The HIP had found documents that indicated a PNC check had been conducted on a person who made a claim for compensation after the disaster. In its report, the HIP raised the concern that more such checks may have been conducted. The IOPC examined the circumstances around this and sought to establish if any similar checks had been made.
The disclosed documents showed that solicitors acting on behalf of SYP wrote to CC Wells on 2 March 1995 to request details of the criminal records of a Liverpool supporter who had claimed compensation for loss of earnings as a result of the disaster. The request was fulfilled by an inspector who was part of the SYP CRO on 15 March 1995 and appears to have resulted in a complaint from the solicitor representing the claimant. A subsequent SYP note indicated that the matter was resolved between the two sets of solicitors, and no further action was required.
In the circumstances, there is no evidence to suggest that this check was carried out inappropriately.
IOPC investigators carried out a comprehensive search of the archived material available to the investigations to establish whether any form of check was conducted on any other individual who made a claim for compensation. Only one was found.
This took place in April 1989, just days after the disaster. It followed the receipt on 18 April 1989 of a claim for compensation against SYP and SWFC for injuries sustained. A document showed that both a PNC check and a CRO check were conducted on the claimant. The document did not explain why these checks were carried out or why a printout of the record was added to the claim file.
While it is possible that further records have been legitimately destroyed in line with retention policies, there is no other evidence to suggest that there was a decision or intention to conduct PNC checks on survivors of the disaster.
On the main HOLMES database used by WMP, the records for 94 of those who died suggest that CRO checks were carried out. A CRO check is not the same as a PNC check. It does not provide the same level of detail and typically only includes any unspent convictions.
The IOPC has not found any specific explanation for why or when CRO checks were conducted, nor any evidence of who conducted them or who instructed that they should be conducted.
This still does not explain how the solicitor obtained the information. There is no record of any direct contact between WMP and the solicitor, and the documents in his possession were PNC printouts, not CRO checks.
Despite pursuing multiple routes, it has not been possible to ascertain how or why he had obtained this information. The IOPC has not found any legitimate reason for it to have been in his possession.
However, the IOPC did find evidence to show that SYP should have conducted PNC checks on all of those who died, shortly after the disaster. This is part of a standard process for updating the PNC and removing the records of those who have died from it. Though there is evidence to suggest that some checks were conducted, they were not done systematically and consistently, as they should have been.
This became apparent when, in June 2014 and with the consent of families, IOPC investigators conducted PNC checks on those who had died in, or as a direct result of, the disaster. If the process had been followed correctly, no records should have been found, as their details should have been removed from the PNC. However, investigators discovered that, as of June 2014, details of nine of those who died had not been removed from the PNC.
Following the IOPC’s discovery, the PNC has now been corrected and the relevant records removed. The IOPC wrote to the families of all those who died, explaining what had happened and offering to inform them if details of their family member had incorrectly remained on the PNC. Separately, the then National Policing Lead for Information Management apologised to the families for this oversight. In a letter, he explained that though he was not able to identify precisely where the process failed, the failure did not appear to have been a deliberate act.
The IOPC sought to establish who carried out the checks, why, and how the information had been given to the solicitor. Investigators made several attempts to interview the solicitor, who had indicated he wanted to speak to the IOPC. However, he was in poor health and unable to answer questions. Members of his family, who had worked with him, and other former colleagues spoke to the IOPC and confirmed they had no knowledge of how he had obtained this information. They allowed the IOPC to take further documents from the solicitor’s home to review, but these contained no further references to the PNC checks.
Supt Marshall stated he had no knowledge of, or involvement in, any PNC checks being carried out in relation to the Hillsborough disaster. Investigators did not find any information to suggest otherwise.
Investigators also compared handwriting on the documents to a sample of Supt Marshall’s handwriting. The visual dissimilarities between the two were so apparent to the naked eye that no further comparative analysis was deemed necessary. Investigators asked the solicitor’s family if they recognised the handwriting as his. They all agreed it was not.
The format of the printouts showed that they were from the original PNC rather than from PNC2, which became available to police forces in 1991. This narrowed the time window; however, it also meant that there were no records to show who had conducted the search or produced the printouts. Under PNC2 and current procedure, the name of the officer who conducts a check is automatically recorded and stored.
IOPC investigators spoke to two former PNC operators at SYP to understand how the PNC was used by the force in 1989 and up to the launch of PNC2. The operators explained that PNC checks were typically conducted by trained staff at a dedicated terminal. As far as they could remember, in 1989 SYP had two PNC terminals in the CRO and an additional two in the Force Control Room. To request a check, officers in the field would call in via radio or telephone. They would have to give their name and collar number, plus the name and date of birth of the subject of the check. The information they requested was recorded on paper logs, along with the date and time the check was requested. The paper logs were kept for 12 months before they were destroyed. In line with this policy, the IOPC has not found any paper logs from the time.
The IOPC asked SYP officers interviewed if they had any recollection of PNC checks being carried out after the disaster. The only officers who referred to anything of this sort were some of those who had been involved at either the gymnasium or at the MLC in documenting the details of each of those who died in the disaster. They noted that the forms they completed included a tick-box referring to PNC checks. This was not ticked on any of the forms, supporting the accounts of the officers that they had not had access to the PNC when they were conducting this task.
The IOPC checked all the HOLMES databases used by SYP and WMP in relation to the disaster. There was no record in any of them of an instruction to conduct PNC checks.
This meant that the IOPC had no further avenues available to establish who conducted the checks or why, or who had provided the solicitor with the information.
The carrying out of Police National Computer checks on those who died and others to establish, if possible, which police force or police officer was responsible for this, the reasons why it was done, and whether it was justified.
What was found?
• The Police National Computer (PNC) checks carried out after the disaster were done using the original PNC, which was replaced by PNC2 in 1991. This meant that, unlike PNC2, there would have been no records in the system to show who had conducted the search or produced the printouts.
• The IOPC has not been able to establish who carried out the PNC checks or wrote the accompanying summary. However, it has established that the handwriting on the summary did not belong to the solicitor who originally provided these documents to the HIP, or to his client, Supt Marshall.
• SYP standing orders from the time indicate that carrying out PNC checks on those who died would have been in line with procedure, so that records could be updated. However, in the aftermath of the Hillsborough disaster, it appears that the process followed was not in line with SYP guidance.
• This was confirmed when in 2014 the IOPC conducted PNC checks on those who died in the disaster and found that records relating to nine of those who died had not been removed, as they should have been. This has since been rectified, and the National Policing Lead for Information Management apologised to the families of those who died for the oversight.
• WMP conducted Criminal Records Office (CRO) checks on 94 of those who died. The IOPC has not found any specific explanation for why or when this was done, nor any evidence of who conducted them.
• In response to the concern that PNC checks had been carried out on someone who claimed compensation after the disaster, the IOPC conducted a comprehensive search of the archived material to establish whether any form of check was conducted on any other individual. Only one more check was found.
Significant new evidence
In June 2016, during a search of SYP premises conducted at the IOPC’s request, a book of SYP standing orders from late 1989/early 1990 was found. This contained the standing orders around use of the PNC referred to in this section.
The IOPC also contacted former PNC operators at SYP to understand how the PNC was used in 1989 and up to the launch of PNC2.
The PNC is a national database of information available to all UK police forces and law enforcement agencies. It holds a range of information relevant to policing, such as records of people who have previous convictions, cautions and formal warnings. It also holds information about all UK drivers and the vehicles they own.
The PNC is used by police officers and some police staff routinely in their daily work, for a range of reasons, but there are strict rules on how it should be used. Looking up whether a person has a criminal record on the PNC is known as conducting a PNC check.
Documents disclosed to the HIP showed that PNC checks were conducted on some of those who died in the Hillsborough disaster. This information had not previously been public knowledge. The documents, which consisted of printouts from the PNC and a handwritten list of personal data about some of those who had died, had been in the possession of the solicitor who had represented Supt Marshall during the original criminal investigation into the disaster and at the Popper Inquests.
The documents gave rise to the concern that, in this instance, PNC checks may have been carried out inappropriately or even unlawfully. One reason for this concern was that the checks appeared to have been carried out systematically on a targeted group: those who died in the disaster and who had blood alcohol levels over zero. Another reason was that the information had been in the possession of a third party (the solicitor) who, under normal police procedure, would not have had access to PNC data.
The HIP Report suggested that the checks were carried out in an attempt to impugn the reputations of those who died. In addition, the HIP Report stated that, in response to claims for compensation for injuries sustained at Hillsborough Stadium, “South Yorkshire Police (SYP) undertook criminal records checks on the claimants.” In fact, the documents available to the HIP provided evidence that this had happened in one case.
As there appeared to be a clear breach of accepted practice around the use of the PNC, both SYP and WMP referred the matter to the IOPC to investigate.
While the testing of blood alcohol levels of those who died in the disaster had been a contentious subject since the Popper Inquests, the testing of blood alcohol levels of survivors only became public knowledge through two documents disclosed to the HIP.
The first was a note from Dr Forrest, the same toxicologist who carried out the blood alcohol testing on the majority of those who died in the disaster, to Mr Alan Crosby, A&E Consultant at the Royal Hallamshire Hospital, on the afternoon of the disaster. The document listed 11 names and/or hospital identification numbers of survivors, a date and time, and their blood alcohol levels. For 9 of the 11 individuals listed, no alcohol was detected.
The second was a document which, under the heading “Alcohol”, recorded the number of those who died that had blood alcohol levels over 80mg/100ml (the legal alcohol limit for driving in England, Wales and Northern Ireland) then included the note: “few of those admitted had appreciable levels”.
The IOPC used these documents as the basis to investigate why blood alcohol had been tested in these cases, and to establish if any other injured patients had been tested.
One of the first things the IOPC established in relation to the first document was that although there were 11 names or identification numbers on the list, it referred to only ten individuals: one was listed twice.
There was no record of this blood alcohol testing in the medical notes of eight of the ten survivors. The reasons for treatment did not suggest any correlation between those who were tested and the injuries they had or treatment they required: the list of those tested included individuals who had only minor injuries as well as some with more serious injuries.
IOPC investigators sought to contact each of the ten individuals listed on the note, or their families, to find out whether they knew anything about the testing. Where individuals gave consent, investigators reviewed the respective medical records to ascertain whether there was any common pattern or clinical reason (such as common pre-existing medical conditions) behind their blood alcohol level being tested.
None was found. Of the ten individuals, four were conscious on arrival; five were unconscious and one semi-conscious. Seven were admitted to intensive care.
Five of the patients agreed to talk to the IOPC. None of those interviewed recalled having their blood taken while in hospital. None thought that having a blood sample taken was an unreasonable step in their treatment, nor did they think they would have objected to it or questioned it at the time. However, none remembered being asked whether they were willing to have their blood taken for alcohol testing or being told that their blood alcohol level would be tested.
The IOPC followed a range of routes to establish whether blood alcohol testing had been carried out on any other injured patients. No evidence was found to suggest it had been.
IOPC investigators interviewed Dr Forrest and Mr Crosby to ask what they remembered of the testing and whether there had been any police influence on the decision to carry out tests.
Dr Forrest said he was aware, when he did it, that he “was carrying out the tests on people who had been injured at Hillsborough.” He said that the tests were authorised by a consultant, and he had no reservations about doing them. He suggested that the consultant may have been intending to write a report or scientific paper on the disaster.
Mr Crosby, who authorised the tests told the IOPC he couldn’t remember asking for them but agreed that the request had come from him. He also accepted Dr Forrest’s suggestion that it was possible he was considering writing a paper. However, he stated: “there would have been an initial clinical reason” for taking blood samples.
Crucially for the IOPC investigation, Mr Crosby stated strongly that he had not been asked by police officers to conduct blood alcohol testing and that “A suggestion like that from a police officer would not have gone down too well.”
The allegation that the decision to test blood alcohol was part of an attempt to discredit Liverpool supporters was reinforced for some by the way the information about blood alcohol was presented at the Popper Inquests. As explained earlier, the blood alcohol levels of all those who died were read out together in the evidence of the toxicologist, Dr Bob Forrest. Each individual’s blood alcohol level was then read out again as part of the factual summary given in relation to that individual.
IOPC investigators asked Dr Popper why blood alcohol levels had been read out twice in this way. Dr Popper could not specifically recall this and suggested “it was merely a matter of convenience”.
Documentary evidence shows that the approach was discussed at a pre-inquest review meeting, attended by some of the solicitors representing the families of those who had died in the disaster. There was no suggestion that any of them voiced any concern about it.
WMP was supporting Dr Popper in his work. The IOPC therefore examined records of WMP’s investigation, such as the policy books of ACC Jones, who led WMP’s work for the Popper Inquests. No reference of any sort was found to when blood alcohol levels should or would be read out.
While presenting the information twice in this way may have been distressing to families, the IOPC found no evidence to suggest it was done in an attempt to discredit those who died, or Liverpool supporters more generally.
The post-mortem examinations of 94 of those who died in the Hillsborough disaster began at around 9am on Sunday 16 April 1989. They were completed the following day.
Dr Popper had made initial arrangements for the post-mortems on the Saturday evening. At some point before they began, he determined that full forensic post-mortems should be conducted in all cases. That included the testing of blood alcohol in all cases, including on those aged under 18.
In the preliminary proceedings to the individual inquests on 18 April 1990, Dr Popper explained that this testing had been done at his direction. He acknowledged that blood alcohol testing was not conducted as a part of every inquest, but commented it is part of “a great number of cases”.
He said he made the decision to authorise the testing because alcohol levels may have been relevant to understanding how people died. He added that he made the decision without knowing the ages of all those who had died and determined that it should be a standard part of all of the post-mortems.
Nothing he said in the preliminary proceedings indicated that any police officer—or indeed any other individual—influenced the decision.
The IOPC sought to re-examine the decision process, reviewing documentation and taking statements from Dr Popper, six of the pathologists who conducted the post-mortems (the other four had died) and various other members of Dr Popper’s team.
Dr Popper reiterated to the IOPC that the decision had been his, and that no police officer had influenced it. He suggested that the question of whether to test blood alcohol had probably been discussed in his initial meetings with pathologists and the deputy coroner, but he couldn’t specifically recall this. He said: “It might have been that one of the pathologists said that we ought to do blood alcohol tests, or I may have spontaneously thought of it myself.”
None of those interviewed by the IOPC who were present in these initial meetings recalled there being any discussion regarding blood alcohol testing—nor of supporter behaviour or alcohol consumption.
Dr Popper also acknowledged that he was aware, from an early stage, of the suggestion that alcohol could have been a factor in the disaster but could not remember how he knew this or whether anyone said anything to him. He also stated that he thought what he had heard about alcohol was “unlikely not to have had an influence” on his decision.
Though he knew that some families were upset by it, he felt it had been the right decision, as doing it meant they had been able to answer the question as to whether alcohol had been a factor in the deaths; the testing provided evidence that it had not been.
In his statement, Dr Popper described the overall sequence of events between when he received the initial call from the police to advise him of the disaster and the start of the post-mortems. This provided an insight into where he went and who he might have spoken to.
He remembered speaking in depth to only one police officer before the post-mortems began. This was D Ch Supt Addis, with whom he discussed the formal identification process and arrangements for transporting those who had died from hospitals to the gymnasium, then on to the MLC.
At least four SYP officers mentioned seeing Dr Popper in the gymnasium. However, none of these officers has at any time mentioned speaking to him at this point.
Dr Popper stated to the IOPC that he had “no recollection of any pressure from the police” in relation to the question of whether blood alcohol testing should be conducted. He added: “I’m as confident as I can be at the present time that I was not put under any pressure to do it.”
No one else interviewed by the IOPC suggested there had been any discussion with police officers about blood alcohol testing. The deputy coroner recalled being present when Dr Popper spoke to some police officers, including CC Wright, but said there was no discussion whatsoever about alcohol or the behaviour of supporters.
Regardless of how the decision was reached, Dr Popper stated to the IOPC: “I do not recall anybody questioned or disagreed with the decision to do the blood alcohol tests.”
This was supported by the statements from the pathologists who, with one exception, felt it had been an appropriate decision in the circumstances. Several of them suggested they would have been more surprised if they had not been instructed to test blood alcohol levels.
The only pathologist who disagreed said that left to his own devices, he would not have tested blood alcohol levels as he didn’t smell any alcohol in the post-mortems that he did. He arrived during the afternoon of 16 April, when the post-mortems were underway, and understood it was a definite instruction.
He also addressed the question of taking blood alcohol levels from those under the age of 18, commenting: “There was no separate discussion about the decision to take blood alcohol levels from those under the age of 18. One of the patients I examined was 14 years old and I didn’t think it was all that appropriate really, I felt slightly uncomfortable doing it.”
Again, this was a different view from the others, who agreed that having decided to test blood alcohol levels of all those who died, there was no need for a separate policy for under 18s.
While there was a difference of opinion on the appropriateness of testing, there was total agreement on the key issue for the IOPC’s investigation: all of the pathologists who provided statements were unaware of any police influence on the decision to test blood alcohol.
D Ch Supt Addis was asked what he recalled of his contact with Dr Popper. He said: “I did not have any conversation with him regarding post-mortems and I had nothing to do with post-mortems whatsoever.” He added: “I had no knowledge of why blood samples was [sic] taken from the deceased and checks on alcohol levels, I wasn’t privy to any discussions regarding this.”
Professor Jack Crane was an experienced pathologist who served as an advisor to the Goldring Inquests on pathological issues. After these ended, the IOPC asked him for an expert opinion on the decision to test blood alcohol levels. He provided a written report, in which he said that “In the circumstances of Hillsborough it seems quite reasonable for BAA [blood alcohol analysis] to be carried out on the majority of victims since there was at least a theoretical possibility that alcohol intoxication could have played a part in the incident.”
He echoed Dr Popper’s view that blood alcohol testing had ultimately proved valuable as it meant “the rumour that drunken fans contributed to the disaster could be, and indeed was, able to be refuted”. However, he said that conducting blood alcohol testing on the children who had died was “disproportionate and inappropriate”.
The checking of blood alcohol levels of those who died and survivors, and what influence, if any, any police officer may have had on the Coroner’s/any other person’s decision to do this.
What was found?
• The IOPC found no evidence to indicate that the decision to test blood alcohol levels as part of the post-mortems following the disaster was influenced by the police. Dr Popper consistently stated that it was his decision and believed it was the correct one. Most of the pathologists who conducted the post-mortems said they agreed with the decision.
• Evidence gathered by the IOPC indicates that blood alcohol testing was not, as the HIP Report suggested, an “unusual” or “exceptional” decision. Official coronial statistics indicate that toxicology testing takes place in around 1 in 5 post-mortems today: by no means a majority, but not rare enough to be deemed exceptional. Blood alcohol was tested in other disasters involving multiple deaths in the era, such as the Herald of Free Enterprise sinking in 1987.
• The IOPC found no obvious clinical reason why ten of those who received hospital treatment after the disaster had their blood alcohol tested. The consultant who authorised blood alcohol testing of survivors stated strongly that he had not been asked by police officers to do this.
• The IOPC has found no evidence that blood alcohol testing was carried out on any other injured patients beyond these ten.
Significant new evidence
New evidence gathered in investigating this term of reference consisted primarily of statements from Dr Popper and his deputy, six of the ten pathologists who conducted the post-mortems and the toxicologists who conducted the tests. In addition, investigators sought to gain the expert view of other coroners and pathologists on the decision to test blood alcohol levels.
On 16 April 1989, the day after the Hillsborough disaster, post-mortem examinations began on all of those who had died. These were carried out at the direction of Dr Popper, to assist in the inquests into the deaths. As part of the post-mortems, blood alcohol levels were tested in all cases—regardless of the age of the individual who died. In the context of allegations from the police and others that a large number of Liverpool supporters had been drinking heavily before the match, this testing has become a source of considerable controversy.
The HIP Report commented that Dr Popper’s decision to conduct the testing was “an unusual direction” and stated: “The bereaved and survivors considered allegations of drunkenness had been compounded by the decision to take and publish blood alcohol levels, impugning the reputation of those who died.”
The reference to publishing the blood alcohol levels reflected the fact that each individual’s blood alcohol level was read out at two separate points during the individual inquests. The first time was at the overall start of proceedings, where the names and blood alcohol levels of all those who died were read out together. The second time was at the start of the specific inquest into each individual’s death.
The HIP Report also showed, for the first time, that the blood alcohol levels of a small number of injured patients had also been tested. It asked why this had been done.
In light of the questions posed by the HIP Report, SYP referred the issue of blood alcohol testing to the IOPC to investigate. The focus of the investigation was to establish whether there was evidence to indicate that the decision to test the blood alcohol in all the post-mortems was influenced by the police.
