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.
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.
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.
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.
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.
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.”
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.
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.
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.
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.”
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.”
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.”
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.
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.
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Figure 5H: The scene in front of the West Terrace, 15:07:04 (Source: SYP)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
At this stage, he was still unaware that there had been any issues outside the stadium.
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.
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.
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.”
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.
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Figure 5F: Supt Greenwood approaching the referee, 15:05:29 (Source: BBC)
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.
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.
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.
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.
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Figure 5G: Supt Murray on the perimeter track, 15:05:43 (Source: BBC)
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.
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.
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.
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Figure 5E: View of the West Terrace from the PCB, 1989 (Source: Richard Haylor, WMP)
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.
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.
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.
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.
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.”
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.
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.
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.
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.
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.
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.
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Figure 5A: Photograph of the broken crush barrier, taken in the aftermath of the disaster (Source: HSE)
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.
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.”
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.
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.
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.
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.
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.
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.
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.
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.
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Figure 5B: View of West Terrace, 2.54pm (Source: Maurice Price)
By 14:55:57, supporters could be seen climbing on the perimeter fence or the radial fences.
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Figure 5C: View of the front of the West Terrace, 14:55:57 (Source: BBC)
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.”
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.
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.
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.
Other officers near the gate have said that when it opened a second time, their perception of the situation also changed.
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.
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.
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Figure 5D: The West Terrace at 2.59pm (Source: Stephen Loftus)
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.
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.
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.
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.
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.
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.
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.”
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.”
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.
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.
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.
This chapter includes witness accounts, images and descriptions of scenes that may be distressing.
What was investigated?
Under the terms of reference for the managed investigation, Operation Resolve investigated: Response of the police to the disaster, including:
a) the early police response to the crush at the Leppings Lane end, including allegations that the police were slow to respond/failed to act when it was obvious the people were in distress b) alleged failures/refusals on the part of the police to open perimeter gates, and allegations that officers pushed supporters back when they were trying to climb to safety—this aspect of the investigation will specifically consider complaints made against PC Peter Smith and PC David Illingworth, as well as any other officers who may have been involved c) subsequent police command and control of the disaster d) the communication between the police and the other emergency services e) the activation and implementation by the police of any pre-planned responses and emergency procedures for such disasters
What was found?
• Accounts from supporters describe a sudden change in the situation in the pens at around 2.55pm, when the pressure from the back suddenly intensified. This is consistent with the influx of supporters into the centre pens after the 2.52pm opening of Gate C. Officers and supporters in the West Stand recalled seeing a huge surge of people coming into the pens around this time.
• Officers from Serial 1, stationed in their usual positions on the perimeter track, did not immediately realise the severity of the situation. When Gate 3 in the perimeter fence burst open at 2.57pm, the officer there (PC Smith) immediately sought to close it again and prevent supporters coming through, assuming it was a pitch invasion. When Gate 3 burst open a second time, it was left open and officers allowed supporters through onto the perimeter track.
• At around this time, a serial of officers from D Division, who were not normally involved in policing Hillsborough Stadium, arrived at the West Terrace. Some of them instantly saw there was something wrong and opened Gate 4, to try to free supporters from Pen 4 towards Pen 6. The evidence indicates that Police Constable David Illingworth (PC Illingworth) from Serial 1 had not yet done so. Other members of the D Division serial have stated that they did not immediately think there was a problem inside the pens, but within a matter of seconds they realised there was. By 2.59pm, all the perimeter gates to the West Terrace were open.
• When the officers in the PCB saw supporters on the perimeter track, they initially assumed it was a result of disorder, and their first request was for dog handlers to be sent to the stadium. At 3.04pm, they saw Supt Greenwood signalling to them that the match should be stopped but still did not know why. Supt Murray was sent down to the pitch, but by the time he had got there, Supt Greenwood had reached the referee to stop the match. Supt Murray returned to the PCB but was sent back down to find out what was happening.
• As soon as the match was stopped, Ch Supt Duckenfield called for Operation Support—a request for all available officers to be immediately deployed from across SYP to assist. However, he did not have the authority to do this; it required ACC Jackson to confirm it, which he did a couple of minutes later.
• At almost the same time, 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. Neither request included any details as to what officers were responding to.
• Most officers who did respond initially assumed that they were dealing with some kind of crowd trouble or pitch invasion. However, as they got closer to the West Terrace, their views changed. Most SJA volunteers and the first SYMAS staff present indicated that their first thought had been the same.
• SYP and SYMAS did not respond in line with their emergency procedures or incident plans. Duties identified as pivotal to the correct allocation of resources and directing the response were not fulfilled. No police officer declared a major incident, so the other emergency services were not correctly alerted to the severity of the situation.
• At first, SYP’s Force Control Room merely advised SYMAS that ambulances may be needed; the Force Control Room received a request from the PCB for a “fleet of ambulances” to be dispatched. This was in response to a message from Supt Murray on the pitch at 3.08pm. However, the Force Control Room was only able to give SYMAS limited information about what had happened, so SYMAS rejected the request for multiple ambulances, instead authorising a limited initial response.
• When further ambulances did arrive, police officers outside the stadium did not know why they had been called or where they were needed. The same issue recurred when teams from SYCFS arrived a few minutes later.
• Rescue efforts were initially hampered by a combination of the narrowness of the perimeter gates, the pressure from the crowd and a lack of organisation. Several officers have described getting in each other’s way as they frantically tried to free trapped supporters. The situation changed after Ch Supt Nesbit arrived at around 3.11pm. He organised officers into chains at each gate, to enable supporters to be carried to safety. Around the same time, other officers, including PS Morgan, entered the pens through the central tunnel at the back, to encourage supporters to move away and help free those at the front.
• There was no central organisation of the rescue effort and no instruction from the PCB. Instead, it was left to those on the pitch to make decisions as best they could. This included SYMAS and SYCFS staff. The PCB did issue requests for help, such as a request for the local radio station to broadcast an appeal for doctors to attend. However, its communications remained poor: at one point, the PCB asked the Force Control Room to set up a “Major Incident Bureau”, confusing two separate functions: a Major Incident Room and a Casualty Bureau. There was also a lack of clarity as to who was in charge.
• Supporters, including some off-duty medical professionals sought to assist, but also received little or no instruction. Numerous supporters helped carry the injured while medical professionals at first attempted resuscitation but were increasingly asked to certify death. There was no police coordination of this, as the SYP Major Incident Manual stipulated there should be. The sole focus appears to have been rescue, with no consideration of how the injured would be managed. The PCB did not offer any direction around this, which also meant that medical resources were not well deployed.
• By 3.31pm, the front of Pen 3 was clear of casualties. However, supporters were still being treated or taken to ambulances. A growing number were confirmed to have died.
• Some of the actions of officers—such as forming cordons rather than assisting in the rescue effort—appeared inappropriate to supporters.
• Evidence has not been found of officers using their truncheons on supporters and there is insufficient evidence to substantiate allegations of officers physically preventing supporters from escaping the pens.
Significant new evidence
There was already a wealth of existing evidence about the emergency response. Operation Resolve enhanced this by time-synchronising it, then using specialist technology to analyse it frame by frame. This provided further insight into the sequence of events and also assisted in the investigation of specific issues, such as the allegations that police officers had used truncheons on supporters.
Operation Resolve also examined in detail recordings and transcripts of police radio communications and telephone conversations, including those between the PCB and SYP’s Force Control Room at Police HQ, and between the different emergency services—some of which had not previously been open to scrutiny.
This chapter focuses on Operation Resolve’s investigation into the short period of time from around 2.45pm, shortly before the exit gates were opened, to 5.15pm when Ch Supt Duckenfield left the stadium. It examines the effectiveness of the SYP response to the situation, comparing what officers did with what—according to SYP’s own Major Incident Manual and Major Incident Plan—they should have done.
It also includes evidence from supporters, police officers and other witnesses describing the situation in the pens, along with some images of the rescue effort. Some may find these accounts and images distressing.
There are, understandably, numerous inconsistencies in witness accounts about precise timings and the exact sequence of events. Where possible, Operation Resolve has used time-synchronised video footage and time-stamped photographs to provide accurate timings.
Operation Resolve investigated a number of complaints and conduct matters relating to the events of the day, up to the opening of the exit gates, and provided reports on each to the IOPC. Having reviewed the evidence detailed in these individual reports, the IOPC opinion was that four officers would have had a case to answer for gross misconduct, if they had still been serving. Some of the grounds for the IOPC’s opinion are set out below.
Ch Supt Duckenfield would have had a case to answer for neglect of duty on several counts, beginning earlier in the day when he did not brief officers in sufficient detail about how they should police the arrival of supporters at the Leppings Lane end. This was then followed by a series of key failings of control as the crowd built.
He did not take reasonable steps to assess the number of spectators yet to enter the stadium, which was directly related to the subsequent decision not to delay the kick-off, also identified as a key failing.
Having failed to prevent a dangerous build-up of supporters outside the Leppings Lane turnstiles, he then authorised opening the exit gates without fully considering the likely impact of doing so. Nor did he give any warning to officers that the exit gates were about to be opened, or any instructions to officers about how to manage the influx of supporters.
Supt Murray would have also had a case to answer for neglect of duty in relation to his failings to prevent a dangerous build-up of supporters outside the gates and to control the movement of supporters following the opening of Gate C. He did not use his additional knowledge and experience to assist Ch Supt Duckenfield: he failed to anticipate that a dangerous build-up of the crowd could occur and advised Ch Supt Duckenfield incorrectly that all the supporters would be able to enter the ground in time for the scheduled kick-off. Neither of them checked turnstile count data.
He also specifically acknowledged that he knew supporters coming through Gate C would be most likely to head to the central tunnel, but he failed to consider the risks of this or give instructions to ensure the safe distribution of supporters.
Supt Marshall would have had a case to answer for neglect of duty because, among other factors, he failed to take steps to ensure that the supporters were able to queue safely for entry through the turnstiles. Once it became apparent that the police had lost control of the situation at the turnstiles, he failed to request that the kick-off should be delayed.
PS Morgan was subject to a conduct investigation, initiated by Operation Resolve rather than as a result of complaints. He would have also had a case to answer for gross misconduct, for the offence of neglect of duty in relation to two issues. The first of these was that he left his allocated area of responsibility on the inner concourse without good reason for over half an hour during the build-up to kick-off. It appears he did not return to this area as swiftly as he could have done, leaving his serial without supervision during the critical period when the crowd built up outside the turnstiles. The second allegation related to his role in the 2.52pm opening of Gate C. With evidence available to indicate that he asked for Gate C to be opened at this time, he failed to consider the impact of opening the gate—even though he had already witnessed the consequences of the 2.48pm opening—and also did not articulate any concerns to senior officers.
Operation Resolve’s investigation demonstrated that throughout the day of the disaster, there was a recurring issue in the way the police managed the situation: a marked lack of effective communication. This began early, when groups of officers chose to apply different tactics to those detailed in the Operational Order, without informing colleagues.
It continued as officers made their own decisions about managing supporters around the city. When PS Miller instructed that certain pubs should be closed, he didn’t advise colleagues at the Leppings Lane end that he would be escorting a large group of supporters to the stadium. He did tell the PCB, but no one passed the message on.
The PCB was not alerted to potentially significant traffic delays further afield, which could have been important in the decision about whether to delay the kick-off. Nor did officers there seek to check the situation.
Most significantly, as the crush built outside the stadium, officers inside had no idea what was happening. They therefore had no reason to be concerned about the unequal distribution of supporters between pens on the West Terrace.
This communication failure culminated in the fact that before Gate C was opened neither the PCB nor the officers inside the gate were informed, so could not prepare. While some did have access to a radio, there were well-documented problems in terms of messages breaking up or simply being inaudible due to the crowd noise. Instructions were not precise and were uncoordinated. The result was the rapid influx of supporters, who took the most logical route to their target destination: the tunnel signposted “standing” which led to the full centre pens. The consequences of this are examined in the next chapter.
