The IOPC investigated the actions of SYP in the aftermath of the disaster, from its involvement in the immediate response and media coverage, through to the way it engaged with the Taylor Inquiry, the Popper Inquests and civil litigation that resulted from the disaster. It also examined the work of West Midlands Police (WMP), which had not previously been scrutinised, as well as some other issues that resulted from the disaster. The IOPC investigation is covered in chapters 7–21 of this report.
Behind the media coverage
The tone and content of the media coverage around the disaster has caused enormous distress, primarily due to recurring allegations that the disaster had in some way been caused by the actions of Liverpool supporters. Like the Taylor Inquiry had done 25 years previously, the Goldring Inquests wholly refuted this; the IOPC has found no evidence to challenge or change that central finding. The focus of the IOPC investigation into media coverage was to try to establish the sources of this coverage—in particular, what role SYP officers played in it.
The first reports blaming Liverpool supporters came in TV and radio coverage on the afternoon of the disaster, where it was stated that supporters had forced entry to the ground. These reports were based on comments made by Ch Supt Duckenfield to FA and SWFC officials, which he has since acknowledged were lies. They were corrected the same evening by CC Wright during a press conference but still featured in newspaper articles the next day. At the Goldring Inquests in 2015, Ch Supt Duckenfield said he apologised unreservedly to the families of those who died for the lies. However, the damage his comments caused was immense and enduring.
Even more damaging and distressing reports were to come, culminating in a notorious article in The Sun which included a number of allegations about the actions of supporters. As set out in chapter 7 of this report, the IOPC examined what evidence existed around each of these allegations and can confirm that there was little or none. There is no evidence that there were large numbers of supporters present without tickets. While some officers were jostled in the rescue efforts, or faced with angry and upset supporters, there is very little evidence to indicate that any supporters attacked or struck police officers. The IOPC found no evidence to support the most lurid allegations published in The Sun about supporter behaviour.
The article in The Sun was based on material that had been published by news outlets in South Yorkshire before it was picked up by the national media. The local coverage included quotes from several police officers. This is part of the evidence that indicates that, in the days that followed, numerous police officers spoke to the media about the disaster and, in several instances, about the behaviour of supporters. However, for the most part they did so anonymously. The IOPC contacted more than 200 journalists but was unable to establish the identity of any of the officers quoted anonymously. None of the officers interviewed said they spoke to journalists in this way. Based on a comparison with the words he has used in other accounts, and the description of the officer included in the media report, the IOPC has identified that Chief Inspector David Sumner (Ch Insp Sumner) was the most likely source of one published comment, that “excessive drinking was a major contributory factor” in the disaster.
Two individuals who spoke to the media gave their names: Police Constable Paul Middup (PC Middup), who was the SYP Police Federation representative, and Irvine Patnick, then MP for Sheffield Hallam. The strong impression is that in a bid to defend police officers, both repeated stories they had been told, without checking them. At an internal meeting, CC Wright indicated his support for PC Middup’s actions; however, the IOPC did not find evidence that he was directed by SYP or that he acted as part of a coordinated effort by the force. In fact, forcewide directions were issued twice, expressly instructing officers not to speak to the media without the express permission of the Chief Constable.
CC Wright’s own interactions with the media were also subject to scrutiny, in relation to allegations that he abused his position by commenting publicly on matters that were still under investigation and that he attempted to promote a false narrative, blaming supporters. Having examined all of his interactions with the media, from the day of the disaster to the day of his retirement, the IOPC view was that he would have had a case to answer for gross misconduct, as his actions were insensitive and could have prejudiced the ongoing investigations, contrary to force Standing Orders.
SYP’s attempt to deflect blame for the disaster away from the police
While there was no evidence of coordination behind the media coverage, the IOPC did find consistent patterns in the way SYP responded to the Taylor Inquiry and then prepared for the Popper Inquests.
This evidence is set out across several chapters of this report. It shows how a group of senior officers within SYP, with the assistance of the legal team appointed by the force’s insurers, presented a case that the disaster was not caused by failings on the part of SYP corporately, or on the part of individual officers.
Having collected a range of evidence, including written accounts from officers who had been on duty, SYP sought to:
minimise potential criticisms of leadership on the day
downplay the significance of changes in the police operation for the 1989 Semi-Final compared with the 1988 game
deny that SYP had any responsibility for monitoring safety in the pens
refute that there was any official police tactic to close the tunnel to the centre pens of the West Terrace, once they were full
In support of this, SYP and its legal team reviewed every officer’s account before it was submitted to WMP and the Taylor Inquiry and amended almost 1 in 4 of them. Through its comprehensive investigation with access to all accounts, the IOPC established that 327 SYP officers’ accounts were amended: 133 more than identified in the HIP Report.
Further analysis of the 327 amended accounts showed that there were 63 accounts from which criticisms of senior officers and/or police command and control were removed or reworded, although the IOPC also identified 49 accounts where such criticisms were not changed. Comments about aspects of police planning and tactics, including pre-match briefings, an apparent shortage of officers and a lack of coordination in the rescue effort were amended in 31 accounts, but left unchanged in 13.
Every reference to monitoring the pens or tunnel closure was removed from the accounts. That was despite senior officers demonstrating their knowledge of such tactics in meetings after the disaster, and SYP having successfully argued in a court case a few years previously that its officers’ role involved maintaining safety on the terraces.
Some officers objected to their accounts being amended. They were then pressured to accept the proposed changes. One of the officers involved in making the amendments was DCI Foster. He also engaged with some of the officers who resisted amending their accounts; the IOPC found he would have had a case to answer for gross misconduct, for directly or indirectly pressuring them to accept the changes.
However, neither DCI Foster nor Ch Supt Denton, who has accepted overall responsibility for the amendment process, would have had a case to answer in relation to the amendment of accounts itself. This was because, as long as the amendments did not actively mislead, SYP was under no obligation to put forward evidence that might undermine the version of events the force and its legal team wanted to portray, unless that evidence was specifically requested.
The same patterns, of removing information that could suggest SYP was responsible for monitoring the pens or had previously closed the tunnel, can be seen in the 120+ page document known as a ‘proof of evidence’ the force submitted to the Taylor Inquiry, and in particular how the content related to such issues was removed or edited by the legal team in the production of the final version. There is some evidence to suggest that several SYP officers, including CC Wright, did have knowledge of previous police actions or available contingencies to close the tunnel. However, even though this material was removed from the written submission, the Taylor Inquiry heard about these actions from some SYP officers who gave evidence.
Before they gave evidence to the Taylor Inquiry, senior officers met with the legal team and agreed some appropriate answers to potential questions they may be asked or criticisms the force could face. In some cases, the answers they then gave could not have been based on their personal experience.
After the Taylor Inquiry hearings, SYP, like other parties was invited to make a closing submission. SYP’s was produced by the appointed Counsel and included numerous references to alleged drunken or disruptive behaviour by supporters, which had not been mentioned in the proof of evidence. It also asserted that no “reasonable relevant criticism can be levelled at police planning for this event.” The evidence available to SYP did not support this assertion. CC Wright and Deputy Chief Constable Peter Hayes (DCC Hayes) were reported to be “very pleased”. This indicates they were aware of its content and tone.
After SYP had agreed to settle claims for compensation relating to the disaster, it started legal proceedings against other parties involved—including SWFC and Sheffield City Council (SCC)—to request that they contributed to the costs.
SYP and its legal team again sought to minimise the available evidence about its responsibility for monitoring the pens and its previous actions to close the tunnel. At the suggestion of Mr Metcalf, four officers were asked to review the evidence they had given to the Taylor Inquiry about these issues, to see if they felt it had given the wrong impression: all refused.
Ahead of the Popper Inquests, SYP also sought to identify witnesses who could give evidence about alleged drunken behaviour by supporters, in keeping with what their solicitor described as a strategy “to bring out the issue of drink-related hooliganism.”
As detailed in the final chapter of this report, the consistency of these actions and of the case SYP advanced led the IOPC to the view that this was a deliberate attempt to deflect the blame. However, SYP was legally entitled to do this. As long as they did not actively mislead the courts or the Taylor Inquiry, neither the force nor individual officers were obliged, unless specifically requested, to put forward any information which might undermine the case SYP was seeking to present.
However, acting in this way was not in keeping with the aims of the Taylor Inquiry, to prevent such events recurring. The IOPC’s analysis found that SYP adopted a highly defensive approach and was selective in what it put forward as evidence. That was despite officers, including CC Wright, knowing from an early stage that the police bore at least some responsibility for the disaster, including for the events around the opening of Gate C.
As he was the officer with overall responsibility for his force’s approach, the IOPC was of the view that CC Wright could be deemed to have breached the Disciplinary Code for discreditable conduct. If he was still serving, he would have had a case to answer for gross misconduct in relation to this, particularly given his stated approval of SYP’s closing submission to the Taylor Inquiry.
Flaws in the work of WMP
As the police force tasked in 1989 with investigating the disaster, WMP was best placed to have gathered and presented evidence to offer a different version of events to that presented by SYP, or at least to question it.
WMP took on a series of responsibilities, starting with gathering evidence for the Taylor Inquiry. The force then conducted a criminal investigation focused on potential manslaughter, a police disciplinary investigation into complaints relating to the disaster and also supported the Popper Inquests.
WMP’s work has not previously been subject to scrutiny. The IOPC examined what WMP did, against the standards of the day, to establish whether the force demonstrated bias or in any way inappropriately influenced the outcomes of the various inquiries and investigations. The findings are summarised in chapters 14–17 of this report.
The first step in the IOPC’s investigation of WMP was a major witness appeal, asking those who had contact with the force in the aftermath of the disaster to share their experiences. This led to 118 complaints about the actions of WMP officers, predominantly around the way they interviewed supporters in the aftermath of the disaster. In total, 41 complaints about WMP were upheld, or the IOPC found that the officers would have had a case to answer.
Further investigation of these complaints found that, while there were several occasions where WMP officers did not show sufficient compassion for traumatised and vulnerable witnesses—leading to complaints being upheld—most officers did attempt to conduct this challenging task with professionalism and sensitivity. Though the evidence indicates that there were instances where WMP officers introduced significant inaccuracies when writing up some witness accounts, again leading to some complaints being upheld, the IOPC did not find that this was a recurring or widespread issue.
Many supporters interviewed by WMP recalled being questioned extensively about their alcohol consumption on the day, and about whether others were drinking. However, the questionnaires and statements WMP completed with supporters included very few responses or comments about alcohol consumption. When supporters either found their accounts on the HIP website or were shown them by the IOPC, they were surprised not to see such information in them.
Senior WMP officers have stated to the IOPC that they believe it was appropriate to ask questions about alcohol consumption in the questionnaire. It was identified early as a necessary line of enquiry, particularly given the media coverage.
The IOPC fundamentally accepts that, in a set of circumstances where alcohol consumption had been publicly and widely identified within days of the disaster as a potential causative factor, it was necessary to ask supporters about this. The fact that it has since been established that the reports of alcohol consumption were exaggerated and that it had no bearing on the events does not change this.
Even though the line of enquiry was relevant, this would not have justified asking supporters aggressively or insistently about the subject. Further, the questions included on the questionnaire appear of limited value in addressing the issue. They offered no insight into whether any alcohol consumption that was witnessed was different from normal. In short, WMP investigated this important topic ineffectively.
WMP also did not interview SYP officers at all. Instead, it chose to rely on the amended accounts submitted by SYP. While this may have been a matter of necessity due to the tight timings of the Taylor Inquiry, when WMP senior officers were alerted to the fact that SYP officers’ accounts were being amended before SYP submitted them, they took no action to check the process or stop it. Instead, Assistant Chief Constable Mervyn Jones (ACC Jones) of WMP, who was leading the work for the Taylor Inquiry, wrote to CC Wright to inform him that officers had expressed concerns about the process.
Further, WMP then continued to rely on these accounts as primary evidence in the criminal investigation, even though in the case file submitted to the Director of Public Prosecutions (DPP), WMP made clear that such accounts were not admissible as evidence for a prosecution.
This was one of several areas identified by the IOPC where WMP’s criminal investigation appeared inexplicably narrow. Between August 1989 and March 1990, it completed just 76 additional actions, beyond the work already undertaken for the Taylor Inquiry, related to lines of enquiry for the criminal investigation. This was an astonishingly limited number for a manslaughter investigation of this size. WMP also delayed interviewing the suspects until after it submitted the file of evidence, and when it did, belatedly, interview the suspects, the interviews were conducted poorly, when measured against the expected professional standards of the day.
The IOPC has further established that the file WMP submitted to the DPP did not accurately reflect the totality of the underlying evidence that WMP had at its disposal. In the section of the file where Detective Chief Superintendent Michael Foster (D Ch Supt Foster) analysed the evidence submitted, he included repeated references to the behaviour of supporters and how much alcohol had been consumed. Unlike other investigations, including the Taylor Inquiry and the Goldring Inquests, he indicated that supporters’ behaviour had affected the events and cited it as a mitigating factor against prosecutions.
Further evidence identified by the IOPC, in the form of a memo he sent to ACC Jones after Counsel to the Taylor Inquiry had made his closing submission in July 1989, indicate that by that stage D Ch Supt Foster had already concluded that alcohol was a key factor in the disaster, and that the Taylor Inquiry did not consider it sufficiently. It appears that he then approached the criminal investigation with this fixed view of the evidence.
The IOPC reached the view that both ACC Jones and D Ch Supt Foster would have had a case to answer for gross misconduct, for failing to investigate SYP effectively and for not intervening in SYP’s account amendment process. Further, D Ch Supt Foster would have had a case to answer for not submitting all relevant evidence to the DPP and for failing to investigate the competence of SYP’s match commander.
Importantly, the IOPC did not find any evidence of an instruction from SYP or any external party to WMP to focus on alcohol consumption or the behaviour of supporters, or to deflect blame from the police. There was no evidence that indicated the flaws in WMP’s investigations were the result of a wider ‘establishment’ cover-up.
The need for a change in the law
The public, understandably, expects that the police will act in an open, honest and transparent way, including when police officers and forces face inquiries and investigations into their actions. The basic assumption is that they should assist the search for the truth in every way and not conceal or omit relevant documents and facts, even if such facts paint the police or individual officers in a bad light.
The aftermath of the Hillsborough disaster shows the consequences when this does not happen. It served as the catalyst for a longstanding campaign for justice, involving families of those who died, survivors of the disaster and others, who correctly recognised that the whole truth had not emerged. This in turn led to a series of investigations and re-examinations of the events, prolonging the trauma and distress for decades, for the families of those who died, for individuals under investigation and for all those who attended the match in any capacity. Public confidence in the police and the justice system has been damaged and the costs to the public purse have been substantial.
It is in this context that the IOPC has supported proposals to introduce a stronger duty of candour for all public servants, including police officers. The Public Office (Accountability) Bill, introduced to Parliament in 2025, includes a positive duty for all public officials, including police officers, to engage with candour, transparency and frankness in their dealings with investigations and inquiries. If they do not, they risk criminal sanctions. This is in addition to the duty to cooperate with investigations and inquiries set out in Schedule 1 to the Police (Conduct) Regulations 2020 and the duty of candour for police chief officers introduced in December 2023 as part of a new Code of Practice for Ethical Policing.
If this stronger duty had been in force in 1989, it may have helped bring the full facts of what occurred to light far sooner. The years and costs of multiple investigations could have been avoided, and most importantly the families of those who were unlawfully killed in the Hillsborough disaster would have experienced a far less traumatic fight for answers about what happened to their loved ones.
Operation Resolve investigated the lead-up to the disaster, in terms of the suitability and safety of the stadium and police planning for the match, what happened on the day itself and how the police responded. The Operation Resolve investigation is summarised in chapters 2–6 of this report.
An unsafe stadium
In relation to safety matters, Operation Resolve drew on expert analysis from John Cutlack, a Chartered Structural Engineer, which showed that Hillsborough Stadium failed on several counts to meet the safety standards of the day. These failings were particularly evident on the West Terrace. There were not enough turnstiles to allow people in safely, emergency exits were inadequate for the number of people permitted in the centre pens and some crush barriers, intended as safety measures, were the wrong height or too far apart.
All of these factors meant that by 1989 the permitted capacity of the West Terrace as a whole, and the centre pens in particular, was much higher than it should have been.
This capacity had been determined in 1979, as part of SWFC’s application for a Safety Certificate. The original assessment of 7,200 was already higher than it should have been, when compared to the requirements set out in the official Guide to Safety at Sports Grounds (the Green Guide). Then, over the following decade, there were numerous structural changes to the West Terrace, most notably the installation of fences to divide the terrace into separate pens. These are detailed in chapter 2. Each of these changes should have resulted in the Safety Certificate being formally reviewed by SWFC, as the certificate holder, and the safe capacity reassessed. This did not happen.
Applying a strict interpretation of the safety standards of the day, Mr Cutlack found that the safe capacity of the West Terrace on the day of the disaster should have been 3,089: less than half the number of supporters stated on the Safety Certificate. Yet some 7,200 tickets were sold for the terrace. In short, the risk of dangerous overcrowding on the West Terrace was extremely high, if not managed properly.
SYP had some involvement in safety matters; it was the driving force behind SWFC's initial application for a Safety Certificate and the installation of fences to create pens. However, it did not have the final say: that lay with SWFC, as ground owners, and the local council, which issued the Safety Certificate and was responsible for monitoring compliance.
The evidence indicates that SYP’s primary focus appears to have been how the stadium layout affected its ability to police matches effectively. In line with that, in 1985 officers had put forward a plan for a comprehensive redesign of the Leppings Lane entrance, clearly aligning banks of turnstiles with different areas and pens. The plan was considered but ultimately rejected for cost reasons, with SWFC prioritising investment in fire safety following a fatal fire at Bradford City’s stadium. Mr Cutlack’s view was that if the redesign had been implemented, the disaster could have potentially been averted; at the very least the consequences of the events would have been less severe.
Despite officers’ awareness of the difficulties at the Leppings Lane entrance and knowledge of previous crushing incidents on the West Terrace, Operation Resolve has found no indication that SYP’s planning for the 1989 Semi-Final took these factors into account.
Complacency in police planning
The 1989 FA Cup Semi-Final was a repeat of the previous year’s match, involving the same teams and the same venue. SYP, SWFC and the FA perceived the 1988 Semi-Final to have been a success, so SYP insisted that the same arrangements should apply for 1989. This included segmenting the stadium geographically, with the north and west sides allocated to Liverpool supporters and south and east sides to Nottingham Forest supporters. The purpose was to keep opposing supporters separate.
Following the disaster, SYP officers insisted that its planning for the 1989 fixture had been strongly based on the 1988 operation. However, there were several important differences, including a reduction in the number of officers on duty, particularly in the areas allocated to Liverpool supporters, and changes in the command team for the match. Because Ch Supt Duckenfield was about to take up the role of divisional commander for the area where Hillsborough Stadium was located, he was appointed as the match commander—the officer in overall charge of the police operation—even though he had no previous experience of commanding major football matches.
While evidence indicates his promotion was made in line with standard procedures, there was minimal time for him to familiarise himself with the stadium and he received little support or knowledge transfer. This was one of several factors in the police planning that had clear consequences on the day of the disaster.
Another was that there had been a change in turnstile arrangements, which meant that all 10,100 Liverpool supporters who had standing tickets had to enter through just seven turnstiles, equating to 1,443 supporters per turnstile. Because each turnstile could admit a maximum of 750 people per hour, the minimum time needed to get all the supporters in would have been almost two hours of constant operation.
By contrast, there were 42 turnstiles for Nottingham Forest supporters with standing tickets, equating to 500 supporters per turnstile. This change was authorised by Mr Mackrell and was the basis for his conviction, as the consequences of it should have been foreseeable.
As examined in chapter 3, the Operational Orders did not adequately address several issues that had occurred at previous matches. For example, though there had been crowd crushes on the West Terrace at previous semi-finals, no officer was instructed to monitor the safety of the crowd. There were also no instructions about how officers should manage the crowd outside the Leppings Lane turnstiles, even though this was a known bottleneck.
Together, these factors indicate a degree of complacency in the police planning, encapsulated in the remarks of Assistant Chief Constable Walter Jackson (ACC Jackson), who was responsible for approving the plans. He told the original inquests led by Dr Stefan Popper (the Popper Inquests) it was “inevitable” that when the plan was complete, it would be right. His confidence was to prove tragically misplaced.
The IOPC was of the opinion that ACC Jackson would have had a case to answer for gross misconduct for failing to plan adequately for the match. As the senior officer with overall responsibility for the planning process and approving the plans, he failed to, among other things, ensure that learning from previous matches was properly gathered and applied. Superintendent Bernard Murray (Supt Murray) drew up the plans; the IOPC view was that he too would have had a case to answer for gross misconduct for failing to plan adequately.
The failure of police control
On the day of the 1989 Semi-Final, there were initially no signs of concern ahead of the 3pm kick-off. Supporters were enjoying the fine weather and generally described as being in good spirits. There were no police reports of any significant trouble.
From around 2.15pm, however, the situation at the Leppings Lane entrance began to change. A crowd began to build, with supporters arriving in greater numbers than could enter the ground through the limited number of turnstiles available.
The number of supporters in the area was sufficiently high that Superintendent Roger Marshall (Supt Marshall), the officer in charge at this end, asked officers in the Police Control Box (PCB) at the stadium to arrange for Leppings Lane to be closed to traffic. But there were no control measures in police plans for managing a crowd in this area. The situation worsened and a serious crush developed outside the turnstiles. By around 2.45pm, supporters entering the stadium were visibly distressed, while those crushed outside were increasingly scared and, in some cases, struggling to breathe.
Officers outside the stadium recognised they had lost control of the situation. However, they did not know that inside the stadium, some of the areas allocated to Liverpool supporters—the side pens of the West Terrace—were still largely empty, indicating there was space for Liverpool supporters once they were able to enter the ground. This was identified by numerous witnesses, including police officers, who commented on the fullness of the areas allocated to Nottingham Forest supporters, compared to those for Liverpool supporters.
Officers in the PCB, including Ch Supt Duckenfield, were in the optimal position to ensure colleagues inside and outside the stadium were aware of this difference, which could have informed policing decisions. The PCB was situated directly in line with the West Terrace and officers there could have seen through the windows that the side pens were particularly empty, while the centre pens appeared full. They also had CCTV showing the situation outside the ground. Despite having the complete picture of what was happening inside and outside the stadium, no one in the PCB shared this with their fellow officers.
With the crush at the Leppings Lane entrance showing no signs of reducing, Supt Marshall spoke to Inspector Robert Purdy (Insp Purdy), an experienced colleague on duty outside the turnstiles. They were both of the view that one or more exit gates should be opened to relieve the crush but have different recollections of what action they agreed to take. Supt Marshall has insisted he told Insp Purdy that they would need Ch Supt Duckenfield’s agreement to open the exit gates and allow supporters into the stadium in greater numbers. He therefore radioed to ask Ch Supt Duckenfield for his approval but received no response. Believing he was not getting through, Supt Marshall tried again.
At 2.48pm, Gate C opened. It appears that this was intended to allow a supporter out. However, an estimated 130–180 supporters entered. Because the numbers were small, officers were able to close the gate again within 30 seconds.
In the PCB, this 2.48pm opening of Gate C was seen on CCTV and greeted with surprise. Supt Marshall, who was not close to Gate C, radioed again, this time more urgently, that unless the gates were opened, someone could be killed. It is not clear whether he knew that Gate C had opened.
This message was heard in the PCB; other officers around the ground have stated they recalled it. It led to a discussion in the PCB and ultimately an instruction from Ch Supt Duckenfield to “open the gates”. It is not clear exactly when this instruction was issued or how many officers heard it; Operation Resolve has not identified any officer who has said they acted in response to Ch Supt Duckenfield’s instruction.
The fact that the 2.48pm opening of Gate C had appeared to help reduce the crush led some officers close to the gate to consider opening it again, in a controlled way, for a similar short duration. Insp Purdy has stated that following his conversation with Supt Marshall, he believed he had the authority to do so. Police Sergeant John Morgan (PS Morgan) guided a small group of supporters to Gate C with this intention.
At 2.52pm, stewards opened Gate C again. Despite comprehensive analysis of CCTV, officer accounts and radio transcripts, Operation Resolve has not been able to establish whether this was on the instruction of PS Morgan or any other officer, or whether the stewards did so themselves. The stewards’ accounts have been contradictory.
It is, however, certain that this time, the number of supporters entering was far higher and the police were unable to control the situation. The gate remained open for several minutes and while estimates vary, the commonly accepted figure is that more than 2,000 supporters entered through Gate C at this point.
Crucially, the police did not prepare for this second opening of the gate in any way, and no measures were taken to control or guide the incoming supporters. These supporters therefore followed the most visible and direct route to watch the match, which for those with terrace tickets was along a tunnel into the centre pens of the West Terrace. When they entered the tunnel, supporters could not see how full those pens were.
The failures in decision making and communication were at the heart of why the IOPC reached the view that Ch Supt Duckenfield would have had a case to answer for gross misconduct in relation to managing the build-up to the game. Supt Murray was in the PCB alongside him and failed to advise him correctly; the IOPC also found he would have had a case to answer for gross misconduct, as would Supt Marshall in relation to failures in controlling the situation outside the Leppings Lane entrance.
The emergency response: continued failures in police control and communication
The rapid influx of supporters into the already full centre pens led to a sudden and devastating change in the situation. With large numbers of supporters entering through the tunnel at once, the pressure of the crowd increased to the extent that at 2.57pm, one of the gates in the perimeter fence at the front of Pen 3 burst open. Officers on the track in front of the pens assumed it was a pitch invasion and sought to close the gate. Supporters who had been thrust through were made to go back in. Almost immediately, the gate burst open again.
This time, some of the police officers on the track began to recognise that this was not a pitch invasion and started to respond, by deliberately opening the other gates to allow supporters through and onto the pitch side. This was against the written instructions officers had been given. By 2.59pm, all of the perimeter gates at the West Terrace were open. Other supporters were climbing over the perimeter fence, to get out of the centre pens. Some officers on the track attempted to guide supporters into the side pens, while other supporters sat or stood at the side of the pitch, in some cases exhibiting clear signs of distress or discomfort.
When those in the PCB saw that supporters were on the pitch, one officer was sent to the perimeter track to see what was going on, but it appears he gathered little information. Ch Supt Duckenfield has said he radioed Superintendent Roger Greenwood (Supt Greenwood), the senior officer on duty on the pitch side, to try to establish what was happening, but there is no record of this.
At 3pm, Supt Greenwood had been at the halfway line. Having seen supporters on the pitch, he had gone to the West Terrace, arriving by 3.02pm. He has said he instantly recognised that supporters were being crushed and at first tried to urge the crowd to go back. Realising this was not working, he then made a gesture to the PCB that the match should be stopped. This was at 3.04pm. He then ran onto the pitch to instruct the referee to stop the game, reaching him at 3.05pm. Following that, he returned to the pens to attempt to free supporters from the crush.
The PCB issued requests for officers to assist but gave no explanation of what had happened or why assistance was needed. After asking officers at the stadium to attend, a request was made to the SYP Force Control Room for Operation Support. This meant all available officers from across the force area were required to come to the stadium. However, Operation Support was designed and understood to be a response to public disorder.
As chapter 5 demonstrates, the lack of clarity about the situation became an increasing problem as attempts were then made to contact the South Yorkshire Metropolitan Ambulance Service (SYMAS). With no understanding of what had happened, SYMAS provided a holding response, rather than dispatching the “fleet of ambulances” requested. There was a protocol for ensuring a rapid response from the emergency services: declaring a major incident. SYP failed to do this.
Though officers on the pitch, aided by St John Ambulance (SJA) volunteers and some supporters, began to engage in frantic rescue efforts, there was no coordination and people were getting in each other’s way. SYP’s Major Incident Manual clearly stated that “the overall control and co-ordination of the effort of all the services involved in dealing with a major incident is a POLICE responsibility.” [Emphasis in the original.]
Evidence clearly shows that the senior officers in the PCB failed to take control of the situation or coordinate the response. The importance of such coordination was demonstrated when Chief Superintendent John Nesbit (Ch Supt Nesbit) arrived and organised officers into chains at each gate. This helped free supporters in a more orderly way.
But freeing supporters from the pens was only the first step; there was then a need for coordination of medical treatment. Again, the police did not provide any guidance to support this. When ambulances first arrived at the stadium, police officers at the entrances had no idea why. When the fire service arrived, they faced similarly confused responses. In the absence of police instructions, both SYMAS and the fire service attempted to coordinate the medical response themselves.
It is clear that Ch Supt Duckenfield froze in the crisis—a fact that his lack of experience in controlling football matches undoubtedly contributed to. However, no one took over or filled the void. ACC Jackson was at the stadium and could have done but did not. Both failed to give coherent instructions that could have helped accelerate the rescue effort.
These failings were at the heart of the IOPC opinion that both officers would have had a case to answer for gross misconduct in relation to several aspects of the way they responded to the disaster. The IOPC was also of the view that Supt Murray would also have had a case to answer for gross misconduct in failing to respond effectively, and Supt Greenwood would have had a case to answer for misconduct.
Chaos and a lack of compassion
Clear control and communication were still lacking in the hours that followed, as families and friends of those injured or missing sought information. The accounts of families, a small selection of which are included in chapter 6, paint a devastating picture of a chaotic response, where there was no effective information flow between the stadium, hospitals and locations set up to assist them. At the hospitals, police teams seem to have been largely invisible.
A Casualty Bureau—essentially a telephone contact centre intended to be the hub of information flow to supporters’ families and between police forces and the other emergency services—was overwhelmed. It had insufficient telephone lines and resources. It later emerged that SYP had only ever set one up once before, for a much smaller incident.
From around 9.30pm, a formal identification process began. The process prioritised consistency of protocol over compassion. All those who died had been returned to the gymnasium at the stadium. After a protracted wait and with little explanation, each family or group of friends was taken through individually and asked to identify their loved one from distressing photographs on boards. They were confronted by the horror of seeing all those yet to be identified, with the police making no attempt to pre-select relevant images (such as the right age group or gender) or to use personal property as the basis for provisional identification.
Once they had found a photograph of their loved one, families and friends were then required to carry out a physical identification. Some reported being prevented from holding or touching their loved one, on the basis that they were now “the property of the Coroner”.
They then had to give an identification statement. Many have reported that during this process they were asked questions about their, or their loved one’s, alcohol consumption. These questions and answers were not recorded in the statements, yet the accounts of those who experienced or witnessed the questioning are strikingly consistent. There would have been no legitimate reason to ask this as part of an identification statement.
Many have subsequently suggested this was the first indication that supporters’ alcohol consumption would be cited as a contributory factor in the disaster. This allegation was categorically rejected by the Taylor Inquiry, and again by the Goldring Inquests, as well as in the subsequent criminal and disciplinary proceedings detailed in this report.
Throughout the night, no senior SYP officer assumed overall responsibility for coordinating the many strands of activity or ensuring effective communication across the different sites. At each location, individual officers, many of whom were themselves exhausted and deeply affected, remained focused only on their immediate tasks. The police relied heavily on volunteers, who provided organisational as well as emotional and practical support, often with great empathy. Many of these volunteers, along with individual officers, went far beyond what could reasonably have been expected. Yet it was the failure of senior police leadership, and the absence of effective command, that left the overall response fragmented, inconsistent and impersonal, compounding an already devastating experience for families, friends and all those affected by the disaster.
The Hillsborough disaster refers to the events at the 1989 FA Cup Semi-Final football match between Liverpool and Nottingham Forest at Hillsborough Stadium in Sheffield. An extreme crush developed in the terraces at the Leppings Lane end of the stadium, resulting in the deaths of 97 Liverpool supporters. In addition, hundreds were injured and thousands left traumatised.
A public inquiry led by Lord Justice Peter Taylor (the Taylor Inquiry) was set up to investigate the causes of the disaster and to prevent similar events occurring. On 4 August 1989, Lord Justice Taylor published his Interim Report, setting out his findings on the causes of the disaster. The Interim Report was highly critical of the police operation and of some of the senior officers in the force responsible for the policing of the match, South Yorkshire Police (SYP). It concluded that “the main reason for the disaster was the failure of police control.”
Lord Justice Taylor also addressed allegations about supporter behaviour that had appeared in some early media coverage, making it clear that in his view, the actions of supporters played no part in the disaster.
Despite this, and a series of further inquiries into aspects of the disaster, until the publication of the HIP Report in 2012, there was a widespread public perception that supporters were in some way to blame for what happened.
The HIP Report transformed such perceptions, setting out documentary evidence that undermined the allegations about supporter behaviour and drawing attention to how the police acted in the aftermath of the disaster. It also raised important new questions about whether the disaster could have been prevented, and whether a more effective emergency response could have saved more lives.
Its impact was immediate. It led to decisions to quash the verdicts of the original inquests into the deaths and to start new inquests, and to launch two substantial new investigations:
a police-led investigation, known as Operation Resolve, into the disaster and its causes
an investigation by the IOPC into police actions in the aftermath of the disaster
About the investigations
The role of the HIP had been to oversee maximum disclosure of existing information about the Hillsborough disaster and explain how this information added to public understanding of the disaster and its aftermath. The IOPC and Operation Resolve by contrast were criminal investigations, which could (and did) result in people facing criminal charges. As well as revisiting all the material the HIP had considered, they had the authority to secure new evidence, by interviewing witnesses and suspects, taking statements and conducting or requesting searches.
Both investigations were also police disciplinary investigations, addressing:
complaints made about the actions of the police in relation to the disaster and its aftermath
conduct matters identified by investigators, where police officers may have committed a criminal offence or behaved in a manner which would justify disciplinary proceedings, but there had not been a complaint about the matter
In addressing this extensive remit, the two investigations examined more material about the disaster and its aftermath than any previous investigation or inquiry.
Having considered all of this material, the IOPC and Operation Resolve found evidence of fundamental failures by SYP in both the planning for the match and the policing of it, as well as in its response to the disaster.
While some of these failures had already been highlighted in previous investigations and inquiries, these investigations found additional evidence that has resulted in a more detailed understanding of what happened on the day and in the aftermath.
The evidence examined by Operation Resolve demonstrated persistent failings in police command and coordination on the day of the disaster.
The IOPC found considerable evidence that SYP adopted a defensive approach to the investigations and inquiries that followed, and sought to control the material submitted to the Taylor Inquiry in an attempt to deflect the blame away from the police. It also found deficiencies and potential evidence of bias in the work of West Midlands Police (WMP), the police force which undertook the original investigations into the disaster and supported the Taylor Inquiry.
Like the HIP Report and the new inquests, the IOPC found no evidence to support police accounts which suggested that the behaviour of supporters caused or in any way contributed to the disaster.
The new inquests
As well as addressing their terms of reference, both investigations supported the Goldring Inquests and conducted enquiries for them. The Goldring Inquests hearings ran for 308 days, spread over two years, and heard evidence from more than 1,000 individuals. The IOPC and Operation Resolve provided the inquests with more than one million pages of investigative material, such as witness statements and documents, together with hundreds of hours of audio-visual (AV) material.
The original inquests had returned a verdict of accidental death. At the Goldring Inquests, the jury concluded that those who died in the Hillsborough disaster were unlawfully killed—a momentous change.
The jury at the Goldring Inquests was also asked to respond to a series of questions about the disaster. One of these was: “Was there any behaviour on the part of football supporters which caused or contributed to the dangerous situation at the Leppings Lane turnstiles?” The jury responded “no”. The jury was then asked if there was any such behaviour which may have caused or contributed to the dangerous situation; again, the answer was “no”. By contrast, the jury answered “yes” to a series of questions about whether there were errors or omissions by police officers in the planning, preparation, decision making and emergency response that caused or contributed to the situation that developed.
Outcomes of the investigations
The investigations led to criminal trials of three former SYP officers and two civilians. The police officers were:
Chief Superintendent David Duckenfield (Ch Supt Duckenfield), the SYP match commander on the day
Chief Superintendent Donald Denton (Ch Supt Denton), who was involved in the way SYP prepared evidence for the Taylor Inquiry and oversaw the amendment of fellow officers’ accounts
Detective Chief Inspector Alan Foster (DCI Foster), who was directly involved in the amendment of fellow officers’ accounts
The civilians who faced trial were:
Graham Mackrell, the Secretary of Sheffield Wednesday Football Club (SWFC), which owned Hillsborough Stadium
Peter Metcalf, a solicitor with the firm Hammond Suddards, who advised SYP in the aftermath of the disaster and suggested amendments to officers’ accounts
None of the police officers was convicted, as explained further in the report, but the Operation Resolve investigation did lead to the conviction of Mr Mackrell for failing to discharge a duty under the Health and Safety at Work etc. Act 1974 (HSWA 1974).
In addition, the IOPC and Operation Resolve investigations examined a vast range of issues, including 260 complaints and 92 conduct matters, involving 137 identified former officers and a further 41 who had not been identified. These included officers from SYP and from West Midlands Police (WMP), the police force which undertook the original investigations into the disaster and supported the Taylor Inquiry.
These complaints and conduct matters have been addressed in 161 separate investigation reports; some conduct reports covered multiple conduct matters, for example where several officers were under investigation for the same issue. Complainants and the officers under investigation have been informed of the outcomes, as have those identified as ‘interested persons’ in any of the individual investigations.
The IOPC had the responsibility, under the Police Reform Act 2002, to make the final decisions about these complaints and conduct matters, including those investigated by Operation Resolve.
However, none of the officers investigated could face disciplinary proceedings, because they had retired before the investigations began. Legislation has now been changed so that retired officers can be subject to disciplinary proceedings.
The IOPC found that 12 officers (10 from SYP, 2 from WMP) would have had a case to answer for gross misconduct in relation to the disaster and/or its aftermath, if they had still been serving. That means that if a disciplinary panel found the allegations proven, they could have been dismissed. Most of these officers were senior officers and would have had a case to answer on multiple counts: for example, Ch Supt Duckenfield would have faced a case to answer for ten alleged breaches of the Police Disciplinary Code. SYP Chief Constable Peter Wright (CC Wright) would also have faced a case to answer on ten alleged breaches, regarding his actions in the aftermath of the disaster.
In addition, the IOPC upheld, or found a case to answer for misconduct in, 92 complaints about police actions.
The IOPC can only uphold complaints or reach a view that the officer would have had a case to answer for misconduct where the available evidence meets the legal thresholds it must apply. This report includes more details on the outcomes of the complaints and conduct matters investigated.
Permanent preservation of investigative material
Both investigations will transfer all the individual investigation reports, plus the new investigative material that is suitable for permanent preservation to The National Archives, following sensitivity checks. This material will be added to the full, digital copy of the historic Hillsborough archive created by the IOPC to provide a permanent record for future public access.
