Yet even while both were in the PCB, the police control of the incident remained poor. Though the PCB was in ongoing communication with the Force Control Room, at no point did it provide a clear explanation of what had happened. The Force Control Room operators therefore had to make assumptions in their communication with SYMAS and SYCFS counterparts.
Requests were made for Operation Support and for all officers at the stadium to head to the Leppings Lane end, but with no explanation given. Those responding did not know what they were responding to. As was the case earlier in the afternoon, those outside the stadium did not know what was happening inside and vice versa. When SYMAS and SYCFS teams turned up, the police officers at the entrances did not know why they were there and could provide no useful direction.
Throughout, radio communications were problematic, but there were other means of communication available. Despite the proximity of the PCB to the unfolding situation, Ch Supt Duckenfield did not at any point go on the pitch to make his own assessment. He has subsequently acknowledged that he froze. Supt Murray did go on the pitch but appears to have done little to assist; he did not provide any instructions beyond the reported words to PS Morgan to do whatever they could.
In short, though the senior officers in the PCB had the means to coordinate a response, and a view of the situation unfolding, they failed to manage the police resources and the other emergency services effectively.
Even by the time they left the PCB, they had still not provided the Force Control Room or other locations with clear information about what had actually happened. This inevitably hampered the efforts of those involved with attempting to assist traumatised supporters and the families and friends of those who were injured, missing or who had already died. This is the focus of chapter 6.
Operation Resolve identified a series of recurring issues that restricted the effectiveness of the emergency response. The first of these was a lack of coordination, command and control. This was mentioned in many of the accounts of SYCFS officers who came to the stadium, but also by SYMAS and a significant number of SYP officers. The most visible police leadership came from Ch Supt Nesbit, in organising officers at the gates. Others—from each emergency service and some of the off-duty medical professionals—also took the initiative to provide some coordination, albeit of small groups, which made the response more effective.
Throughout, the processes that formed part of the Major Incident Plan and Manual were not followed. Key omissions included the failure to declare a major incident, and the failure to have a visible site commander in overall control of the emergency response.
Both Ch Supt Duckenfield as match commander and ACC Jackson as the on-call chief officer could have performed this role. Even after both have given evidence on multiple occasions, it is still not clear which of them was the site commander or who was in charge of the emergency response.
At the Taylor Inquiry, ACC Jackson told Counsel to the Inquiry that he did not at any point tell Ch Supt Duckenfield that he was no longer in charge. ACC Jackson said that as the senior officer there, he was at Ch Supt Duckenfield's side, assisting and making sure that everything was done that possibly could have been done. However, ACC Jackson agreed with Lord Justice Taylor that, by the time Ch Supt Mole arrived at the PCB, he had taken over control from Ch Supt Duckenfield.
At other times, ACC Jackson has insisted that Ch Supt Duckenfield had remained in control and assumed the role of site commander in the major incident response. Then at the Goldring Inquests, he said he couldn’t remember whether Ch Supt Duckenfield had performed that role.
At the Goldring Inquests on 18 March 2015, Ch Supt Duckenfield told his own Counsel that ACC Jackson had not offered to take over command, had not overruled any of his decisions and had not given him advice. Two independent expert witnesses—both highly experienced match commanders—said they would have expected ACC Jackson, as the more senior officer, to have assumed command in this situation.
Aside from this lack of clarity about command, from 3.35pm to 3.48pm, both ACC Jackson and Ch Supt Duckenfield were away from the PCB in the boardroom, updating FA and SWFC officials about what had happened and their proposed approach. In the boardroom, Ch Supt Duckenfield repeated the lie that the disaster had been caused by supporters forcing their way into the stadium.
During this period, Supt Murray was left in charge, having recently returned to the PCB from the pitch. Operation Resolve found no evidence to suggest that Supt Murray was given any formal handover of control before ACC Jackson and Ch Supt Duckenfield left the PCB to go to the meeting in the boardroom. It was during this time that SO Fletcher visited the PCB to speak to the senior police officer but received no useful information.
Ch Supt Duckenfield told the Goldring Inquests that he was annoyed at being taken away from the PCB to brief the officials and suggested ACC Jackson should have done this alone.
The efforts of those involved at the front of the pens and in taking casualties away had an impact. By 3.30pm, the front of Pen 3 had been cleared of casualties. This was 25 minutes after Supt Greenwood had caused the match to be stopped.
Tragically, this was already too late for many. At 3.29pm, an entry on the Force Control Room extended incident log recorded that the PCB requested that the Sheffield city mortuary, located at the Medico-Legal Centre (MLC), should be warned “to expect several bodies.”
There was still a major medical effort, including at the back of the West Stand, to try to resuscitate some and treat others.
There were also still large numbers of supporters on the pitch, and some police officers were concerned that there was a risk of confrontation between opposing supporters, with some Nottingham Forest supporters in the Spion Kop area chanting and whistling. This led to the police forming further cordons, to prevent Liverpool supporters on the pitch from reaching the areas allocated to Nottingham Forest. By 15:38:30, police officers had formed a cordon in front of the Spion Kop, near the edge of the penalty box.
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Figure 5N: A police cordon in front of the Spion Kop, 15:38:30 (Source: SYP)
The cordon then moved up the pitch guiding supporters back towards the Leppings Lane end. There were no confrontations between rival supporters.
Shortly before the cordon was formed, at 3.37pm, two police officers on the pitch close to the Spion Kop had their truncheons drawn. This took place at a time when some Liverpool supporters were making their way towards the Nottingham Forest end of the ground. The footage shows that the truncheons were not used to strike anyone and were put away within moments of them being drawn.
Operation Resolve conducted a comprehensive review of all available video footage, in response to allegations that police officers used truncheons, sticks, canes or batons to prevent supporters seeking to escape from the West Terrace. This was the only instance found of police officers drawing their truncheons during the whole day. Operation Resolve did not identify any footage that supports the allegations. It should be noted that the footage, though extensive, is not continuous.
Further, Operation Resolve did not identify anyone who said they were struck by a police officer with a truncheon or something similar while climbing on or over the perimeter fence of the West Terrace.
SWFC CCTV footage shows that supporters and police officers continued to carry casualties through Gate C to ambulances that were still arriving. In total, SWFC CCTV filmed the arrival of 20 ambulances. The last casualty was carried out of the ground by supporters and police officers at 3.51pm.
At 3.56pm, Liverpool manager Kenny Dalglish gave a message over the stadium PA to ask supporters to remain calm and cooperate with the police. At 4.17pm, a further message was broadcast to inform supporters that the match had been abandoned. By around 4.40pm, Ch Supt Mole arrived at the stadium and went to the PCB, where he assumed command of the remaining operations, allowing Ch Supt Duckenfield and ACC Jackson to return to SYP HQ to brief the Chief Constable.
The focus shifted from the situation on the pitch to the gymnasium and the hospitals, which are examined in chapter 6.
As well as the emergency services, supporters played a pivotal role in the rescue effort. Many tried to help those being crushed in the pens. Others, including some who had escaped from the pens themselves, sought to assist the injured. This included helping carry casualties to the gymnasium on advertising hoardings, which were used as makeshift stretchers.
Several off-duty medical professionals who were at the match as spectators also assisted, as did off-duty police officers. Like the other emergency services, they were hindered by a lack of information; there was no instruction for them to help, so they did whatever they could in response to the situation in front of them. When they tried to get information, police officers initially did not know where to send them and there was no specific organisation. Several assisted with resuscitation efforts on the pitch; others helped in the gymnasium or at the back of the West Stand. They were also hampered by a lack of medical equipment, both on the pitch and elsewhere.
In addition to resuscitation efforts, some were involved in the triage of casualties, to prioritise who should be taken to hospital and to provide direction to SJA volunteers and police officers. The arrangements for assessment and triage of casualties on the pitch were largely driven by the individual response of the medical personnel. Operation Resolve has found no evidence that a systematic approach was put in place or facilitated by those in the PCB, or senior police officers on the scene.
The third primary role undertaken by off-duty doctors was to certify the deaths of supporters. Some were directed to the gymnasium to assist with this. The situation in the gymnasium is examined in chapter 6.
With a hole already made in the fence, there was no longer a need for the cutting equipment brought by the fire service. Several SYCFS officers have said that when they arrived and asked where they were required, the initial response from the police was to suggest they weren’t needed. Other police officers could offer no direction or information. The SYCFS officers decided to go into the stadium anyway; when they saw the situation, they recognised the most useful way they could assist was with resuscitation and first aid.
Station Officer Brian Fletcher (SO Fletcher) was the day shift station officer at Sheffield Central Fire Station, from where three SYCFS vehicles had been dispatched. In a statement made in 2013, he said that due to the large number of casualties, he decided to go to the PCB to find out who was in charge and to see if there was a designated area for casualties. When he got there, he was told that Ch Supt Duckenfield (who he knew) was in charge, but away at that time. They were unable to provide him with any information, so he “decided to return back to the pitch area to set up my own casualty handling area.”
It appears this was at the time Ch Supt Duckenfield was visiting the SWFC boardroom, as discussed at paragraph 5.171.
In his 1989 account, SO Fletcher said that he instructed the SYCFS drivers to set up a casualty handling area behind the South Stand, as he knew there was access to that area, and to organise the ambulances when they arrived. He also arranged for his officers to provide first aid wherever necessary. He estimated that about 20–30 people were taken to the SYCFS casualty handling area on makeshift stretchers.
Station Officer Robert Horner, from a different fire station, described how he and his crew went straight onto the pitch when they arrived, bringing resuscitation equipment. He said that he and his crew spread out among the casualties to provide treatment and resuscitation where necessary. He recalled asking “two senior police officers if those spectators not injured in any way could be moved out of the congestion to enable those endeavouring to give assistance more room to work, the reply was 'we have already tried to do this'.” He commented: “Police co-ordination and control seemed to be non-existent on the playing area.”
The on-call SYCFS Divisional Officer David Lockwood arrived at the stadium at 3.24pm and assumed command of the fire service response. He too was unable to find a senior police officer, so went to the PCB and introduced himself. He said: “I didn't receive any direction from anyone in the police box as to what they wanted me to do.”
The evidence of the SYCFS personnel who arrived at Hillsborough Stadium is highly consistent. All highlighted a lack of direction or instruction when they arrived, with police officers apparently surprised at the arrival of the fire service and having no idea why SYCFS had been called. This reinforces the lack of communication between the PCB—which had requested the fire service attend with cutting equipment—and the rest of the police officers on duty. When SYCFS officers sought to identify and speak to the SYP officers in command of the situation, they were unable to do so.
Some SYCFS officers have described similar difficulties in engaging with SYMAS teams on site.
In the absence of any direction from the other emergency services, the SYCFS officers sought to assist as best they could, predominantly by providing first aid, making use of their resuscitation equipment and organising aspects of the triage and casualty clearance response. They took numerous practical steps from clearing the pitch to aiding the movement of ambulances and providing advice to supporters. The one thing they had been specifically called to provide—cutting equipment—proved not to be needed.
By 3.10pm, a huge number of police officers were involved in the rescue effort. Figure 5J shows the situation at 15:11:30. Numerous officers had climbed on the perimeter fence; some were in Pen 2, to the left of the photo. Many more were on the pitch. Some supporters were also on the fence; others were being helped into the West Stand above and still more were climbing the radial fences between pens.
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Figure 5J: View of the West Terrace, 15:11:30 (Source: BBC)
Figure 5K, taken at 3.11pm, shows the chaotic nature of the response from a different angle. While some officers were predominantly engaged at the exit gates, others were standing further back from the fence, appearing unsure how to help. Some may have been part of a cordon. The photograph offers no sign of a coordinated rescue effort.
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Figure 5K: The front of the West Terrace, 3.11pm (Source: SYP)
It was around this time that Ch Supt Nesbit arrived at the Leppings Lane end. Ch Supt Nesbit was the head of the SYP Traffic Division. In an account from 1989, he explained that he had been on patrol in Sheffield city centre and arrived at Hillsborough Stadium shortly after the referee had stopped the match. His arrival was not in response to the call for Operation Support. When he got to the gymnasium, Insp Sewell told him they were evacuating the West Terrace and that supporters had been injured.
Ch Supt Nesbit went onto the pitch at the Spion Kop end and saw what he first thought to be a pitch invasion. However, he then spotted that some of the supporters climbing over the perimeter fence were being assisted by police officers. In his 1989 account, he said that as he approached the goal area, he saw that the perimeter track was filled with police officers and supporters, and that a number of casualties were being attended to by SJA personnel and uniformed police officers.
He said that when he reached the front of Pen 3, “to my horror I could see bodies piled on top of each other with other spectators being pressed against the fencing.” He said that Gate 3 was open but blocked by two supporters who were unable to move; he assumed they had died. He instructed officers to try to move them, to free the gateway.
He quickly realised that “Police Officers and spectators in their endeavours to help, were getting in each others way.” He instructed officers to form a chain onto the pitch, so that casualties could be pulled out and carried away from the pens.
This approach began to create some order in the rescue effort. Figure 5L shows the scene at 15:20:24. By this time, Supt Greenwood was standing on what appears to be a stepladder with a loud hailer in his hand. Ch Supt Nesbit was in the open gateway, attempting to pull people out of Pen 3. There were fewer supporters at the gate, with the police taking control of the rescue operation.
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Figure 5L: The front of Pen 3, as viewed from the West Stand, 15:20:24 (Source: BBC)
The more organised response at the gates was assisted by having increased access to the pens. In a statement from 2014, Inspector Richard Dews recalled that shortly after Ch Supt Nesbit arrived at Gate 3, he saw police officers and supporters kicking and pulling the wire of the perimeter fence back to create another escape route. He said that he radioed the PCB and asked for bolt cutters to assist in cutting the mesh.
At 15:13:09, the Racal system recorded a radio transmission from the PCB to the Force Control Room, requesting that SYCFS be contacted to attend the stadium with cutting equipment. The Force Control Room promptly contacted their counterparts at SYCFS and requested this, but they were still unable to provide SYCFS with details of what had happened. However, the Force Control Room operator did refer to there having been a “major accident” and later in the conversation “a major incident inside the ground”, even though one had not been formally declared, and they did not have the knowledge or authority to do so. In accordance with the SYCFS Major Incident Contingency Procedures, SYCFS dispatched six standard fire engines, a control unit and an emergency tender (a vehicle designed to carry extra water supplies) to Hillsborough Stadium.
The first of these did not reach Hillsborough Stadium until 3.22pm. By this time, supporters and police officers had managed to bend back a small section of the perimeter fence at the front of Pen 3, adjacent to the radial fence with Pen 4. This created an additional escape route from the pens, through which officers and supporters worked to free more people. The impact of this is shown in figure 5M, taken from BBC footage a few minutes later at 15:26:28. By this time, large numbers of officers were inside Pen 3, both at Gate 3 to the right-hand side of the ambulance and at the newly created break in the perimeter fencing, at the bottom left of the image.
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Figure 5M: The rescue effort aided by the hole in the perimeter fence, 15:26.28 (Source: BBC)
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.”
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.
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.
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.
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.
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.”
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.
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.”
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.
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.
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Figure 5I: The SJA ambulance arriving on the pitch (Source: BBC)
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.
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.”
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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.
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.
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.
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.”
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.”
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).
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.”
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.”
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.
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.
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.
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.
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.
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.
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.
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”.
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.
However, when asked specifically whether he knew the code word 'Catastrophe', he conceded that at the time of the disaster he did not.
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
