• Read more about Appendix A: Terms of reference

Operation Resolve Terms of reference 

IOPC investigation Terms of reference

• Read more about Glossary

Appropriate Authority 
In police complaints, the Appropriate Authority is the police chief officer or policing body (such as PCC) that is responsible for recording the complaint and making the final decision on it.

Association of Chief Police Officers (ACPO)    
A forum for chief police officers in England, Wales and Northern Ireland. It was replaced in 2015 by the National Police Chiefs’ Council. 

Body continuity
The formal process by which police officers and others ensure that as the body of a person who has died is moved, identified and where necessary examined, all those involved are dealing with the same body. The process should be fully documented so that there is no unauthorised contact with the body.

Case to answer
In police complaints and conduct matters, an officer has a case to answer when there is enough evidence that a reasonable misconduct meeting or disciplinary hearing panel, could find misconduct or gross misconduct proven on the balance of probabilities.

Civil litigation
A term used to describe for non-criminal legal disputes. 

CJA statements
Statements are made in the majority of criminal investigations by police officers and other witnesses. They are made under the provisions of the Criminal Justice Act (CJA) 1967 and include a signed declaration of truth. They are sometimes referred to as CJA statements. 

Complaint
The IOPC defines a complaint as any expression of dissatisfaction with a police force expressed by or on behalf of a member of the public.

Conduct matter
Any matter which is not and has not been the subject of a complaint, where there is an indication (whether from the circumstances or otherwise) that a person serving with the police may have committed a criminal offence or behaved in a manner which would justify disciplinary proceedings.

Conspiracy to pervert the course of justice
Where two or more people agree to commit an act, or series of acts, intended to pervert the course of justice. To prove the offence, there must be evidence of both the agreement and the intent of that agreement.

Covert activity
Surveillance activities carried out in a calculated way to ensure that people who are under surveillance are unaware that it is taking place.

Crown Prosecution Service (CPS)
The CPS prosecutes criminal cases that have been investigated by the police and other investigative organisations in England and Wales. The CPS makes decisions independently of the police and Government.

Decision maker
The IOPC decision maker is responsible for setting out their opinion about what action should be taken regarding a complaint or conduct investigation. The decisions and opinions that the IOPC decision maker can make are set out in law. 

Director of Public Prosecutions (DPP)
The head of the CPS. 

Disclosure
Providing interested parties with copies of, or access to, all material for a court procedure. In this report, it may relate either to disclosure before criminal trials or disclosure in relation to the Goldring Inquests.

Discreditable conduct 
Under paragraph 1 of the 1985 Code of Conduct, discreditable conduct was committed where a member of a police force acted in a disorderly manner or in a manner prejudicial to discipline or reasonably likely to bring discredit on the reputation of the force or the police service.

Floppy disk
A computer storage medium used in the 1980s, 1990s and early 2000s.

GEN 18 form
A form used by SYP for recording details of all sudden deaths, whether suspicious or not.

Generic hearing
The second phase of the Popper Inquests, which examined the circumstances leading up to the deaths during the disaster. The generic hearing is sometimes referred to as the “resumed inquests”.

Goldring Inquests
The inquests into the disaster that were opened in 2013, after the Lord Chief Justice quashed the verdict of the original inquests. The new inquests were led by Lord Justice Goldring.

Green Guide (Guide to Safety at Sports Grounds)
The Green Guide was the official Government publication ‘The Guide to Safety at Sports Grounds’. First published in 1973, it was recognised as the core guidance for all football grounds to follow. 

Gross misconduct
A breach of the Standards of Professional Behaviour so serious that dismissal would be justified. 

Ground commander
The senior police officer who was responsible for overseeing the events inside the football ground and the officers deployed there. The ground commander was part of the senior command team managed by the match commander. 

Health and Safety Executive (HSE)
Britain’s national regulator for workplace health and safety. 

Hillsborough Independent Panel (HIP)
The HIP was set up in 2009 to oversee maximum public disclosure of all documents relevant to the disaster held by central government, local government and other statutory bodies. The HIP was also tasked with producing a report that explained “how the information disclosed [added] to public understanding of the tragedy and its aftermath”. 

Hillsborough Steering Committee
The Hillsborough Steering Committee was set up on 16 April 1989 to act as a focal point for the large number of solicitors’ firms instructed to represent the bereaved families and/or those injured in the Hillsborough disaster. 

HOLMES (Home Office Large Major Enquiry System)
An IT system designed to support large police investigations and follows the processes used in major incident rooms. It provides a standard and controlled means of storing, categorising and linking the information gathered by police—letters, emails, transcripts, statements, reports etc.—as well as the actions investigators took. A new account is typically created for each investigation. Both the IOPC and Operation Resolve used HOLMES in their investigations; SYP and WMP did the same.  

Inquest
Inquests are legal inquiries into the cause and circumstances of a death. Their parameters are clearly defined in law.

Interested person (IP)
In the IOPC’s work, an IP is someone who has a legitimate reason to be kept informed about another person’s complaint or conduct matter. In the Hillsborough investigations, the families of those who died in the disaster were offered IP status for a number of complaints and conduct matters that investigators identified as being of probable interest and relevance to them.

Interview under caution
A police interview with an individual suspected of a criminal or police disciplinary offence, where at the start of the interview, the interviewee is cautioned about their rights. The caution can be for a criminal offence or police misconduct.

Major Incident Room (MIR)
The purpose of an MIR is to serve as the hub for the collection of evidence related to a major incident. MIRs operate to a standard administrative process (MIRSAP), which helps bring order to the information gathered and the use of investigative resources. 

Manslaughter by gross negligence
Where a death is a result of a grossly negligent (though otherwise lawful) act or omission on the part of the defendant.

Match commander
The officer in charge of the police operation at a football match. 

Medico-Legal Centre (MLC)
A purpose-built centre in Sheffield designed to provide the facilities and services required for the investigation of a sudden or unexpected death. It comprises the offices of HM Coroner for South Yorkshire (West) District and the public mortuary. It opened in 1978. 

Misconduct
Misconduct is defined in the Police Reform Act 2002 as “a breach of the Standards of Professional Behaviour”. However, where a matter is being dealt with under the Police (Conduct) Regulations 2020, the following definition applies: “a breach of the Standards of Professional Behaviour that is so serious as to justify disciplinary action”.

Misconduct in public office (MIPO)    
A criminal offence that can only be conducted by public office holders while they are carrying out the duties of that office. It is committed when the office holder “wilfully neglects to perform his duty and/or wilfully misconducts himself to such a degree as to amount to an abuse of the public’s trust in the office holder, without reasonable excuse or justification.”

Negligence
A civil wrong or tort that defines any conduct or failure to act that breaches an established duty of care.

Operational order
A document that links information regarding an event or incident with the structure of the police response and the operational resource requirement.

Pen
An area of a terrace that was completely fenced in so that access in and out was controlled. There were seven pens on the West Terrace in 1989.

Perverting the course of justice
A serious offence which is committed when a person intentionally carries out an act which could interfere with ongoing or anticipated judicial proceedings, whether it has that effect or not. 

Popper Inquests
The original inquests into the Hillsborough disaster. They were led by the then Coroner for South Yorkshire (West District) Dr Stefan Popper.

Prepared statement
Section 34 of the Criminal Justice and Public Order Act 1994 gives anyone interviewed as a suspect the right to be silent when being interviewed. However, at the start of the interview suspects are cautioned that an adverse inference may be drawn if they choose not to answer questions and so do not provide evidence that they later rely on in court. If the suspect reads out a prepared statement (or their lawyer does so on their behalf) then no adverse inferences can be drawn in respect of matters dealt with in the statement.

Professional standards
The Standards of Professional Behaviour that apply to all police officers in England and Wales. 

Referral
A submission from an appropriate authority about an incident that is serious enough to be sent to the IOPC. It can be in the form of a complaint or conduct matter, or it could involve death or serious injury after contact with the police.

Regulation 16 Notice
This is a notice of the alleged breach of the Standards of Professional Behaviour, served under Regulation 16 of the Police (Complaints and Misconduct) Regulations 2012 (for people no longer serving with the police).

Safety Certificate
The Safety of Sports Ground Act 1975 introduced a requirement for larger stadia to obtain a 'Safety Certificate' from the local authority and comply with the terms and conditions of that Certificate. 

Salmon letter
A letter sent to a person or organisation who may be subject to criticism when a public report is published. The purpose of the letter is to give the person or organisation the opportunity to prepare a response. 

Stuart-Smith Scrutiny
An independent judicial scrutiny of evidence related to the disaster which was not made available to previous investigations. It began in 1997 and was led by Lord Justice Murray Stuart-Smith.

Telex
A method of sending simple written messages over the telephone network. Messages were printed out on specialist printers. It was discontinued in 2008.

Terms of reference
Terms of reference set out the scope and objectives of the IOPC and Operation Resolve’s investigations. 

The Taylor Inquiry
An independent inquiry led by Lord Justice Peter Taylor into the Hillsborough disaster. It was a non-statutory departmental inquiry, not a statutory public inquiry. 

Treasury Solicitor's Department
A government department that provided legal services to central government and other public bodies. It changed its name to the Government Legal Department in 2015.

• Read more about Timeline of the IOPC’s investigations

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• Read more about The case for a statutory duty of candour

1. The evidence in this investigation, and indeed in other investigations conducted or overseen by the IOPC, demonstrates the impact on individual lives and confidence in the police service when the police do not act with candour, transparency and frankness in their dealings with inquiries and investigations into their actions.
    
2. SYP’s persistent defensive approach to the various investigations and the fact that it did not put forward potentially relevant evidence are among the reasons why it has taken considerably longer than it should have done for the full circumstances of the disaster to be brought to light. Complaints made against officers at the time have had to be reinvestigated decades later. New inquests were required, and became the longest in English history, running for 308 days, spread over two years, and hearing evidence from more than 1,000 individuals. Having heard the evidence, the jury at the Goldring Inquests concluded that those who died in the disaster were unlawfully killed—a significant change from the conclusion of the Popper Inquests, which had been a verdict of accidental death in all cases.
    
3. The impact of this has been significant, on multiple fronts. While 15 April 1989 was the date of the disaster, the trauma and distress associated with it have been prolonged unnecessarily. The families of those who died have repeatedly been compelled to defend themselves and their loved ones against allegations that have never been proven and have had to wait years for the outcomes of their complaints and the investigations. Similarly, individuals under investigation and, in some cases, facing prosecution, have faced prolonged waits for decisions.
    
4. Collectively, these factors have damaged public confidence in the police and the justice system and cost the public purse substantial sums of money. These outcomes may have been avoided if SYP and its legal team had approached the initial investigations into the causes of the disaster with openness and transparency.
    
5. The Public Office (Accountability) Bill was introduced by the Government to address these kinds of issues. Reflecting the campaigns of Hillsborough families and others, it will impose a duty on all public authorities and public officials, including police officers, to act with candour, transparency and frankness in their dealings with inquiries and investigations. This will be reinforced by potential criminal sanctions for those who fail to do so. 
    
6. If such a duty had existed 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 the families of those who were unlawfully killed would have experienced a far less traumatic fight for answers about what happened to their loved ones at Hillsborough. 

• Read more about Considering whether WMP also sought to deflect the blame away from the police

1. The IOPC was also tasked to investigate whether there was evidence that WMP sought to deflect blame for the disaster away from fellow police officers. As set out in chapters 14–17, the IOPC has identified a number of issues for which WMP’s investigations could be—and, in some cases, have been—criticised. None of these offer evidence that WMP deliberately attempted to deflect blame away from the police, nor that it was instructed to. 
    
2. A large number of Liverpool supporters have made complaints about aspects of WMP’s evidence collection in Merseyside shortly after the disaster (see paragraphs 14.55–14.94). While such complaints paint a picture of an approach that lacked compassion, they do not suggest a deliberate attempt on the part of those officers to deflect blame from the police. In particular, the recording of large numbers of criticisms of SYP indicates a willingness on WMP’s part to accept there were flaws in the police operation at the 1989 Semi-Final.
    
3. However, WMP’s approach to its work may have made it easier for SYP to shape its case and control the story. In particular, WMP’s decisions not to take statements from SYP officers, and to allow SYP and its legal team to amend officer accounts, meant that some potentially relevant evidence from officers was not presented to the Taylor Inquiry (see paragraphs 14.95–14.124).
    
4. Though WMP knew that SYP officers’ accounts were not sufficient to be used as evidence for a criminal prosecution, it continued to refer to them throughout its criminal investigation and the file of evidence it submitted to the DPP for a charging decision. This was one of several flaws the IOPC has identified in WMP’s criminal investigation; others included the small number of investigative actions it undertook and the decision not to interview suspects under caution before submitting the file. 
    
5. Though these were significant shortcomings in the investigation, they did not directly deflect blame for the disaster away from the police and the IOPC has not found evidence that this was WMP’s intention. However, there is evidence that the two officers leading WMP’s work—ACC Jones and, in particular, D Ch Supt Foster—did hold the view that the Taylor Inquiry underestimated the importance of the behaviour of supporters (see paragraphs 14.150–14.164).
    
6. This serves as a possible explanation for why WMP repeatedly referred to aspects of alleged supporter behaviour in the file of evidence it submitted to the DPP and, in its analysis, focused on how supporter behaviour may have affected police actions on the day.
    
7. D Ch Supt Foster rejected this suggestion and denied that this—or any other failing identified by the IOPC—was a result of bias or part of an attempt to cover up SYP’s part in the disaster. This view was echoed by other WMP senior officers including CC Dear and ACC Jones, who stated to the IOPC that he completely refuted such allegations.

• Read more about No evidence found of masonic influence

1. It has been suggested that one reason some senior officers persisted in these attempts to deflect blame was because they were Freemasons, and wished to protect a fellow Freemason, Ch Supt Duckenfield. 
    
2. At some point after the disaster, it became public knowledge that Ch Supt Duckenfield was not only a Freemason but actually had been the head of a masonic lodge in Sheffield. This led to allegations that he was promoted above his capability and experience because he was a mason, and that fellow masons ‘closed ranks’ around him in the aftermath of the disaster.
    
3. To investigate these allegations, the IOPC sought to establish which other SYP officers were Freemasons; whether there was evidence to support the inference that membership of the masons improved career prospects within SYP; and, specifically, whether any of the officers who were masons were in a position to influence Ch Supt Duckenfield’s promotion or to protect him following the disaster.
    
4. When interviewing SYP and WMP officers, IOPC investigators routinely asked them whether they were or had ever been a member of the Freemasons. Very few stated they were, or had ever been, masons. However, some alleged that masons were in a position of influence in SYP at the time and that being a mason increased an officer’s likelihood of promotion. Others wholly dismissed this.
    
5. The IOPC approached UGLE, the governing body of Freemasonry in England, Wales and the Channel Islands to ask for its assistance. UGLE agreed and in May 2016, the IOPC provided UGLE with a list of 98 names that had featured in its investigation, to ask if they had been masons. These included senior officers from both SYP and WMP who featured repeatedly in the IOPC investigation.
    
6. Of the 98 names submitted, UGLE found 12 matches on its membership records. Nine of these were confirmed matches; there were also one possible and two probable matches. This indicated that membership among senior officers was not as widespread as had been rumoured.
    
7. ACC Anderson was one of the confirmed matches and some in the force believed he remained a high-ranking mason in 1989. This has led to the suggestion that he recommended the promotion of Ch Supt Duckenfield because both were masons. At the Goldring Inquests, ACC Anderson asserted he did not know Ch Supt Duckenfield was a mason; the IOPC has not found any evidence to support or challenge this. 
    
8. Having reviewed details of his career, the IOPC has not found evidence to indicate that Ch Supt Duckenfield was promoted because he was a mason.
    
9. Nor has the IOPC found evidence that SYP’s actions in the aftermath of the disaster were motivated by a desire to protect fellow masons; there were multiple other potential motivations. Further, the IOPC has not found evidence to support claims of a broader masonic conspiracy or cover-up.

• Read more about The response of SYP officers to allegations of a cover-up

1. The allegation that there was a deliberate attempt to blame supporters for the disaster was repeatedly raised during the Goldring Inquests. Several former senior SYP officers were asked by barristers representing some of the families whether their actions in the aftermath of the disaster had been part of a cover-up. While some accepted that, in hindsight, certain actions were hard to justify, and in some cases even acknowledged that SYP had been on the defensive, all denied that they were involved in a deliberate cover-up of any form.
    
2. Ch Supt Duckenfield was asked if his lie was the start of a cover-up; he said no. Ch Insp Beal was directly accused of being a key figure in a police cover-up—an accusation he strongly rejected. 
    
3. DCC Hayes was asked: “It is right, isn't it, that in preparing for the inquests in particular, officers under your command were trying to raise the profile of evidence which blamed the fans?” He replied: “Yes, I think that’s true.” He later reframed this as SYP trying to draw attention to evidence that involved supporters, rather than blamed them. He also rejected the suggestion this amounted to a cover-up.
    
4. Ch Supt Wain was asked about a memo he had written, in which he instructed DI Cleverly to “interrogate the system” to identify the officers who could give the best evidence about “Unruly behaviour by Liverpool fans” and high levels of alcohol consumption. He responded that he was “shocked” to see it and, when the barrister described it as “clear evidence of an attempt to denigrate the fans”, Ch Supt Wain replied: “I must agree with you.”

• Read more about SYP’s right to deflect the blame away from the force and its officers

1. While the evidence points to SYP undertaking such a coordinated effort, there is an essential point to recognise: it was legally entitled to do so and to present its ‘best case’ to the Taylor Inquiry. There was no legal duty for the force, or individual officers, to obtain or put forward to the Taylor Inquiry any information which might present a different version of events to their preferred narrative. As long as officers did not put forward evidence that was false, misleading or inaccurate, they were not breaching the professional standards of the time.
    
2. In the aftermath of the disaster, SYP was, rightly, under intense scrutiny. Its reputation was under threat, damaging public confidence in the force. It faced the prospect of officers being prosecuted and the force having to pay large sums in compensation to those affected. As a publicly funded body, the force had a right to defend itself and to seek to fairly apportion blame, if it believed other individuals and organisations were to some degree responsible.
    
3. This appears particularly applicable to SYP’s persistent argument that officers were not responsible for safety on the terraces, and that this was the role of SWFC stewards, as the Green Guide would indicate. 
    
4. In such circumstances, a police force is—like any other party—allowed to defend itself against allegations and put forward its best case. However, this did not give SYP total freedom to consistently and intentionally:
    
   • present unbalanced and unsubstantiated evidence, placing a disproportionate emphasis on supporter behaviour even where it could not prove certain allegations (for example, that large numbers of supporters attended without tickets and/or arrived late, deliberately)
   • alter the underlying evidence of officers before it was submitted, by amending accounts to fit the narrative it wished to present
   • minimise the evidence that was given in relation to previous police actions to close the tunnel and monitor capacity in the pens, and in relation to the extent to which the police had previously managed the arrival of supporters at the Leppings Lane end
      
5. While such actions may have been legally permissible in relation to the Taylor Inquiry, where there was no duty of candour, they were very clearly not in keeping with the Inquiry’s aim to gain a full understanding of the disaster and prevent such an incident from happening again. 

• Read more about Speculation about links to Orgreave

1. There has been speculation that one reason SYP adopted this unusual approach to collecting evidence was because of its experiences in the aftermath of events at Orgreave coking plant, during the 1984/85 miners’ strike. 
    
2. On 18 June 1984, Orgreave was the scene of violent confrontations between police officers and striking miners. The plant was in the SYP area, near Sheffield, so a substantial proportion of these officers were from SYP; however, officers were also drawn from other forces around the country. Following the events, 55 protesters were charged with riot. All charges were eventually withdrawn, amid questions over the validity of some of the arresting officers’ statements. It transpired that, among other issues with the statements, when officers from other forces were making statements, SYP officers gave them a standard introduction to use, which set out key locations that the visiting officers would not have known.
    
3. Between 2012 and 2015, the IPCC received two voluntary referrals from SYP in relation to allegations of police misconduct relating to Orgreave. In 2015, having reviewed the available information, the IPCC announced its decision not to investigate these allegations nor to reopen complaints about police conduct relating to Orgreave. 
    
4. After this decision was announced, the IOPC Hillsborough investigation team requested access to the material that had been considered in making it. This was because of the possibility that there could be parallels between SYP’s approach to evidence gathering in both cases.
    
5. The Hillsborough investigation team appointed independent counsel to conduct a comprehensive review of the Orgreave material, to assess its relevance to the Hillsborough investigation. The review found there was no material related to Orgreave that was relevant to the Hillsborough criminal investigations or the complaint and conduct investigations being undertaken by the IOPC and Operation Resolve.

• Read more about The extent of the attempt to deflect the blame

1. While the examples listed here appear to demonstrate a wide-ranging and consistent attempt to deflect the blame away from the police, not all of SYP’s actions in the aftermath of the disaster—or those of its officers—form part of this pattern. 
    
2. For example, chapters 12 and 13 of this report summarise the IOPC’s investigation into the allegations that blood alcohol testing and PNC checks were carried out on those who died to besmirch their reputations: the IOPC has not found evidence that this was the intent. Nor is there evidence that SYP was behind, or even involved in, the disappearance of two video tapes from the SWFC control room.
    
3. There is no doubt that Ch Supt Duckenfield’s lie that the disaster was caused when supporters broke through a gate has had a lasting impact. Similarly, the media coverage after the disaster that focused on the behaviour of supporters led to an enduring public perception that they had somehow been to blame, even though the Taylor Interim Report wholly rejected that view. The HIP Report again called this perception into question and the Goldring Inquests reaffirmed that the actions of supporters in no way caused or contributed to the disaster.
    
4. Yet despite the immense damage and hurt that the lie and the media coverage caused, it is not clear that either was the result of a coordinated corporate attempt to deflect blame from the police. The lie was told so quickly, there was no chance for SYP to organise it, and CC Wright corrected it on the night of the disaster. Aside from CC Wright, the central figures quoted in the media reporting did not act or speak on behalf of SYP. The IOPC has not found evidence to indicate that the ensuing coverage was a result of any organised effort by SYP or its legal team. 
    
5. Though large numbers of SYP officers have provided accounts or statements, and given oral evidence, in which they have highlighted the behaviour of supporters, it is not clear that these accounts were made purely or primarily in an attempt to deflect or minimise blame. Many were responding to a request to provide recollections of what they did and saw, “including crowd behaviour” and to comment on issues such as the mood of the supporters and their own “fears, feelings and observations.”
    
6. While the result is that officers described personal experiences that, when viewed collectively, may have supported an attempt to deflect the blame, the IOPC has not found evidence that they wrote their accounts to fit an ‘agreed’ storyline, on the instruction or under direction from senior officers.
    
7. Officers made these accounts in an unusual format (see paragraph 9.80). This offered SYP an opportunity to control and amend the evidence its officers gave. However, it cannot be determined that this was SYP’s intention from the outset. Some senior officers have provided plausible alternative explanations for the approach. Further, the evidence indicates there was no forcewide instruction to officers that they should not write pocket notebook entries as normal. Therefore, the IOPC does not view the fact that accounts were made in an unusual format, or the fact that some officers have stated they were not to use their pocket notebooks, as part of the coordinated attempt to deflect blame.