• Read more about Arrival of ambulances and the continued rescue effort

1. After alerting the other emergency services to a major incident, one of the next crucial steps is to coordinate the other services. SYP took no steps to do this or to achieve a common understanding of the situation. This was demonstrated when SYMAS did not immediately dispatch the requested “fleet of ambulances.”
    
2. At 15:08:01, SO Higgins informed SYMAS Control that there were casualties and asked for the ambulance that was already on standby to be sent to the gymnasium entrance of the ground. In his 1989 account, SO Higgins said SYMAS Control asked him whether this was the same incident that the police had notified them of. He said that he simply confirmed the location and told them that they would need to access the pitch from the gymnasium end of the ground. He then began to treat other casualties at the ambulance.
    
3. At 3.09pm, the Racal system recorded a phone call from the SYP Force Control Room to SYMAS Control, reiterating that they wanted as many ambulances as possible on site immediately. SYMAS replied that one was on its way, and they would assess the situation. In his 1989 account, SYMAS Supt Clarke said that at this point, he assessed how many ambulances SYMAS would require to maintain normal duty cover and then arranged for the remaining eight vehicles to go to Hillsborough Stadium. 
    
4. In a statement dated 8 May 1989, Deputy Chief Ambulance Officer Alan Hopkins (DCAO Hopkins) recalled that he was in the SYMAS Control Room on an unrelated matter when SYP telephoned and asked for a fleet of ambulances to attend the Leppings Lane end of Hillsborough Stadium. He said that he knew the liaison officers inside the ground would have difficulty getting out to Leppings Lane to report what was happening there, so he left the SYMAS Control Room to go to the ground. On his way out, he met Assistant Divisional Officer Rodger Morley (ADO Morley), and they set off for the stadium together. While they were on their way to the stadium, he could hear SYMAS Control sending multiple vehicles to the stadium. He said he told ADO Morley to radio SYMAS Control to instruct all ambulances to make themselves available for redeployment to Hillsborough Stadium as soon as possible, particularly those in the Sheffield area.
    
5. At 3.11pm, SYMAS Control radioed SO Higgins to ask for an update. He advised them that there were a number of people on the pitch, but that they were “probably just winded”. Then at 15:12:08, SYMAS Control contacted him again to say they had received reports from the police that “There could be quite a number crushed.” SYMAS Control asked SO Higgins to look into this. At 15:13:54, he advised them that there was a possibility that some people had died. He suggested that ambulances should not be directed to the Leppings Lane entrance but should come to the gymnasium, which was where he then headed.
    
6. At 15:14:19, the first SYMAS ambulance arrived at Hillsborough Stadium. It drove through the outer perimeter gates at Leppings Lane and stopped outside Gate C. The ambulance team recalled police officers giving them no direction; one said the officers seemed surprised at their presence “and were not aware that ambulances had been requested.”
    
7. They were about to go into the ground when Gate C opened, and they met a group of supporters carrying a casualty with a chest injury. The casualty was taken to the ambulance for treatment. As they were dealing with the first casualty, more supporters began to spill onto the inner concourse from the central tunnel. At the same time, police officers entered the stadium through Gate C, which was open. The scene became increasingly chaotic.
    
8. Supporters and officers began to carry casualties out of the tunnel and either laid them on the ground on the inner concourse or took them through Gate C to the ambulance that was parked there. Supt Marshall later recalled that police officers tried to take casualties out to the service road. He said the casualties “…were there separated into three groups – those apparently dead, those seriously injured, and those less seriously hurt.”
    
9. While ambulances were arriving on the service road, with the number of casualties on the pitch increasing, police officers in front of the West Terrace became concerned about the lack of ambulances at their location. 
    
10. Supt Greenwood dispatched a detective sergeant to ask the SJA ambulance to come to the West Terrace. The detective sergeant recalled that this took some persuasion, but at 15:15:29, the ambulance was driven onto the pitch from the vehicle access ramp at the north-east corner of the ground. It continued along the side of the pitch; BBC footage shows it coming to a stop near Gate 3 about two minutes later.

Image

Figure 5I: The SJA ambulance arriving on the pitch (Source: BBC)

1. There were still no signs of SYMAS ambulances on the pitch. More had arrived close to the stadium, but due to limited access had parked a short distance away and gone to assess the scene. At 15:18:42, a qualified ambulance officer (QAO) from the crew that had been dispatched at 3.05pm used the radio from the ambulance that was already at Gate C to inform SYMAS Control that this was a major incident. SYMAS Control did not pass the message on.
    
2. In his 1989 account, the same QAO then described the efforts being made by police officers, SYMAS staff and others to resuscitate supporters and help casualties into the ambulance. He observed: “During this time I did not see any sort of command and control structure anywhere around the ground. I saw a lot of police officers but no one seemed to be in control. All the officers I saw were busy treating casualties.”
    
3. This was correct; the police had taken no steps to coordinate the medical response or triage the injured, focusing on rescue and in some cases resuscitation. While both tasks were vital, this meant that the available medical resources were not used as effectively as they could have been. The PCB for example could have identified an officer to oversee triage but did not.
    
4. Instead, its focus was on the lack of response from SYMAS. At 15:19:48, a message was sent to ask the Force Control Room to confirm the situation. The PCB operator said they needed at least 20 ambulances, but at present there were only three, all of which were near Gate C. At 15:20:47, the first SYMAS ambulance arrived on the pitch.
    
5. Though the number of casualties was still uncertain, at 15:21:26, SO Higgins advised SYMAS Control that was this a major incident. SYMAS Control assured SO Higgins that nine or ten vehicles were on their way to the stadium but still did not inform the other emergency services. 
    

6. In his 1989 statement, SO Higgins recalled that at 3.23pm DCAO Hopkins and ADO Morley arrived and parked next to his ambulance. SYMAS Divisional Superintendent Trevor Dale arrived shortly after. This meant that several senior SYMAS staff were now on site. More ambulances followed shortly after.

    

7. SO Higgins said he told DCAO Hopkins that 30–40 supporters had died and many more were injured; DCAO Hopkins ran down to the pitch to see what was happening for himself. 
    
8. In his own account, DCAO Hopkins said he returned almost immediately and told ADO Morley to contact SYMAS Control to get the major incident vehicle and ambulances to go to the Penistone Road end of the ground.
    
9. ADO Morley recalled that the matchday ambulance was parked on the vehicle access ramp with its rear doors wide open, but there were no wheeled stretchers inside and there were no SYMAS staff with it. He commented: “the whole area of the entrance off Penistone Road was bedlam at the time.” He then began to organise the arriving ambulances to receive casualties.
    
10. SWFC CCTV footage timed at 15:28:00 captures the first SYMAS ambulance departing from Gate C taking casualties to hospital. Rather than reversing out, it went along the service road behind the South Stand towards Penistone Road.
     
11. By this stage, several of the tasks that formed SYP’s Major Incident Plan had been undertaken but none of this was done in a controlled or systematic way. In his expert report for the Goldring Inquests dated 29 November 2013, paramedic David Whitmore observed that SYMAS staff had been left to act on their own initiative and without any formal command and control in place. He added that SJA staff had also been left “largely to their own devices.” 
     
12. Operation Resolve found no evidence to suggest that the police coordinated the activity of the other emergency services or SJA volunteers. Instead, the evidence highlights a lack of communication and coordination, particularly between SYP and SYMAS.
     
13. At 15:31:38, a radio message was sent from the PCB to the SYP Force Control Room, asking for SYMAS Control to be contacted so that the senior SYMAS officer could be sent to the PCB. While such coordination would have been desirable, this request from the PCB was almost 24 minutes after the initial request from the PCB for a fleet of ambulances, and almost ten minutes after DCAO Hopkins and ADO Morley had arrived at the ground. The ambulance operation was by this stage underway, taking casualties to hospitals. In short, the request was too late. 
     
14. No evidence has been found to suggest that SYP took any action to locate the senior ambulance officer at the ground in an effort to coordinate the rescue activity.

• Read more about The failure to declare a major incident

1. At around 3.08pm, ACC Jackson arrived at the PCB from his seat in the South Stand. In his 1989 account, ACC Jackson said that when he got to the PCB, he spoke to Ch Supt Duckenfield, who was unable to explain what had happened, so decided to go down to the pitch to see what the problem was.
    
2. In evidence to the Taylor Inquiry, ACC Jackson said that on the pitch he spoke to Supt Greenwood who told him there were injuries. He could also see that a rescue effort was underway. He said he went back to the PCB and was asked what he intended to do there. He replied: “The first thing in my mind was to ensure that sufficient ambulances had been called and also it was clearly a necessity to implement the major incident procedure.”
    
3. In his 1989 account, ACC Jackson said that on his return to the PCB, he was made aware that a fleet of ambulances had been requested. He said: “Because of the seriousness of the situation and together with Chief Superintendent Duckenfield we gave instructions to the Control Room Staff for implementation of the major disaster plan.”
    
4. While this may have been his intention, a range of evidence shows that SYP did not follow the correct procedure for implementing its Major Incident Plan (or major disaster plan).
    
5. In his 1989 account, Ch Supt Duckenfield said that as a result of the request for a fleet of ambulances, he had become aware of the gravity of the situation. He said: “I then began to give instructions to the Control Room staff in conjunction with Mr Jackson for the implementation of the Major Disaster Plan.”
    
6. He further stated: “I asked for the Casualty Bureau to be set up, to warn hospitals of the large number of injuries, any doctors in the ground to Leppings Lane goal for deployment, off duty police officers to be called to duty and rendezvous at Hammerton Road Police Station. Mr Jackson supplemented my requests, asking Superintendent Torr to attend in respect of the Casualty Bureau; Detective Chief Superintendent Addis to attend to co-ordinate the investigation side of the enquiry. I asked for a Counselling Service and Victims Support Staff.” 
    
7. Ch Supt Duckenfield's 1989 account gave the impression that he remained in control and issued a series of orders, with ACC Jackson supporting the process. However, in 2015, Ch Supt Duckenfield gave evidence over seven days to the Goldring Inquests. During extensive questioning by barristers representing different groups and organisations, he conceded that, having given the order to open the gates, he froze. The evidence of the other officers in the PCB tends to support this admission and indicates that they, and other officers at the ground, were increasingly acting on their own initiative.
    
8. The presence of ACC Jackson in the PCB meant the Force Control Room could ask for his authorisation for Operation Support, which was promptly given. The Force Control Room then issued the call for Operation Support at 3.10pm. At 15:17:01, the PCB asked SYP Force Control Room to contact the Northern General and Royal Hallamshire Hospitals.
    
9. However, despite the accounts of both ACC Jackson and Ch Supt Duckenfield that they intended to initiate the “major disaster plan”, there is no evidence that at any point SYP declared a major incident.
    
10. This was a critical omission. The declaration of a major incident immediately informs all emergency services of the severity and scale of what has happened. It therefore demands a comprehensive response from the emergency services, who are obliged to take it on trust from those declaring the major incident that their services are required. Further, once declared, it requires a coordinated multi-agency response, which should be led by the police, as clearly stated in SYP’s Major Incident Manual.
     
11. There were clear procedures in place in South Yorkshire for the declaration of a major incident, using an agreed code word, ‘Catastrophe’, to provide an unambiguous alert to all emergency services of the severity of the situation. Operation Resolve has found no evidence in Racal transcripts, or in the accounts of other emergency services or police officers who were on the pitch, to show that a major incident was declared, or that the code word was used.
     
12. The evidence shows that Ch Supt Duckenfield and ACC Jackson implemented certain aspects of the Major Incident Plan at the time the call for Operation Support was made. For example, instructions were issued for the Casualty Bureau to be set up, and for hospitals to be warned about the disaster. The instruction to set up a Casualty Bureau features as a consideration in both the Major Incident Plan and the actions to be taken after the call for Operation Support.
     
13. While some aspects of the SYP Major Incident Plan were initiated, they were not coordinated. Others within SYP were not informed that these actions were being implemented as part of a bigger response.
     
14. Ch Supt Duckenfield told the Taylor Inquiry that while in the PCB, he “gave the instructions to activate the Major Incident Plan.” He was then asked what instructions he had given. He replied: “Only in general terms that we would require ambulances”.
     
15. At the Goldring Inquests on 10 March 2015, Counsel to the Inquests asked Ch Supt Duckenfield about his knowledge of the SYP Major Incident Manual. Ch Supt Duckenfield confirmed that he was aware that it stated that the police were in control of the response to a major incident, and of the various roles and responsibilities described in the document. He said he understood how important it was to declare a major incident as soon as possible and to ensure that all of the emergency services worked in accordance with the major incident plans and procedures.
     
16. However, when asked specifically whether he knew the code word 'Catastrophe', he conceded that at the time of the disaster he did not.
     
17. In his original account from 1989, ACC Jackson wrote that, when he was in the PCB with Ch Supt Duckenfield, they instructed the PCB staff to implement the Major Incident Plan because of the seriousness of the situation. In a criminal and discipline interview under caution conducted by WMP on 28 June 1990, he was asked whether he was surprised that there was no record of the activation of the Major Incident Plan. He said he wasn’t and suggested that when he confirmed that Operation Support should be called for and that a fleet of ambulances was required, officers would immediately implement the Major Incident Plan.
     
18. There was no guidance anywhere that suggested a major incident should or would be activated automatically if a request was made for both Operation Support and ambulances.
     
19. ACC Jackson told the Goldring Inquests that he believed either he or Ch Supt Duckenfield had declared a major incident. However, he accepted that communication records showed that no one actually used those words. He said he also regretted the fact that he never used the word 'Catastrophe', adding that he was aware that if he had, then everyone would have known the severity of the incident they were dealing with. He accepted the suggestion that he simply assumed that officers in the Force Control Room would implement the Major Incident Plan based on what the officers at the ground were saying. While Chief Inspector Malcolm Edmundson in the Force Control Room ultimately did inform the other emergency services there was a major incident, he was acting independently and had insufficient information to work from. 
     
20. SYP's Major Incident Manual made it clear that the first essential action in the event of a major incident was to alert the other emergency services. In this instance, it did not take place. Further, the evidence not only indicates that neither ACC Jackson nor Ch Supt Duckenfield called a major incident, but that they did not instruct anyone else to do so either. This meant that even though Ch Supt Duckenfield and ACC Jackson had recognised there was a major incident, the other emergency services were still not aware.
     
21. Officers responding to the call for Operation Support had still not been given any clear indication of the situation they were attending, and those in areas such as the Casualty Bureau had not been given a clear picture either.
     
22. This persistent lack of effective communication was therefore a substantial failure of SYP’s emergency response, and one of the reasons for the IOPC reaching the view that Ch Supt Duckenfield and ACC Jackson would have had a case to answer for neglect of duty.
     
23. During this period, FA officials Graham Kelly and Glen Kirton also visited the PCB to find out what was going on. Though there is no recording of what was said, Ch Supt Duckenfield led them to understand that a gate had been forced by Liverpool supporters. When speaking to the BBC shortly after, Mr Kelly repeated this explanation of what had happened. Ch Supt Duckenfield has since acknowledged it was a lie. The consequences of this lie in terms of public perceptions of the disaster are considered further in chapter 7.

• Read more about Efforts to free the pens from the back

1. At around this time, PS Morgan arrived on the perimeter track having responded to the radio requests for assistance. In his 1989 account, he said that as he arrived, he saw Supt Murray, who seemed deeply shocked and told him simply to “do whatever you can”. PS Morgan said that as he reached the pens, he immediately saw the horror of the situation but also noted a lack of organisation in the police response: “I quickly realised that I would be able to achieve very little if I remained on the track. A lot of officers were standing looking at the scene in stunned disbelief”. He decided to enter the centre pens from the tunnel at the rear, so that he could get supporters to move back, or out, and reduce the crush. He ordered some officers to come with him.
    
2. He found no problems getting through the tunnel but when he reached the pens, spectators and police officers there appeared to have no idea what was happening. He went into the pens and tried to persuade supporters to leave. He said: “I was obliged to grab each person and haul them backwards, just shouting, ‘Get out’ to each one as I progressed towards the front. Many were in deep shock and resisted me, pulling away and refusing to co-operate. The crowd was not densely packed and I was able to move quite freely.”
    
3. While PS Morgan’s actions may have had some positive impact, they were not coordinated with any other part of the rescue effort, and he did not communicate his intent to the PCB or any senior officer. Other officers also took action without seeking to coordinate them, adding to the sense of disorganisation at the heart of the police response.

• Read more about Initial response of SYMAS and SJA

1. The SJA and SYMAS staff present at this stage were those who had been at the stadium before kick-off. The accounts of several of the SJA volunteers stationed in corners of the ground indicate that they saw supporters coming out of the pens—either through gates or over the fence—but were initially unsure what was happening. As they got closer, they realised that supporters were being crushed; they began to treat casualties as best they could. They did so without any specific instruction from the police.
    
2. Two SYMAS officers were on their usual duty at the stadium: Station Officer Paul Eason (SO Eason) and Station Officer Patrick Higgins (SO Higgins). They were supported by Qualified Ambulance Officer Stephen Chippendale (QAO Chippendale) and Qualified Ambulance Officer Leslie Worrall. They were standing near their ambulance which was parked close to the gymnasium, the designated casualty treatment area at the stadium.
    
3. In a 1989 account, SO Eason said that at about 3.03pm, he saw what he believed to be a scuffle taking place in the middle of the West Terrace. He and QAO Chippendale walked along the perimeter track past the North Stand to investigate. As they got closer, they saw that several supporters were on the pitch and some seemed injured. SO Eason tried to radio SO Higgins to bring a stretcher and first aid equipment but couldn’t get through. 
    
4. At 15:05:48, when Supt Greenwood was on the pitch, SO Higgins contacted SYMAS Control. He advised them that there were some crowd problems and that one or two may be injured, but he thought the injuries could be slight. 
    
5. In short, SYMAS officers did not recognise the severity of the situation at the West Terrace any sooner than the police. They were positioned further away from the pens than the police, but even on arrival in front of the West Terrace they did not immediately identify that there were large numbers of casualties.
    
6. Very soon after SO Higgins had contacted SYMAS Control, the SYP Force Control Room did too. This was after the PCB had requested Operation Support. Recordings show that Police Constable Kenneth Rook (PC Rook) in the Force Control Room at first told SYMAS: “There's been an incident at the Leppings Lane End at the Hillsborough Football ground, where we may—we may need a few ambulances. It's just an advisory at this stage. There's been pushing and shoving and there might have been quite a few injuries.”
    
7. However, while PC Rook was speaking to SYMAS Superintendent Raymond Clarke (Supt Clarke), who was on duty in SYMAS Control, the SYP Force Control Room received an urgent radio request from the PCB for “a fleet of ambulances”. This was timed at 15:07:15 and followed Supt Murray’s message from the pitch.
    
8. The recording of the conversation between PC Rook and SYMAS Control shows that he passed this request on verbatim. Though PC Rook was not able to provide full details, he stated there were a lot of people injured. Supt Clarke replied that they would instigate an initial response and assess the situation.

• Read more about The initial rescue effort

1. Several of those who were closest to the perimeter gates have described how the combination of the crowd pressure, the narrow gates and the general level of panic slowed their ability to free supporters.
    
2. PS Swift recalled that Gate 4 only opened 90 degrees to form a right angle to the fence. He said that as a result “only two Officers of [sic] a time could efficiently work at pulling people free by approaching from the front and the left hand side. In our obvious frantic efforts to assist we were inevitably getting in each other's way.” 
    
3. Police Constable Adrian Taylor at Gate 3 had similar issues: “The gate was so narrow, with the gate opening outwards onto the field, it prevented assistance from the right and a lean to support on the left gate pillar prevented assistance from the left of the gate. Three officers or supporters could only enter the gateway at one time to pull because of the tight space.” 
    
4. He also highlighted further challenges: “The step up from the centre south enclosure caused people to trip over, falling to the ground, then on top of each other. The gate became eight deep in fallen people, so tightly packed that they could not be pulled free. As one supporter was pulled free your momentum followed the supporter back onto the field, other supporters and officers then took your place at the gate pulling.”
    
5. Police Constable Martin Cooper was also at Gate 3, and he recalled that a further problem occurred if a supporter became stuck in the gateway for any reason. As some were unconscious, this happened on a few occasions.
    
6. At first, injured supporters were carried onto the pitch where officers, SJA volunteers and SYMAS staff—as well as fellow supporters—attempted to provide first aid or resuscitate them. This became a chaotic scene, with many people present and little organisation, as can be seen in figure 5H. 

Image

Figure 5H: The scene in front of the West Terrace, 15:07:04 (Source: SYP)

• Read more about The first response from the PCB

1. At 15:05:37—within a few seconds of the referee stopping the match—the Racal system recorded a message from the PCB to the Force Control Room calling for Operation Support to be initiated. Operation Support was a documented contingency under which all available SYP officers would be immediately deployed to assist with an incident. It was generally understood to be used in response to incidents of large-scale disorder.
    
2. In his 1989 account, Ch Supt Duckenfield said that he called for Operation Support and evidence has not been found to suggest that anyone else was responsible for the initial request.
    
3. Because implementing Operation Support would have a significant impact on operations within the SYP area, the decision to do so required authorisation from the ACC (Operations) or the designated duty chief officer. As ACC Jackson was at Hillsborough Stadium on 15 April 1989, he was in a position to give such authorisation, but he was not in the PCB at the time it was first requested. He arrived a couple of minutes later, of his own volition rather than as a result of a request from the PCB, and authorised Operation Support at 15:09:07. 
    
4. At about the same time that the request for Operation Support was made, the PCB sent a radio message instructing all available officers at the ground to make their way to the perimeter track at the Leppings Lane end. The message has not been recorded anywhere, but numerous officers have described hearing it. SWFC CCTV footage suggests that the radio message was broadcast at about 15:05:41, as it shows that a number of police officers were standing outside Gate C at that time; they promptly made their way through the gate into the stadium.
    

5. Though officers responded immediately, they did not know what they were responding to. Some indicated that the message referred to crowd trouble or disorder; others just assumed this was the explanation. When they saw supporters on the pitch, this appeared to confirm their views.

    

6. Inspector John Beresford (Insp Beresford) was dispatched from the gymnasium with Serial 21, to help deal with unspecified “trouble” at the Leppings Lane end. He saw spectators on the pitch and others climbing the fence, but when he arrived at the corner of the North Stand and West Terrace, he could not see the cause. In his 1989 account, he said: “The only police action which seemed obvious to me was to form an open cordon across the touch line from the northwest corner flag towards the goal mouth.” Though Insp Beresford did not explicitly state the purpose of forming such a cordon, it is a relatively standard police tactic to manage the movement of a crowd. On this occasion, the logical reason for establishing one would have been to prevent a pitch invasion. 
    
7. CCTV footage at 15:06:19 shows Insp Beresford appearing to organise officers into a cordon. However, in his 2013 statement, Insp Beresford recalled that as he neared the goalmouth, he realised that supporters were injured and that “this was no pitch invasion but a rescue operation.” He said his officers quickly left the cordon to assist in different ways.
    
8. BBC footage shows the cordon being formed at around 3.06pm but becoming fragmented by about 3.13pm. By 3.16pm, it had fully dispersed.
    
9. The formation of this cordon, and others in different locations later, have been the subject of complaints from supporters, on the basis that officers should have been engaged in more practical assistance. The evidence suggests that officers in the cordons felt the same way; they had responded on limited information and followed instructions, but once they saw what has happening, many chose to leave the cordon to assist in the rescue effort.
    
10. However, there is also evidence of a further issue emerging: that officers, lacking instruction or coordination, were getting in each other’s way in their frantic rescue efforts.

• Read more about The decision to stop the match

1. At 3pm, Supt Greenwood was standing by the players’ tunnel, in front of the South Stand by the halfway line. In an account dated 3 May 1989, he said he saw supporters climbing over the perimeter fence behind the goal at the Leppings Lane end of the ground. Because two or three police officers were with them, he immediately realised there must have been a crowd problem. However, he did not believe it was fighting or a pitch invasion, because he did not expect that to happen so early in a match. He immediately made his way to the West Terrace, along the perimeter track.
    
2. At this stage, he was still unaware that there had been any issues outside the stadium.
    
3. By 15:01:11, Supt Greenwood was close to Gate 1, which was open. CCTV footage shows that he walked past PC Richardson, who was ushering supporters into Pen 1, and past Ch Insp McRobbie, without apparently speaking to either. He arrived in front of Pen 3 by 15:02:01.
    
4. In his first written account of the disaster dated 3 May 1989, which was submitted to WMP and the Taylor Inquiry, Supt Greenwood recalled that he looked at the crowd in Pen 3 behind the goal and saw that people were being crushed against the perimeter fencing. He said the area behind the gate was heavily congested, preventing people from getting out, though police officers were trying to help them.
    
5. He climbed on an advertising hoarding to get a better view, and at first gestured to the crowd to move back, as he thought this could help. He said that when this proved ineffective, he decided to stop the match. In a prepared statement dated 27 June 1990, ahead of his interview under caution by WMP, Supt Greenwood said: “I broadcasted by personal radio to the Control Box that there were potential casualties and that the game had to be stopped. I also waived [sic] both my arms towards the Control Box in a signaling motion to the effect that the game must be stopped.” 
    
6. After doing so, he ran onto the pitch to attract the referee’s attention to stop the match. Figure 5F, taken from BBC footage, shows Supt Greenwood on the pitch approaching the referee at 15:05:29. He then returned to the perimeter fence in front of Pen 3.

Image

Figure 5F: Supt Greenwood approaching the referee, 15:05:29 (Source: BBC)

1. In their original accounts, both Supt Murray and Ch Supt Duckenfield referred to seeing Supt Greenwood signalling towards the PCB that the match should be stopped. Ch Supt Duckenfield said he sent Supt Murray to do this; Supt Murray said he was preparing to go, when Ch Supt Duckenfield confirmed he should.
    
2. Supt Murray suggested this was at 3.03pm. They both said that there were increasing numbers of supporters on the pitch by this stage. Racal recordings confirm that at 3.03pm, the PCB sent a radio message to the SYP Force Control Room at Snig Hill Police Station asking for dog handlers to be dispatched to the stadium, indicating they assumed they were dealing with some sort of crowd trouble.
    
3. When interviewed under caution by WMP on 25 June 1990, Supt Murray said that when he went onto the pitch, his intention was to stop the match. However, before he was able to attract the attention of match officials, he saw Supt Greenwood speaking to the referee, so returned to the PCB. He said he did not recognise that there was a serious problem on the West Terrace because he had not gone far enough across the terrace. 
    
4. Figure 5G is taken from BBC footage timed at 15:05:43. It shows Supt Murray on the perimeter track facing the West Terrace, just after the game had been stopped. There were dozens of supporters on the perimeter track and officers at Gates 3 and 4 were engaged in an effort to help supporters out of the pens. Almost all of the D Division officers under PS Swift have given accounts in which they stated they were aware by this time of supporters being crushed. In the background of figure 5G, supporters can be seen on the pitch in front of the pens. It is therefore striking that even at this point Supt Murray and others in the PCB had not recognised the severity of the situation. 

Image

Figure 5G: Supt Murray on the perimeter track, 15:05:43 (Source: BBC)

1. During this same interview under caution, Supt Murray said that when he returned to the PCB, Ch Supt Duckenfield sent him straight out again to clear the supporters from the pitch. However, when he reached the pitch, he realised that the situation was different: he saw people crushed against the fence, so borrowed a radio to contact the PCB and asked for ambulances to be dispatched to the stadium. This call was made at about 3.07pm and is examined further from paragraph 5.79.

• Read more about The view from the PCB

1. Several of the officers closest to the West Terrace described attempting to radio the PCB, to alert them to the situation, request assistance or ask for authorisation to open the gates. However, they said their messages didn’t get through, or at least they didn’t get a response.
    
2. The PCB was located on the corner of the West Terrace and South Stand, below the scoreboard. It had windows in line with the perimeter track and front of the West Terrace. Figure 5E shows the view from the PCB across the West Terrace. 

Image

Figure 5E: View of the West Terrace from the PCB, 1989 (Source: Richard Haylor, WMP)

1. This should have provided those in the PCB with a good view of the unfolding situation—both in terms of seeing the front of the pens and the perimeter gates and having a view from above the pens.
    
2. PC Bichard was the CCTV operator in the PCB. In his 1989 account, he said that at about 2.55pm, those in the PCB began to notice Liverpool supporters climbing up into the West Stand from the terracing below, with people in the West Stand helping them up. However, he said that the same thing had occurred at the 1988 FA Cup Semi-Final.
    
3. Shortly after this, they saw some supporters climbing the perimeter fence and others on the perimeter track. PC Bichard said that he and his colleagues in the PCB assumed it was some sort of crowd trouble.
    
4. In his original account, Supt Murray said that at about 2.58pm he became aware of something happening near the goal area. Though he could not see exactly what was going on, he realised that officers had opened either Gate 3 or Gate 4, or both gates. He said that a handful of supporters were on the perimeter track and were walking calmly and slowly towards Gate 1, while other supporters were standing aimlessly on the track. He recalled that the officer at Gate 1 appeared to be totally unaware of their presence, so Chief Inspector Robert McRobbie (Ch Insp McRobbie), who was in the PCB to observe and not in any operational role, went down to the track to draw the officer’s attention to what was happening.
    
5. In his 1989 account, Ch Supt Duckenfield described this scene in a very similar way. As the numbers of supporters making their way onto the track increased, he said he “considered there may have been a pitch invasion or that people were being taken out for re-location in the two wing pens.” 
    
6. At the Goldring Inquests, he was asked what he thought was happening and whether it occurred to him that it could have been a result of Gate C being opened. He replied that he thought there may have been crowd disorder and that he had made no connection with the opening of Gate C.
    
7. In his 1989 account, Ch Supt Duckenfield said that as the numbers on the pitch increased, he asked for Supt Greenwood to go and find out what was happening. Supt Murray similarly mentioned this in his 1989 account. However, Operation Resolve has found no evidence in Racal recordings or the accounts of officers outside the PCB of any communication with Supt Greenwood.

• Read more about 2.40pm–3.15pm: The experiences of those in the pens

1. Chapter 4 showed that by about 2.40pm, Pens 3 and 4 of the West Terrace were full, or very close to full, and according to some supporters, the situation there was becoming uncomfortable. By contrast, the side pens still had lots of space in them. Supporters have described in painful and traumatic detail what happened shortly after this point.
    
2. One supporter recalled that after getting through the turnstiles at about 2.45pm, he went with his father and sister through the central tunnel. He could see that Pen 3 and Pen 4 were packed, but in his opinion, they were not overly congested. The supporters did not appear to be being crushed and were able to stand still, rather than being moved around by the flow of the crowd. The supporter and his family took a couple of steps down to decide where to stand when there was a sudden surge from the central tunnel and the size of the crowd increased dramatically. He recalled that this surge carried him forward to the centre of Pen 3 with his feet not touching the ground.
    
3. A second surge shortly after took him forward further, until he was trapped against a metal crush barrier, which then collapsed. He was caught with his legs underneath the barrier and doubled up on the floor with the bar on top of his stomach. His head was face down on the corner of a step. He heard people screaming all around and could feel people falling on top of him. In his statement, he said that he could not breathe and thought he was going to die, so he just lay there until he lost consciousness. He awoke to feel someone pulling at his arms and managed to whisper to them that he was trapped under the barrier. Rescuers lifted the crush barrier slightly and were able to pull him out. An ambulance took him to hospital where, for several days, doctors treated him for severe injuries to his hips, stomach and back.
    
4. Several other supporters recounted similar experiences when the crush barrier collapsed. One supporter was desperately holding on to a man he didn’t know, who was being crushed against the barrier in immense pain; the barrier then gave way. He recalled: “I lost my grip on this lad and fell forward onto the backs of the people in front of me, I totally lost my balance. I did not fall to the floor, but onto the backs of people who had fell over in front of me. I then felt people falling on top of me.” He was unable to breathe or move but could see his brother on the pitch and screamed out to him. Eventually the pressure eased, and he was able to escape with the help of a police officer.

Image

Figure 5A: Photograph of the broken crush barrier, taken in the aftermath of the disaster (Source: HSE)

1. Others were trapped elsewhere. A woman who had positioned herself behind the goal at about 1.40pm said that at about 2.55pm, there was a push from behind, which knocked her into the perimeter fence. She and others initially managed to push back, which relieved the pressure; she recalled that people were screaming at the police to open the gate at the front of Pen 3, but the police officers shook their heads and turned their backs. There was then a second surge which forced her into the fencing again. She said that this time “my arm was trapped across the fencing, and my legs were forced against the wall by the force of people from behind. I couldn't move my head at all.” She estimated she was stuck in this position for almost half an hour before she was freed.
    
2. A supporter in Pen 4 described how they were squeezed down the tunnel into the pen, when almost immediately the person in front of him passed out. He tried to keep hold of the man but said: “My arms and shoulders were on fire with the pain and my legs were turning to jelly. The lad was a dead weight and by this time his head had slumped down to chest level. His legs were dragging on the floor and I felt myself going.” He added: “I couldn't do anything and I was trying as best as I could to keep my feet on the ground to avoid being tripped. I felt my grip on the lad begin to go, his shirt rolled up around his chest and his trousers began to drop. The pain in my arms and shoulders became unbearable and I lost him in the crush.”
    
3. While they were there, others were climbing or crawling over them towards the perimeter fence. He recalled officers on the other side of the fence telling them to push back, which they couldn’t do. Eventually, he reached the fence, where a police officer guided his hand to the wire. He gripped on to this to get his breath back, before inching his way along the fence to the gate.
    
4. Many supporters witnessed horrific injuries or were acutely aware of others losing consciousness around them. Their fear grew, often worsened by being separated from friends or family.
    
5. A common theme is that the crush suddenly and dramatically intensified at around 2.55pm. The obvious conclusion is that this was a result of the rapid influx of supporters following the 2.52pm opening of Gate C. The evidence of Insp Bullas, who was in the West Stand above, supports this. He described how, at a point between the teams coming onto the pitch (which was at 2.54pm) and the kick-off, he saw what he described as a river of people suddenly enter the terracing from the central tunnel. He added: “This wedge of people seemed to go forward down the terracing but unlike the swaying motions that had taken place earlier on did not sway backwards but remained where it was.” He said: “At this stage I could see the people towards the front of the terracing were being 'crushed forward’”. He attempted to radio the PCB but could not get through.
    
6. It appears that shortly after this influx, the crush barrier in Pen 3 collapsed. Mr Cutlack believed that similar events were only narrowly avoided in Pen 4, where two barriers were severely damaged on the day of the disaster.
    
7. The accounts of supporters broadly indicate that police officers on the perimeter track in front of the pens did not initially recognise the severity of the situation, even when supporters were screaming for help. Many described officers simply telling or gesturing at them to move back, which they could not do.
    
8. PC Smith and PC Illingworth were two of the officers on duty on the perimeter track. This was a role they had performed frequently, and they were in their regular positions; PC Smith in front of Pen 3 and PC Illingworth in front of Pen 4. They had both returned there at around 2.50pm, following a meal break.
    
9. In his 1989 account, PC Smith wrote that as the teams came onto the pitch at 2.54pm, he made his way to stand in front of Gate 3 in the perimeter fence. He described some supporters jumping up and down and pushing, which caused the crowd to surge forward to the perimeter fence. He said the people at the front shouted and screamed, and the crowd then moved back. However, he didn’t suggest this was anything out of the ordinary; he later told the Taylor Inquiry there were no signs of overcrowding.
    
10. Figure 5B was taken by a supporter in the North Stand at 2.54pm. The contrast between the density of the supporters in the centre pens and outer pens is evident. 

Image

Figure 5B: View of West Terrace, 2.54pm (Source: Maurice Price)

1. By 14:55:57, supporters could be seen climbing on the perimeter fence or the radial fences. 

Image

Figure 5C: View of the front of the West Terrace, 14:55:57 (Source: BBC)

1. At 2.57pm, Gate 3 burst open; PC Smith closed it immediately. This was in line with instructions to police officers not to allow anyone onto the pitch. In his 1989 account, he commented: “I assumed the pressure of a surge had opened the gate. There was no great pressure on fans at the front after the gate was re-secured.”
    
2. PC Smith said that no one came out of the pen at this point. However, some supporters and at least two police officers have said that a small number of supporters did go through the gate but were immediately pushed back into the pen by the police. 
    
3. One supporter’s account described seeing the perimeter fence gate spring open and his son and two others being pushed through it by the pressure of the crowd. He said the police returned them to the pen. Other supporters indicate that those who went through the gate fell or stumbled out of the pen, rather than walking through it.
    
4. However, within under a minute the gate opened again. PC Smith stated he was not able to close it. He said that two other officers came to assist him, and that at this stage supporters were screaming and shouting that they were being squashed. PC Smith said he stepped back from the gate, leaving the other two officers there and saw “people were tight up to the fence, particularly two or three young women to my right of the gate.” He tried to send a radio message to the PCB to ask if the gates could be opened: “I got no reply but think there was some message about a gate being opened elsewhere. The noise was terrible and people were screaming, a different type of scream and I opened the gate 3 fully.” His account of attempting to contact the PCB is supported by Racal recordings, which included a message from an officer with his call sign at this time. The message itself was largely inaudible.
    
5. Other officers near the gate have said that when it opened a second time, their perception of the situation also changed.
    
6. The supporter whose son had gone through Gate 3 at its first opening said that when it opened again, he, his son and his son’s friends were among the first to go through it. They walked along the track in the direction of the South Stand, where they sat down on a bench near the south-west corner of the pitch. This is confirmed by SYP CCTV footage timed at 15:00:17. He said that a police officer, later identified as Police Constable Fiona Richardson (PC Richardson), told them they could not stay there and took them to Pen 1 of the West Terrace.
    
7. Gate 3 remained open from this point and by 2.59pm, all the perimeter gates were open, as shown in figure 5D. A number of supporters can be seen on the perimeter track while others were climbing over the fence in front of Pen 4, or over the radial fence from Pen 4 into Pen 5.

Image

Figure 5D: The West Terrace at 2.59pm (Source: Stephen Loftus)

1. The officers who assisted PC Smith at Gate 3 were from D Division. Their initial duty had been to escort Liverpool supporters on buses from Sheffield Midland Railway Station in the city centre to the ground. They got to the stadium following the last of these escort trips at about 2.50pm. Seeing the crowd at the Leppings Lane entrance, Police Sergeant Howard Swift (PS Swift) asked their driver to take them to the Penistone Road entrance, where they went to the gymnasium and reported to Insp Sewell as planned.
    
2. Almost immediately, a message came over the radio asking for assistance at the Leppings Lane end. PS Swift assumed it related to the situation outside the turnstiles. Insp Sewell sent PS Swift and his serial to the Leppings Lane end, and they walked around the perimeter track, which was the most direct route.
    
3. As they walked round, they noticed the difference in fullness between the centre pens and the outside pens. At about 2.58pm, they stopped in front of the centre pens and several members of the serial recognised that supporters were extremely distressed. 
    
4. PS Swift decided to try to open the gate at the front of Pen 4 so that supporters could move into the emptier pens. He said that due to the noise of the crowd, it was not possible to use his radio to inform the PCB of his intentions, or to hear any radio transmissions. Instead, he waved to the PCB to indicate that he was going to open the perimeter gates. He said he knew that there were not enough police officers on the perimeter track to control the number of supporters he expected to come through the gates but recognised that those at the front of the pen were extremely distressed.
    
5. He was waiting for spectators to surge onto the track, but quickly realised the pressure was too great, so they had to pull each one out individually.
    
6. His recollections were supported by two other officers from his serial, Police Constable Philip Hooson (PC Hooson) and Police Constable Lillyan Akred (PC Akred). In his 1989 account, PC Hooson recalled: “As I neared Gate 4 I realised that the people in the West Stand were not shouting but were screaming. I realised then that something was seriously wrong and I heard people in the crowd screaming, 'let us out’.” He said there were three police officers standing on the track, but they were not doing anything. In a 2013 statement, he said the situation was worsening by the second.
    
7. PC Akred said she didn’t realise the gravity of the situation until she faced the crowd in front of Pen 4. In her 1989 account, she commented: “I then saw that people at the front of the crowd were going blue in the face and were apparently unconscious, only being kept up by the weight of people at each side. I shouted for people to try and ease back, but they were unable to do so.” 
    
8. She said that once they opened the gate, people were panicking: “Many were ignoring our instructions and just climbing over people who had already stumbled.”
    
9. Several supporters who were in Pen 4 have referred to the efforts made by a bald-headed officer and female police officer to lead the rescue effort. These were PS Swift and PC Akred.
    
10. Operation Resolve investigated complaints about the initial response of both PC Smith and PC Illingworth; these complaints concerned whether they recognised the situation fast enough and the way they dealt with supporters. Having examined the evidence set out in individual complaint reports, the IOPC was of the view that neither officer would have had a case to answer, if they had still been serving. While they did not immediately recognise the severity of the situation, neither did others: it was not clear that any delay in their response was a result of neglect of duty.
     
11. Further, while the evidence—including his own later admission when interviewed under caution by WMP—does suggest that PC Smith did push a small number of supporters back into Pen 3, this was at the point when he and another officer assumed they were dealing with a pitch invasion. He has explained that once he realised the gravity of the situation, he did push some people out of the way as he attempted to rescue those who were trapped.