# The Hillsborough Stadium Disaster Interim Report/Part 3

PART III - CONCLUSIONS
CHAPTER 16 BRIEF SUMMARY OF CAUSES
265. The immediate cause of the gross overcrowding and hence the disaster was the failure, when gate C was opened, to cut off access to the central pens which were already overfull.
266. They were already overfull because no safe maximum capacities had been laid down, no attempt was made to control entry to individual pens numerically and there was no effective visual monitoring of crowd density.
267. When the influx from gate C entered pen 3, the layout of the barriers there afforded less protection than it should and a barrier collapsed. Again, the lack of vigilant monitoring caused a sluggish reaction and response when the crush occurred. The small size and number of gates to the track retarded rescue efforts. So, in the initial stages, did lack of leadership.
268. The need to open gate C was due to dangerous congestion at the turnstiles. That occurred because, as both Club and police should have realised, the turnstile area could not easily cope with the large numbers demanded of it unless they arrived steadily over a lengthy period. The Operational Order and police tactics on the day failed to provide for controlling a concentrated arrival of large numbers should that occur in a short period. That it might so occur was foreseeable and it did. The presence of an unruly minority who had drunk too much aggravated the problem. So did the Club's confused and inadequate signs and ticketing.
CHAPTER 17 THE FA's CHOICE OF GROUND
269. The FA were strongly criticised by the Football Supporters' Association and others for having imposed the Hillsborough venue on Liverpool for a second year running. The Liverpool supporters had to travel much further to Sheffield than their Nottingham rivals. The police required that if the match was to be at Hillsborough at all, Liverpool would have to have the west and north side accommodation. The disadvantages of that and the disparate numbers of home supporters of the two clubs have already been set out. Liverpool had had to knuckle under to the arrangement in 1988. They resented having it imposed in 1989. To hold the match at Old Trafford would have been a perfectly good and acceptable alternative. Indeed, the FA nominated Old Trafford as the venue for the replay should there be a draw at Hillsborough.
270. Mr Kelly, the FA's Chief Executive, sought to give reasons for preferring Hillsborough, but the only one which seemed to have any validity was that the 1988 match had been considered a successfully managed event. He admitted that a telephone call from the Chief Executive of the Liverpool Club protesting and putting Liverpool's case had not been mentioned to the FA committee which finally decided the venue. Mr Kelly frankly conceded that "there was an element of unfairness" to Liverpool in choosing Hillsborough for a second time. I think the decision was ill-considered. No doubt in future the FA will be more sensitive and responsive to reasonable representations.
271. However, it was not suggested that the choice of venue was causative of this disaster. The only basis on which that could be said would be that, because of its layout, the Leppings Lane end was incapable of being successfully policed for this semi-final. I do not believe that to be so.
CHAPTER 18 POLICE
Choice of Ends by the Police
272. There was much bitterness amongst Liverpool supporters that they had to make do again for the second year with the Leppings Lane end. But, cogent as their complaints were, they amounted to reasons for choosing a different ground altogether. Given Hillsborough as the venue, I think the police were right to allocate the sections of the ground as they did. The direction of arrival and the need for segregation made it sensible and to reverse the 1988 arrangements would have made for confusion. As with choice of venue, I do not consider choice of ends was causative of the disaster. Had it been reversed, the disaster could well have occurred in a similar manner but to Nottingham supporters.
Police Planning
273. The Operational Order for 1989 left much unsaid. Apart from the lack of any provision for late or congested arrivals, or any provision for the avoidance of overcrowding on the terraces, there was a number of other omissions. For example, there was no specific deployment of officers to man the perimeter gates. The Order did not detail the duties of the mounted officers deployed at the Leppings Lane entrance, who included Liverpool officers to assist in marshalling their own fans. The duties of Superintendents (especially Mr Greenwood and Mr Marshall) were not defined so as to achieve clarity and efficiency. By an oversight, the provision requiring mobile (Tango) patrols to assist the emergency services was omitted from the text.
274. The 1988 Order was never substantially reviewed save to reduce the number of officers deployed in shopping areas and to emphasise in capital letters the embargo on fans having access to the pitch. Satisfaction with the 1988 event led to complacency. That some thought the pens overfull in 1988 and that the tunnel was closed off on that occasion did not figure in or influence the plan for 1989.
{{anchor+|275. Mr Duckenfield was promoted and put in charge of F Division only 21 days before this semi-final. The pre-planning was already in progress under Mr Mole who had been in command both in 1987 and in 1988. It might have been wiser to have left Mr Mole in charge of this operation. On the other hand, it is quite understandable that Mr Duckenfield should have been expected to take command of events in his Division from the date of his promotion. In view of his lack of experience at Hillsborough and of a semi-final match, however, it was imperative that he be fully briefed and that he should also brief himself.
276. He was not informed of the crushing incident in 1981 nor did he make inquiries which would have revealed it. He did not know the arrangement as between Club and police for monitoring the Leppings Lane terraces. He did not visit and tour the ground before approving the Operational Order. Although he attended a match on 2 April, there was only a small crowd present and he left control of the game to the Superintendents.
Policing on the Day
277. One of the regrettable features of the football scene as it has developed is the enormous expenditure of money, time and effort in employing large numbers of police all over the country to guard against the sort of disorder and misbehaviour which have become endemic. Police management of a game of football has become a military operation. The problems faced and the responses received must be disheartening and may have tended to harden police attitudes to supporters in general.
278. It is fair to state that over many years the South Yorkshire Police have given excellent service to the public. They have handled crowd problems sensitively and successfully at a large number of football games including major matches, during strikes in the coal industry and the steel industry, and in other contexts. Unfortunately, their policing on 15 April broke down in the ways already described and, although there were other causes, the main reason for the disaster was the failure of police control.
279. In all some 65 police officers gave oral evidence at the Inquiry. Sadly I must report that for the most part the quality of their evidence was in inverse proportion to their rank. There were many young Constables who as witnesses were alert, intelligent and open. On the day, they and many others strove heroically in ghastly circumstances aggravated by hostility to rescue and succour victims. They inspired confidence and hope.
280. By contrast, with some notable exceptions, the senior officers in command were defensive and evasive witnesses. Their feelings of grief and sorrow were obvious and genuine. No doubt those feelings were intensified by the knowledge that such a disaster had occurred under their management. But, neither their handling of problems on the day nor their account of it in evidence showed the qualities of leadership to be expected of their rank.
​281. Mr Duckenfield leant heavily on Mr Murray's experience. Between them they misjudged the build-up at the turnstiles and did little about it until they received Mr Marshall's request to open the gate. They did not, for example, check the turnstile figures available from Club control or check with Tango units as to the numbers still to come. They did not alert Mr Greenwood to the situation at the fringe of his area of command. They gave no instructions as to the management of the crowd at Leppings Lane. Inflexibly they declined to postpone kick-off.
282. When Mr Marshall's request came, Mr Duckenfield's capacity to take decisions and give orders seemed to collapse. Having sanctioned, at last, the opening of the gates, he failed to give necessary consequential orders or to exert any control when the disaster occurred. He misinterpreted the emergence of fans from pens 3 and 4. When he was unsure of the problem, he sent others down to "assess the situation" rather than descend to see for himself. He gave no information to the crowd.
283. Most surprisingly, he gave Mr Kelly and others to think that there had been an inrush due to Liverpool fans forcing open a gate. This was not only untruthful. It set off a widely reported allegation against the supporters which caused grave offence and distress. It revived against football fans, and especially those from Liverpool, accusations of hooliganism which caused reaction not only nationwide but from Europe too. I can only assume that Mr Duckenfield's lack of candour on this occasion was out of character. He said his reason fornot telling the truth was that if the crowd became aware of it there might be a very hostile reaction and this might impede rescue work. He did not wish to divulge what had happened until he had spoken to a senior officer. However, reluctance to tell Mr Kelly the truth did not require that he be told a falsehood. Moreover, although Assistant Chief Constable Jackson was at hand, Mr Duckenfield did not disclose the truth to him until much later.
284. The likeliest explanation of Mr Duckenfield's conduct is that he simply could not face the enormity of the decision to open the gates and all that flowed therefrom. That would explain what he said to Mr Kelly, what he did not say to Mr Jackson, his aversion to addressing the crowd and his failure to take effective control of the disaster situation. He froze.
The Police Case at the Inquiry
285. It is a matter of regret that at the hearing, and in their submissions, the South Yorkshire Police were not prepared to concede they were in any respect at fault in what occurred. Mr Duckenfield, under pressure of cross-examination, apologised for blaming the Liverpool fans for causing the deaths. But, that apart, the police case was to blame the fans for being late and drunk, and to blame the Club for failing to monitor the pens. It was argued that the fatal crush was not caused by the influx through gate C but was due to barrier 124a being defective. Such an unrealistic approach gives cause for anxiety as to whether lessons have been learnt. It would have been more seemly and encouraging for the future if responsibility had been faced.
CHAPTER 19 THE CITY COUNCIL AND THE SAFETY CERTIFICATE
286. The performance by the City Council of its duties in regard to the Safety Certificate was inefficient and dilatory. The failure to revise or amend the certificate over the period of three years preceding this disaster, despite important changes in the layout of the ground, was a serious breach of duty. There were, as a result, no fixed capacities for the pens. The certificate took no account of the 1981 and 1985 alterations to the ground.
287. A number of breaches of Green Guide standards were permitted and persisted eg the spacing of the crush barriers, the width of perimeter gates and the gradient in the tunnel (1 in 6 as against the Green Guide maximum of 1 in 10).
288. The Advisory Group lacked a proper structure; its procedure was casual and unbusinesslike. Its accountability to the General Purposes Panel was ill-defined. Decisions were taken informally and too much was left to Mr Bownes. In particular, the decision to remove barrier 144 was not referred to the Panel and ought not to have been made.
CHAPTER 20 THE CLUB AND DR EASTWOOD
289. It should be recorded that in general the Club has over the years adopted a responsible and conscientious approach to its responsibilities. It retained the services of Dr Eastwood as consultant engineer and abided by his advice. For his part, Dr Eastwood is skilled and experienced in this field, as already indicated, and he sought I have no doubt to act efficiently and professionally in his advice and practical work. The Club also retained Mr Lock who had acquired great experience and knowledge of Hillsborough during his police service. A number of witnesses described Hillsborough as a very good ground, "one of the best in the country". The police agreed that relations between them and the Club were good. Over the last four years, the Club had spent some £ 1 & million on ground improvements.
290. Nevertheless, there are a number of respects in which failure by the Club contributed to this disaster. They were responsible as occupiers and invitors for the layout and structure of the ground. The Leppings Lane end was unsatisfactory and ill-suited to admit the numbers invited, for reasons already spelt out. The Club was aware of these problems and discussed solving them in various ways between 1981 and 1986. In the result, there remained the same number of turnstiles, and the same problems outside and inside them. The plan for this semi-final, involving as it did the loss of 12 turnstiles for the north stand and large numbers to be fed in from Leppings Lane, was one agreed between the Club and the police. The Club knew best what rate of admission the turnstiles could manage and ought to have alerted the police to the risks of the turnstiles being swamped.
291. The alterations inside the turnstiles and on the terraces clearly affected capacity, but no specific allowance was made for them. In that respect, both Dr Eastwood and the Club should have taken a more positive approach. Either a scheme such as one of those Dr Eastwood put forward should have been adopted giving more turnstiles and total separation of areas or at the very least the capacity of the new pens and of the terraces as a whole should have been treated more cautiously. The police view in 1981 that 10,100 was too high a figure was known to the Club (although Dr Eastwood says not to him). Yet, despite that and the sub-division into pens, the figure remained.
292. Although the police had assumed responsibility for monitoring the pens, the Club had a duty to its visitors and the Club's officials ought to have alerted the police to the grossly uneven distribution of fans on the terraces. The Club operated and read the closed circuit television and the computer totaliser. Liaison between Club and police on the day failed to alert the latter to the number of Liverpool supporters still to come. The onus here was on the Club as well as on the police.
293. The removal of barrier 144 was the responsibility of the Club although it clearly acted on the advice of Dr Eastwood and the Advisory Group which in this instance was misguided.
294. Likewise, the breaches of the Green Guide were matters which the Club should have appreciated and remedied.
295. Lastly, as already indicated, the poor signposting on the concourse tended to produce under-filling of the wing pens and over-filling of pens 3 and 4. Poor signposting outside the turnstiles and the unhelpful format of the tickets also led to confusion aggravating the build-up in the turnstile area.
CHAPTER 21 FIRST AID AND EMERGENCY SERVICES
No Fault by the Emergency Services
296. I say at the outset of this chapter that no valid criticism can be made of the response by the St John Ambulance Brigade, by SYMAS or by the fire brigade on 15 April. Indeed, no represented party ventured any criticism of them. The only attack on SYMAS came from two Liverpool doctors. One claimed that ambulances did not arrive swiftly or with sufficient equipment and that there was a lack of triage. He was proved to be wrong in all three respects. Unfortunately he had seen fit to go on television on 15 April when he said more lives could have been saved if staff and equipment had arrived earlier. Apart from being proved wrong in fact as to the times of arrival of ambulances, he conceded in evidence that it was not possible to say whether lives could have been saved. His comments on television were irresponsible. The other doctor complained of the absence of defibrillators. I am satisfied on overwhelming evidence that to attempt to use a defibrillator on the pitch with people milling about would have been highly dangerous owing to the risk of injury from the electric charge.
297. I find that all three of the emergency services named above responded promptly when alerted, that they brought appropriate equipment and that their personnel operated efficiently.
298. It would be unreasonable to expect, at any sports stadium, medical facilities capable of dealing with a major disaster such as occurred. To have in advance at the ground, oxygen, resuscitators, stretchers, other equipment and medical staff sufficient to deal with over 100 casualties is not practicable.
299. What is required is a basic level of provision for first aid, for professional medical attention and for ambulance attendance, together with a system of co-ordination with the emergency services which will bring them to the scene swiftly in whatever numbers are required. What will amount to an appropriate basic provision for the future eg the equipment in a first aid room, requires expert evaluation and advice.
300. On the day, there was no clear understanding between the Club and Dr Purcell as to his role. He believed he was primarily there to attend to the players. The Club regarded him also as the "physician available to attend at the first aid room if required", as laid down in the Safety Certificate.
301. There was insufficiently close co-operation between the police and the emergency services. It is clear that SYMAS and the fire brigade should have been called earlier than they were. However, in view of the nature and extent of the crushing, the time when police rescue began and the pathetically short period for which those unable to breathe could survive, it is improbable that quicker recourse to the emergency services would have saved more lives.
302. Finally, there was evidence that an advertising board had to be knocked down at the north-east corner of the ground to allow an ambulance onto the pitch and that at the top of the ramp leading to the pitch the access for ambulances was inadequate. There was also evidence that the pre-match arrangement for ambulances to use the two gates from Penistone Road at the north-east end of the ground as in and out routes was frustrated by the presence of vehicles just inside the ground. In the event, none of these matters affected operations. The hoarding was quickly knocked down. The difficult access to the ramp was negotiated and ambulances used one entrance satisfactorily by backing out when loaded.
CHAPTER 22 COMMUNICATIONS
303. One problem which impeded police control and the gathering of intelligence was the intermittent failure of communication by radio. There was the period of two or three minutes when the control room was out of radio contact. Even when that was remedied, it was only by using a hand set in the control room. This meant that control could not override any other messages. No effective radio communication seems to have reached control from the perimeter track at the relevant time. Mr Greenwood's request for the match to be stopped and various messages from Constables reporting the distress in the pens did not register. Likewise, communication from Leppings Lane to control was unreliable. Undoubtedly these breakdowns made it more difficult for those in command to make proper assessments and exercise effective command.