Hillsborough: Inquest Answers
April 26, 2016
by Martin Odoni
At the time of writing it is the 25th of January 2016. The Coroner of the ‘re-booted’ Inquest into the Hillsborough Disaster of 1989, has begun his sum-up of evidence, and is about to send the jury to deliberate on their verdict of the ninety-six deaths.
The questions the jury must consider for such a verdict are as follows in bold type. The responses I would give, were I on the jury, follow in normal type; –
a) Do you agree with the following statement which is intended to summarise the basic facts of the disaster: “On 15 April 1989 96 people died at the disaster as a result of crushing in the central pens of the Leppings Lane terrace following the admission of a large number of supporters to the stadium through exit gates.”
More or less agree, although there is a misleading element in the statement as worded. The opening of exit gate C is implied to be the immediate cause of the tragedy, when it was more a contributory factor than the decisive cause. For reasons I list here, my position is that, even without the opening of the gate, a disaster would still have occurred.
b) Police planning for the semi final match – was there any error or omission in police planning or preparation for the semi final which caused or contributed to the dangerous situation that developed on the day of the match?
Emphatically yes. There were serious problems with crushing and overcrowding in Leppings Lane and on the terrace below the West Stand in the three previous semi-finals held at Hillsborough in the 1980’s, and the warning signs therein were completely ignored. The police duty plan for the 1989 semi-final was identical to the one used in 1988, up to and including the same spelling mistakes. For some reason, the 1988 plan was never updated to include the technique of ‘filtering‘ in Leppings Lane (see next question), which implies that the indicators of what was working and what was failing in 1988 were not really being taken on board by the police. The appointment of newly-promoted Chief Superintendent David Duckenfield to be the match commander was also an astonishingly myopic start to preparations, given he had no experience of policing a football match in over ten years, and was completely ill-prepared for trying to run the operation of an FA Cup semi-final.
c) Policing of the match and the situation at the turnstiles – Was there any error or omission in policing on the day of the match which caused or contributed to a dangerous situation developing at the Leppings Lane turnstiles?
Strongly yes. There were nowhere near enough officers in Leppings Lane during the last two hours prior to kick-off, and the ‘filtering’ system deployed the previous year, to get spectators organised into queues up the road from the stadium, was not re-used. This oversight led to enormous confusion and chaos in the entry concourse to the stadium.
d) Policing of the match and the crush on the terrace – Was there any error or omission by commanding officers which caused or contributed to the crush on the terrace?
Firmly yes. No officer, even in the control room with its multiple CCTV screens, monitored the build-up of spectators arriving on the terrace. As the terrace was divided by fences into pens, areas could become over-full long before the terrace as a whole was full. Thus when the central pens were already packed, no officer was instructed to close off access to them.
e) The opening of the gates – When the order was given to open the exit gates at the Leppings Lane end of the stadium was there any error or omission by the commanding officers in the control box which caused or contributed to the crush on the terrace?
Strongly yes. The match commander was correct to order the exit gate be opened, but he did not pause first to assess where many hundreds of extra people were likely to go once beyond the turnstiles if they were not given any guidance. By far the likeliest place most of the new arrivals would head towards would be gangway 2, the tunnel heading below the West Stand, leading into the central pens, as it was immediately opposite the gate. It also had a sign saying ‘STANDING’, and as the new arrivals would in the main have tickets for standing room, they would mainly have assumed this applied to them. Because the match commander did not take this into account, he did not check to make sure that the central pens had sufficient space for hundreds of extra spectators; in the event, they had no remaining space at all.
f) Are you satisfied so that you are sure that those who died in the disaster were unlawfully killed?
Yes. The series of blunders were evidently the result of lazy complacency (hence the bit about copying spelling mistakes in question b)), which is negligence. Except in cases of murder, negligence is one of the central features of an Unlawful Killing.
g) Behaviour of the supporters – Was there any behaviour on the part of the football supporters which caused or contributed to the dangerous situation at the Leppings Lane turnstiles? If yes was that behaviour unusual or unforeseeable?
No. This is not meant to imply that the behaviour of the spectators was immaculate, as it was not. But what bad behaviour there was was isolated, infrequent, unremarkable, played no role in causing or contributing to the disaster i.e. the disaster would still have happened if every single spectator had behaved impeccably, and was largely in response to the situation instead of what was triggering it. Examples of bad behaviour that eye-witnesses have cited were entirely foreseeable, as they were quite in-keeping with the general behaviour of football crowds of the time; often unpleasant, but easily policed.
h) Defects in Hillsborough stadium – Were there any features of its design, construction and layout which were dangerous or defective and which caused or contributed to the disaster?
Emphatically yes. The decision to divide the terrace into three pens – and then subsequently into five – was one of the most bewildering decisions Sheffield Wednesday Football Club ever made. The club did it in response to a serious crush that developed on the terrace in 1981, when 38 Tottenham Hotspur fans suffered injuries as they were pinned against perimeter fences. The idea that the problem of crushing against fences could be solved by adding more fences is like trying to save a drowning man by sending more water in his direction. Equally, 24,256 fans all had to enter the stadium via the West Stand, through a narrow concourse that had only 23 turnstiles, which was a glaring bottleneck. Furthermore, the signposting at Hillsborough was appalling, and it was entirely possible for a spectator who was new to the stadium never to realise that the wing-pens of the west terrace had entirely separate entrances from the tunnel. Furthermore again, the lay-out of crush barriers on the terrace had changed quite a bit over the years, and one of the changes meant that barrier 124a became exposed to very high pressure levels during the crush, leading it to collapse (see question j).
i) Licensing and Oversight of the stadium. Was there any error or omission in the safety certification and oversight of Hillsborough Stadium that caused or contributed to the disaster?
Cautiously yes. I cannot be definite about this as regards to directly contributing to the disaster, but there is no doubt that the maintenance of Hillsborough Stadium was atrocious, and the safety certification was shockingly out-of-date. The turnstiles at the west end of the stadium were quite dilapidated, slowing rate-of-entry, while the safety certificate for the ground was issued in 1979. Since that time, the West Stand had had radial fences installed on the terrace, extra dividing walls had been installed in the turnstile areas, limiting movement, and the Spion Kop End had been fitted with a new roof. None of these changes had been assessed for their safety implications, and were therefore completely unmentioned in the certificate, and so evacuation procedures for the stadium were long out-of-date.
j) Conduct of Sheffield Wednesday FC before the day of the match. Was there any error or omission by SWFC and its staff in the management of the stadium and/or preparation for the semi final match on 15 April 1989 which caused or contributed to the dangerous situation that developed on the day of the match?
Cautiously yes. The standard of maintenance and preparation, as mentioned earlier, was not good, but again we need to assess it in terms of whether it contributed to the disaster. I would say it probably did, although not decisively. Shortage of medical equipment in the stadium suggests complacency, although in fairness, a disaster on this scale would have been a difficult proposition for which to prepare. The key area of concern is that a crush barrier near the front of pen 3 collapsed during the disaster, upping the death toll. Subsequent analysis of the wreckage showed signs of corrosion on the joints securing it to the surface of the terrace, and at least 13 different coats of paint. Meanwhile, an old bit of newspaper was found stuffed inside the barrier as litter, and was found to be dated from 1931. This all strongly implies many, many years of casual neglect, which almost certainly contributed to the barrier collapsing.
k) Conduct of Sheffield Wednesday FC on the day of the match. Was there any error or omission by SWFC and its staff on 15 April 1989 which caused or contributed to the dangerous situation that developed at the Leppings Lane turnstiles and in the west terrace?
No. Nothing the club staff did on the day seems to have contributed to the disaster in any way, although they might have requested that the police delay the kick-off. It is highly questionable whether that would have made any difference though. For one thing, the police do not appear to have been willing to carry out such a request. For another, even if they had, the crushes both at the turnstiles and on the Leppings Lane terrace were already in progress, and simply moving the kick-off back would not have magically made extra space for the people caught up in them.
l) Conduct of Eastwood & Partners (SWFC engineers) – should Eastwood and Partners have done more to detect and advise on any unsafe or unsatisfactory features of the stadium which caused or contributed to the disaster?
Emphatically yes. Eastwood & Partners showed all the signs when routinely testing the crush barriers down the years of ‘going through the motions’, and of not really paying any attention to what they were examining. Year after year, they had missed the corrosion on the crush barrier that collapsed (see question j)), but Professor Eastwood himself showed great arrogance when interviewed in the days after the disaster, insisting that standards of maintenance were rigorous.
m) Emergency response and the role of South Yorkshire Police – After the crush in the West Terrace had begun to develop was there any error or omission by the police which caused or contributed to the loss of lives in the disaster?
Firmly yes. Police officers were just yards from spectators who were crying out to them for help from behind the perimeter fence, and in the main just ignored the appeals. Then, the knee-jerk police response to spectators pouring out of the central pens was to assume hooligans were invading the pitch. So slow-on-the-uptake were some police officers that they actually stopped desperate spectators from escaping the crush and pushed them back into the pens. The emergency response plan was never, at any stage, put properly into effect. There is no doubt that the police response was completely inappropriate, and if anything, made deaths more likely to occur than if they had just stood back and done nothing at all.
n) Emergency response and the role of South Yorkshire Metropolitan Ambulance Service (SYMAS) – After the crush in the west terrace had begun to develop, was there any error or omission by the ambulance service SYMAS which caused or contributed to the loss of lives in the disaster?
Cautiously yes. There appears to have been a significant delay on the part of the ambulance staff present at the stadium in cottoning onto what was happening. However, it is possible that, even had they reacted sooner, the number of lives lost would have been the same, so caution is required.
Now, before assuming that David Duckenfield was responsible for any negligence, the Coroner stipulated that the jury must be satisfied that the following conditions hold good; –
- Firstly, that as match commander, he owed a duty of care to the 96 who died.
- Secondly, that he was in breach of that duty of care by analysing his conduct before and on the day.
- Thirdly, they must be sure his conduct caused or contributed to the deaths “not merely in a minimal way”.
- Finally, the jury must be sure that, as match commander, Mr Duckenfield’s conduct was so bad it amounted to “gross negligence”, so bad it was equal to a criminal act or omission.
My assessment of these points is as follows; –
- Firstly, yes of course he had a duty of care to the people who died; he was a member of the police. All officers sign up to a duty of care to the public on the day they join the force, so this is not even up for debate.
- Secondly, by failing to learn enough about the peculiarities of Hillsborough Stadium in the weeks beforehand, by declining an offer of help from his predecessor Brian Mole, by failing to control the ingress of the spectators to the stadium, by failing to monitor crowd build-up in individual enclosures around the ground, by not pausing to consider where large numbers of spectators would go were the exit gate opened, by failing to put the emergency plan properly into effect when disaster broke, and by failing to take command of the emergency-response, his preparation for the event and conduct during it were clearly lax and semi-conscious. The safety of the people attending the stadium that day depended on Duckenfield being alert, pro-active and aware of the dangers.
- Thirdly, Duckenfield’s actions did not contribute to the deaths in a ‘minimal way’, they were directly and unambiguously the immediate cause.
- Fourthly, the sheer number of duties Duckenfield failed on, as listed above, clearly add up to gross negligence when put together. This would be true even if the singular blunder of not giving guidance to the spectators arriving through the exit gate were not enough to constitute gross negligence on its own. But the scale and consequences of that unthinking mistake are so huge that it did anyway.
My conclusion therefore, were it for me to say instead of the jury, is that the victims who lost their lives at the Hillsborough Disaster were all Unlawfully Killed due to gross negligence on the part of David Duckenfield, aggravated by further negligence on the part of Sheffield Wednesday Football Club, Eastwood & Partners, and the wider South Yorkshire Police.
EDIT ON DAY OF PUBLICATION: Remarkably, the jury’s conclusions, when announced, matched mine almost eerily closely.