it
is not germane to an Inquest. I could allow it if you as
Jepre*entative, say, "I do not mind, let us read it all
thaTaIpectnofWihe matter! *“ * U t U e b U concerned about
MR. ISAACS:
There are two ways of looking at it, with
respect. First of all, it can be edited by agreement and
indeed on your direction because you will have read his
evidence that he gave some time ago now to Lord Justice
Taylor's Inquiry. Alternatively it can go before the Jury
and you can give directions as to those parts which are
germane to the Jury’s task in this particular Inquiry. I
should point out, sir, that the offer I made was made on the
basis that he was not called. I think my learned friend
understood that and it was not in the way of holding a gun to
your head at all.
It was a view to being helpful.
THE CORONER:
Mr. Isaacs, may I ask you this because it
seems to me that it might be possible to achieve the best of
all worlds in this situation bearing in mind the point which
you have made and the acceptance of the issue? It is my
reluctance in a sense to make a ruling that we were not
calling him because I am a little bit reluctant, despite the
very persuasiveness of a lot of what, you said to me, but it
seems to me that your client would not be in any particular
danger of prejudice if the solicitors, Mr. King in
particular, were to agree that if we were to put Mr.
Duckenfield in the witness box having either read his
transcript either i a toto or edited by agreement, that he
would agree not to pursue questions which clearly were
incriminatory because that would then give the advantage of
having Mr. Duckenfield here and yet without having the thing
which I perceive to be your main fear is that he will have to
answer hundreds of questions all of which he will answer by
saying, "I am not answering that question because it is
prejudicial**. What do you feel about that?
MR. ISAACS:
What will happen is this, let us say it is
my learned friend and he will ask a question which he
believes does not have the tendency to incriminate. Either
yourself or Mr. Duckenfield or myself will say, "We take the
view that it is". The Jury will go out. There will be some
legal argument. There will be some reference perhaps to some
parts of the evidence he. has given. That matter having been
resolved the Jury will come back in. The next question will
be asked and exactly the same thing will happen. I can
foresee unfortunately that one will have a morning, a day,
two days or three days and after every question that is asked
the Jury will go out, there will be legal argument and so it
will go on.
/With respect, sir
With respect, sir, that cannot be right, and however much
you, sir, would like to see him here, unfortunately the
very nature of tho difficulty that he is in, and I stress
against tne inck^round that he does not accept that he has
committed any wrong-doing, but that others may take a
different view, that in those circumstances, and I say
this advisedly, the compromise that seems to have been
accepted is one which should commend itself to you, and
overcorae what I appreciate to be your natural reluctance
not to call, even to say, "What is your name?", a chief
player. Sir, that is th-a only way that I can put it, but
I do hope tnat perhaps Soth myself and Mr. King can manage
in the event to persuade you to take the course which is
now being put forward, ->oth of us no doubt for different
reasons but, having said tnat, reasons that are to each
CKher reasonably cogent.
TH., CORONER:
Did you want, to say anything more, Mr.
King?
MR. KING:
THE COilvMlER:
McBrien?
No.
Did you want to say anythin?, Mrs.
MllS. tlcBRIEN:
I thin!; it would be useful to use the
transcripts from the Taylor Inquiry but we all know that
the Taylor Inquiry was never to blame anybody, it was a
different sort of inquiry to this one, but it would be
better than nothing, I think. Rather thanhave nothing
at
all I would be happy with that*
THE COKONER:
You are going along with what is being
proposed as the best?
MRS. McBRIEU:
Yes, but I really would prefer Mr.
Duckenfield to appear
in person so that Icould put
questions to him, not
in an incriminatory
way,just to
speak to him.
TH.*2 CORONER:
I think I ought to say that I know
Lord Justice Taylor said that he was not going to blame
anybody. In fact, it
is only fair to say
thatan inquest
is in exactly .tae same situation. We are not here to
blame people we are hsre to enquire into how a deceased
person died and, in fact, the rules I have already
referred to expressly say that you must -not give averdict
which in any way blames somebody, and I would follow that
ruling exceedingly strictly,, I can assure you of that. I
appreciate that you may want to ask the questions as
gefTCly as possible but that is not, in fact, the issue.
The issue is not wnetner you are asking a question nicely
or nastily, but what is the content of the question, and
does it tend to increase the risk even by a little bit
tnat a person might be prosecuted.
That is the point. It
is - ot now you ask t ;e question, wnich I am sure you ..ill
do in a ladylike manner, but that is not really the issue.
MRS. McBillEN:
I think that he would be able to give
u.i far more information about that day than anybody elsa
as '.e <as ’..le prime actor.
Tll.C CO'.’OrtEK:
Yes, but M rs. HcBrien, I thin’< it is
only fair to s a v , as I have already indicated, it is, in
fact, practic'llv impossible to frame a question, to put
•. *e question where a person is in tne position of Chief
Superintendent Duckenfielci, which is not incriminating.
It may i.ot be incrimi.mting but it is almost impossible to
frame it and the point is that ho does not have to answer
that question.
Wnetter it is incriminatory or not, you
c'.nnot dr a- a conclusion from it.
If I ask a driver,
"Were you doing 40 miles an nour in a 30 miles an hour
area?", h: can say, "This is an incriminatory question, I
an .ot ijiswevring it".
You cannot (’raw the conclusion that
h was doing 40 tailed an hour from that.
He might have
been but ne might not.
He might just not want to answer
tna q u e :tion and t tere is no w^y of finding out, not in
this Court, and that is tie difficulty in this situation.
It is a difficulty' wuich is almost insoluble I think.
riRS. McBKlEN:
If I formed some questions and handed
ta-m t.'> you for you to look at ...?
V:-E CO.UmER:
You could do it but it won't make any
differenc . *ou would be a ver.’ clever lady if you could
think of a question which actually gave you an answer.
MRS. McSRJEK:
.HE CORONER*
I would not be recriminatory.
Th an k you, Mrs. UcBrien.
You will nave guessed that ray inclination had been to
turn your request d own from what I nave said, but on tae
o:. :2 r hand I h a v e to take into account what Mr. Kin g has
said, and I have heard, of course, what Mrs. Mc3rien has
said and I have to take that into account as well, though
it is clear, I am sure, to you that my experience is
similar ts? yours, tnat it is exceedingly difficult to
•ictu-jlly f o r m u W i t e tae questions in a meaningful sort of
w y.
I know you won't be here tomorrow .but I am still
::oing to cfer a 'ecision for a day or two.
We are not in
a hjre. in 1 12 sen.is that he is coming tomorrow.
It will
be, I am afraid, several weeks before we actually get to
c r u c i a ’ situ tion but I will think about it quite hard
o-ause obviously if it is acceptable to everybody t"*en
tnat may W'ill be th*; most convenient way irrespective of
my :’orm\l
- ‘d i c e .
I appreciate it is a little, bit
i ”C fsnve*ie.:t for you but I don't think I can do anything
hout it.
c.?= sidor.
I do think it is something that I need to
Mi'. MAi.NIivG:
Per :a >s juat to follow from that, you
n
:nte that you will -«;ive the decision w jen you teel
a-ile t. do so. Can I ask a backwards way round assurance,
it as .10 1 my intention to come tomorrow .norning .because
t-nn v d i o s ace soraethi g with which I am familiar. Could
I be assured by you that you would not ~ive that
adju iL:ntio : at 1-.’ o'clock tomorrow morn'ng, it would be 4
o'cl ck?
T 1.. CO.iOiJEil:
You cs.n be assured of that and, in
f ct, if it ,111 .telp you I will say that I won't >ive a
d cision at all.and that I will let your instructing
sol
•lors of t'e Of: cers involved ';now w •sen I am raady
t make a » a m ju-ement, so that your instructing
sol
tors and otners can be nere.
tW. ISAACS:
I am ver. grateful, sir, because I was
j::"t oing 1 0 ask if you could give us otice then
c rtai ly some arrangement would be made to ensure tnat
your
cision on this matter will be heard by somebody
representing Hr. Duc'<enfield. I aiso ask tnis, that I
as~.ime :nerefore that you will near no furtner submissions
o . t ?is p^rticul r matter without somebody being in
attendance.
I assume t'.ere will be no more in any event
no..?
/*
TJL;^ CO.<ONErt:
Thi only submission, if you like, that
1 would like to near, and I don't think this will
prejudice your client, will be from tha representatives of
.e o. ^er people w.no are in tiie, sane boat; shall we say.
as t wnetacr or nor they would go alo g with the
proposals which have been made.
MK. ISAA f>:
Clearly that cannot affect Mr.
Duckenfield.
I was only concerned that you stay near - and
I tiouht you woul" no-, but may near submissions about my
P i ) l :c*»tion in roy absence or in tie absence of any other
representative of Mr. Duckenfiel*.
rE
No, that would not be my intention
b-;c :a e I quite u d rsta.-.d this is an exc.e^.ingly
im srtant matter for you and for tne other Officers.
Ms’
.., ISAACS:
Effectively submissions on this point
nti ow he r
ir*ed as clossd until ydu make your
d cisior.?
TM:. Cu'iIOW^H:
Yes, that is ri.;ht.
MR. ^AVIiE:
I won*er if I might just mention that
t’
.are is anotner potential passenger in tlvs boat who has
t been mentioned so far and that is Assistant Chief
Constable Ja;.;son. I just mention this so that you know
96
that *e may be ad-ad to lie group whose submissions you
w 11 be c nsid r ng i ; <iue cour.-e, whan tne decision is
m -v e -:bout r.-se position of Nr. Duckenfield.
TMJ: COilONER:
Can we ju t make sure that we know who
e ire
Iking about.
I ‘:now Ur. H.sle isn t iere but tie
p te'.tia peo le w.. are talking about is Mr. Marshall, is
that rignt?
M.'.. PAY..E:
Yes, the lis’. is Assistant Chief
C -a* able J cks.-n, Superinten ient Greenwood,
Su •.r nt nd nt Murr .y. Superintendent, I believe, Marshall
an*i, of course, Mr. Duckenfield.
Til- CO:*.Oi>::Rs
And you would want to add Mr.
homings orth and Mr. Smith, I take it?
MISS ADDLEMAK:
j.:iE CORONER:
Tnat is rUht.
4
What about you?
j
j
MR. CATCHPoLE:
Si?, as I said before, at the moment
11 I can say, sir, is that we would like to reserve our
posi' ion. It may wall be that for tha purposes of. fir. ,,
King and tne families it would be better all round,if all j
ti»e statements went in from tha principal players but we
.lejd to : -Ik to our clients direct and also to have,;
discussion between ourselves.
^i ,
;
T**,.r. COKOIIERs
You will appreciate that in' res poet ofquite a ‘ew of tne names that have been mentioned tnere
a.*e ver/ comprehensive PACE statements. w*iich, of course, ;
^*11 be read anyway,'whatever we do'about it. ~What~'do you
say t tnat, Mr. King? Suppose for a minute that all
tiiese colleagues of yours said, yas, they think it is a
splendid id a of your.; and Mr. Isaacs, we will apply it to
11 of • 'em. Would you accept it?
Hit. Ki; G:
Si -, my position is I would have liked to
h:ve read out t ie whole of the Taylor Report and the whole
of tis tr nscr:pt and just submitted to law on you, so to :
that extent, sir, I would not object to that course.
,
.Til.: COitONERs
Than*< you.
i1R. CATCHPOLE:
There was one point you menti^ed
t iat t.sere woul-i be some live evidence tomorrow. Tnat
certainly took me sonewhat by surprise and I ttiink tnose
a;:ou-d me as w-.ll. I wonder if you ••••.
xHE OOKOUER:
Sorry about that. W ten I ^eei^ed to
scr .p, if tiat is the ri^ht word, th-.* summaries, or the
spe<3c:ies or whatever you like to call the:?., I thought we
woul ha.e a bit of time, so we are going to take tha
fi*st four people on the list for Wednesday morning and
t at will give u* a slightly easier day on Uednesday, and
97
*:e have ,>ut it up at the back actually. It is there.
That is where we are going to put the list. We intend to
put tie list up at the back so that it is visible, j
So tne plan tomorrow is morning, videos, afternoon,
four witnesses whose names I can't quite remember at the
moment.
MR. KIllG:
The four witnesses at the top of the list
for Wednesday, sir?
Til : COROiJEH:
Yes, I think so. Certainly three of
em but we may have had to shift the fifth and the fourth
arou d. It is the top end of the Wednesday list.
I just vant to check one other thing. You remember I
meitionei the transcript*; to you at the business meeting?
We have he~rd from three firms. One said they did not
w n t one, two said thsy did. Is that correct? It is no
use turning up tomorrow morning and saying, "Yes, I did
w.nt a transcript". As I explained to you, it is entirely
up to you. It does not make ;*ny difference to me whether
you have th-2 ::i or not.
HISS HAMPT:'K:
I thin: we would be a third firm that
would require a transcript.
TH u COrfONER:
Thank you. Ladies and gentlemen, .-.:,
thank you very much indeed. It has been quite a long day,
as Hr. Isaacs said - interesting, in many respects. We will adjourn then. •
(Tne Inquests were adjourned until tne following morning)
^ '......
:
•
3 ^
EBtJCA TlO N ^EBA TE
^ K eH m st^ roi^ tragedy;
James Wardrope, Frank Ryan, Geoirge.Clark," Graham Venables, A Courtney Crosby, Paul Redgrave
On 15 April 1989 Liverpool and Nottingham Forest because of hooliganism. At about 1520 Radio Sheffield
met at Hillsborough football stadium for an FA Cup made an urgent appeal for local doctors to go to the
semifinal match. The ensuing crush disaster,- in which 'ground. Between 1530 and 1545,20 doctors arnved in
i 95 spectators were killed, has been.s tudled. in. an official. the sports hall. Nearly all were general practitioners
carrying equipment that they.would normally take on a .
rreport.
^home visit; The^OTppUesvrerequicldyexhaustediBy^
ffiegfoffiidr(fig 1) ih e £ ^ w M ||i'i^ e d byjfiveradialJ ■V1615 most o f the injured had been removed to hospital. ■_
7m e^^ arners, \yith furA eipnetil ba niers capped by,; V The greatesfdifficulty for doctors at the stadium was
'backwards turned bars to'prevent invasion' of'the": ,i|th e; overwhelming ‘number -,of ■;casualties .^.requiring •
pitch. -.The pens also had longitudinal .barriers tp.‘-^immediate attention. Unusually for a major incident,
■ control crowd su ites. The effect of this design was that • • the dead and seriously injured had no wounds or
the central pens, 3 and 4, lying immediately behind the obvious sign of injury. Most were very young. This led
Liverpool goal, became confined spaces, leaving as the to a dilemma in differentiating those who should
only free oudets the tunnel along which the spectators benefit from resuscitation from those who could be
had entered and one small gate for each pen in the pronounced •dead. The paucity of equipment for
resuscitation resulted in frustration and feelings of
perimeter and side fences (1-12; fig 1 ).: '
A sudden late influx of an additional 2000 spectators inadequacy. ■
into the central pens led to a severe crush, which was
exacerbated by surges in the crowd when the match Hospital accident and emergency departments
started. One o f the horizontal crush barriers (124a; fig
1) in pen 3 collapsed and large numbers of spectators - — The-accidcnt and emergency departments of the
were thrown forwards under a weight of falling bodies Northern' General and Royal Hallamshire Hospitals
Northern General
(fig 2). At 1506 a police officer ran on to the pitch and received a message from the police at 1520 to say they
were “on casualty standby.” The agreed and correct
Hospital, Sbeffietti S i 7AU
the match was stopped.
James Wardrope, frcs,
procedure, however, was to telephone the hospital
consultant in accident end
switchboard with the message, “Implement the major
emergency medicine
disaster plan.” N o such message was received.
Frank Ryan, frcp,consultant Actions at scene
physician
Gates 3 and 4 were opened and the police -and NORTHERN GENERAL HOSPITAL
George Clark, ffarcs,
spectators worked quickly -to move the critically
After the police message at 1520 key staff at the
coiuuitam anaesthetist
injured and dead on to the pitch. Others were evacu­ Northern General Hospital, including the consultant
ated through the tunnel. First aid was administered by in accident and emergency medicine and two assistant
Royal Hallamshire
HosriHkSheffield S10 2JF police and St John Ambulance personnel together with matrons, were informed that the hospital should
seven or eight doctors and a few nurses who had been expect casualties. At 1525 a message was received from
Grali^^enables, mkcp,
spectators. The resuscitation equipment available was the South Yorkshire Ambulance Service control to
consultant neurologist
A Courtney Crosby, frcs,
very limited and included only a single oxygen “expect a child with a cardiac arrest.” There was no
consultant in accident and
cylinder. The nine available stretchers were quickly reference to Hillsborough or indication that a major
emergency medicine
used up, and spectators resorted to using advertising incident was taking place.
Paul Redgrave, mrcgp
hoardings to carry bodies to the gymnasium, which
Shortly afterwards three patients receiving cardio­
served as a makeshift mortuary.
pulmonary resuscitation arrived, and only then,
Correspondence to:
Help was not summoned over the public address after conversation with the ambulance crew, did the
Air Wardrope.
system until 1530. By then some doctors had left the charge nurse in the accident and emergency depart­
ground thinking that the match had been abandoned ment implement the proper major disaster procedure.
BStJ I991J03.1M15
Failure to implement the major incident alert earner
meant that only a few staff had to cope with a large
clinical workload in addition to implementing the
major incident plan. The consultant physician on rail
was not included in the first line rail of the major
disaster plan but had been alerted by seeing the BBC
television broadcast at 1525. He arrived at 1555,
West staod
when his presence was important in coordinaung the
hn P«n4 SVVio
efforts of medical and nursing staff dealing with the
immediate resuscitation and treatment of the pauents
K01Z4*
with crush asphyxia. Within five minutes many more
staff had arrived, and two doctors were dispatched to
the stadium with the major accident equipment.
Presentation a n d disposal o f patients
M o s t o f th e s e r io u s lv in ju r e d a r riv e d at th e h o s p ita l
.....
■>!)
■'.i-j-'nl* worsr
s u m m a ris e s th e s u m s o i p a tie n ts o n a r r iv a l a n d t h e ir
s u b s e q u e n t m a n a g e m e n t a n d d is p o s a l.
T h e a c c id e n t .a n d .c u ie rg c n c y , d e p a r t m e n t
oi
th e
N o r t h e r n G e n e r a l, H o s p it a l .is d e s ig n e d to_ co|>e w it h
la rg e
B h >
n u m b e r s _ o f —p a tie n ts
T h e re
a rc
fo u r
r e q u ir in g
p e rm a n e n t
and
re s u s c ita tio n .
e ig h t
p re p a ck e d
r e s u s c ita tio n p o in t s . B u t e v e n th e s e fa c ilit ie s w e r e n o t
s u f f ic ie n t , a n d e a c h p o in t w a s u s e d m o r e - t h a n o n c e as
v •<•j
p a tie n ts w e r e m o v e d o n e ith e r as a r e s u lt o f b e in g
..
d e c la re d d e a d o r b e in g re m o v e d to a s u p p o r t w a r d .
R OYAL H A L L A M S H IR E HO SPITAL
A t th e R o y a l H a lla m s h ir e H o s p it a l th e a c c id e n t a n d
e m e rg e n c y
c o n s u lta n t a n d
s e n io r
r e g is t r a r
a r r iv e d
to g e th e r a t 1 5 3 7 . T h e n u r s in g s t a f f h a d a lr e a d y b e g u n
to p r e p a r e t h e d e p a r t m e n t to re c e iv e la rg e n u m b e r s o f
c a s u a ltie s . W h e n t w o p o lic e o ffic e r s a r r iv e d a n d c o n ­
f ir m e d
t h a t a m a jo r d is a s te r w a s
t a k in g
p la c e
th e
h o s p ita l i m p le m e n t e d th e m a jo r d is a s te r p la n .
T h e f i r s t n v o p a tie n ts a r r iv e d a t 1 5 4 0 . O n e w a s d e a d
a n d th e o t h e r r e q u ir e d in t u b a t io n a n d w a s tr a n s fe r r e d
to
th e . i n t e n s i v e c a r e u n i t r _ B e in g . f u n h e r ' f r o r n
th e
s ta 'd iu m , th e h o s p ita l th e n h a d a q u ie t p e r io d , w h e n
" t h e 'd e p a r t m e n t a l p la n s " c o u ld b e o r g a n is e d . B e tw e e n
1 6 0 0 a n d 1 7 0 0 th e d e p a r t m e n t r e c e iv e d a f u r t h e r 69
'p a t ie n ts , 2 4 o f w h o m r e q u ir e d a d m is s io n . F i g u r e 3
s h o w s th e d is p o s a l o f p a tie n ts . F o r t y fiv e w e r e d is ­
c h a rg e d a f t e r tr e a tm e n t.
1 2 —Photograph o f west urraces at 1459 shooing ozercroizding in pens 3 d m / 4. Police obserM w n post
r&zrtd
I n t e n s iv e c a r e u n it s
re s u s c ita tio n .
S e v e n te e n p a tie n ts w e re a d m itte d to in te n s iv e c a r e at
I n i t i a ll y th e s e p a tie n ts w e re tr e a te d in th e r e s u s c ita tio n
th e N o r t h e r n G e n e ra l H o s p it a l a n d o n e a t th e R o y a l
a re a s , a n d c a r d ia c o u t p u t w a s r e s to r e d in th re e o f th e m .
H a lla m s h ir e H o s p it a l. S ix o f th o s e i n i t i a l l y a d m it t e d to
A s m o re p a tie n ts r e q u ir in g re s u s c ita tio n a r r iv e d th o s e
th e N o r t h e r n G e n e ra l w e re s u b s e q u e n tly t r a n s fe r r e d to
r e c e iv in g
b a s ic
c a r d io p u lm o n a r y
p a tie n ts a r r iv in g in c a r d ia c a r re s t w e re tria g e d to th e
th e R o y a l H a lla m s h ir e f o r c o m p u te d t o m o g r a p h y a n d
m o rtu a ry .
to re lie v e p r e s s u re o n s t a f f a t th e N o r t h e r n G e n e r a l.
Two
of
th e
p a tie n ts
re s u s c ita te d
fr o m
On
c a rd ia c a rre s t re a c h e d in te n s iv e c a re b u : s u b s e q u e n tly
a d m is s io n
to
in te n s iv e c a re a ll p a tie n ts
had
a r te r ia l lin e s , c e n tr a l v e n o u s p r e s s u re Line s, u r in a r y
d ie d .
F ift e e n o th e r p a tie n ts h a d s e v e re n e u r o lo g ic a l p r o b ­
c a th e te r s , a n d n a s o g a s tric tu b e s in s e r te d . C a re w as
le m s . N in e w e re a d m itte d u n c o n s c io u s o r c o n v u ls in g .
a im e d
A
s e iz u re s , a n d tr e a tin g p r e s u m e d c e r e b r a l o e d e m a . A l l
f u r t h e r s ix w e re c o n fu s e d
o n a r r iv a l a n d s u b s e ­
at
good
o x y g e n a t io n ,
p r e v e n t in g
fu r th e r
q u e n tly d e te r io r a te d , a n d a ll s ix b e g a n h a v in g seve re
p a tie n ts w e r e h y p e r v e n tila te d to a c h ie v e a n a r te r ia l
c o n v u ls io n s r e q u ir in g r e s u s c ita tio n , in t u b a t io n , a n d
c a r b o n d i o x id e p re s s u re o f 3 - 5 -4 - 0 k P a a n d a n a r te r ia l
v e n tila tio n in th e a c c id e n t a n d e m e rg e n c y d e p a r t m e n t
oxygen
o r o n th e r e c e iv in g w a r d . A n a d d it io n a l 15 p a tie n ts lo s t
in t r a c r a n ia l p r e s s u re w h ile m a in t a in in g g o o d c e r e b ra l
p r e s s u re o f 1 5 -2 0 k P a ,
a im e d a t r e d u c in g
c o n s c io u s n e s s in th e c r u s h . T w o o f th e se w e re c o n ­
p e r fu s io n a n d o x y g e n a t io n .1 V e n t ila t io n w a s c o n tin u e d
fu s e d o n a d m is s io n b u t r a p i d l y im p r o v e d . O n e s u b ­
f o r o n e to 15 d a y s . O n e p a tie n t a d m it t e d to in te n s iv e
s e q u e n tly
c a re
d e v e lo p e d
c o r tic a l
b lin d n e s s .
F ig u r e
3
at
th e
N o rth e rn
G e n e ra l H o s p it a l
d ie d
so o n
. i. mortuary, dead on arrival
• 7 mortuary after attempted resuscsaiion
13 Cardiac acres;
' 2 Intensive care unit after resuscitation
Jl1
5 Confused • deteriorated
-
-
5 re ce iving w a r d
t ventilation
■ ^ |
N o rth ern G e n e ra l H c sp ita i
in te n siv e c a r e unit
6
R o y al H allam sh ire H c s p n ^
i n t e n s i v e c a r e unit
Northern
Genera
Hospna
..17 ventilated
patients
- 1 0 * re su sc ita tio n / ventilation
10 Unconscious / convulsing
15 History of loss of .
consciousness
L
f s jl
}
irans/er 10 Royal
HaUamshire Hospital
/ h lir v - in
(blindness)
1 intensive care unit
(pneumothorax)
26 ward
45 Other injury
18 home
1 C ardiac arrest
m o r t u a r y , d e a d o n a r ri v a l
1 U n c o n scio u s-
re su sc ita tio n • v e n tila te d — intens*ve c a r e unit-—
71
Royaf
Hallamshire
Hoiprtal
‘6 9 O l h e r in j u ry
2 4 a d m i t t e d ------------------------------------------- 2 5 o n w a r d
* O n e patient d e te rio ra te d at - 6 h o .^ s
45 hom e
fjr, 3 —
o f p j r i a t t i through uc:ul<rnt
7 ventilated patients
r vt^v
J ^ ittm ,-nt\ o f S o r t k i r n G *m cral a n d R o y a l H a lltim ih irc H o s p t t c h . T'nrc<
o m ^t
a fte r w a r d s , J T lic
10 p a tie n ts w h o
re m a in e d
U nconscous at Hiasborouqn
'.it th a t
h o s p ita l w e re a ls o c re a te d w i t h m . m n it o l, f l u i d r e s t r ic ­
t i o n . a n d fn is e m id e to e n s u re a s lig h t ly n e g a tiv e f lu id
b a la n c e w h ile e n s u r in g a n a d e q u a te c a r d ia c o u t p u t . A l l
10 p a tie n ts a ls o r c c c iv e d h ig h d o s a g e d e x a m c th a s o n e (1
m g /k g ) . F o u r p a tie n ts w h o r e m a in e d a t th e N o r t h e r n
G e n e ra l H o s p ita l a n d
fo u r
a d m it t e d
to
th e
R oyal
H a lla m s h ir e H o s p it a l h a d r e f r a c t o r y s e iz u re s w h ic h
w e re c o n tr o lle d w i t h in tr a v e n o u s a n tic o n v u ls a n ts , tw o
p a tie n ts r e q u ir in g t h io p e n t o n e .
I n fiv e p a tie n ts th e r e w a s e v id e n c e o f in h a la t io n o f
Unconscious.
g a s tr ic c o n te n ts ( o b s e rv e d a t in t u b a t i o n , i n a s p ir a te
seizures
f r o m e n d o tr a c h e a l tu b e s , o r i n c h e s t r a d io g r a p h s ) . A l l
th e s e p a tie n ts re c e iv e d p r o p h y la c t ic m e tr o n id a z o le a n d
c e fu r o x im e a n d n o n e d e v e lo p e d c h e s t in f e c t io n . F iv e
p a tie n ts n o t g iv e n p r o p h y la c t ic a n t ib io t ic s d e v e lo p e d
c h e s t in fe c tio n s . I n
a d d itio n a l to
th e s e p a tie n ts a p o te n tia l cau se
in h a la t io n
m ay
ha ve been
Persistent
vegetative state
p r o lo n g e d
Recovered
Handicapped
v e n t ila t io n f r o m f o u r t o 11 d a y s . O n e p a tie n t w h o d ie d
w a s c o n fir m e d
to
have
in h a la t io n a l p n e u m o n ia
•Glasgow coma score <2-4*2
TGtasgow coma score >2*4-2
at
n e c ro p s y .
FIG 4 —N eurologic a 1 injuries and outcome at 48 hours and c m month
Crush asphyxia
f o r u p t o ' 7 2 h o u r s a n d s ix ' f o r u p to ‘ 14 d a y s . E a c h o f
T h e d is a s te r a t H ills b o r o u g h r e s u lte d i n a g r a d u a l
a n d p r o lo n g e d c r u s h a f f e c t in g la rg e n u m b e r s o f p r e ­
th e s e -six p a t ie n t s h a d a s e v e re n e u r o lo g ic a l d e f ic it at
one m o n th .
F iv e
v io u s ly f i t v o tin g p e o p le . T h e p a tie n ts p re s e n te d w i t h
p a t i e n t s ’ d e te r io r a te d
l i t t l e e v id e n c e o f th e c la s s ic s ig n s o f tr a u m a tic a s p h y x ia
of
t h e ir
in itia l
— fa c ia l o e d e m a ; c y a n o s is o f fa c e , n e c k , s h o u ld e r s , a n d
s ta rre d
u p p e r c h e s t; s u b c o n ju n c t iv a l h a e m o r rh a g e s ; s c a tte re d
d e te r io r a t in g
to
re c o v e ry .
s c re a m ,
w ith in
W ith o u t
d e v e lo p e d
tw o
h o u rs
w a r n in g ,
m y o c lo n u s
each
and
a
le v e l o f c o n s c io u s n e s s , a n d w e n t in t o
p e te c h ia e o v e r th e u p p e r p a r t o f th e b o d v w — y e t m a n y
s ta tu s e p ile p t ic u s . T h e s e p a tie n ts , r w o o f w h o m h a d
d e v e lo p e d s e rio u s n e u r o lo g ic a l c o m p lic a tio n s , u s u a lly
a lre a d v b e e n m o v e d to m e d ic a l w a r d s , r e q u ir e d u r g e n t
s a id to b e r a re .157
A l l th e a s p h y x ia te d
r e s u s c ita tio n , i n c lu d in g v e n t ila t io n a n d tr e a tm e n t o f
’
c r a n io c e r v ija l
s e iz u re s . A s ix t h p a t ie n t , w h o s e e m e d to be r e c o v e r in g ,
c v a n o s is , w h ic h c le a re d c o m p le t e ly w i t h i n tw o h o u r s o f
d e te r io r a te d a f t e r 4 8 h o u r s . F iv e o f th e s ix m a d e a g o o a
th e tr a u m a . O n l y t w o p a tie n ts h a d p e te c h ia l h a e m o r ­
rh a g e s (c h e s t a n d fa c e ) a n d o n e o e d e m a o f che re tin a s
p h y s ic a l r e c o v e r y . A s e v e n th p a t ie n t d e v e lo p e d c o r tic a l
b lin d n e s s a f t e r s ix h o u rs b u t s u b s e q u e n tly m a d e a g o o d
a n d o p t ic d is c s . F ig u r e 4 s u m m a ris e s th e n e u r o lo g ic a l
n e u r o lo g ic a l r e c o v e r y .
p a tie n ts
had
c o m p lic a tio n s a n d s u b s e q u e n t o u tc o m e . A lt o g e t h e r 22
p a tie n ts s u ffe r e d n e u r o lo g ic a l i n j u r y d u e to a s p h y x ia .
T h e ir a g e s ra n g e d f r o m 14 to 41 y e a rs ( m e d ia n 1 9 ), a n d
O U T C O M E A F T E R N E U R O L O G IC A L IN JU R Y
F ie u r e 4 s h o w s th e o u tc o m e a t o n e m o n th in p a tie n ts
a ll h a d b e e n u n c o n s c io u s a t th e g r o u n d . T w o d ie d tw o
w ith
a n d 4 8 h o u rs a f t e r a d m is s io n w i t h o u t r e g a in in g c o n ­
h o s p ic a l.
n e u r o lo g ic a l
sc io u s n e s s .
r e m a in e d so o n e y e a r a ft e r i n j u r y . F o u r p a tie n ts h a d
EARLY RECOVERY
o n e p a tie n t w h o w a s c o n ic a lly b l i n d . T h e ta b le g iv e s
The
in ju r y .
cw o
Two
p a tie n ts
in
p a tie n ts
a
d ie d
v e g e ta tiv e
in
sta te
m a jo r n e u r o lo g ic a l a n d c o g n itiv e h a n d ic a p s , i n c lu d in g
S ix v e n tila te d
p a tie n ts
( in c lu d in g
fo u r w h o
s e c o n d a ry d e te r io r a t io n ) re c o v e re d w i t h i n
had
24 h o u rs
th e d e ta ils o f s e v e n r e p r e s e n ta tiv e cases, to g e th e r w i t h
th e o u tc o m e s a t s ix m o n th s .
a n d w e re e x tu b a te d . F o u r p a tie n ts r e q u ir e d v e n t ila t io n
Seizures
S e iz u re s o c c u r r e d in 16 p a tie n ts , m o s tly as m u lt ip le
tprtsentative case histories o f patients vrith neurological injury
to n ic - c lo n ic e v e n c s asso cia ced w i t h m y o c lo n u s . F o u r
p a tie n ts
i<e
o
Sex a n d
age
(y e ars)
M 4I
F 26
M 2!
re a c h in g
T im e and s u tu s
on ad m issio n
1700. A g itated ,
r e s p o n s i v e to
p ain
1600. U n c o n scio u s
1630. U n c o n scio u s
P ro g re ss
O u tc o m e at s is m o n th s
1745 D e v e l o p e d s u m s e p i l c p u 'c u s . S e d a t e d
an d ven tilated fo r 24 h o u rs
N o n e u r o l o g i c a l d e f .c i :
1730 D e v e l o p e d s e i z u r e s a n d m y o c l o n u s .
S e d a te d a n d v e n tila te d f o r 24 h o u rs .
S everal ep iso d e s o f u p w a rd d e v ia tio n o f
N o f o r m a l fo l l o w c p .
R e p o r te d ly in g o o d
eyes
IS00 Im p ro v e d a n d a Je rt, th e n s u d d e n ly
r e s tl e s s a n d i r r i t a b l e w i t h d e t e r i o r a t i o n in
1 6 IS . U n c o n s c io u s
M 20
1547. A lre ad y
in tu b a te d .
u n co n sc io u s
M 16
M 23
1630. U n c o n scio u s
1640. R esp o n d ed i
q u estio n s
V e n tila te d o v e r n ig h t
Im p ro v e d b u t at 1700 b e c a m e a g ita te d a n d
had seiz u re. T re a te d w ith b e n z o d ia z e p in e s
an d ven tilated o v ern ig h t
1625 R e c o v e r e d c o n s c i o u s n e s s a n d e x t u b a t e d .
1730 B e c a m e o b t u n d c d a n d h a d s e i z u r e s .
G iv en b e n z o d ia z e p in e s a n d v e n tila te d
o v ern ig h t
1 7 00 I t j d f irs t s e i z u r e . G i v e n t h i o p e n t o n e ,
so d iu m v alp ro a te , a n d p h c n y to in an d
v e n t i l a t e d fo r 4 8 h o u r s . B e c a m e a b l e t o
o b ey c o m m a n d s . R e la p s e d w ith fu r th e r
seiz u re s. V e n tila te d for s e v e n m o re d a y s
2230 C o m p la in e d o f p o o r v isio n , c o n f u s e d ,
co n fa b u la tin g . T e s ts s h o w e d p e rc e p tio n o
tig h t o n ly . G rad u al i m p r o v e m e n t over
djv\
know n
h o s p it a l,
to
have
12 h a d
had
s e iz u re s
s e iz u re s
in
th e
b e fo re
a c c id e n t
r o o m , a n d f iv e c o n tin u e d to h a v e s e iz u re s d e s p ite la rg e
do ses o f c o n v e n t io n a l a n t ie p ile p t ic d r u g s . N o p a tie n t
w h o m a d e a c o m p le te p h y s ic a l r e c o v e r ) ’ h a d h a d a n y
health
M in o r beh av io u ral
p ro b le m s
c o n s c i o u s l e v e l. S p a s m s . T r e a t e d w i t h
ch lo rm e th ia z o lc a n d s o d iu m v a lp r o a te .
M 17
w e re
f u r t h e r s e iz u r e s b y o n e y e a r o f f o l l o w u p .
Ocher neurological injuries
S ix p a tie n ts h a d n e u r o p r a x ia , o f
b r a c h ia l
p le x u s
in ju r ie s , a n d
one
w h o m
each
th r e e h a c
had
s c ia tic
n e rv e , la te r a l c u c a n e o u s n e rv e o f t h ig h , a n d p o s te r io r
D i f f i c u l t y in c o n c e n t r a t i n g .
.M e n ta l i m p a i r m e n t o n
p sy ch o lo g ica l te stin g
N o n e u r o lo g ic a l or
psych o lo g ica l
im p a irm e n t
S p a stic w e a k n e s s , c o g n itiv e
h an d ic ap
in te ro s s e o u s n e r v e in ju r ie s .
O t h e r i n j u r ie s
F iv e p a tie n ts s u ffe re d a p n e u m o th o r a x , b ila te r a l jr.
one.
w h ic h
in
fo u r
cases
la ry n g e a l o e d e m a , w h ic h
N e ed ed m p jtie n t
p s y c h ia tr ic c a r e . S ev e re
m v m o r v Io m a n d d j n u » : c
i«* rij-lii u*mp*»ral li*lv
re q u ire d
c ra in a g e .
O ne
p a tie n t w a s n o te d a t in i t i a l in t u b a t io n to h a v e severe
p e rs is te d
and
r e q u ir e d
a
tr a c h e o s to m y .
. , ,
N in e p a tie n ts h a d e v id e n c e o f r ig h t h e a rt s tr a in in
th e i n i t i a l e le c t r o c a r d io g r a m ( f o u r o f the se cases h a v e
be en
r e p o r t e d ’ ;.
T h re e
p a tie n ts
had
p e r ic a r d ia l
I 'm lia c ul:r.is«iin)m:i|'liy slum'ctl tr.niMi:tii
iitipairmciu l’l rig '" ventricular (unction m seven
patients. Hypotension was noted in two patients. O n e
patient lia'd laparotomy lor a rigid abdomen and was
found to have gastric dilatation.
c liu \ii> n v
\y iu lrmnc ilewlopcil much earlier aiul lliete were n,i
e.\ir:ipyr:iniiJ:tl features. In reirosjKCl, computed
tomography a n d electroencephalography, undertaken
b c c a u s e o f u n e e n a in ty a b o u t th e n a tu r e o f th e a cu te
b r a in i n j u r y , a d d e d n o t h in g to p a tie n t m a n a g e m e n t o r
T h e r e w e r e la r g e n u m b e r s o f s o ft tis s u e in ju r ie s to
to u n d e r s t a n d in g th e m e c h a n is m o f th e d e te r io r a tio n .
th e c h e s t, b a c k , a n d p e lv ic a r e a — e s p e c ia lly in p a tie n ts
D c x a m c th a s o n c rc d u c e s o e d e m a a r o u n d tu m o u r s b u t
w h o h a d b e e n c r u s h e d a g a in s t th e m e ta l b a r r ie r s — b u t
its p la c e in th e m a n a g e m e n f o f h y p o x ic o e d e m a is less
s u r p r is in g ly fe w fr a c tu r e s . O n e p a t ie n t h a d a f r a c tu r e d
' c e r ta in . I t w as use d in tT ie s e p a tie n ts o n th e b a sis th a t it
s k u ll b u t n o s e r io u s n e u r o l o g i p l d a m a g e , f o u r p a tie n ts
m i g h t b e b e n e fic ia l a n d w a s u n li k e ly to d o h a r m .
I n h a la t io n o f g a s tric c o n te n ts w a s a p r o b le m in s ix
h a d r i b fr a c t u r e s , a n d o n e p a u e n t e a c h h a d fr a c tu r e s o f
r a d iu s
and
u ln a ,
pa u e n t had
a rc h
s ty lo id
p ro c e s s , a n d
a n k le .
O ne
s o n o g r a p h y b e c a u s e o f a w id e n e d
m e d ia s tin u m s u s p e c te d o n c h e s t r a d io g r a p h y , b u t th e
r e s u lt w a s n o r m a l. I n s e v e n p a tie n ts c h a n g e s c o m p a t ­
i b le w i t h a s p ir a t io n w e r e seen i n c h e s t
p a tie n ts ; seve re e x te rn a l p r e s s u re o n th e a b d o m e n , a
f u l l s to m a c h , a n d u n c o n s c io u s n e s s a re
p o te n t c o n ­
d it io n s f o r in h a la tio n a l p n e u m o n ia . O u r e x p e rie n c e
s u g g e s ts th a t p r o p h y la c tic a n t ib io t ic s h e lp e d re d u c e
th e r i s k o f c h e s t i n f e c t io n i n th e s e p a t ie n t s .
x r a y f ilm s .
IMPLICATIONS FOR DISASTER PLANNING
C o m m u n ic a t io n d if f ic u lt ie s a re a n i m p o n a n t fe a tu re
D i s c u s s io n
-
W e h a v e u s e d .th e te r m “ .c ru s h a s p h y x ia ” to d e s c rib e
th e
n e u r o lo g ic a l
m a in -
in ju r y
in
th e s e
p a tie n ts .
in
m o s t m a jo r d is a s te rs r e p o r t e d . 1415 I n
n e it h e r o f th e tw o m a in h o s p ita ls
o u r series
r e c e iv e d
p ro p e r
A l t h o u g h th e r e w e r e s im ila r it ie s t o t r a u m a t ic a s p h y x ia ,
w a r n in g t h a t a m a jo r d is a s te r w a s t a k i n g p la c e , w h ic h
th e c o n d it io n s d i f f e r i n m e c h a n is m o f i n j u r y , c lin ic a l
d e la y e d im p le m e n t in g t h e m a jo r d is a s t e r p la n s . F o n u -
f in d in g s , m a in c o m p lic a t io n s , a n d o u tc o m e .
n a t e ly , m a n y s t a f f a r r iv e d b e c a u s e o f th e m e d ia c o v e r­
T r a u m a t ic a s p h y x ia is u s u a lly c a u s e d b y a h e a v y
a g e , b u t in o th e r c ir c u m s ta n c e s — p a r t i c u l a r ly a t n ig h t
w e ig h t f a l l i n g o n th e c h e s t o r a v io le n t c r u s h b e r o e e n
— t h is m i g h t h a v e r e s u lte d in i m p o r t a n t d e la y s . W e
h e a v y o b je c ts , s u c h as m o t o r v e h ic le s . O f t e n t h e v i c t i m
s t r o n g ly
ha s w a r n i n g t h a t h e o r s h e is a b o u t t o b e c r u s h e d , a n d
m e n d e d in th e re c e n t g o v e r n m e n t g u id e lin e s , “ M a jo r
th e n a t u r a l r e fle x is to s u d d e n ly in h a le a n d th e n c lo s e
th e g l o t t i s . 15 I t h a s b e e n s u g g e s te d th a t th is r e s u lts i n
m a s s iv e in c re a s e i n p re s s u re in th e s u p e r io r v e n a c a v a ,
e x p la in in g
th e
c la s s ic
p r e s e n ta tio n
of
t r a u m a t ic
a s p h y x ia , w h e n p e te c h ia l h a e m o rrh a g e s in th e s u p e r io r
v e n a c a v a l d i s t r i b u t i o n a n d s u b c o n ju n c tiv a l h a e m o r rh a g e s a re a lm o s t a lw a y s f o u n d . ’ w A n y n e u r o lo g ic a l
c o m p lic a t io n s d o n o t u s u a lly le a d to p e r m a n e n t d is ­
a b il i t y . I f th e p a u e n t s u r v iv e s th e i n i t i a l c r u s h , th e n a
f u l l r e c o v e r y u s u a lly e n s u e s .’ !"
B y c o n t r a s t , c r u s h a s p h y x ia is c a u s e d b y a g r a d u a lly
in c re a s in g a n d
s u s ta in e d p r e s s u re o n th e c h e s t, so
p r e v e n t in g in s p ir a t io n a n d m a k in g i t m o r e l i k e l y th a t
th e g lo t t is
w ill
r e m a in
o p e n . T h is
m a y le sse n
th e
in c re a s e i n p r e s s u re in th e s u p e r io r ven a c a v a , w h ile th e
s u s ta in e d n a tu r e o f th e c r u s h m a y b e i m p o n a n t in th e
I n t h is s e rie s a m a jo r c o n t r ib u t io n to th e e v e n tu a l
of
r e s u s c ita tio n
w as
th a t
24
a n a e s th e tis ts
a r r iv e d a t th e a c c id e n t a n d e m e rg e n c y d e p a r t m e n t o f
th e N o r t h e r n G e n e r a l H o s p it a l, m a k in g i t p o s s ib le to
a llo c a te a n i n d i v i d u a l a n a e s th e tis t t o e v e ry u n c o n s c io u s
p a tie n t.
S y n d r o m e s c a u s e d b y a c u te c e r e b ra l a n o x ia w e re
r e v ie w e d
by
P lu m
and
P osner
and
in c lu d e
e a r ly
d e la v e d p o s t- a n o x ic e n c e p h a lo p a th y a n d p o s t- a n o x ic
m y o c lo n u s . 11 I n
r e m a in e d
our
s c rie s
s e r io u s ly
30%
d is a b le d
at
o f p a tie n ts
s ix
( 6 /2 0 )
m o n th s .
Two
d e a th s w h ic h o c c u r r e d e a rly in h o s p ita l a re in c lu d e d
b e c a u s e th e y a d d e d s u b s ta n tia lly to th e m a n a g e m e n t
b u r d e n . T h e d e la y e d n e u r o lo g ic a l d e t e r io r a t io n w as
u n e x p e c te d in p a tie n ts w h o h a d s e e m e d to b e r e c o \ e r in g a n d w e r e a lr e a d y b e in g m o v e d to m e d ic a l w a rd s
aw av
fro m
in te n s iv e
m o n it o r in g
and
r e s u s c ita tio n
f a c ilit ie s . T h e d e t e r io r a t io n o c c u r r e d b e tw e e n tw o a n d
48 h o u r s a f t e r th e a n o x ia h a d p a s s e d , a n d a ll b u t o n e
p a tie n t
D e ta ile d
seem ed
to
m ake
an
u n e v e n t fu l
re c o \e ry .
n e u r o p s y c h o lo g ic a l a s s e s s m e n ts ,
h o w e v e r,
s u b s e q u e n tly s h o w e d tw o p a tie n ts to h a v e c o g n itiv e
d c fc c ts .
T h e r e w a s n o e x t r in s ic re a s o n f o r th e n e u r o lo g ic a l
d e t e r io r a t io n a n d w e c a n o f f e r n o e x p la n a tio n o r m e c h a ­
n is m . W e p r e s u m e th a t i t w as a n o th e r re s p o n s e o f
y o u n g b r a in
yx
to p r o lo n g e d h y p o x ia . N o p a th o lo g ic a l
m a te r ia l w a s a v a ila b le f o r e x a m in a tio n . T h e d e t e r io r a ­
t io n d id n o t re s e m b le d e la y e d p o s t- a n o x ic e n c e p h a lo p a t h y ,:
or
d e la y e d
p o s t- a n o x ic
m y o c lo n u s " ;
d e c la re d — a c tiv a te
ih e
p la n , ”
m essage
s h o u ld
re c o m ­
b e used
to a le r t h o s p ita ls o f a m a jo r i n c i d e n t . " T h i s ta s k s h o u ld
b e u n d e r t a k e n b y th e a m b u la n c e s e r v ic e , a n d o th e r
e m e r g e n c y s e rv ic e c o m m u n ic a tio n s to h o s p ita ls s h o u ld
b e re la y e d v ia th e a m b u la n c e s e r v ic e .
O u r p r e v io u s m a jo r d is a s te r p la n e x p e c te d th e ".u n o r
s t a f f , o n re c e iv in g th e d is a s te r c a ll, to c o n ta c t th e ir
s e n io rs in th e cascade s y s te m . T h i s p r o v e d im p e r m e ­
a b le b e ca u se o f th e la rg e n u m b e r s o f p a tie n ts r e q u ir in g
t h e i r im m e d ia te s e rv ic e s f o r r e s u s c ita tio n . W e have
a lte r e d
o u r p la n to
d e le g a te
t h is
r e s p o n s ib ly
to
a d m in is t r a t iv e p e rs o n n e l, a n d w e s u g g e s t th a : c ’J ie r
h o s p ita ls s h o u ld m o d if y t h e i r p la n s a ls o . T h e ir J iia l
im p r e s s io n w as th a t a la rg e n u m b e r o f p a tie n :s w ith
h e a d in ju r ie s w e re to b e e x p e c te d , a n d a s u r p c s ily
d ir e c te d
m a jo r
d is a s te r
M e d ic a l s k i l l p ro v e d
d e v e lo p m e n t o f s e r io u s n e u r o lo g ic a l c o m p lic a tio n s .
succe ss
in c id e n t
a d v is e th a t t h e -s ta n d a rd
to
p la n
w as
im p le m : r . : e d .
be im p o n a n t
in
th e e a rly
m a n a g e m e n t o f th e n e u r o lo g ic a l ca se s, a n d w e re c o m ­
m e n d th a t a c o n s u lta n t p h y s ic ia n s h o u ld b e in d u c e d
w i t h th e a n a e s th e tic a n d s u r g ic a l te a m s i n th e £ n : lin e
c a ll f o r a ll m a jo r d is a s te r p la n s . T h o u g h n e u r e .c r .s ts
a re n o t u s u a lly in c lu d e d i n m a jo r d is a s t e r p l a r s . th e y
m a v h a v e u s e fu l a d v ic e to g iv e a b o u t th e m a n a g e r r .in t
o f c e r e b ra l a n o x ia a n d s e iz u re s .
T h e v ic t im s a t H ills b o r o u g h w e r e s i m i l a r ir. age,
m a in l y
w o re
T
id e n t if ic a t io n .
p e o p le
w as
s h ir t s
and
je a n s ,
I d e n t if y in g
th e re fo re
a
and
c a r r ie ;
u n c o n s c io u s
m a jo r
anc
no
ce a d
p r o b le m
ani
th e
u n c e r ta in tie s a n d p ro c e s s o f i d e n t i f i c a t i o n
v e r-
d is ­
tre s s in g to re la tiv e s . T h e d e a d a t th e s t a d i u n w e re
p h o to g r a p h e d ,
w h ic h
h e lp e d
id e n t if ic a t io r . .
^*e
re c o m m e n d u s in g a P o la r o id c a m e ra f o r t h is a n - ..ov.
in c lu d e a m e d ic a l p h o to g r a p h e r in o u r m a jo r i r . : : : ; n t
p la n .
.
.
D o c to r s a t th e scene h a d l i t t l e e q u ip m e n t : : r.e .p
w i t h th e r e s u s c ita tio n o f la rg e n u m b e r s o f ca su a .u e s.
b u t , g iv e n th e l i t t l e l ik e lih o o d o f a r e c u r r e n c e o . —
3
d is a s te r, i t seem s im p r o b a b le th a t a n y s p o r t i r . i v er.ue
w o u ld be e q u ip p e d w i t h s u c h fa c ilit ie s . N e v e r ;:.;.e s s ,
h ir s e s ta d iu m s a n d s im ila r v e n u e s s h o u ld e n s u re _~.3t
th e ' p e rs o n n e l a n d e q u ip m e n t n e c e s s a ry f o r a - - ' ; - r e d
lif e
s u p p o r t a rc a v a ila b le to d e a l w i t h
e m e rg e n c ie s , s u c h as a c a r d ia c a r r e s t.
s m a h tr ;r s !e
It
h -i
.- - - n
re c o m m e n d e d th a t th e re s h o u ld b e in c re a s e d p r r - ; ; ;on
o f re s u s c ita tio n e q u ip m e n t a t la r g e
fu tu re
a m b u la n c e s e rv ic e s
w ill
e v e n ts ,
d e p lo y
t h e ir
in
.T.nor
in c id e n t v e h ic le s n e a r s ta d iu m s w h e r e c r o w d s ir. cxrcss
J IM J
v o t.i \ u : 30?
30
MU!
* 1'
o f 25000
needed.
a rc ^ c x p o c t c d . 1 N o w
le g is la t io n
m av
I*-'
»» I’ffU 111., Chjiwllcr
Tr au matic jtphyiu.
7
l'/*0;29.SM'1 ’
7 C«»renuon 1., flL»ir <*K, ShjivlliiiK II. T h e
duUhtMl.J
.Vw*x IVX**;JII:75J-A.
1 Channcr K S .
T h is re p o rt was c o m p ile d on b e h a lf o f th e s ta ff at (he
N o rth e rn General 1lo s p iu l, S lie lric ld , th e .s ta ff at the Royal
H a lla m s h irc H o s p ita l, S h e ffie ld , and the m a n y people w h o
helped at the scene. T h e e ffo rts o f h u n d re d s o f professionals
and volun teers w ere v ita l and g re a tly a p p re c ia te d . W e th a n k
N e il A p p le v a rd . D a v id E d b ro o k e , D a v id D a w so n , S tuart
Yates, Ian W in s to n , Jo h n D u n c a n , G A B a k e r, C harlie
C ooper, K a th S h e rry , T im S haw , and A M o ss fo r access to
the neuropsychological re p o rts on som e o f th e su rv iv o rs .
«»f iraumjiK* J»p)ivtn «n
Dl„, M o i r c t At. .Mclluph I*. Michael i
Acuic nelii
tl.MJ
heart strain alter crushing injury ai lliM»t>«oueh (otrihjll v ^ J < u m
!W 9£99:1J79-S0.
9 Williams JS. M i n k e n -S L . A d a m t
. 4 « n 5 w f I96J:M7;J*4.92.—
JT.
Traumatic a s p h y n a
....
_. -
reappraised.
........
10 T h o m p s o n A, lltewas F F , C h i u RC-J. W h y is the lower torvo protcvtcd in
traumatic asphyxia? A n e w hypothesis. A m
o f ttupor
11 I M u m F, Posncr JB. 7 V <Jtjpwhi
ThorocSfrg 1989;47:247-9.
comw. 3rd ed. Philadelphia:
a<J
F A Davis. 19ft.
12 P l u m F, Posner JB« Kain R F . Delayed neurological deterioration after anoxia.
Arth in u m M td
1962;! 10.1 *-23-
intention or action
Brain 1963;54:111-35.
13 Lance J, A d a m * R O . T h e s y n d r o m e o f
sequel lo hypoxic cncephaJopathy.
myoclonus ai a
14 Staff of the Accident a n d E m e r g e n c y Departments of Derbyshire Royal
1 Taylor P.
T tu H ^hbcm tgk tutJium
Juoi&t.
inurim report.
Infirmary,
L on d o n : H M S O ,
2
Shapiro
HM.
NcurosurpcaJ
uuciuSou
and
intracranial hypertension.
In* Miller R O . ed. .I JU AtAohL 2 n d ed. V ol
2.
1127. A m tafa fH y fis n *
3 Saodiford JA. SickJer O .
m
Queens
MedicaJ
Centre.
BM J
198S-^9l.*94S-8.
pianm*c » (Air S H S : fuaUM te rv u tt
erranfemnus for dealing with major iitcidtnu. Lo ndon: K H S M a n a g e m e n t
16 N H S M a n a g e m e n t Executive. Em ergency
1985^:831*41.
4 O U m e r d'A. Rcfatioa n o l i a l c des c vescnent survcnus a u Champ i-d c- At in
Tk
Infirmary,
DJ .r ra /.T r c a u a a u of bu r n casualties after the fire at Bradford C r y foot ba ll
ground.
JT rm m *
le 14 juj),
RoyaJ
15 S h a r p e D T , R o b e r t s A H N , B a r c l a y T L , D i c k s o n VTA. S e ttle J A D , C ro c k e tt
Ediobur|h; Churchill
Livingstone, 19$6:1373.
3 Lia de rc up cr j. Cogbiil T . Long-term follow u p after traumatic asphyxia.
sequelae. J
Leicester
Nottingham. C o pi ng with the early stages of the M l disaster: at the icenc
and o o arrival at hospital. B M J 1989;298:651-4.
1939.
Executive, 1990.
1537.18:486*9.
. . ---
Traumatic asphyxia with severe neurological
*
(Accepud 28 A ugust 1991)
1974;14:805-9.
Doctor-patient communication: the Toronto consensus
statement
r ia , S o u th A fric a
le l S im p s o n ,
SYCH, consultant
jMichael S im pson, R obert B u c k m a n , Moira Stewart, Peter M agu ire, M a c k L ip k in , D en n is N ovae*
James T ill
<
anist
a to -B a y v ie w R e g io n a l
: r C e n tre , U n iv e r s ity
r o n to , T o r o n to ,
io , C a n a d a
i B uckm an, fr c p ,
it oncologist
E ffe c tiv e c o m m u n ic a tio n b e tw e e n d o c t o r a n d p a tie n t
s u b s ta n tia l d e fic ie n c ie s
is a c e n tr a l c lin ic a l f u n c t io n th a t c a n n o t b e d e le g a te d .
p r o p o r t io n o f v is it s w i t h d o c to r s in c lu d e a n y p a tie n t
M o s t o f th e e s s e n tia l d ia g n o s tic i n f o r m a t io n
r s ity o f W e s te rn
io, L o n d o n , O n ta rio ,
a N 6 A SC I
S te w a rt, PHD,
3T o f family medicine
rRese^xh
u'gn P ^ ^ h jlo g ic a J
ine G r o ^ p , C h ris tie
a l, M a n c h e s te r M 2 0
director,
o f primary care
ipkin, m d ,
J n iv e r s ity S c h o o l o f
le . P ro v id e n c e ,
s ta n d , U S A
N ovack, M D ,
professor o f
ty health
in d e n cc to: D r
p r o p o r t io n
of
p h y s ic ia n s t e ll th e m a b o u t d ia g n o s is a n d tr e a tm e n t.'*
c o m p lia n c e
and
p o s it iv e ly
in f lu e n c e
h e a lth
o u tc o m e s .1'1 S u c h s k i l l s , i n c lu d in g a c tiv e lis te n in g to
p a tie n ts ’
c o n c e rn s ,
a re
am ong
th e
q u a litie s
of
C u lt u r a l
d iffe r e n c e s
a ls o
im p e d e
a
P a tie n t
a n x ie t y
u n c e r ta in ty
d is s a tis fa c tio n w i t h th e m e d ic a l p r o fe s s io n is , in g o o d
and
p a r t, r e la te d to d e fic ie n c ie s in c lin ic a l c o m m u n ic a tio n .
m is p e rc e iv e
and
and
fe e d b a c k
la c k
fro m
th e
d is s a t is f a c tio n
of
th e
d o c to r.
am ount
and
S tu d ie s in m a n y c o u n tr ie s h a v e c o n f ir m e d th a t s e rio u s
p a tie n ts
u n c le a r , b o t h as r e g a rd s th e
a re
com m on
in
c lin ic a l
w o rk
w a n t.
The
is
i n f o r m a t io n ,
c o m m u n ic a tio n
p ra c tic e .
p r o b le m s
th e
w ith
p a tie n ts .1111
p h y s ic ia n m o s t d e s ir e d b y p a t ie n t s . 1 In c r e a s in g p u b lic
la n g u a g e
re k te d
Y e t d o c to r s
ty p e
to
e x p la n a tio n ,
o fte r.
o f in f o r m a t io n
d o c to r s
use
is
u se o f ja r g o n
o fte n
a n d in
r e la tio n to a la c k o f th e e x p e c te d s h a re d m e a n in g s o f
T h is c o n s e n s u s s ta te m e n t a d d re s s e s th r e e issu e s:
r e la tiv e ly c o m m o n t e r m s . ” -”
W h a t a re th e m o s t i m p o n a n t fa c ts w e a lr e a d y k n o w
a b o u t d o c to r - p a tie n t c o m m u n ic a t io n ?
im p r o v e
th e
s itu a tio n ?
and,
W h a t a re th e
be done no w
W hat
a re
th e
C O M M U N IC A T IO N PR A CTIC ES I N R ELA TIO N TO OUTCOMES
to
m ost
T h e q u a l i t y o f c lin i c a l c o m m u n ic a tio n is r e la te d to
p o s itiv e
h e a lth
o u tc o m e s ." “
p re s s u re w a s s i g n if ic a n t ly
R e d u c tio n
g r e a te r in
ir.
b lo o d
p a tie n ts
w ho,
d u r in g v is its to th e d o c t o r , h a d b e e n a llo w e d to e x p re s s
t h e ir
W h a t a r e th e m o s t i m p o r t a n t fa c t s w e a lr e a d y k n o w
a b o u t d o c t o r - p a t ie n t c o m m u n ic a t io n ?
h e a lth
c o n c e rn s
w ith o u t
i n t e r r u p t i o n s . -'
C o n c o rd a n c e b e tw e e n p h y s ic ia n a n d p a tie n t in i d e n t i ­
f y in g th e n a tu r e a n d s e rio u s n e s s o f th e c lin ic a l p r o b le m
PROBLEM S I N PRACTICE
is r e n t e d to im p r o v i n g o r r e s o lv in g th e p r o b le m . 5’
E x p la in in g
C o m m u n ic a t io n p r o b le m s in m e d ic a l p r a c tic e a rc
when
and
th e y
u n d e r s t a n d in g
cannot
be
p a tie n t
r e s o lv e d ,
c o n c e rn s ,
b o th im p o n a n t a n d c o m m o n . F o r e x a m p le , 5 4 % o f
even
p a tie n t c o m p la in ts a n d 4 5 % o f p a t ie n t c o n c e rn s a rc n o t
s ig n ific a n t f a l l in a n x ie t y . ” G r e a te r p a r t ic ip a t io n b y th e
re s u lts
3
e lic ite d b y p h y s ic ia n s .5 P s y c h o s o c ia l a n d p s y c h ia tr ic
p a tie n t in
c o m p lia n c e 1 a n d o u tc o m e o f tr e a tm e n t ( f o r e x a m p le ,
the se d ia g n o s e s a rc m is s e d in u p to 5 0 % o f e a ses.*: I n
c o n tr o l o f d ia b e te s a n d h y p e r t e n s io n ) . -' ’ T h e ! : v e l o:
50 % o f v is its th e p a tie n t a n d th e d o c t o r d o n o t a g re e o n
p s y c h o lo g ic a l d is tr e s s in p a tie n ts w i t h s e rio u s iii.-e s s is
In one
s tu d y p a tie n ts w e re in t e r r u p t e d b y p h y s ic ia n s so so o n
18 s e c o n d s ) t h a t th e y
fa ile d
to
less w h e n th e y p e r c e iv e th e m s e lv e s to h a v e re c e iv e d
B e n e fic ia l
r o u t in e ly
in
c lin ic a l
c o m m u n ic a tio n
c lin ic a l p r a c t ic e
and
d is c lo s e o t h e r s ig n if ic a n t c o n c e r n s .10 M o s t c o m p la in ts
d u r in g
b y th e p u b lic a b o u t p h y s ic ia n s d e a l n o t w i t h c lin ic a l
p r o lo n g in g
c o m p e te n c y
le a rn e d th e r e le v a n t te c h n iq u e s . “
p r o b le m s ,
but
w ith
c o m m u n ic a tio n
anc
a d e q u a te in f o r m a t io n . - -’ ”
a fte r th e y b e g a n d e s c r ib in g t h e ir p r e s e n t in g p r o b le m s
(o n a v e ra g e w i t h i n
th e e n c o u n t e r im p r o v e s s a tis fa c tio n
in
p ro b le m s a re c o m m o n i n g e n e ra l m e d ic a l p r a c tic e , b u t
th e n a tu r e o f th e m a in p r e s e n t in g p r o b l e m . ”
C a n c e r In s titu te ,
: M a rg a r e t H o s p ita l
i, O n t a r io , C anada
i l l , P H D , sentor
h ig h
a lo w
s k ills a ls o la r g e ly d e te r m in e th e p a t i e n t ’ s s a tis fa c tio n
im p o n a n t u n a n s w e r e d q u e s tio n s ?
ra e n t o f M e d ic in e ,
irk . U n iv e r s ity
o f M e d ic in e , N e w
JS A
a s u r p r is in g ly
O n ly
p a tie n ts d o n o t u n d e r s t a n d o r r e m e m b e r w h a t th c - r
m o s t im p o r t a n t th in g s t h a t c o u ld
la g u ire , f r c p s y c h ,
e d u c a tio n ,15 a n d
s tu d ie d .
fr o m th e in t e r v ie w , a n d th e p h y s ic ia n ’ s in te r p e r s o n a l
and
c f o r S tu d ie s in
y M e d ic in e ,
a rise s
when
is
ca n
fe a s ib le
b e a c r je v e c
n o r m a l c li n i c a l e n c o u n t e r s , w it h o u t u n d u ly
th e m ,
p r o v id e d
th a t
th e
c lin ic ia n
has
“
p r o b le m s ,” a n d th e m a jo r i t y o f m a lp r a c t ic e a lle g a tio n s
a ris e
fr o m
tra in e e s ’ ’
c o m m u n ic a t io n
;in d
p r a c tis in g
e rro rs ,
p h y s ic ia n s
R e s id e n ts
or
E D U C A T I O N A L IS S U E S
■/rsr^N
To
b e c o m e e f fe c ti v e c o m m u n i c a t o r s .
phy3:ci:ins
W h e n Ian w a s l i f t e d o n t o th e p i t c h he w a s p l a c e d in a p o s i t i o n
c l o s e to t he g o a l m o u t h .
H is b r o t h e r Joe was w i t h him when a
p o l i c e o f f i c e r p r o n o u n c e d h i m d e a d a nd c o v e r e d h i s f a c e w i t h a
pullover.
J o e a n d a g r o u p of f a n s c a r r i e d Ian on a m a k e s h i f t
s t r e t c h e r to t h e g y m n a s i u m w h e r e he w a s e x a m i n e d b y a d o c t o r wlro
f o u n d a p u l s e o n h i m and a t t e m p t e d r e s u s c i t a t i o n (N B t h i s w a s
a p p r o x i m a t e l y t w e n t y m i n u t e s a f t e r th e p o l i c e o f f i c e r had
pronounced him dead).
I b e l i e v e that this issue w a s i n a d e q u a t e l y
d e a l t w i t h at t h e i n q u e s t a n d r e q u e s t t h a t a d e t a i l e d e x p l a n a t i o n
is s o u g h t at t h e s o o n to be r e s u m e d i n q u e s t s b y c a l l i n g the
relevant witnesses.
T h e r e are t h r e e issu e s
and his i d e n t i f i c a t i o n
r e l a t i n g to the n o t i f i c a t i o n of
w hich I feel need addressing:
Ian
s dea>.n
<a>
On t-he e v e n i n g of the d i s a s t e r I t r a v e l l e d to B a r n s l e y
h o s p i t a l to s e e my i n j u r e d son, J o e ( h a v i n g b e e n m r o r m e a or
his w h e r e a b o u t s b y my o t h e r so n J o h n ) .
T h e p o l i c e a^ th-i.^
s t a g e k n e w t h a t Ian w a s d e a d ( J o e had i d e n t i f i e d h i m in the
g y m n a s i u m in th e a f t e r n o o n ) . . H o w e v e r , an o f f i c i a l - at the
h o s p i t a l c h e c k e d a c o m p u t e r p r i n t - o u t and i n f o r m e d me tnat
Ian w a s a l i v e b e c a u s e he w a s n o t on the list.
(b)
W h e n I w a s at th e g y m n a s i u m a n d b<?f Q E3. I had l o o k e d at the
p h o t o g r a p h s of the d e c e a s e d I w a s told by a p o l i c e m a n in
r e c e p t i o n a r e a that b o t h Ian a m i J o e w e r e d e a d .
%
(
>
W h i l s t I w a s b e i n g g i v e n the a b o v e i n f o r m a t i o n in Yorktfnirw a
p o l i c e o f f i c e r v i s i t e d my h o m e in L i v e r p o o l an d i n f o r m e d my
w i f e t h a t J o e w a s i n j u r e d y e t m a d e no m e n t i o n
or*lan^eve.n
t h o u g h It w a s s o m e t h r e e and a h al f nou
s
u n o f f i c i a l l y
i d e n t i f i e d hi m in the g y m n a s i u m g i v i n g ni i n a m e
and
address
to a p o l i c e
officer.
r r e q u e s t t h a t w i t n e s s e s be c a l l e d to e x p l a i n h o w t n i ^ m a u U i i . n ' .
Information was disseminated.
M o r e o v e r , an o f f i c i a l ooiiiPiaUM'
m a d e by m y s e l f r e g a r d i n g the a c t i o n s of S o u t h Y o r n s n i r e p>» l *.oe
has . to d a t e .
bcOn
.
When ran w a s b r o u g h t h o m e f r o m S h e f f i e l d his n e c k w a s m
a collar
we w e ^ e t o l d b v th e u n d e r t a k e r t h a t it w a s n e c e s s a r y _b e c a u s e r;
n e r k was b r o k e n .
W h e n t hi s i s s u e w a s r a i s e d at t h e m q u e s . i„
May, P r o f e s s o r U s h e r ( F a t h o l o g i s t ) s t a t e d that th e c o l l a r w a s a
d e v i c e u s e d b y u n d e r t a k e r s to s t o p the d e c e a s e d s c n i n f r o m
f i o p o i n g b e f o r e r i g o r m o r t i s s e t s in.
F o l l o w i n g t h i s ex p l ^ n a . - o n
the c o r o n e r a s k e d M r F r a s e r if I w a s s a t i s f i e d .
However
I have
to s t a t e t h a t g i v e n th e f o r m a l s t r u c t u r e or t n e c o u r t I d i d no
f - e l a b l e to s o e a k o u t and r e g i s t e r m y d i s s a t i s f a c t i o n w i t h ^ ,
explanation given.
M o r e o v e r , I r e c e i v e d yet a n o t h e r p o s s i b l e
e v p i s n a t i . ™ f r o m a L i v e r p o o l b a s e d c o n s u l t a n t w h o s t a t e d t h ^ ....
a ; V J V the c o l l a r w a s p r o b a b l y a d i r e c t c o n s e q u e n c e or tne tos,
examination.
It is c l e a r t h e n t h a t t h e r e a r e t n r e e
e x p l a n a t i o n s as to w h y I a n ' s n e c k w a s m
a c o l l a r ana per nap*
c o r o n e r w i l l u n d e r s t a n d m y c o n c e r n o v e r t h e i s s u e w n e n 1 te i
to
c o r o n e r t h a t w h i l e Ia n w a s r e s t i n g in o u r h o m e h i s h e a d f l o p u . ^ .
cont inued
"Tu^i
«i
fc*.
Jc^_v—
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J’
Wwv^
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V^W>'w — ]wh».
i-t^,
5 ^^-
SUBMISSIONS AS TO DELAY
J ,J ^ ^ 2 _
\
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(£Xc>^J
S X l o JQ)'
GENERAL SUBMISSIONS
I.
|
The Solicitors and Counsel who present this application were not instructed by
any party in either the inquest or any of the various proceedings which arose
_i
from the Hillsborough Disaster of 15th April 1989.
I
|
k.
Counsel has been required to read the lengthy transcripts of the relevant
"mini inquest^1, the resumed inquest and all other documenation gathered and
’^^supplied by the Applicants.
Certain items of new evidence have been discovered which have been included in
the memorial to the Attorney General.
It has taken time to assimilate these
and to assess their value to the overall case.
THE SPECIFIC CHRONOLOGY
28th March 1991
inquest verdict announced
Ai.^1 1991
families seek advice of the Steering Committee -of lawyers involved in the
Hillsborough cases as to the prospect of overturning the inquest verdict,
jidvised against pursuing any further action.
f
***
families seek advice of Hillsborough project and Liverpool City Council's
"Hillsborough Disaster Working Party.
I
i the Steering Committee.
Advised to seek a legal opinion outsid“
ra m i l i e s
seek Counsel
to pursue an a p p e a l a g ai ns t
the verdict.
4ay 1991
le bereaved father requests his Solicitor to seek leave for Judicial Review and
,to apply for Legal Aid for that purpose.
Solicitor agrees and .later confirms to
ather that he has submitted an application to the Legal Aid Board.
- i
une 1991
i
Advice sought from INQUEST Organisation.
October 1991
contact is made by Sheila
■June Tweedie of INQUEST.
Coleman, researcher from theHillsborough Project,
After discussions it isrecommended to contact
with
Edward
'itzgerald of Counsel.
tctober 1991
families visit Edward Fitzgerald in London for a preliminary assessment.
November 1991
Bereaved father discovers that his Solicitor
has never applied for Legal Aid
or
sought leave to apply for Judicial Review.
Alternative Solicitor is sought.
- November 1991
Malcolm J Gregg & Co, Solicitors, agree to act.
Edward Fifzgerald, formally instructed by Malcolm J Gregg & Co, visi:s Liverpool
p n 29th November 1991 for further discussion.
I
It is recognised that "he relevant
'facts regarding each of the deceased must be set out in the proposed -.emorial to
~mber 1991
|n Sinclair, one of the Applicants,
is delayed in compiling the facts relating
he death of her brother, Michael Kelly, by reason of her mother's terminal
i.ness,
ie Williams, an Applicant herein,
son.
traces an off-duty Police Officer who assisted
She meets him on 15th December 1991 and he reveals what she considers to
Yital information.
Solicitors endeavour to contact the officer at his place of
)C.
\
M *r 1992
licitor interviews the off-duty Police Officer on 10th January 1992, who declines
make a further statement.
iividual statements of the families are forwarded to Counsel.
uary - February 1992
[Duth Yorkshire Police refuse to release statements of witnesses even though all
;ice Disciplinary Proceedings have been discontinued.
aruary 1992
jtatements of witnesses sought from the Crononer's Office.
|.nne Williams receives statements of two witnesses.
She makes contact with an
e -Special Constable who reveals facts relating to the making of
a
second
tatement.
I
|Vpr i1 1992Ward Fitzgerald of Counsel meets Applicant families on 8th April 1992 and
v ;-,ents draft of memorial to the Attorney General.
I’Vtnorinl
■South
Some corrections are proposed.
is submitted to the Attorney General on 15th A pin. I 1992.
Yorkshire Police todate are still refusing statements to the Applicants.
4
Application for Leave adjourned by Single Judge, with liberty to restore after the
Attorney General has notified his decision on the Application for a Fiat.
June 1992
Copies of proceedings served on HM Coroner, South Yorkshire Police, West Midlands
Police and South Yorkshire Metropolitan Ambulance Paramedic Service.
August 1992
Attorney General's Office advised by letter of 18th August 1992 that an Application
will not be made to the High Court.
Crown Office notified on 20th August 1992 with a view to Application being relisted.
September 1992
Further Affidavit filed, sworn 11th September 1992.
March 1993
Listing date received.
Notification sent to Sheffield City Council (for the Coroner),
West Midlands Police Authority, South Yorkshire Police and South Yorkshire Metropolitan
Ambulance Paramedic Service.
Crown Office
Ref
./Hioc nci
In the High Court of Justice
Queens Bench Division
Crown Office List
CO
1 0 0 9 / 9
07/
Ex parte
^
.
£<3(0
In the matter of an application for Judicial Review O ' ! t
The Queen - v - 14-Efl fY ]& r^STYj
z
3 (© ^ 2 . ° S
(2 o d o ^E :(L
o t tj ie f £
Application for leave to apply for Judicial Review
NOTIFICATION of the first Judge's decision (Order 53 r.3)
Following :
oonoiderarion of the de euroents-eftl-yi
«=•
r e c o n s id e ra tio n of the documents and oral submissions by the applicant
— or counsel
ftT Z j£E M O )\ in open court.
O rd er by the Honourable Mr Justice
Observations for thf? applicant-:•
-v
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W s
O k
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^
Where leavetoapply has been granted, applicantsand theirlegaladvisersare reminded of
theirobligation toreconsider the meritsoftheirapplicationinthe lightofthe respondent's
affidavit.
Notes fo r the applicant
Sent/Handed to the applicant/
(]) Where the Judge has refused leave an applicant
or his solicitor may renew his application by
completing and returning form 86B within 10 days
o f the service upon him of this notice. The application
may not be renewed in a non-criminal cause or matter
if the Judge has heard oral argument.
the applicant's solicitors
(2 : If leave has been granted the applicant or his solicitor
must within 14 days from the grant of leave :
a) serve on all persons directly affected
- copy Notice of Motion in form 86 together with
Form 86A, supporting affidavits and exhibits;
b) enter in the Crown Office the original Notice of
Motion in form 86, together with :
- 2 copies; £$0 fee; affidavit of service.
on (date); i s h
h
2
/DtLCDLH O'. aae&C- r C
Applicant's Ref No.
h
|LE.( 1+3 S’ %
CASE CO/1009/92
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
CROWN OFFICE LIST
IN THE MATTER OF AN APPLICATION
FOR JUDICIAL REVIEW
BETWEEN
REGINA
-vHER MAJESTY'S CORONER FOR SOUTH YORKSHIRE
Ex Parte
SANDRA STRINGER AND OTHERS
AFFIDAVIT
I, JEREMY JOHN MURRAY HAWTHORN of Malcolm J Gregg & Co,
■1
r
i
Solicitors of 31 North John Street, Liverpool 2, MAKE OATH
and say as follows:j
1.
I make this Affidavit on behalf of all six Applicants
herein further to the Affidavit already sworn on 5th May 1992.
2.
On 2nd June 1992,pursuant to the Direction given by this
Court, I caused to besent to the office of Her Majesty's
'
j
Coroner for South Yorkshire a copy of the Form 86A and Affidavit:
in Support which are filed herein.
Also included was a copy
of the Memorial submitted to the Attorney General and the
two bundles of further material exhibited thereto.
3.
On 22nd June 1992I caused to be sent a copy of the Form
86A filed herein and a copy of the Memorial to the Attorney
General (not including the two bundles of further material)
,
SWORN AT LIVERPOOL
)
IN THE COUNTY OF MERSEYSIDE
)
THIS
//^
DAY OF
1992 )
iOUcoKV L t ^ y Z s ^ s i
lkr» f»
\
)t~~. K ~ * “ ~A
I r tc-
~ ^
A
1^ J ~V A. i* r‘« * - '” '■
_ 10 -
LCXO-*_&
JJH 11
4iJU
.
BECK cont:
gives the Coroner so much discretion to
define the parameters of the investigation.
The real question
for the coroners
is why they use their discretion so
conservatively.
In theory at least, their unique remit would
seem to allow them to take the investigation where they want.
So what's holding them back? Dr Stefan Popper was a coroner for
six years. He retired last year after conducting the country's
longest inquests into the deaths at Hillsborough. He argues that
Coroners Courts need to be conservative in their remit, because
they must avoid influencing what happens in other courts, either
civil or criminal.
Dr Popper says (inquests are not about
^
apportioning blame or liability.
POPPER:
If
purpose of the inquest is to
establish the four factors, who, when, where and how, then the
inquest does actually have a part to play and fits in to the
other jurisdictions. But X think in many cases, what people are
actually looking for isn't the establishment of those factsT what
happened; what they are trying to establish is liability or
blameworthiness, and I don't think that as the law stands, the
inquest is the right place for that.
The civil court ought to
be concerned with aspects of negligence and compensation - has
somebody done something for which a sum of -money ought to be paid
£
to compensate the injured?
concerned,
And the criminal court is to be
or should be concerned with the question of, has
somebody done something for which a punishment should be exacted?
So those are the two venues where the issues of people liability,
one civil, one criminal, ought to be dealt with, not by some
circuitous means of dealing with it through the coronal Court.
BECK:
And the law makes clear that inquests
must not stray into the territory of apportioning blame.
It was
changed in 1977 after an inquest jury named Lord Lucan as the
killer of his children's nanny.
Today, if an inquest begins to
point the finger of blame, the Coroner is legally obliged to stop
it.
But the barrister, Ed Fitzgerald, argues that coroners are
mistaken in making an assumption that deaths in contentious
- 12 -
>, =» to exercise his discretion in a
b e c k cont:
incmest. At the beginning of
specific manner during the
consiaered all the medical
the hearing, b. stated that h.
to ^
fact that the
evidence at the mini in^Ue
« ■ *
within 3 to 6 minutes.
ha; e
d
any • * » —
scene after -a--*-
~
KB a
at t h e
fatal
MV objective was to try, as far as it
POPPER!
.
aB if it was just one death.
-,s possible, to deal
x would be led astray
• x thought that if I applied otter
^
limits which a coroner
and be diverted from the parame^ ^
j
fco maintain was,
has.
underlying p n
P
what would I do if this a
where one person had died. ®h
had was
that these
Bay_ a road traffic incident
^,erwhelming evidence which we
^
^
of traumatic
poor peop
su£fered irretrievable
asphyxia,
virtually
having been achieved,
damage within minutes of the
^ 3_1 5 _ ^ t injury would
Whichever way you looked at i . ^
So i didn't and X
have taKen place with each and every,^
f<jr example
o r
don't feel that it is a c°r°n
^
„hat changes, if any,
the quality of the
c<jronal case, take again the road
Should be made. In the n
in what happened, why the
traffic accident. One is mtereste ^
^
£ollow the
car crashed,
*
if you W » -
ambulance all the way
resuscitation room, »“
nor do „ e go into the
on the wards checking
of the evidence, that the
*>." 1
out what happens. I fal ' “
was asphyxia, which these poor
injury which had caused the death was
P Y
people suffered on the terraces.
Several people were affected by the 3 15
BBCK:
.
.. _ the Stringer family, whose son Paul die
cut off point, including
first to be brought from
a t Hillsborough.
Although °n*
^
dead at 4 .3 5 . Because of
the terraces, Paul was
Stringers have no idea what
-
~
—
-
-
*—
“
■
13 -
BECK cont:
Donna, Paul's sister and his mother
Sandra, heard his name mentioned only once in the entire 80 day
main inquest.
mbs STRINGER:
When * “ ked
clerk' 1 Mas told ****■
the witnesses I had requested to be brought in were after quarter
past three, and I couldn't have them brought in.
Why?
BECK:
MRS STRINGER:
Because Dr Popper had decided on cutting
the inquest's time for quarter past three, and he told*me the
damage was already done then, that there was no need to bring
witnesses after quarter.past three. I kept asking why Paul was
never taken in an ambulance to a hospital. I'm still waiting for
that question to be answered.
I still don't know why he was
left; he was first to be taken from the terraces, at 3.15 - I was
told that by a West Midlands police officer.
SISTER:
Because Paul died together with 94 other
people, it was just like some sort of conveyor belt.
The times
from quarter past three to 4.35 we don't know anything about;
what time he was taken to the temporary mortuary, how long he was
left there, who he was with, and it's just torment.
All the
time.
You lie awake thinking who was he with, did anyone help
him?
It's just torture all the time because you don't stop
asking the questions.
BECK:
There is no doubt that the 3.15 cut off
point caused more dispute than any other single decision at the
inquest. Professor Phil Scraton is a lecturer in criminology at
Edge Hill College.
His department is conducting a long term
study into the aftermath of the Hillsborough disaster and whilst
he accepts that Dr Popper was completely within his powers to
implement the cut off point, he thinks it was a wrong decision.
- 14 -
SCRATON:
I feel that it was a profound mistake
that the coroner ruled that there should be a 3.15 cut off. I
feel that a lot of evidence that came after 3.15 should have been
heard. I think it is an absolutely crucial issue, because what
we're dealing with here is not the immediate moment at which
death is invoked. I understand the logistical problem of calling
all those people to give evidence, and how much longer the
procedure would have gone on, but let me just put it
way.
The reason that most families are upset over the 3.15 cut off is
because there is crucial evidence that they know exists about
people trying to revive and resuscitate their loved ones which
^
is never heard before the court. Now they have a right to hear
that evidence heard, because it could be that in that situation,
not. enough was done or too much of the wrong thing was given or
whatever; I'm not in any way trying to assume guilt as to what
happened after 3.15, but there is a right to investigate it and
there is a riglit to make an informed judgement on it. That right
has been completely abolished
in this case.
I just find it one
of the saddest aspects o f the Hillsborough disaster; it's
certainly the one that has had the most profound effect on the
families.
BECK:
Dr Popper accepts that the cut off point
p a u s e d distress at the time of the inquest. But he believes that
“
it stemmed mainly from a mismatch between the expectations of the
families and his remit as Coroner.
POPPER:
I know this caused a lot of anxiety to
families, but I think it is misunderstanding of the duties and
the powers that the Coroner has got.
Had people felt really
strongly that I was making a mistake, they were all advised,
legally advised I mean, there was opportunity for appeal and
judicial review. X made it quite plain right from the beginning
what I was intending to do; I gave my reasons for what they were
worth, and it was open to people to challenge them, and they
should have challenged them if they really felt strongly then.
That's
not to
say that ;somebody else may not have
taken a
\
15 %
POPPER cont:
different view; I'm not saying that I'm
infallibly right.What
I am saying is, that was the view I took,
and I did it to the best of my ability at the time.
BECK;:
Although the Coroner appears to have
great discretion to conduct broad or narrow investigations of
contentious deaths, in practice the pressure is mostly in the
direction of conservatism.
Better to be safe than sorry. But
barrister Tim Owen argues that the system can no longer afford
to rely on its inquisitorial purity. Controversial deaths, by
Lr very nature, beg to be looked at in a wider context.
OWEN:
In controversial cases, the idea that
you can avoid, if you like, an adversarial contest or conflict
is absurd. There plainly are frequently different views about
culpability, whether proper care was given, and it's absurd to
think that an inquest process can be shorn of that type of
controversy. And once you accept that the controversy exists,
then
the
current
procedure
is
not
a
satisfactory
one
for
resolving it, because it leaves too much discretion in the hands
of coroners, it keeps too much information back from people who
have a legitimate interest in knowing about it before the
i*-~uest, and it leaves the jury and the Coroner with too narrow
# function, if you like, in returning the verdict, because the
verdicts,
as they are now returned, are simply too brief and
don't disclose in clear terms the full circumstances in how
somebody died, and what measures sire necessary to prevent death
in the future.
BECK:
21 years ago, the Brodrick Report looked
at all aspects of the Coroners Court and made its recommendations
- advance disclosure, legal aid and wider rights of appeal
against verdicts were all put forward as ways of making the
system more acceptable to both sides. They were largely ignored,
as were the recommendations of a committee in 1986 which looked
at the
inquest system and
controversial deaths.
suggested
a way
of
dealing with
Evan Stone, QC was the chairman of that
SCRATON cont:
much of the work of the coroner cam be
done
efficiently
and
effectively
through
the
present
inquisitorial system.
The investigation work is okay, the
inquest work is okay and the outcome is generally satisfactory.
However, in these high profile cases where clearly liability is
a contradictory construct, then it's important that another tier
exists, and I think what we need is a tier which is openly
adversarial, where cross-examination is as thorough as it needs
to be, where rules that we would accept in other courts, more
normal courtroom rules, apply; where families are actually legal
aided so they have a right of representation, and where the
person who is presiding over it has experience of working in
high-profile adversarial circumstances - in other words, I'm
thinking of a judge.
BECK:
We have been told that the idea of
inquests becoming more like public inquiries, at least for deaths
in contentious circumstances, is now being seriously discussed
by coroners.
The Coroners Society, however, refuses to comment
on it publicly.
It's perhaps no surprise that those who seem
especially interested in the new system are coroners who've had
to conduct inquests after major disasters.
Dr Stefan Popper's
experience at the Hillsborough inquest has convinced him that it
is now time to grasp the nettle of reform.
POPPER:
expectation.
I think that there is a dichotomy in
It seems to me that the legislature has tended to
limit the powers of coroners whereas the public, certainly at the
moment, is expanding their expectations.
And I think what is
needed is either the coroners should be more given more teeth, so
that they can actually do and say things which carry true weight.
Or, and this may possibly be a better solution, that coroners
inquests should be turned into fact finding exercises, and the
conclusions and verdicts should be deleted altogether from their
power, so that their power is to establish the facts, and for
others, civil or criminal courts, to draw whatever conclusions
need to be drawn from a particular event.
Somebody, and by that
- 18 -
POPPER cont:
I mean Parliament, has got to make up
their mind what they want. Do they want inquests to carry on as
they are, or do they want them restricted, or do they want them
expanded? I don't think that carrying on as we are is the best
way forward.
And as I say, the public expectation seems to me
that they want more from Coroners Court, and they want more power
there.
If that's what the public want, in a democracy, then
there's no reason they shouldn't have it .
BECK:
Inquests were once regarded as a legal
backwater.
But a series of major public disasters and the
controversy surrounding individual cases has changed all that.
The weaknesses
of the system are being highlighted by
dissatisfied families and lawyers who Recognise that deaths in
controversial circumstances can't be examined in the same way as
others.
But as yet, there are few signs that the legislators
have recognised the problems.
It's significant, for example,
that the Royal Commission, which is examining all aspects of the
legal system, is not investigating inquests.
To barrister Ed
Fitzgerald, what is at stake is the credibility of the inquest
system in the eyes of the public.
FITZGERALD:
If we don't reform the system now, there
will be a great injustice to the families of the deceased. They
will continue to be left with a sense of real grievance, that
they haven't had proper inquests, that they haven't been able to
participate in inquests on a basis of equality with those in
authority who may have been responsible for the deaths of their
relatives.
if we don't reform the system, the worst result of
all will be that families will continue to have to live with a
lifetime of bitterness, that the questions that they really
needed answered were not answered at the inquest.
SIGNATURE TUNE
TWI» ft fc* c*Lvlv
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t h e leg al sec r eta r ia t t o t h e l a w o f f ic e r s
ATTORNEY GENERAL'S CHAMBERS
9 BUCKINGHAM GATE
LONDON SW1E 6JP
General enquiries 071-828 7155
Direct line
071-828
1721
Messrs Malcolm J. Gregg & Co.,
Second Floor,
Century Buildings,
31 North John Street,
Liverpool, L2 6RG
Your ref: JH/LF/H359
Our ref: INQ/4/92
^
August 1992
Dear Sirs,
PAUL
PETER
CARLILB.
TOOLE
(APPLICATION
IAN
and
GLOVER.
KEVIN
UNDER
RICHARD
JONES.
MT CHART.
TTRT.T.vf
WILLIAMS
SECTION
13
OF
THE
CORONERS
ACT
1988)
Further to my letter of 21 April 1992, the Law Officers have now
given very careful consideration to the application made by your
clients for authority under section 13 of the Coroners Act 1988
to apply to the High Court for an order directing a fresh inquest
in relation to the above named persons who died in the Hills­
borough disaster on the 15 April 1989.
The material submitted
under cover of your letter of 3 June 1992 has also been taken
into account together with representations received on behalf of
some of your clients from Members of Parliament with Merseyside
constituencies and a letter received direct from Mrs Teresa
Glover.
As you will know section 13 of the Act applies when an inquest
has been held and, "by reason of fraud, rejection of evidence,
irregularity of proceedings, insufficiency of inquiry, the
discovery of new facts or otherwise, it is necessary or desirable
in the interests of justice that another inquest should be held."
The Law Officers have considered the matter very carefully but
they have come to the conclusion that there is nothing which
would justify authorising an application to the High Court for
a new inquest in any of the above cases.
They have reached this decision on the grounds that the applica­
tion would have no reasonable prospect of establishing that it
is necessary or desirable in the interests of justice for a fresh
inquest to be held.
The Law Officers recognise the importance to the families of the
deceased of having the fullest possible information about the
precise circumstances of the deaths and have taken that carefully
into account when considering the sufficiency of the inquiry made
by the Coroner and his directions to the jury. All these issues
must, however, be considered in the context of the statutory
framework within which Coroners are required to work and the
questions required to be answered on the inquisition.
It is not
appropriate, therefore, that they authorise an application to the
High Court under section 13 unless it could be said, with
reasonable confidence, that further information would be likely
to be elicited which would have a bearing on the issues to be
considered at any such further inquest.
The Law Officers recognise that this decision will be deeply
disappointing to your clients. They are aware of the strength of
the continuing feeling on the part of those whose friends and
relatives died or were -^injured , in the.^tragic eventsLrat
Hillsborough but their task has been to evaluate the application
objectively against the statutory criteria. Their decision does
not indicate any lack of fedl£ng for the families of those who
died at Hillsborough for whan they have the deepest sympathy.,
Yours faithfully,
<
S. J. WOOLER
ft*.
Lr
v
/w«*~ K U \l>- <3*-y A
^t<Vo^ ' * " x
jjtm
DEPARTMENT OF FORENSIC MEDICINE
GUY’S HOSPITAL
(UNIVERSITY O F L O N D O N )
Dr. LE. WEST, MJB-, Ch-B^ F.R.C.Path., D 14J.
Dr. R.T. SHEPHERD B-Sc„ M i.. B.S.. M.R-C-Path., D.MJ.
Direct Telephone Line 071-407 0378 / 071-403 1118)
UNITED MEDICAL AND DENTAL SCHOOLS
GUYS AND ST. THOMAS'S HOSPITAL
LONDON BRIDGE. SE1 9RT
TELEPHONE: 071-955 5000 Ext: 3118/3119
(Fax:071-403 7292)
SCO:21/92/IEW
20th August 1992
t
<5-t-udied the papers that you have submitted to me regarding the
Jraalc d e a t h f of thlfl young people.
They include the post mortem
reports on Paul Carlisle, Gary Church, Ian Glover, Richard Jones, Michael
navid Kellv Peter Tootle, Kevin Daniel Williams and Philip Hammond.
,e a l s o studied the relevant extract from the inquest -the overview
eDared by Professor Usher, the report prepared by Dr. Burns and the
ground's on which applications are to be made to set aside the o n g
inquest.
f
T have experience
a s p h w ia H n o lu d in g
of a substantial number of deaths from traumatic
victims o f the Clapham R a i l distaster and explosion
at the Grand Hotel, Brighton.
It is clear from post mortem appearances that we are dealing with two
^?ff0ron+- natterns of injury, namely a number of victims who showed the
c l a s s i c
appearances of traumatic asphyxia and other where the classic
signs of traumatic asphyxia were absent or slight.
The differen
•
t ^ t h in k
relevant in respect of the precise mechanism by which each
i n d ^ i d u a l died
It may well be that some confusion has developed over
the use of the term traumatic asphyxia.
in the classic sense traumatic asphyxia is taken to imply injuries caused
by the application of mechanical pressure to the chest and
in some
i stances, the abdomen, so that death results from asphyxiation.
The
mechanism of asphyxiation in the classic case is thought to be twofold.
First there is a mechanical impedence of the movement of the chest w a n
a ^ diaphragm, thereby severely restricting inspiratory ^ resP“ a*°2_
movements.
The second mechanism and one which accounts for t
striking findings found in cases of traumatic asphyxiqa is compression
of the chest and abdomen resulting in direct compression over the
superior vena cava, thereby causing a sudden and dramatic rise in th
Pressure within the superior vena cava resulting in engorgement of the
b 1ood vesseisin the head and neck.
It is this displacement of blood
into the superior vena cava and the failure to drain blood |romthe
superior vena cava which accounts for the swelling of the f* ^ a l features
and the gross petechial haemorrhages so regularly seen in the face, neck
and chest above the level of constriction.
•
Where no obstruction to the venous circulation occurs then the usual
sians of asphyxia are present but not those of the classic traumatic
asphyxia 1 death. The face may be suffused and cyanosed and there may be
fine petechial haemorrhages, in some instances scanty or even absent. The
facial features do not appear strikingly swollen and the coarse petechial
haemorrhages are not apparent.
DEPARTMENT OF FORENSIC MEDICINE
GUY’S HOSPITAL
(UNIVERSITY OF LONDON)
Dr. I.E. WEST, M 3 ., Ch-B., RR.C.Path., DJMJ.
Dr. R.T. SHEPHERD B-Sc„ M.B., B.S„ M.R.CJPath., DJM.J.
Direct Telephone Line 071-407 0378 / 071-403 1118)
(Fax:071-4037292)
UNITED MEDICAL AND DENTAL SCHOOLS
GUTS AND ST. THOMAS'S HOSPITAL
LONDON BRIDGE, SE1 9RT
TELEPHONE: 071-955 5000 Ext: 3118/3119
Unfortunately it has become a habit for pathologists to call all such
deaths traumatic asphyxia and it may well be correct m one sense inas
much as trauma to the chest has resulted in the mechanical obstruction
of respiration. In pathological terms there is probably little relevance
in distinguishing between the two mechanisms as the term merely implies
that death has resulted from a mechanical obstruction to respiration
resulting from pressure being applied to the torso.
I^_;linical terms however there does seem to be a difference in the two
different types of traumatic asphyxia with a much graver prognosis being
present in those where there has been evidence of a sudden and acute
severe rise in the venous pressure in the upper part of the body. In fact
most of the individuals who suffer from this classic form of traumatic
asphyxia do not survive if they are severely affected and not rescued
rapidly.
Where the individual suffers primarily an obstruction to his movements
of respiration death will occur as the result of hypoxic damage to the
brain. This may take a much longer time than in individuals who have
been crushed so impedence of the venous return to the heart occurred.
Indeed
some
individuals
will
survive
but
remain
permanently
neurologically damaged as a result of suffering severe anoxic cerebral
injury.
It is probable that a period of at least some 10 minutes or so would be
necessary before one would be able to state categorically that absent
^
>iratory movement would lead to death. Consciousness may be lost quite
rapidly but where the obstruction has not been complete consciousness may
take a considerable time to be lost. I have experience of cases where
individuals have died through anaesthetic accidents whereby no oxygen was
being supplied to the lungs whilst they were paralysed during surgery.
In two of the cases in excess of 10 minutes elapsed before the surgeon
noticed that the heart action was in the terminal stages of failure.
It is also known that individuals who have suffered severe hypoxic damage
may not die immediately.
They may be recovered unconscious with an
active circulation but the circulation rapidly fails despite all attempts
at resuscitation. This may well represent concomitant damage to the heart
muscle leading to what is in effect a heart attack (anoxic myocardial
infarction).
Severe hypoxia of several minutes duration would be
necessary for this to occur. It is therefore possible that a young man
who had been asphyxiated by being crushed, would be capable, after being
removed from danger, of some conscious activity but could still die as
a result of hypoxia in the ensuing minutes.
DEPARTMENT OF FORENSIC MEDICINE
GUY'S HOSPITAL
(UNIVERSITY OF LONDON)
Dr. LE. WEST, MJB., ChJ3„ F.R.C-Padu, D.M J .
Dr. R.T. SHEPHERD B-Sc., M i . B.S., M.R.C-Pailu, D.M.J.
Direct Telephone Line 071-407 0378 / 071-403 1118)
(Fax:071-4037292)
UNITED MEDICAL AND DENTAL SCHOOLS
GUTS AND ST. THOMAS'S HOSPITAL
LONDON BRIDGE. SE1 9RT
TELEPHONE: 071-955 5000 Ext: 3118/3119
Anoxic brain damage could also be aggravated by the failure to maintain
a patent airway in individuals who were unconscious but still, capable of
respiration when retrieved from the crowd.
The failure to place the
individual in the recovery position, for instance, could lead to
subsequent respiratory obstruction.
Experience from a number of instances where individuals have died from
t^unatic asphyxia has also demonstrated that not all individuals appear
IPaave been effected at the same time. Some could have been effected by
movement of the crowd in the minutes after the disaster occurred. Others
could have had only partial or incomplete respiratory obstruction
initially and then either suffered complete mechanical obstruction of
respiration or died as the result of prolonged incomplete respiratory
obstruction. This could take many minutes to cause death and it is
entirely possible that death would occur more than 15 minutes after the
incident began.
I have not seen the post mortem photographs and therefore am having to
rely solely on the description provided in the post mortem reports. I
will deal with each case individually.
1.
£
Paul Carlisle - He was examined by Professor Usher who describes
suffusion of the upper body and petechial haemorrhages on the
forehead, eyelids and within the conjunctivae.
These would be
consistent with the classic traumatic asphyxia whereby there has
been a mechanical obstruction and mechanical interference with the
circulation.
2.
Richard Jones - He was examined by Professor Usher who again found
signs which would be consistent with the classic features of
traumatic asphyxia. The petechial haemorrhages noted in his loins
are probably the result of pressure causing local obstruction to the
circulation in that area.
3.
Ian Glover Again examined by Professor Usher. The examination
revealed changes of asphyxia, ie the cyanosis and visceral
haemorrhages.
The signs of venous obstruction were relatively
slight and in the form of small petechial haemorrhages in the upper
eyelids and conjunctiva of the left eye.
There were scanty
petechiae also found in the larynx.
In my opinion he has died
primarily as the result of impedence of respiration and any
interference with his venous circulation was minimal.
4.
Peter Tootle
- Was examined by Dr. Slater. Dr. Slater described
changes in Mr. Tootle which are consistent with a degree of classic
traumatic asphyxia but I suspect that the main reason for death has
been compression of the chest resulting in impedence of respiratory
DEPARTMENT OF FORENSIC MEDICINE
GUY'S HOSPITAL
(UNIVERSITY OF LONDON)
Dr. I.E. WEST. M i., Ch-B., F.R-C.Path.„ D.MJ.
Dr. R.T. SHEPHERD B-Sc„ M.B., B.S„ M.R.CJ?«du D.M.J.
Direct Telephone Line 071-407 0378 / 071-403 1118)
(Fax:071-4037292)
UNITED MEDICAL AND DENTAL SCHOOLS
GUVS AND ST. THOMAS'S HOSPITAL
LONDON BRIDGE. SE19RT
TELEPHONE: 071-955 5000Ext: 3118/3119
movement. Without the post mortem photographs I am not clear as to
why Dr. Slater feels that there has been intensive blunt compression
of tlie right side of his face.
5.
.[s-
A
0.
Kevin Williams
Was examined by Dr. Slater who describes the
external features of classic traumatic asphyxia with cyanosis of the
face extending onto the chest with numerous petechial arid larger
haemorrhages on the face and neck. He found bilateral'fractures of
the hyoid bone and of the superior horns of the thyroid cartilage
on both sides of the larynx^ These appear related to a number of
linear abrasions over the front of his neck and on the undersurface
of the chin. There appears to have been local pressure to his neck.
It was possible that when he was crushed in the crowd, the front of
his neck was pushed against some rigid 'structure.
It is also
possible that, for instance, he could have been trodden on during
the panic subsequent to the incident occurring.
I do not believe it is possible to say how long consciousness would
have been retained but he certainly would not have become
unconscious between 3 and 5 seconds of being crushed. Again I would
not agree with Dr. Slater in estimating how long the deceased would
have survived. Although he has suffered injuries to the neck these
are by no means invariably fatal and can be seen in those surviving,
strangulation and quite striking signs of classic traumatic asphyxia
can be seen in individuals who survive crush incidents because they
are removed from danger in time to prevent death. As I have already
indicated he could well have survived for a considerable period,
well beyond 3.15 pm.
He suffered convulsions as the result of anoxic brain damage.
Whether Mr. Brooder saw convulsions or twitching is irrelevant.
A dead body neither convulses or twitches. Dr. Gompert's point that
bodies may twitch after brain stem death: has taken place is, of
course, correct and to some degree reflects the dilemma over
precisely defining death.
One sees it in individuals who are
maintained on a respirator but whose heart is still functioning.
One also may see it during the process of dying as the heart is
stopping and for a very short period after the heart stops. This
phenomenon only occurs for a very short period after death unless
muscles are electrically stimulated. Twitching movements, however,
suggest that one is much more likely to be dealing with a live body
than with a dead one.
The evidence of Special Constable Martin is difficult to refute in
some respects. Whilst it is possible for an individual examining a
dead body to mistakenly feel an apparent pulse it is uisually
difficult to be mistaken over whether somebody is making breathing
DEPARTMENT OF FORENSIC MEDICINE
GUY'S HOSPITAL
(UNIVERSITY OF LONDON)
Dr. I.E. WEST. M B , Ch-B., F.R.CPath., D.M J .
Dr. R.T. SHEPHERD B.Sc„ M J , B.S., M-R.CJath.. D.M.J.
Direct Telephone Line 071 -407 0378 / 07M 03 1118)
(Fax: 071-4037292)
UNITED MEDICAL AND DENTAL SCHOOLS
GUY’S AND ST. THOMAS’S HOSPITAL
LONDON BRIDGE, SE1 9RT
TELEPHONE: 071-955 5000 E xt 3118/3119
movements or not. I am, of course, making the assumption here that
when the term breathing is used, that we are referring to movements
of respiration and. not merely sounds.
Sounds frequently emanate
from the air passages of a recently dead body when it is being
moved.
6.
^
Gary Church - He was examined by Dr. Slater who found changes
which would be consistent with classic traumatic asphyxia. He had
a dislocated right sternoclavicular joint. This type of injury is
most likely to occur as the result of falling. It would require
very severe crush injuries to dislocate the sternoclavicular joint
and the post mortem findings do not appear to reflect severe local
pressure on the chest or shoulder area.
It is possible that he
received this injury as the result of falling over in an attempt to
escape and has suffered pain and discomfort consequent upon this
injury.
7.
Michael David Kelly - He was examined by Dr. John Clark who found
non specific signs of asphyxia; the external appearances do not show
evidence of classic traumatic asphyxia. The petechial haemorrhages
on his right arm I am sure reflect a obstruction to the circulation
in the arm caused by local pressure.
The internal examination
revealed no other explanation for death other than it having
resulted from anoxia and it is probable here that we are dealing
with a case where there is no evidence whatsoever of obstruction to
the large veins in the body but where death has occurred as the
result of progressive cerebral anoxia resulting from prolonged and
severe compression of the chest.
^ Kelly was treated as described by PC Maughan and apparently
successfully resuscitated then it is possible that he has died as
the result of hypoxic damage affecting his heart or as the result
of some other form of respiratory obstruction. He appears not to
have been placed in the recovery position and this may well be
material. There is nothing to indicate that this man was definitely
dead by 3.15pm;
indeed the evidence available to me suggests
otherwise.
8.
Philip Hammond - this young boy does not bear the classic signs
of traumatic asphyxia although there are generalised asphyxial signs
and evidence of anoxic damage to the brain.
Dr. Slater who
performed the post mortem found extensive haemorrhage in both lungs
and a laceration of the right lung associated with a fracture of the
right ^2nd rib. I think the death of this young man is rather more
complicated than some of the other cases. There is certainly
evidence that he has suffered from asphyxia and there is evidence
in his brain of anoxic damage.
However, the primary pathology
DEPARTMENT OF FORENSIC MEDICINE
GUY'S HOSPITAL
(UNIVERSITY OF LONDON)
Dr.LE.WEST. M-B„Ch.B„F.R.C.Path.,D.MJ.
Dr. R.T. SHEPHERD B.Sc., M-B-. B.S.. M.R.CJ»ath.. D.M.J.
Direa Telephone Line 071-407 0378 / 071-403 1118)
(Fax: 071-403 7292)
•
UNITED MEDICAL AND DENTAL SCHOOLS
GUY’S AND ST. THOMAS’S HOSPITAL
LONDON BRIDGE, SE1 9RT
TELEPHONE: 071-955 5000 E xt 3118/3119
appears to be in his lungs which were bruised with a laceration of
the right lung associated with a rib injury. The rib injury and
bruising of the adjacent intercostal spaces suggests a localised
pressure or impact in that region of the right chest. It is likely
to have been due to localised pressure, probably on the young man's
back, forcing the right side of his chest against an object causing
the right sided ribs to be forced inwards towards the spine. If
this pressure were maintained then death would undoubtedly occur
very rapidly but I would have expected to have found some.evidence
of the more classic changes associated with traumatic asphyxia. If,
however, the pressure is relieved then death from injuries of this
type may take considerable time to supervene. Unconsciousness is
likely to be fairly rapid but death could have taken a substantial
number of minutes and it would be impossible, from a medical point
of view, to state that this boy was dead at 3.15 pm.
In conclusion there is clear evidence that some of the victims have
suffered severe traumatic asphyxia in the classic sense in which the term
is employed. Unconsciousness is likely to have occurred quite rapidly,
in probably somewhere between 15 and 45 seconds but death would have been
delayed for a number of minutes. In those who where severely crushed so
the venous drainage from the head was impeded then it is probable that
death would have occurred within 10 minutes of sustained pressure
commencing.
If the pressure was not continuous survival could be for
a longer period.
M
the individuals who have scanty signs or no signs of traumatic
asphyxia it is much more difficult to predict the survival time.
To
reduce the survival time to a very short number of minutes would require
continuous sustained severe compression of the chest. Because of the
nature of the incident it is impossible in many instance to know when
mechanical compression of the chest would have commenced. I feel it is
impossible to state purely from the medical point of view that a number
of the young men that I have indicated above could not been alive at 3.15
pm. Those dying as the result of anoxic damage consequent to their chests
being crushed could well have survived for a much longer period only to
die subsequently from the effects of irreversible anoxia.
Iain Eric West, M.B., CK.B., F.R.C'TP^fcW. , D.M.J. ,
Consultant Forensic Pathologist,
Director, Department of Forensic Medicine,
United Medical Schools of Guy's and St. Thomas1,
Guy’s Hospital,
London, SE1 9RT.
1
MICHAEL KELLY
(1)
_
I opened the Inquest on Michael Kelly oiT"l8th April 1989 and
evidence of identification was taken.
The autopsy was
carried out by Dr. Clark.
(2)
On 1st May 1990 the Inquest concerning Michael Kelly was
reconvened.
Mr. Fraser appeared for the deceased's family.
I explained the procedure that I was proposing to adopt.
No
objection was made by Mr. Fraser.
(3)
Dr. John Clark cave evidence and in answer to me stated:-
"Cause cf death was crush asphyxia. This was based on
findings of signs of asphyxia in his lace. Eis face was
rather congested and had a bluish discoloration. These
changes, I have to say, were fairly mild in comparison to a
lot of the other people and one of the other features of
asphyxia is to find little haemorrhages on the skin. These
were not in fact present".
" ... In any event there was nothing to indicate he suffered
for any great length of time. He probably lost
consciousness within a short period of time, 10 or 15
seconds or so, and then knew nothing about it after that.
As I said, there were not any major injuries internally".
Mr. Fraser had no questions for Dr. Clark.
(4)
Dr. Clark was a Forensic Pathologist from the University of
Glasgow who had been in Sheffield on the weekend of the
tragedy.
Towards the end of my questioning he said in an
entirely unsolicited comment after I had thanked him for his
invaluable assistance:-
,IN THE HIGH COURT OF JUSTICE
CASE C0/10Q9/92
jQUEEN'S BENCH DIVISION
|CROWN OFFICE LIST
jIN THE MATTER OF AN APPLICATION FOR A JUDICIAL REVIEW
jBETWEEN
REGINA
AND
HER MAJESTY'S CORONER FOR SOUTH YORKSHIRE
EX-PARTE
STRINGER AND OTHERS
AFFIDAVIT
11, JEREMY JOHN MURRAY HAWTHORN of Malcolm J Gregg & Co Solicitors
of 31 North John Street, Liverpool 2, MAKE OATH and say as
fol 1ows:-
1.
I have the conduct of this matter on behalf of the
Applicants and make this Affidavit further to my Affidavits
|sworn herein on 5th May 1992, 11th September 1992 and my
|Affidavit as to service sworn on 29th April 1993.
I have been
|asked to provide a fuller Affidavit as to the chronology of
events which form the background to this Application.
2.
The significant dates are as follows:-
i
i15.4.89
Hillsborough Disaster
;17.4.89
Lord Justice Taylor appointed to conduct an
;
Ihquiry.
18.4.89
Inquests formally opened by the Respondent and
adjourned.
4.8.89
Interim Report of Lord Justice Taylor.
10.10.89
It is announced that disciplinary papers have
been served on some Police Officers.
29.1.90
Final Report of Lord Justice Taylor.
18.4.90
Inquests resumed - "mini inquests".'
4.5.90
Conclusion of "mini inquests".
Inquest proceedin
further adjourned.
19.6.90
"Quantum Hearings" in civil proceedings before
Mr Justice Hidden where the issue is "Proximity"
(Alcock and others).
25.6.90
"Quantum Hearings" in civil proceedings before
Mr Justice Hidden where the issue is "Pre Death
Trauma" (Hicks and others).
Aug/Sept 1990
Decision of Director of Public Prosecutions not
to institute criminal proceedings.
8.10.90
"Apportionment Hearing" involving the three
Defendants to the civil proceedings.
The hearing
takes place in private and the outcome is not
disclosed.
j
19.11.90
Inquests resumed.
28.3.91
Verdicts of Inquests announced.
April 1991
Applicants and other bereaved receive advice of
Applicants and other bereaved meet informally
j
j
j
j
j
j
with Terry Munyard of Counsel.
]
the Steering Committee not to pursue matters
further.
Advice sought of Hillsborough Project
and Liverpool City Council Hillsborough Working
Party.
18.6.91
I am given to
understand by Ann Addlington, a Solicitor
j
employed by Liverpool City Council who attended
j
the meeting, his advice was that substantial
documentation would have to be considered and
that some expertise would be required as to
personal injury'litigation as well as Inquest
procedure.
June 1991
Applicant John Glover instructs Solicitor to
pursue Application for Judicial Review and to
apply for Legal Aid.
His Solicitor agrees
and confirms Application for Legal Aid has
been submitted.
Applicants Sandra Stringer
and Joan Tootle give similar instructions to
the same Solicitor.
June 1991
Advice sought from "Inquest" Organisation.
11.7.91
Police Complaints Authority directs that
Police Disciplinary charges be pursued against
two Officers.
7.10.91
House of Lords hears appeal on the issue of
"remoteness" (Alcock and others).
5.11.91
Applicants visit Edward Fitzgerald of Counsel
for a preliminary assessment.
It is still
believed that John Glover, Sandra Stringer
and Joan Tootle are awaiting a decision on
their Application for Legal Aid.
November 1991
John Glover discovers that an Application
for Legal Aid was never submitted.
November 1991
My firm agrees to act.
29.11.91
Edward Fitzgerald visits Liverpool and meets
with the Applicants.
Options discussed and
it is recognised that the most appropriate
approach is to submit a Memorial to the
Attorney General.
Applicants agree to supply
material regarding each'of the deceased.
December 1991
Applicant Joan Sinclair is delayed in compiling
her material by the terminal illness of her
mother.
15.12.91
Applicant Anne Williams meets with PC Bruder
and informs me of that conversation.
I
endeavour to contact that officer at his
place of work.
His shift arrangements make
a meeting difficult to arrange.
10.1.92
I meet with PC Bruder in company with an
Inspector.
He declines to make a further
statement but confirms that’'had"IfOeerf
called to attend the Inquest he would fiave'
done so and that if another Inquest were
held he would attend if called.
13.1.92
Announcement that the anticipated Police...
disciplinary proceedings will not take place.
I produce as JJH/1 a copy of the press release
to that effect issued by the Police'CompTaints
Authority.
January 1992
Individual statements of Applicants forwarded
to Counsel.
30.1.92
.......
House of Lords hears appeal on the issue of
"Pre Death Trauma" (Hicks and others).
18.2.92
Anne Williams receives two witness statements
and compares them with Inquest transcripts.
She then contacts and meets with WPC Martin.
12.3.92
I am advised by Counsel that an Application
for a Judicial Review
is also appropriate
although it is nonetheless right first to
submit the proposed Memorial.
Conference
date is provisionally set for 8.4.92.
8.4.92
Conference with Counsel and Applicants.
Draft Memorial is circulated and some
corrections proposed.
j
15.4.92
Memorial submitted to attorneyGeneral.
j
5.5.92
Application for a Judicial Reviewsubmitted
j
J
to Crown Office.
15.5.92
Application for Leave adjourned by Mr Justice
May, with
liberty to restore after the
Attorney General's decision on the Application
i
at a comparatively late stage was it decided to make this
Application for the reasons set out in the Form 86A herein.
SWORN AT LIVERPOOL
IN THE COUNTY OF MERSEYSIDE
DATED THIS
OF OCTOBER 1993
BEFORE ME
SOLICITOR/ COMMISSIONER FOR O/tfHS.
J c ^
1.
J ju~
HwfcM.
A-^lti,
Ji*|
On 11 J u l y , 19 91 the Polios complainta A u t h o r i t y d i r o o t o d that
charges
of
negl ect
of
duty
ba
pr«£ e r r e d
against
a
Chief
Superi n t a n d o n t and a Superintendent of the South Yorkshire Police,
in r a a p o c t
of thoir hand l i n g of polio® o p e r a t i o n s
Football Stadium on 15 April, 1989.
at H i l l s b o r o u g h
The Authority wish to make it
clear that their direction was not & finding of culpability, which
woul d be a jaattor oololy for tho diooiplinary tribunal hearing fcho
charges to adjudicate upon.
2
.
on 10 November, ie?l the CJiicf Suporintondont vao rotirod from
the Force on medical grounds with the consequence that h«. was, with
effect from that date, no longer subject to the Police Discipline
cod« and, fch«rofor», the disciplinary proceedings against him could
not continue.
3.
^ T h e s o u t h Yorkshir® Police have n o w sought: tha l « a v e
Authority
to
withdraw
the
single
charge
laid
of this
against
the
S u p e r i n t e n d e n t , w ho v&s subordinate to t h e C h i e f S u p e r i n t e n d e n t at
m
the r e l e v a n t
4■
tim®..
Tha Authority have considorad the regu.st with great cars and
conclude that it „oula be un;)ust onfl in(,pproprlata ^
charge againet the Superintendent alon.,
>«up.rior
officer.
iecretion,
. ,
in
we hove therefore
accordance
^
in the absence of his
^
exeroiaa
^
with
section S 3 ( 6) of Ule Polio* and
c r im in a l E v id e n c o A ct 1 9 R4 t-rs rr-;
v. ^
ACt
1984' to 91va
^ r o e leave not to proe.d
„
with the charge.
s.
<-« fron their original decision to
^
oormWar8d
The Authority do not
direot that Charges »gainet both officers
by . d i s c i p l i n a r y tribunal.
Ha » «
ottiofiod «■ a
,.oi. .Videnc. to support such charges.
ot th3 Chief
SuperinWent,
^
t ir»m e nt
The aubee^ent
on - i c a l
ground
has,
hov.ver,
cubctantially altorad th« pooition-
#
«
o£
The charges against the Chief Superintendent covared a m » * e 2
di£(« m t
*»
Auth« i t y
dir*=t.d
that
on.
«.
charges* should bo laid both again.t the Chief s u p e r i n t e n d e n t and
the S u p e r i n t e n d e n t ,
as his immediate subordinate.
This oharg
allayed failure to control the m o v w e n t of *upport«rs tsub»equen
the opening of Gate *c\ which was opaned in order to avert danger
to supporters outside the ground.
7.
We have made our deaieion to aacede to the South Yorkshire
Polio© requests for the following reasonsi
a.
the background to th« alleged failure to control thosa
• entering through Gate ‘C ‘ involved, intar alia, preliminary
planning
and .preparation
for
the po lice
operation
wh i c h
it
would be impossible to assess fairly at a disciplinary hearing
in
the
absenoa
of
the
offioer
in
charge
of
tho
whole
operation;
b.
the. primary responsibility,
entering
Gate
Superintendent;
-c
aid
not
for c ontrolling
lie
directly
speatatore
Kith
the
o.
precise nature of the Sup.rint.nd.nt' a respo n s i b U i t y
« M
c a n n o t b. ada^uataly « « . « «
in th. absence of hi. sup.r
o f f i o o r at. t h a tribunal;
«.
what is, in effect, a 3oint .Illation of negi«ct of duty
cannot
b«
fairly heard in th© abeenoa
of
th*
®oro
scni r
officer/
..
thc superintendent's . M U *
fully
in
th.
to put forward hi. o a »
absance of his superior
officer
would b.
impaired/ and
f,
it would
be an injustice to
the
superintendent,
who
conducted hiaseif with dignity at the Inquaat and throughout
the investigation*, for him to stand alono chax-<?#« with being
a, cauaa of the tragady which occurred and thus to appear to be
a
'scapegoat’ for faults vhiah nay well be attributable to
others.
8.
In reaching what we hava found to bs a very difficult decision
we have t-«.)cen in t o .acoount th« inturesus and Ceelings of those who
have mads complaint* about the polio© conduat,
tho Hillsborough
Families Support Group, all those who have suffered bereavement as
the result of the tragic events and tfte public interest on the one
hand *nd, on the other, justice to the Superintendent and th® sense
of
unfairness
which
would result from
continuing
the
against hire alone in the absence of hie superior a f i i c e r .
process
The
South
Authority h a v e therefore gra nt ed the xeavs s o u g h t by th©
Yorkshire
Police
dir<aot-ed i g & i n c t tho
not
to proceed
suparintendont.
wi t h
the
charge
vh~ch
“Tuc,
«i lt«-
^
<m.icytv
tr h-c
M a l c o l m j.
G r e g g ^ L G ^ .
*'«
JirtJ
Solicitors
to.J.GREGG, LL.B.
--------------------------------j. J. M. HAWTHORN, M.A.
Our Ref:
SECONDFLOOR
CENTURY BUILDINGS
31 NORTH JOHN STREET
LIVERPOOL L2 6RG
sphone:
Fax No.
DX
0 5 1 -2 3 8 9085
0 5 1 -2 3 6 4182
14175
JH/LF/H359
Office of the Attorney General
9 Buckingham Gate
LONDON
SW1E 6JP
3rd June 1992
Dear Sir
Re:
Coroners Act 1988 - Paul Carlile And Others
Hillsborough Inquest_____________________
We write further to our letter of 15th April 1992 which enclosed
a Memorial on behalf of the next of kin of six of those who lost
their lives in the Hillsborough Disaster of 15th April 1989.
There are certain details which we would wish to add to the Memorial
for your assistance:
1.
Omitted from the bundle was the middle page of the letter sent
to the Coroner by John Glover and dated 15th October 1990.
We now enclose a copy of that middle page which we have numbered
"50A" for inclusion at the appropriate point in Appendix 1.
2.
Also omitted was the transcript of the Inquest Hearing relating
to Ian Glover on 4th May 1990. We enclose herewith a copy
of that transcript.
3.
On Page 45 of Appendix 1 it is said incorrectly that "The jury
never heard from Joseph Glover himself". His evidence as given
to the jury appears at Pages 52 to 66 of Appendix 1. It is
however our submission in relation to his evidence that the
ruling of the Coroner in relation to the "cut off point" prevented
Continued
- 2 -
.—
Continued
him from contributing relevant evidence.
We further enclose herewith letters sent personally by your Memorialists
which are in support of their request that you grant leave under
section 13 of the Coroners Act 1988. Included with these is a
letter from Doctor Steven Crosby who is the General Practitioner
of the Parents of kevin Williams.
Yours faithfully
Enc.
11
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O n - ^ e iS tb A p n i \ 359 i'~Y~)uj
13 u e o r old b r o t h e r f t u | William C ad ile died a t -Hillsborrxiqh
■vSi’s i t h a s be€r> an tfxh^M^'bnd and € ^ o b c /^ l
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n&oteue 6tll fm f& ^ d tio n i^ a /d /n d ] f e t d oL h\$ inchest
\b is 'th ree ueeus since, m u brothers death and I -feel
he .sb/(I ha-6 n o t had -the \n q a isb h e t^as enabled -bo. i
f e d mo| brother has &e£n dfjar'itfed o f an 1nauest because he
died in 6 u d i a l a m e disasber. 'Vn&re was s-c-h a bncje cpp
.b&b^e&o -the mint - inauesb (rnocj f^ O j e n d -thd- ^Sunn^d jnaadSi
Cj^o\Jember 193 ij .Secauso o f di&tp\)nanes j^ero teas a
;&uiole<r>o€' j&nb e&uJd nob be^ heasd . I'better cxll evid en ce}
‘. nob <smaU p ieces y<shocJd b e h ea rd m comrb.
onkj &j\&es\(Us concerning PaaA Mno& ua^s p u t hfee
p a 6 i& S iC a lfo to b & b p e n h & ^ o s in a n d - t h e -bong
tooidcl
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unconc'i& ^s iJ<bh»n <second<s .Unotoare b o -Bne -fam) ly cxbbteZ
Umo
coroner had in h>6 p o sse ssio n o. .st^ r t& n e n t/
fic-'V) COr -Hoi\i ncj hu^sb(a p£\jch\atr'io nurse) Lchtch sta rted
ftxa-l locks CesnojOUS fo r ■S,cT'n€
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nob
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■from a octet six m onths o f t ^ r -the d is a s te r 1 .spoke
t o o W est iTf«dlancfcs ft>lice o f
a ^ d co rrb n u a lly asked'
ijhern on&,$hon£ feepjd ^na fin d . I
bdd fttu.1 had -clied
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Elbow Lane, Formby L37 4A W
Telephone:(07048) 78661
Fax:(07048) 32488
Our Ref:
SJC/CA
15th April 1992
TO WHOM IT MAY CONCERN
Dear Sir/Madam
Re:
Mr & Mrs J S Williams
In my opinion a further inquest on my patients son's death would
be beneficial to a more sustained emotional recovery from the
severe bereavement stress that both parents have been coping with
for years. The longer the delay 1 fear the longer it will take
for them to come to terms with Kevin's death.
Recently, more information concerning events at the scene have
improved their state of mind and although attendance at an inquest
would indeed by stressful, I am confident that they are able and
willing to deal with this most pressing and urgent matter.
Yours sincerely
Dr S J Crosb
^<T
Roger Parker
• Forbes Innes
•
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HILLSBOROUGH lN a m R Y TEAM
J MERVYN JONES MSc
DEPUTY CHIEF CONSTABLE
NECHELLS GREEN POLICE STATION
CORONER'S OFFICER
Furnival House
Furnival Gate
Eyre Street
Sheffield S1 4QN
Telephone: 0 7 4 2 -7 3 1 5 4 6
Fax
: 0 7 4 2 -7 3 1 4 8 3
Fowler Street
Birmingham B7 50A
Your Ref:
CHESHIRE CONSTABULARY
Police Headquarters
Chester CH1 2PP
Telephone: 0 2 4 4 -3 5 0 0 0 0 Ext 2091
Fax
: 0244
Our Ref:
Date:
JM J / F R
28t h M a r c h 1991
(
Dear Madam,
REQUEST FOR THE RELEASE OF INFORMATION
I refer
to y o u r letter r e g a r d i n g y our r e q u e s t f o r c o p i e s
of stat e m e n t s in
c o n n e c t i o n w i t h y o u r son Paul.
The p o l i c y o n the release of i n f o r m a t i o n is as
follows
The C h i e f C o n s t a b l e of S o u t h Y o r k s h i r e P oli ce i n v i t e d the W e s t M i d l a n d s Police
b a c k In A p r i l 1989 to u n d e r t a k e the i n v e s t i g a t i o n i n t o t he H i l l s b o r o u g h Disaster.
In f u l f i l l i n g this i n v e s t i g a t o r y role the W e s t M i d l a n d s P o l i c e c o n s t i t u t i o n a l l y
w e r e a c t i n g as the agents
of S ou th Y o r k s h i r e
Police.
The p o l i c y o n the release of i n f o r m a t i o n has
v a r i o u s l y b e e n d e t e r m i n e d by Lord
J u s t i c e T a y l o r , l ater the D i r e c t o r of P u bl ic
P r o s e c u t i o n s (in c o n j u n c t i o n w i t h the
P o l i c e C o m p l a i n t s A u t hority ), and the Coroner.
I n o w h a v e to loo k to South
Y o r k s h i r e P o li ce, as p r i n c i p a l s of the i n f o r m a t i o n , f or the p o l i c y in responding
to y o u r
requ est.
At the p r e s e n t time the p o l i c y of S o u t h Y o r k s h i r e P o l i c e d i r e c t e d to me is not to
r e l e a s e a n y i n f o r m a t i o n to a n y party.
This is b a s e d o n l e g a l advice that has been
g i v e n w h i c h i n d i c a t e s that i n f o r m a t i o n s h oul d o n l y be r e l e a s e d on the order of a
court whi c h could
include
that of the Coronet1.
I a m s o r r y I c a n n o t be any m o r e h e l p ful at the m o m e n t a n d as e x p l a i n e d at th^
tiuirt I m u s t d e c lin e your request.
Yours
faithfully.
J . Mervyn JONES,
Deputy Chief Constable.
*j«**!H
T ELEP HONE:
SHEFFIELD (0742) 768522
TELEX: 547996
FAX; (0742) 523243
S O U T H Y O R K S H I R E POLICE
POLICE H E A D Q U A R T E R S
SNIG HILL
SHEFFIELD S3 8LY
G M O O R E ESQ BA
ASSISTANT CHIEF CONSTABLE
v iscipline & Complaints)
Our ref:
ACC/AF/CJD HD /3 9
12 June 1991
Mrs S Stringer
Dear Madam
Thank you for your letter which was received on 11 June 1991 asking for
certain material arising from the Hillsborough Investigation.
The position
is that South Yorkshire Police have adopted a policy based on legal advice
that at the present time means that none of this type of material is released.
If there is any change in this policy I will write to you again.
I am very sorry to learn of your sorrow arising from the tragedy and would
extend my deep sympathy at your loss.
Yours f a i t h f u l l y
Assistant Chief Constable
SOUTH YORKSHIRE POLICE
POLICE HEADQUARTERS
SNIG HILL
SHEFFIELD
S3 8LY
TELEPHONE (0742) 768522
TELEX 547996
ALL COMMUNICATIONS SHOULD BE ADDRESSED TO “THE CHIEF CONSTABLE”
r
n
Ms D Carlile
Your Ref:
Our Ref: CCO/EB/NJP HD. 40
Date;,
L
17 September 1991
J
Dear Madam
I acknowledge receipt of your letter received in this office today.
Your
request is receiving attention and I will write again in due course.
Yours faithfully
Brian L Mole
Chief Superintendent
Discipline & Complaints
The officer dea"ng with this correspondence is
$
/
-f. ?P.s.P®?t'P.r.
Extension
............
ADM/1
4-2,
SOUTH YORKSHIRE POLICE
POLICE HEADQUARTERS
SNIG HILL
SHEFFIELD
S3 8LY
TELEPHONE (0742) 768522
TELEX 547996
ALL COMMUNICATIONS SHOULD BE ADDRESSED TO “THE CHIEF CONSTABLE
r
n
Ms D C a r l i l e ,
Your Ref:
Our Ref:
CCO/BLM/SB
HD.40
Date:
23 December 1991
J
L
Dear Ms Carlile,
Thank you for your letter which was responded to by the Chief Constable’s
Staff Officer, on the 13th November 1991.
As indicated in the Staff Officer's letter we were awaiting legal advice,
^ d I have to inform you that that advice directs us not to release any
information until such time as all discipline matters tave^beenjjinali s e d . ^
You will no doubt be aware that discipline matters are still p e n d i n g against
« e officer in South Yorkshire, and until such time as the outcome of that
matter is determined, I am unfortunately unable to release any material.
I can once again assure you that the photograph has not been forgotten,
and I will make every effort to release it as soon as I am in a positio
to do so.
Yours sincerely,
Brian L Mole
Chief Superintendent
The officer dealing with this correspondence is
SOUTH YORKSHIRE POLICE
POLICE HEADQUARTERS
SNIG HILL
SHEFFIELD
S3 SLY
TELEPHONE (0742) 768522
TELEX 547996
ALL COMMUNICATIONS SHOULD BE ADDRESSED TO “THE CHIEF CONSTABLE
r
“i
Mrs S Stringer
Your Ref:
Our Ref:
CCO/EB/NJP HD. 39
Date:
19 February 1992
J
L
Dear Mrs Stringer
Thank you for your letter of 17 January 1992 which has been passed for my
attention.
Please accept my apologies for the delay in replying.
trust you will accept that urgent attention is being given to the many
requests for copy statements and photographs which we have received.
Each
request is receiving individual consideration and therefore some delay may
be experienced in our final response to you.
I
I "will however write to you again as soon as I
positively to your request.
am in a position to respond
Yours sincerely
DJL'JLtLll
Li I 'iU X C
Chief Superintendent
Discipline & Complaints
The fficer dealing with thi? correspondence is A /C frte.f .In .s p .e q to .
ADM/1
B r e n tn a .ll..
^
Extension
$.421
SOUTH YORKSHIRE POLICE
POLICE HEADQUARTERS
SNIG HILL
SHEFFIELD
S3 8LY
TELEPHONE (0742) 768522
TELEX 547996
ALL COMMUNICATIONS SHOULD BE ADDRESSED TO “THE CHIEF CONSTABLE’
r
Mrs S Stringer
Your Ref:
Our Ref:
CCO/BLM/EB/LM HD39
Date:
4 March 1992
_l
L
Recorded Delivery No: N 842866
)
Dear
In response to your requests for material gathered in the Hillsborough Disaster
Enquiry I am now able to provide you with a copy of the photograph you seek.
Unfortunately the question of release of statements made by various
individiuals poses additional problems.
I trust that you will appreciate
that I am not trying to be evasive in this matter, but I feel it only proper
that I should seek the authority of the makers of statements before releasing
them to a third person.
I await that authority and should the statement makers
agree I will provide you with copies without delay.
May I take this opportunity of thanking you on behalf of the South Yorkshire
Police for the patience you have shown in awaiting the release of information
and would apologise for the delay.
Yours
£-*■
Chief Superintendent
pp Assistant Chief Constable
(Complaints & Discipline)
Enc:
Copy Photograph, copyright retained by Chief Constable,
South Yorkshire Police - not to be reproduced without permission.
The office dealing with this correspondence is
ADM/1
Insp Brentnall
Extension
8421
South Yorkshire Police
PLEASE REPLY TO
FORCE HEADQUARTERS ,
SNIG HILL,
SHEFFIELD.
S3 8 LY
TELEPHONE: (0742) 768522
FAX: 523411
r
Mrs S Stringer,
YOUR REFERENCE
OUR REFERENCE
CCO/BLM/EB/SB
HD39
DATE
1 April 1992
L
Recorded Delivery:
842897
Dear Mrs Stringer,
Reference is made to your request for copies of statements made during
the Hillsborough Disaster Enquiry.
Enclosed herewith are copies of statements where the makers have given
me written authority to release the documents.
Unfortunately, I still await a reply in respect of one statement and I
am sure that you would wish to know that I am making efforts to contact
the maker to seek his permission to release the statement to you.
May I take this opportunity of thanking you on behalf of the South
Yorkshire Police for the patience you have shown in awaiting the release
of information and would apologise for the delay.
Yours sincerely,
B L Mole
Chief Superintendent
Discipline and Complaints
t
ADM /1
Inspector Brentnall
THE OFFICER DEALING WITH THIS CORRESPONDENCE IS....................
8415
EXTENSION........................
South Yorkshire Police
Discipline and Complaints Department
Windsor Road, Sheffield, S8 8UB
PLEASE REPLY TO
Tel:
(0742)
Fax:
500700
r
(0742)
523855
1
YOUR REFERENCE
Mr L Heaven
OUR REFERENCE
D&C/JML/KG/SB HD66
DATE
16 September 1993
J
L
Dear Mr Heaven
I
refer
to
a
letter
received
from
Mrs Stringer,
a
copy
of
which
I have
attached for your information.
The material
Mrs Stringer
has
requested
was
not
introduced
at
the
inquest
and as such is not in the public domain.
It is the policy of South Yorkshire Police not to release
photographs and to date no such material has been released.
post
mortem
Please be assured that I do not wish to be obstructive and am eager to assist
in whatever way I possibly can.
Yaurs sincerely
J W Lowe
Onief Superintendent
Discipline and Complaints
PC Greenway
ADM /1
T h e
m e m b e r
of staff dealing with this correspondence is .............................
3068
Ext .............
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OFFICE OF H.M. CORONER
SOUTH YOR KSH IR E
(West District)
M E D IC O -L E G A L C EN TR E
W A T E R Y ST R E E T
SH E FFIE L D
S3 7ET
Telephone:
Sheffield (0742) 738721
H .M . C o ro n e r
Christopher P. Dorries
CPD/BMW
12th M a r c h 1992
A.
M.
Adlington,
Li ai son Officer,
H i l l s b o r o u g h W o r k i n g Party,
Li v e r p o o l City Council,
R o o m 42,
M u n i c i p a l Buildings,
Dale Street,
Liverpool,
L69 2DH.
De ar Sir,
Re;
Ian G LOVE R
(deceased)
Thank you for your letter of the 4th M a r c h c o n c e r n i n g the above.
You w i l l obviously a p p r e c i a t e the disa dv a n t a g e that I a m under in this m a t t e r
h a v i n g been app ointed to this juris d i c t i o n only at the end of last year.
I
have therefore i nheri ted a large amount of p a p e r w o r k relati ng to the
H i l l s b o r o u g h Inquest and I a m not p e r s o n a l l y familia r either w i t h this
pa p e r work nor w i t h the m a j o r i t y of the evidence at the Inquest.
I a m not quite sure w h a t is m e a n t by your request for "a copy of the West
M i d la nds Police Report".
You are aware, I a m sure, that Rule 57 of the
Coroners Rules 1984 i n d i cate s that a C o r o n e r shall supply an i n t e r e s t e d party
wi.th a copy of a Post M o r t e m Report, or n otes of eviden ce or of any doc ument
put in evidence at an Inquest.
On the basis of the inf orm a t i o n that I have I
cannot see h o w this s e ctio n w o u l d a pply to a n y t h i n g that cou ld be d e s c r i b e d
as a Police Report.
This does not n e c e s s a r i l y m e a n that Mr. & Mrs. G l o v e r cannot get to see
d o c u m e n t a t i o n outside the scope of Rule 57.
It simply means in m y v i e w that
they should apply to the P o l i c e for the release of any relevant d o c u m e n t a t i o n
rather than me.
I have of course n o t e d y o u r comment, that the family h a v e been a w a i t i n g
certain witness statements from the South Y o r k s h i r e Police and I hav e spoken
to the Officer d e a l i n g w i t h such requests a s k ing h i m to expedite any papers
req uested by Mr. & Mrs.
Glover.
If I can
k n o w and
Yours
assist Mr. & Mrs. G lover u nder the terms of Rule
I will give as m u c h help as I can.
faithljkrtTy
D U T X T E 5
H. M. Coron er
BMWABC
R86(K>
Fax: (0742) 726247
57 p l e a s e let
me
South Yorkshire Police
PLEASE REPLY TO
Discipline and Complaints Department
Windsor Road, Sheffield, S8 8UB
Tel:
(0742)
Fax:
500700
r
(0742) 523855
1
YOUR REFERENCE
Mr J Glover
OUR REFERENCE
D&C/JML/KG/SB HD69
DATE
22 September 1993
J
L
Dear Mr Glover
I refer to your letter to the Coroner requesting post mortem photographs.
The material you request was not introduced at the inquest and as such is
not in the public domain.
It is the policy of the South Yorkshire Police not to release post
photographs and to date no such material has been released.
Please be assured that I do not wish to be obstructive and am eager
in whatever way I possibly can.
Yours sincerely
J M^jowe
Chief Superintendent
Discipline and Complaints
ADM /1 The m em ber of staff d e a lin g with this correspondence is
mortem
to assist
_t x
M E D IC O -L E G A L C E N T R E
a
OFFICE OF H.M. CORONbR
w a te ry s tr e e t
*
x
S H E F F I E L D
SOL'TH YORKSHIRE
S 3
7 E T
Telephone:
H . M . C o ro n e r
Sheffield
(0742)
738721
C h r is t o p h e r P. D o rrics
17th February 1992
CPD/PAD
Mrs. A . E . Williams,
>Dear
M r s .
Williams,
,
Further to my letter of the 4th February I have n o w had the
opportunity of discussing your request with Dr. Popper.
It is apparent that the situation is not as simple as your letter
originally led me to believe.
The statements of Mr. Bruder and
WPC M a ^ I n were not tendered in evidence at the Inquest as such
rat her* it was a oase of the contents of the statements being referred
to w h e n either the Presenting Officer or the doctor were questioned.
I do however accept that short extracts from Mr. Bruder s statement
w er e quoted in this m a n n e r .
As a matter of general principle I should say that I might not
accept that Rule 57 of the Coroners R u l e s 19 84 therefore applie
to these statements.
However, having spoken both wi t h Dr. P°PP®
and Chief Superintendent Mole (who is now in charge of the paper
w o r k retained by So ut h Yorkshire Police) we feel that as you p e a r l y
are still very anxious that an exception can be mad e in this ca
.
.Accordingly I enclose copies of the statements of Mr. ^ d e r and
^WPC Martin.
There is also a ph o t o c o p y of a form compl
Y
Martin and referred to in her statement.
So far as the photographs are concerned it is not within my ability
to let you have copies and I have referred this to
le
-th C O nies
Superintendent Mole.
He informs me that he will supp y y
of the photographs requested subject only to confirma
than with
copyright of those photographs lies with the police ra
. •
individual news media.
Mr. Mole is in the process o
o g
.
photographs etc. for a large number of relatives an
ao _ 4-cw i l l ask you to be patient whilst he deals with all requ
I hope that provision of these documents will ul t i ma t e l y
in coming to terms w i t h the terrible tragedy which has
your life.
Yours sincerely,
C.P. Dorries
H.M. Coroner
Fax:
(0742) 7 2 6 2 4 7
^
IN THE HIGH COURT OF JUSTICE
CASE CO/1009/92
QUEEN'S BENCH DIVISION
CROWN OFFICE LIST
IN THE MATTER OF AN APPLICATION FOR JUDICIAL REVIEW
BETWEEN:-
REGINA
AND
HER MAJESTY'S CORONER FOR SOUTH YORKSHIRE
EX-PARTE
STRINGER AND OTHERS
AFFIDAVIT
I, SANDRA STRINGER of
MAKE OATH
and say as follows:1.
I am one of the Applicants herein and I make this Affidavit
having seen the Affidavit of the Respondent Coroner sworn herein
on 10th September 1993.
2.
I respectfully refer to page 10 of the transcript of the
! "Business Meeting" held on 30th October 1990, which is exhibited
j
| to the said Coroner's Affidavit.
I note that the Coroner there
s announced a decision not to circulate copies of statements that
i
had been made by prospective witnesses.
i
: 3.
The effect of this was that Counsel who appeared for the
bereaved families only had copies of statements if the witness
concerned had managed to retain a copy at the time the statement
was made.
I understand that when Stephanie Jones, daughter of
my fellow Applicants Leslie and Doreen Jones, made her witness
statement it was insisted that a copy be retained and that this
assisted Counsel when she gave evidence.
4.
By contrast, Counsel appearing for the Police appeared to
have available copies of all witness statements and witnesses
were very frequently cross examined by reference to the statements
5.
It was further my observation that Police Officers due to
give evidence before the Inquest had with them photocopies of thei
own statements which they were free to study at length, to discuss
with colleagues and even to take with them into the witness box.
In contrast, supporters did not have such copies unless they had
retained a copy vyhen they made the statement.
If they did not
have a copy, they only had a brief opportunity to read them in
noisy and crowded conditions for a few minutes before having to
give them back and then give evidence and face cross examination.
6.
It was further my observation that the warning against self­
incrimination was given to the majority of Police Officer witnesse
but was not given to supporters even though they were invariably
cross examined as to their alcohol intake and as to their conduct
while at the ground.
7.
In my view these apparent disparities of treatment may well
have affected the content and quality of the evidence put before
the jury in the Inquest proceedings.
SWORN AT LIVERPOOL
IN THE COUNTY OF MERSEYSIDE
DATED THIS
f t t ^ F / n r m R F R 1QQ3
BEFORE ME SOL ICITOR/COMMI SSJOMER-FOR OftlHS
i IN THE HIGH COURT OF JUSTICE
CASE C0/10Q9/92
! QUEEN'S BENCH DIVISION
j
j
—
CROWN OFFICE LIST
I IN THE MATTER OF AN APPLICATION FOR JUDICIAL REVIEW
I
BETWEEN
REGINA
AND
HER MAJESTY'S CORONER FOR SOUTH YORKSHIRE
EX-PARTE
STRINGER AND OTHERS
AFFIDAVIT
MAKE OATH and
I, JOHN GLOVER of
say as follows:| 1.
I am one of the Applicants herein and make this Affidavit
| upon seeing the Affidavit of the Respondent Coroner sworn herein
I on 10th September 1993.
i
i
2.
I note that in the "continuity chart" relating to my son Ian
1 Glover (which begins at Page 101 of Section 8 of the Exhibits)
!
j
there is reference to a PC 1100Fojut and what
Ipresume is a
! quotation from his witness statement to the effect that Ian
;
was
;
j
!
! "vomitingas we carried him".
3.
Although I knew at the time of the Inquest that PC Fojut had
made a statement naming my son, I never saw either the continuity
j
sheet or his witness statement.
I have never before known that
he referred to Ian as "vomiting" and I was most upset to read it
here for the first time.
4.
I am aware that at the "mini inquest" hearing regarding Ian
doubt was expressed as to whether the Officer had made a correct
identification.
By reason of what my son Joseph told the Police
it was assumed that the Officer was mistaken.
PC Fojut was however
not called to give evidence for his identification to be tested.
Nor have I to date been able to see his witness statement, so I
still do not know what he was saying.
SWORN AT LIVERPOOL
IN THE COUNTY OF MERSEYSIDE
(
THIS
DAY O p OCTOBER 1993
BEFORE
SOLIfllTOR/COMMISSIOfO TOR OATH
I