Operation Resolve investigated the lead-up to the disaster, in terms of the suitability and safety of the stadium and police planning for the match, what happened on the day itself and how the police responded. The Operation Resolve investigation is summarised in chapters 2–6 of this report.
An unsafe stadium
In relation to safety matters, Operation Resolve drew on expert analysis from John Cutlack, a Chartered Structural Engineer, which showed that Hillsborough Stadium failed on several counts to meet the safety standards of the day. These failings were particularly evident on the West Terrace. There were not enough turnstiles to allow people in safely, emergency exits were inadequate for the number of people permitted in the centre pens and some crush barriers, intended as safety measures, were the wrong height or too far apart.
All of these factors meant that by 1989 the permitted capacity of the West Terrace as a whole, and the centre pens in particular, was much higher than it should have been.
This capacity had been determined in 1979, as part of SWFC’s application for a Safety Certificate. The original assessment of 7,200 was already higher than it should have been, when compared to the requirements set out in the official Guide to Safety at Sports Grounds (the Green Guide). Then, over the following decade, there were numerous structural changes to the West Terrace, most notably the installation of fences to divide the terrace into separate pens. These are detailed in chapter 2. Each of these changes should have resulted in the Safety Certificate being formally reviewed by SWFC, as the certificate holder, and the safe capacity reassessed. This did not happen.
Applying a strict interpretation of the safety standards of the day, Mr Cutlack found that the safe capacity of the West Terrace on the day of the disaster should have been 3,089: less than half the number of supporters stated on the Safety Certificate. Yet some 7,200 tickets were sold for the terrace. In short, the risk of dangerous overcrowding on the West Terrace was extremely high, if not managed properly.
SYP had some involvement in safety matters; it was the driving force behind SWFC's initial application for a Safety Certificate and the installation of fences to create pens. However, it did not have the final say: that lay with SWFC, as ground owners, and the local council, which issued the Safety Certificate and was responsible for monitoring compliance.
The evidence indicates that SYP’s primary focus appears to have been how the stadium layout affected its ability to police matches effectively. In line with that, in 1985 officers had put forward a plan for a comprehensive redesign of the Leppings Lane entrance, clearly aligning banks of turnstiles with different areas and pens. The plan was considered but ultimately rejected for cost reasons, with SWFC prioritising investment in fire safety following a fatal fire at Bradford City’s stadium. Mr Cutlack’s view was that if the redesign had been implemented, the disaster could have potentially been averted; at the very least the consequences of the events would have been less severe.
Despite officers’ awareness of the difficulties at the Leppings Lane entrance and knowledge of previous crushing incidents on the West Terrace, Operation Resolve has found no indication that SYP’s planning for the 1989 Semi-Final took these factors into account.
Complacency in police planning
The 1989 FA Cup Semi-Final was a repeat of the previous year’s match, involving the same teams and the same venue. SYP, SWFC and the FA perceived the 1988 Semi-Final to have been a success, so SYP insisted that the same arrangements should apply for 1989. This included segmenting the stadium geographically, with the north and west sides allocated to Liverpool supporters and south and east sides to Nottingham Forest supporters. The purpose was to keep opposing supporters separate.
Following the disaster, SYP officers insisted that its planning for the 1989 fixture had been strongly based on the 1988 operation. However, there were several important differences, including a reduction in the number of officers on duty, particularly in the areas allocated to Liverpool supporters, and changes in the command team for the match. Because Ch Supt Duckenfield was about to take up the role of divisional commander for the area where Hillsborough Stadium was located, he was appointed as the match commander—the officer in overall charge of the police operation—even though he had no previous experience of commanding major football matches.
While evidence indicates his promotion was made in line with standard procedures, there was minimal time for him to familiarise himself with the stadium and he received little support or knowledge transfer. This was one of several factors in the police planning that had clear consequences on the day of the disaster.
Another was that there had been a change in turnstile arrangements, which meant that all 10,100 Liverpool supporters who had standing tickets had to enter through just seven turnstiles, equating to 1,443 supporters per turnstile. Because each turnstile could admit a maximum of 750 people per hour, the minimum time needed to get all the supporters in would have been almost two hours of constant operation.
By contrast, there were 42 turnstiles for Nottingham Forest supporters with standing tickets, equating to 500 supporters per turnstile. This change was authorised by Mr Mackrell and was the basis for his conviction, as the consequences of it should have been foreseeable.
As examined in chapter 3, the Operational Orders did not adequately address several issues that had occurred at previous matches. For example, though there had been crowd crushes on the West Terrace at previous semi-finals, no officer was instructed to monitor the safety of the crowd. There were also no instructions about how officers should manage the crowd outside the Leppings Lane turnstiles, even though this was a known bottleneck.
Together, these factors indicate a degree of complacency in the police planning, encapsulated in the remarks of Assistant Chief Constable Walter Jackson (ACC Jackson), who was responsible for approving the plans. He told the original inquests led by Dr Stefan Popper (the Popper Inquests) it was “inevitable” that when the plan was complete, it would be right. His confidence was to prove tragically misplaced.
The IOPC was of the opinion that ACC Jackson would have had a case to answer for gross misconduct for failing to plan adequately for the match. As the senior officer with overall responsibility for the planning process and approving the plans, he failed to, among other things, ensure that learning from previous matches was properly gathered and applied. Superintendent Bernard Murray (Supt Murray) drew up the plans; the IOPC view was that he too would have had a case to answer for gross misconduct for failing to plan adequately.
The failure of police control
On the day of the 1989 Semi-Final, there were initially no signs of concern ahead of the 3pm kick-off. Supporters were enjoying the fine weather and generally described as being in good spirits. There were no police reports of any significant trouble.
From around 2.15pm, however, the situation at the Leppings Lane entrance began to change. A crowd began to build, with supporters arriving in greater numbers than could enter the ground through the limited number of turnstiles available.
The number of supporters in the area was sufficiently high that Superintendent Roger Marshall (Supt Marshall), the officer in charge at this end, asked officers in the Police Control Box (PCB) at the stadium to arrange for Leppings Lane to be closed to traffic. But there were no control measures in police plans for managing a crowd in this area. The situation worsened and a serious crush developed outside the turnstiles. By around 2.45pm, supporters entering the stadium were visibly distressed, while those crushed outside were increasingly scared and, in some cases, struggling to breathe.
Officers outside the stadium recognised they had lost control of the situation. However, they did not know that inside the stadium, some of the areas allocated to Liverpool supporters—the side pens of the West Terrace—were still largely empty, indicating there was space for Liverpool supporters once they were able to enter the ground. This was identified by numerous witnesses, including police officers, who commented on the fullness of the areas allocated to Nottingham Forest supporters, compared to those for Liverpool supporters.
Officers in the PCB, including Ch Supt Duckenfield, were in the optimal position to ensure colleagues inside and outside the stadium were aware of this difference, which could have informed policing decisions. The PCB was situated directly in line with the West Terrace and officers there could have seen through the windows that the side pens were particularly empty, while the centre pens appeared full. They also had CCTV showing the situation outside the ground. Despite having the complete picture of what was happening inside and outside the stadium, no one in the PCB shared this with their fellow officers.
With the crush at the Leppings Lane entrance showing no signs of reducing, Supt Marshall spoke to Inspector Robert Purdy (Insp Purdy), an experienced colleague on duty outside the turnstiles. They were both of the view that one or more exit gates should be opened to relieve the crush but have different recollections of what action they agreed to take. Supt Marshall has insisted he told Insp Purdy that they would need Ch Supt Duckenfield’s agreement to open the exit gates and allow supporters into the stadium in greater numbers. He therefore radioed to ask Ch Supt Duckenfield for his approval but received no response. Believing he was not getting through, Supt Marshall tried again.
At 2.48pm, Gate C opened. It appears that this was intended to allow a supporter out. However, an estimated 130–180 supporters entered. Because the numbers were small, officers were able to close the gate again within 30 seconds.
In the PCB, this 2.48pm opening of Gate C was seen on CCTV and greeted with surprise. Supt Marshall, who was not close to Gate C, radioed again, this time more urgently, that unless the gates were opened, someone could be killed. It is not clear whether he knew that Gate C had opened.
This message was heard in the PCB; other officers around the ground have stated they recalled it. It led to a discussion in the PCB and ultimately an instruction from Ch Supt Duckenfield to “open the gates”. It is not clear exactly when this instruction was issued or how many officers heard it; Operation Resolve has not identified any officer who has said they acted in response to Ch Supt Duckenfield’s instruction.
The fact that the 2.48pm opening of Gate C had appeared to help reduce the crush led some officers close to the gate to consider opening it again, in a controlled way, for a similar short duration. Insp Purdy has stated that following his conversation with Supt Marshall, he believed he had the authority to do so. Police Sergeant John Morgan (PS Morgan) guided a small group of supporters to Gate C with this intention.
At 2.52pm, stewards opened Gate C again. Despite comprehensive analysis of CCTV, officer accounts and radio transcripts, Operation Resolve has not been able to establish whether this was on the instruction of PS Morgan or any other officer, or whether the stewards did so themselves. The stewards’ accounts have been contradictory.
It is, however, certain that this time, the number of supporters entering was far higher and the police were unable to control the situation. The gate remained open for several minutes and while estimates vary, the commonly accepted figure is that more than 2,000 supporters entered through Gate C at this point.
Crucially, the police did not prepare for this second opening of the gate in any way, and no measures were taken to control or guide the incoming supporters. These supporters therefore followed the most visible and direct route to watch the match, which for those with terrace tickets was along a tunnel into the centre pens of the West Terrace. When they entered the tunnel, supporters could not see how full those pens were.
The failures in decision making and communication were at the heart of why the IOPC reached the view that Ch Supt Duckenfield would have had a case to answer for gross misconduct in relation to managing the build-up to the game. Supt Murray was in the PCB alongside him and failed to advise him correctly; the IOPC also found he would have had a case to answer for gross misconduct, as would Supt Marshall in relation to failures in controlling the situation outside the Leppings Lane entrance.
The emergency response: continued failures in police control and communication
The rapid influx of supporters into the already full centre pens led to a sudden and devastating change in the situation. With large numbers of supporters entering through the tunnel at once, the pressure of the crowd increased to the extent that at 2.57pm, one of the gates in the perimeter fence at the front of Pen 3 burst open. Officers on the track in front of the pens assumed it was a pitch invasion and sought to close the gate. Supporters who had been thrust through were made to go back in. Almost immediately, the gate burst open again.
This time, some of the police officers on the track began to recognise that this was not a pitch invasion and started to respond, by deliberately opening the other gates to allow supporters through and onto the pitch side. This was against the written instructions officers had been given. By 2.59pm, all of the perimeter gates at the West Terrace were open. Other supporters were climbing over the perimeter fence, to get out of the centre pens. Some officers on the track attempted to guide supporters into the side pens, while other supporters sat or stood at the side of the pitch, in some cases exhibiting clear signs of distress or discomfort.
When those in the PCB saw that supporters were on the pitch, one officer was sent to the perimeter track to see what was going on, but it appears he gathered little information. Ch Supt Duckenfield has said he radioed Superintendent Roger Greenwood (Supt Greenwood), the senior officer on duty on the pitch side, to try to establish what was happening, but there is no record of this.
At 3pm, Supt Greenwood had been at the halfway line. Having seen supporters on the pitch, he had gone to the West Terrace, arriving by 3.02pm. He has said he instantly recognised that supporters were being crushed and at first tried to urge the crowd to go back. Realising this was not working, he then made a gesture to the PCB that the match should be stopped. This was at 3.04pm. He then ran onto the pitch to instruct the referee to stop the game, reaching him at 3.05pm. Following that, he returned to the pens to attempt to free supporters from the crush.
The PCB issued requests for officers to assist but gave no explanation of what had happened or why assistance was needed. After asking officers at the stadium to attend, a request was made to the SYP Force Control Room for Operation Support. This meant all available officers from across the force area were required to come to the stadium. However, Operation Support was designed and understood to be a response to public disorder.
As chapter 5 demonstrates, the lack of clarity about the situation became an increasing problem as attempts were then made to contact the South Yorkshire Metropolitan Ambulance Service (SYMAS). With no understanding of what had happened, SYMAS provided a holding response, rather than dispatching the “fleet of ambulances” requested. There was a protocol for ensuring a rapid response from the emergency services: declaring a major incident. SYP failed to do this.
Though officers on the pitch, aided by St John Ambulance (SJA) volunteers and some supporters, began to engage in frantic rescue efforts, there was no coordination and people were getting in each other’s way. SYP’s Major Incident Manual clearly stated that “the overall control and co-ordination of the effort of all the services involved in dealing with a major incident is a POLICE responsibility.” [Emphasis in the original.]
Evidence clearly shows that the senior officers in the PCB failed to take control of the situation or coordinate the response. The importance of such coordination was demonstrated when Chief Superintendent John Nesbit (Ch Supt Nesbit) arrived and organised officers into chains at each gate. This helped free supporters in a more orderly way.
But freeing supporters from the pens was only the first step; there was then a need for coordination of medical treatment. Again, the police did not provide any guidance to support this. When ambulances first arrived at the stadium, police officers at the entrances had no idea why. When the fire service arrived, they faced similarly confused responses. In the absence of police instructions, both SYMAS and the fire service attempted to coordinate the medical response themselves.
It is clear that Ch Supt Duckenfield froze in the crisis—a fact that his lack of experience in controlling football matches undoubtedly contributed to. However, no one took over or filled the void. ACC Jackson was at the stadium and could have done but did not. Both failed to give coherent instructions that could have helped accelerate the rescue effort.
These failings were at the heart of the IOPC opinion that both officers would have had a case to answer for gross misconduct in relation to several aspects of the way they responded to the disaster. The IOPC was also of the view that Supt Murray would also have had a case to answer for gross misconduct in failing to respond effectively, and Supt Greenwood would have had a case to answer for misconduct.
Chaos and a lack of compassion
Clear control and communication were still lacking in the hours that followed, as families and friends of those injured or missing sought information. The accounts of families, a small selection of which are included in chapter 6, paint a devastating picture of a chaotic response, where there was no effective information flow between the stadium, hospitals and locations set up to assist them. At the hospitals, police teams seem to have been largely invisible.
A Casualty Bureau—essentially a telephone contact centre intended to be the hub of information flow to supporters’ families and between police forces and the other emergency services—was overwhelmed. It had insufficient telephone lines and resources. It later emerged that SYP had only ever set one up once before, for a much smaller incident.
From around 9.30pm, a formal identification process began. The process prioritised consistency of protocol over compassion. All those who died had been returned to the gymnasium at the stadium. After a protracted wait and with little explanation, each family or group of friends was taken through individually and asked to identify their loved one from distressing photographs on boards. They were confronted by the horror of seeing all those yet to be identified, with the police making no attempt to pre-select relevant images (such as the right age group or gender) or to use personal property as the basis for provisional identification.
Once they had found a photograph of their loved one, families and friends were then required to carry out a physical identification. Some reported being prevented from holding or touching their loved one, on the basis that they were now “the property of the Coroner”.
They then had to give an identification statement. Many have reported that during this process they were asked questions about their, or their loved one’s, alcohol consumption. These questions and answers were not recorded in the statements, yet the accounts of those who experienced or witnessed the questioning are strikingly consistent. There would have been no legitimate reason to ask this as part of an identification statement.
Many have subsequently suggested this was the first indication that supporters’ alcohol consumption would be cited as a contributory factor in the disaster. This allegation was categorically rejected by the Taylor Inquiry, and again by the Goldring Inquests, as well as in the subsequent criminal and disciplinary proceedings detailed in this report.
Throughout the night, no senior SYP officer assumed overall responsibility for coordinating the many strands of activity or ensuring effective communication across the different sites. At each location, individual officers, many of whom were themselves exhausted and deeply affected, remained focused only on their immediate tasks. The police relied heavily on volunteers, who provided organisational as well as emotional and practical support, often with great empathy. Many of these volunteers, along with individual officers, went far beyond what could reasonably have been expected. Yet it was the failure of senior police leadership, and the absence of effective command, that left the overall response fragmented, inconsistent and impersonal, compounding an already devastating experience for families, friends and all those affected by the disaster.
