The Hillsborough Disaster Part I

 

The Hillsborough disaster was a fatal human crush during a football match at Hillsborough Stadium in Sheffield, South Yorkshire, England, on 15 April 1989. It occurred during an FA Cup semi-final between Liverpool and Nottingham Forest in the two standing-only central pens in the Leppings Lane stand allocated to Liverpool supporters. Shortly before kick-off, in an attempt to ease overcrowding outside the entrance turnstiles, the police match commander, David Duckenfield, ordered exit gate C to be opened, leading to an influx of supporters entering the pens. This resulted in overcrowding of those pens and the crush. With 97 deaths and 766 injuries, it has the highest death toll in British sporting history. Ninety-four people died on the day; another person died in hospital days later, and another victim died in 1993. In July 2021, a coroner ruled that Andrew Devine, who died 32 years after suffering severe and irreversible brain damage on the day, was the 97th victim. The match was abandoned and restaged at Old Trafford in Manchester on 7 May 1989; Liverpool won and went on to win that season's FA Cup.

In the following days and weeks South Yorkshire Police (SYP) fed the press false stories suggesting that football hooliganism and drunkenness by Liverpool supporters had caused the disaster. Blaming Liverpool fans persisted even after the Taylor Report of 1990, which found that the main cause was a failure of crowd control by SYP. Following the Taylor Report, the Director of Public Prosecutions ruled there was no evidence to justify prosecution of any individuals or institutions. The disaster led to a number of safety improvements in the largest English football grounds, notably the elimination of fenced standing terraces in favour of all-seater stadiums in the top two tiers of English football.

The first coroner's inquests into the Hillsborough disaster, completed in 1991, concluded with verdicts of “accidental death” in respect of all the deceased. Families disputed the findings, and fought to have the case re-opened. In 1997 Lord Justice Stuart-Smith concluded that there was no justification for a new inquiry. Private prosecutions brought by the Hillsborough Families Support Group against Duckenfield and his deputy Bernard Murray failed in 2000. In 2009 a Hillsborough Independent Panel was formed to review the evidence. Reporting in 2012, it confirmed Taylor's 1990 criticisms and revealed details about the extent of police efforts to shift blame onto fans, the role of other emergency services and the error of the first coroner's inquests. The panel's report resulted in the previous findings of accidental death being quashed, and the creation of new coroner's inquests. It also produced two criminal investigations led by police in 2012: Operation Resolve to look into the causes of the disaster, and by the Independent Police Complaints Commission (IPCC) to examine actions by police in the aftermath.

The second coroner's inquests were held from 1 April 2014 to 26 April 2016. They ruled that the supporters were unlawfully killed owing to grossly negligent failures by police and ambulance services to fulfil their duty of care. The inquests also found that the design of the stadium contributed to the crush and that supporters were not to blame for the dangerous conditions. Public anger over the actions of their force during the second inquests led to the suspension of SYP chief constable, David Crompton, following the verdict. In June 2017 six people were charged with offences including manslaughter by gross negligence, misconduct in public office and perverting the course of justice for their actions during and after the disaster. The Crown Prosecution Service subsequently dropped all charges against one of the defendants.

Before the disaster

Venue

Hillsborough Stadium had been constructed in 1899 to house Sheffield Wednesday. It was selected by the Football Association (FA) as a neutral venue to host the FA Cup semi-final between Liverpool and Nottingham Forest football clubs. Kick-off was scheduled for 3:00 pm on 15 April, and fans were advised to take up positions 15 minutes beforehand.

At the time of the disaster most English football stadiums had high steel fencing between the spectators and the playing field in response to pitch invasions. Hooliganism had affected the sport for some years and was particularly virulent in England. From 1974, when these security standards were put in place, crushes occurred in several English stadiums.

A report by Eastwood & Partners for a safety certificate for the stadium in 1978 concluded that although it failed to meet the recommendations of the Green Guide, a guide to safety at sports grounds, the consequences were minor. It emphasised the general situation at Hillsborough was satisfactory compared with most grounds. Sheffield Wednesday were later criticized for neglecting safety in the stadium, especially after an incident in the semi-final of the 1981 FA Cup. The Leppings Lane end of the ground did not hold a valid safety certificate at the time of the disaster; it had not been updated since 1979.

Risks associated with confining fans in pens were highlighted by the Committee of Inquiry into Crowd Safety at Sports Grounds (the Popplewell inquiry) after the Bradford City stadium fire in May 1985. It made recommendations on the safety of crowds penned within fences, including that "all exit gates should be manned at all times ... and capable of being opened immediately from the inside by anyone in an emergency".

Previous incidents

Hillsborough hosted five FA Cup semi-finals in the 1980s. A crush occurred at the Leppings-Lane end of the ground during the 1981 semi-final between Tottenham Hotspur and Wolverhampton Wanderers after hundreds more spectators were permitted to enter the terrace than could safely be accommodated, resulting in 38 injuries, including broken arms, legs and ribs. Police believed there would have been a real chance of fatalities had swift action not been taken, and recommended the club reduce its capacity. In a post-match briefing to discuss the incident, Sheffield Wednesday chairman Bert McGee remarked: "Bollocks—no one would have been killed". The incident nonetheless prompted Sheffield Wednesday to alter the layout at the Leppings Lane end, dividing the terrace into three separate pens to restrict sideways movement. This 1981 change and other later changes to the stadium invalidated the stadium's safety certificate. The safety certificate was never renewed and the stated capacity of the stadium was never changed. The terrace was divided into five pens when the club was promoted to the First Division in 1984, and a crush barrier near the access tunnel was removed in 1986 to improve the flow of fans entering and exiting the central enclosure.

After the crush in 1981, Hillsborough was not chosen to host an FA Cup semi-final for six years until 1987. Serious overcrowding was observed at the 1987 quarter-final between Sheffield Wednesday and Coventry City and again during the semi-final between Coventry City and Leeds United at Hillsborough. Leeds were assigned the Leppings Lane end. A Leeds fan described disorganization at the turnstiles and no steward or police direction inside the stadium, resulting in the crowd in one enclosure becoming so compressed he was at times unable to raise and clap his hands. Other accounts told of fans having to be pulled to safety from above.

Liverpool and Nottingham Forest met in the semi-final at Hillsborough in 1988, and fans reported crushing at the Leppings Lane end. Liverpool lodged a complaint before the match in 1989. One supporter wrote to the Football Association and Minister for Sport: "The whole area was packed solid to the point where it was impossible to move and where I, and others around me, felt considerable concern for personal safety."

South Yorkshire Police command changes

Police presence at the previous year's FA Cup semi-final (also between Liverpool and Nottingham Forest and also at Hillsborough Stadium) had been overseen by Chief Superintendent Brian L. Mole. Mole had supervised numerous police deployments at the stadium in the past. In October 1988 a probationary PC in Mole's F division, South Yorkshire was handcuffed, photographed, and stripped by fellow officers in a fake robbery, as a hazing prank. Four officers resigned and seven were disciplined over the incident. Chief Superintendent Mole himself was to be transferred to the Barnsley division for "career development reasons". The transfer was to be done with immediate effect on 27 March 1989.

Meanwhile, Hillsborough was accepted as the FA Cup semi-final venue on 20 March 1989 by the Football Association. The first planning meeting for the semi-final took place on 22 March and was attended by newly promoted Chief Superintendent David Duckenfield, not by Mole. No known minutes exist of this meeting. Although Mole could have been assigned the semi-final match's planning despite his transfer, that was not done. This left planning for the semi-final match to Duckenfield, who had never commanded a sell-out football match before, and who had "very little, if any" training or personal experience in how to do so.

Disaster

Leppings Lane was the sole access point for Liverpool supporters. The approach has been described as a "bottleneck" in which attendees had to fill two sides of the stadium.

Build-up

Opposing supporters were segregated, as is common at domestic matches in England. Nottingham Forest supporters were allocated the South Stands and Spion Kop on the east end, with a combined capacity of 29,800, reached by 60 turnstiles spaced along two sides of the ground. Liverpool supporters were allocated the North and West ends (Leppings Lane), holding 24,256 fans, reached by 23 turnstiles from a narrow concourse. Turnstiles numbered 1 to 10, ten in all, provided access to 9,700 seats in the North Stand; a further six turnstiles (numbered 11 to 16) provided access to 4,456 seats in the upper tier of the West Stand. Finally, seven turnstiles (lettered A to G) provided access to 10,100 standing places in the lower tier of the West Stand. Although Liverpool had more supporters, Nottingham Forest was allocated the larger area, to avoid the approach routes of rival fans crossing. As a result of the stadium layout and segregation policy, turnstiles that would normally have been used to enter the North Stand from the east were off-limits and all Liverpool supporters had to converge on a single entrance at Leppings Lane. On the day of the match, radio and television broadcasters advised fans without tickets not to attend. Rather than establishing crowd safety as their top priority, the clubs, local authorities and police viewed their roles and responsibilities through the 'lens of hooliganism'.

Timeline

Three chartered trains transported Liverpool supporters to Sheffield for a match in 1988, but only one such train ran in 1989. The 350 passengers arrived at the ground at about 2:20 pm. Many supporters wished to enjoy the day and were in no hurry to enter the stadium too early. Some supporters were delayed by roadworks while crossing the Pennines on the M62 motorway which resulted in minor traffic congestion. Between 2:30 pm and 2:40 pm, there was a build-up of supporters outside the turnstiles facing Leppings Lane, eager to enter the stadium before the game began. At 2:46 pm, the BBC's football commentator John Motson had already noticed the uneven distribution of people in the Leppings Lane pens. While rehearsing for the match off-air, he suggested a nearby cameraman look as well. "There's gaps, you know, in parts of the ground. Well, if you look at the Liverpool end, to the right of the goal, there's hardly anybody on those steps...that's it. Look down there."

Outside the stadium, a bottleneck developed with more fans arriving than could be safely filtered through the turnstiles before 3:00 pm. People presenting tickets at the wrong turnstiles and those who had been refused entry could not leave because of the crowd behind them and remained as an obstruction. Fans outside could hear cheering as the teams came on the pitch ten minutes before the match started, and as the match kicked off, but could not gain entrance. A police constable radioed control requesting that the game be delayed, as it had been two years before, to ensure the safe passage of supporters into the ground. The request to delay the start of the match by 20 minutes was declined.

With an estimated 5,000 fans trying to enter through the turnstiles, and increasing safety concerns, the police, to avoid fatalities outside the ground, opened a large exit gate (Gate C) that ordinarily permitted the free flow of supporters departing the stadium. Two further gates (A and B) were subsequently opened to relieve pressure. After an initial rush, thousands of supporters entered the stadium "steadily at a fast walk".

Crush

When the gates were opened, thousands of fans entered a narrow tunnel leading from the rear of the terrace into two overcrowded central pens (pens 3 and 4), creating pressure at the front. Hundreds of people were pressed against one another and the fencing by the weight of the crowd behind them. People entering were unaware of the problems at the fence; police or stewards usually stood at the entrance to the tunnel and, when the central pens reached capacity, directed fans to the side pens, but on this occasion, for reasons not fully explained, they did not.

The match between Liverpool and Nottingham Forest began as scheduled at 3:00 pm. Fans were still streaming into pens 3 and 4 from the rear entrance tunnel as the match began. For some time, problems at the front of the Liverpool central goal pens went largely unnoticed except by those inside them and a few police at that end of the pitch. Liverpool's goalkeeper, Bruce Grobbelaar, reported fans from behind him pleading to him for help as the situation worsened. The police at first attempted to stop fans from spilling out of the pens, some believing this to be a pitch invasion. At approximately 3:04 pm, a shot from Liverpool's Peter Beardsley hit the bar. Possibly connected to the excitement, a surge in pen 3 caused one of its metal crush barriers to give way.

South Yorkshire Police Superintendent Greenwood (the ground commander) realized the situation, and ran on the field to gain referee Ray Lewis's attention. Lewis stopped the match at 3:05:30 as fans climbed the fence in an effort to escape the crush and went onto the track. By this time, a small gate in the fence had been forced open and some fans escaped via this route, as others continued to climb over the fencing. Other fans were pulled to safety by fans in the West Stand above the Leppings Lane terrace. The intensity of the crush broke more crush barriers on the terraces. Holes in the perimeter fencing were made by fans desperately attempting to rescue others.

The crowd in the Leppings Lane Stand spilt onto the pitch, where the many injured and traumatized fans who had climbed to safety congregated. Football players from both teams were ushered to their respective dressing rooms, and told that there would be a 30-minute postponement. Those still trapped in the pens were packed so tightly that many victims died of compressive asphyxia while standing. Meanwhile, on the pitch, police, stewards and members of the St John Ambulance service were overwhelmed. Many uninjured fans assisted the injured; several attempted CPR and others tore down advertising hoardings to use as stretchers. Chief Superintendent John Nesbit of South Yorkshire Police later briefed Michael Shersby MP that leaving the rescue to the fans was a deliberate strategy, and is quoted as saying "We let the fans help so that they would not take out their frustration on the police" at a Police Federation conference.

SYMAS response to the crush

The agreed upon protocol for the South Yorkshire Metropolitan Ambulance Service (SYMAS) was that ambulances were to queue at the entrance to the gymnasium, termed the casualty reception point, or CRP.  Any individuals within the stadium in need of medical attention were to be delivered expeditiously by police and paramedics to the CRP.  The system of ferrying injured from any location within the stadium to the CRP required a formal declaration to be made by those in charge for it to take effect.  As this declaration was not immediately performed, confusion reigned over those attempting to administer aid on the pitch. This confusion migrated to the first responders waiting in ambulances at the CRP, a location which quickly deteriorated into an ambulance parking lot. Some crews were hesitant to leave their vehicles, unsure of whether patients were coming to them, or vice versa.  Others who did leave their vehicles were then faced with the obstacles inherent in placing distance between themselves and their equipment. As the Panel explained in their report:

The equipment was no use on the ambulance vehicle when critical early resuscitation was taking place some distance away on the pitch, behind the Leppings Lane end and in the gymnasium. Some ambulance crew did take equipment when they left their vehicle, but there was no systematic direction to do so, not all did, and none initially had been given any information about the situation inside the stadium.

A total of 42 ambulances arrived at the stadium. Out of this number, two managed of their own accord to make their way onto the pitch—while a third ambulance made its way onto the pitch at the direction of DCAO Hopkins, who felt its visibility might allay crowd concerns. The remaining 39 ambulances were collectively able to transport approximately 149 people to either Northern General Hospital, Royal Hallamshire Hospital, or Barnsley Hospital for treatment.

The adverse comments of two doctors regarding the emergency response appeared in the media. Their views were not "the maverick view from a disaffected minority but the considered opinion of the majority of professionals present from the outset".

Reactions

Condolences flooded in from across the world, led by the Queen. Other messages came from Pope John Paul II, US President George H. W. Bush, and the chief executive of Juventus (fans of Liverpool and Juventus had been involved in the Heysel Stadium disaster) amongst many others.

Prime Minister Margaret Thatcher and Home Secretary Douglas Hurd visited Hillsborough the day after the disaster and met survivors. Anfield stadium was opened on the Sunday to allow fans to pay tribute to the dead. Thousands of fans visited and the stadium filled with flowers, scarves and other tributes. In the following days more than 200,000 people visited the "shrine" inside the stadium. The following Sunday, a link of football scarves spanning the 1 mile (1.6 km) distance across Stanley Park from Goodison Park to Anfield was created, with the final scarf in position at 3:06 pm. Elsewhere on the same day, a silence—opened with an air-raid siren at three o'clock—was held in central Nottingham with the colours of Forest, Liverpool and Wednesday adorning Nottingham Council House.

At Liverpool Metropolitan Cathedral, a requiem mass attended by 3,000 people was held by the Catholic Archbishop of Liverpool, Derek Worlock. The first reading was read by Liverpool goalkeeper Bruce Grobbelaar. Liverpool players Ronnie Whelan, Steve Nicol, and former manager Joe Fagan carried the communion bread and wine.

The FA chief executive Graham Kelly, who had attended the match, said the FA would conduct an inquiry into what had happened. Speaking after the disaster, Kelly backed all-seater stadiums, saying "We must move fans away from the ritual of standing on terraces". Standing on terraces and the use of perimeter fencing around the pitch, the use of CCTV, the timing of football matches and policing of sporting events were factors for a subsequent inquiry to consider.

UEFA President Jacques Georges caused controversy by describing the Liverpool supporters as "beasts", wrongly suggesting that hooliganism was the cause of the disaster, which had occurred less than four years after the Heysel Stadium disaster. His remarks led to Liverpool F.C. calling for his resignation, but he apologized on discovering hooliganism was not the cause.

At the 1989 FA Cup Final between Liverpool and local rivals Everton, held just five weeks after the Hillsborough disaster, the players from both participating teams wore black armbands as a gesture of respect to the victims.

During the final match of the 1988–89 English Football League season, contested on 26 May 1989 between Liverpool and second-place Arsenal, the Arsenal players presented flowers to fans in different parts of Anfield in memory of those who had died in the Hillsborough disaster.

Disaster appeal fund

A disaster appeal fund was set up with donations of £500,000 from the UK Government, £100,000 from Liverpool F.C. and £25,000 each from the cities of Liverpool, Sheffield, and Nottingham. The Liverpool F.C. donation was the amount the club would have received (as its share of the match income) had the semi-final gone ahead as planned. Within days, donations had passed £1 million, swelled by donations from individuals, schools and businesses. Other fundraising activities included a Factory Records benefit concert and several fundraising football matches. The two teams involved in the Bradford City stadium fire, Bradford City and Lincoln City, met for the first time since the 1985 disaster in a game that raised £25,000 for the Hillsborough fund. By the time the appeal closed in 1990, it had raised more than £12 million. Much of the money went to victims and relatives of those involved in the disaster and provided funds for a college course to improve the hospital phase of emergency care.

In May 1989, a charity version of the Gerry and the Pacemakers song "Ferry Cross the Mersey" was released in aid of those affected. The record was produced by Stock Aitken Waterman and featured Liverpool musicians Paul McCartney, Gerry Marsden (of the Pacemakers), Holly Johnson, and The Christians. It entered the UK Singles Chart at number 1 on 20 May, and remained at the top of the chart for three weeks. Despite having stronger ties to Liverpool F.C., Gerry and the Pacemakers' earlier hit "You'll Never Walk Alone" was not used because it had recently been re-recorded for the Bradford City stadium fire appeal.

Effect on survivors

By the disaster's 10th anniversary in 1999, at least three people who survived were known to have taken their own lives. Another survivor had spent eight years in psychiatric care. There were cases of alcoholism, drug abuse, and collapsed marriages involving people who had witnessed the events. The lingering effects of the disaster were seen as a cause, or contributory factor, in all of these.

Victims

In total, ninety-seven people died as a result of injuries incurred during the disaster. Ninety-four people, aged from 10 to 67 years old, died on the day, either at the stadium, in the ambulances, or shortly after arrival at hospital. A total of 766 people were reported to have suffered injuries, among whom 300 were hospitalized. The less seriously injured survivors who did not live in the Sheffield area were advised to seek treatment for their injuries at hospitals nearer to their homes. On 19 April, the death toll reached 95 when 14-year-old Lee Nicol died in hospital after being taken off life support. The death toll reached 96 in March 1993, when artificial feeding and hydration were withdrawn from 22-year-old Tony Bland after nearly four years, during which time he had remained in a persistent vegetative state showing no sign of improvement. This followed a legal challenge in the High Court by his family to have his treatment withdrawn, a landmark challenge which succeeded in November 1992.

Andrew Devine, aged 22 at the time of the disaster, suffered similar injuries to Tony Bland and was also diagnosed as being in a persistent vegetative state. In March 1997—just before the eighth anniversary of the disaster—it was reported he had emerged from the condition and was able to communicate using a touch-sensitive pad, and he had been showing signs of awareness of his surroundings for up to three years before. Devine died in 2021, as a consequence of the injuries sustained at Hillsborough, with his death being ruled by the coroner to have been an unlawful killing, raising the total death toll of the disaster to 97.

Two sisters, three pairs of brothers, and a father and son were among those who died, as were two men about to become fathers for the first time: 25-year-old Steven Brown of Wrexham and 30-year-old Peter Thompson of Widnes. Jon-Paul Gilhooley, aged 10, was the youngest person to die. His cousin, Steven Gerrard, then aged 8, went on to become Liverpool F.C.'s captain. Gerrard has said the disaster inspired him to lead the team he supported as a boy and become a top professional football player. The oldest person to die at Hillsborough was 67-year-old Gerard Baron, an older brother of former Liverpool player Kevin Baron.

Stephen Whittle is considered by some to be another victim of Hillsborough, as due to work commitments, he had sold his ticket to a friend (whom he and his family chose not to identify), who then died in the disaster; the resulting feeling of survivor guilt is believed to be the main reason for his suicide in February 2011.

The majority of victims who died were from Liverpool (37) and Greater Merseyside (20). A further 20 were from counties adjacent to Merseyside. An additional three victims came from Sheffield with two more living in counties adjacent to South Yorkshire. The remaining 14 victims lived in other parts of England.

Ages

Of those who died, 79 were aged under 30, 38 of whom were under 20, and all but three of the victims were aged under 50. Andrew Devine, who was 22 at the time of the disaster, died in 2021 at the age of 55.

10–19 38 36 2

20–29 41 37 4

30–39 12 11 1

40–49 3 3 0

50–59 1 1 0

60–69 2 2 0

Totals 97 90 7

1989–1991 coroner's hearing

Inquests into the deaths were opened and adjourned immediately after the disaster.

Resumed on 19 November 1990, they proved to be controversial. South Yorkshire coroner Dr Stefan Popper limited the main inquests to events up to 3:15 pm on the day of the disaster—nine minutes after the match was halted and the crowd spilt onto the pitch. Popper said this was because the victims were either dead, or brain dead, by 3:15 pm. The decision angered the families, many of whom felt the inquests were unable to consider the response of the police and other emergency services after that time. The inquests returned verdicts of accidental death on 26 March 1991, much to the dismay of the bereaved families, who had been hoping for a verdict of unlawful killing or an open verdict, and for manslaughter charges to be brought against the officers who had been present at the disaster. Trevor Hicks, whose two daughters had been killed, described the verdicts as 'lawful' but 'immoral'.

Popper's decision regarding the cut-off time was subsequently endorsed by the Divisional Court who considered it to have been justified in the light of the medical evidence available to him. Relatives later failed to have the inquests reopened to allow more scrutiny of police actions and closer examination of the circumstances of individual cases.

Families believed that Popper was 'too close' to the police. After the verdicts Barry Devonside, who had lost his son, witnessed Popper hosting a celebration party with police officers.

One of the individual cases where the circumstances of death were not fully resolved was that of Kevin Williams, the fifteen-year-old son of Anne Williams. Anne Williams, who died in 2013, rejected the coroner's decision that the Hillsborough victims, including her son, had died before 3:15 pm, citing witness statements that described him showing signs of life at 4:00 pm. She unsuccessfully appealed to the European Court of Human Rights in 2009. The Hillsborough Independent Panel considered the available evidence and stated that "the initial pathologist's opinion appeared definitive, but further authoritative opinions raised significant doubts about the accuracy of that initial opinion."

Popper had excluded the witness evidence of two qualified Merseyside doctors (Drs. Ashton and Phillips) who had been inside the stadium on the day and who had been critical of the chaotic emergency response. The views of both were dismissed by the Taylor report. They both gave evidence at the 2016 Warrington inquests. Phillips stated that the exclusion of their evidence was a 'serious error of judgment' by Popper. He said that he 'could not fathom why he didn't call us, other than he specifically did not want to hear our evidence, in which case the first inquests were colored and flawed before they even started'.

Ashton and Phillips were not the only doctors present at the disaster not to be called to give evidence to the Popper inquests. The only one called was the Sheffield Wednesday club doctor.

Taylor Inquiry

After the disaster, Lord Justice Taylor was appointed to conduct an inquiry into the events. The Taylor Inquiry sat for a total of 31 days (between 15 May and 29 June 1989) and published two reports: an interim report (1 August 1989) which laid out the events of the day and immediate conclusions; and a final report (19 January 1990) which outlined general recommendations on football ground safety. The two publications together became known as the Taylor Report.

Taylor concluded that policing on the day "broke down" and "the main reason for the disaster was the failure of police control". Attention was focused on the decision to open the secondary gates; moreover, the kick-off should have been delayed, as had been done at other venues and matches.

Sheffield Wednesday was also criticized for the inadequate number of turnstiles at the Leppings Lane end and the poor quality of the crush barriers on the terraces, "respects in which failure by the Club contributed to this disaster".

Police control

Taylor found there was "no provision" for controlling the entry of spectators into the turnstile area. He dismissed the claim by senior police officers that they had no reason to anticipate problems, since congestion had occurred at both the 1987 and 1988 semi-finals. He said that "the Operational Order and police tactics on the day failed to provide for controlling a concentrated arrival of large numbers should that occur in a short period. That it might so occur was foreseeable". The failure by the police to give the order to direct fans to empty areas of the stadium, was described by Taylor as "a blunder of the first magnitude".

There was no means for calculating when individual enclosures had reached capacity. A police officer ordinarily made a visual assessment before guiding fans to other pens.[99] However, on the day of the disaster, "by 2:52 pm when gate C was opened, pens 3 and 4 were over-full [...] to allow any more into those pens was likely to cause injuries; to allow in a large stream was courting disaster".

The report noted that the official capacity of the central pens was 2,200, that the Health and Safety Executive found this should have been reduced to 1,693 due to crush barriers and perimeter gates, but actually an estimated 3,000 people were in the pens around 3:00 pm. The report said "When spectators first appeared on the track, the immediate assumption in the control room was that a pitch invasion was threatened. This was unlikely at the beginning of a match. It became still less likely when those on the track made no move towards the pitch. ... [T]here was no effective leadership either from control or on the pitch to harness and organize rescue efforts. No orders were given for officers to enter the tunnel and relieve pressure". Further that: "The anxiety to protect the sanctity of the pitch has caused insufficient attention to be paid to the risk of a crush due to overcrowding".

Regarding the decision to allocate Liverpool spectators to the West and North Ends, Taylor stated "I do not consider choice of ends was causative of the disaster. Had it been reversed, the disaster could well have occurred in a similar manner but to Nottingham supporters".

Lord Taylor noted with regard to the performance of the senior police officers in command that "...neither their handling of the problems on the day nor their account of it in evidence showed the qualities of leadership to be expected of their rank".

Behavior of fans

Lord Taylor concluded that the behaviour of Liverpool fans, including accusations of drunkenness, were secondary factors, and said that most fans were: "not drunk, nor even the worse for drink". He concluded that this formed an exacerbating factor but that police, seeking to rationalize their loss of control, overestimated the element of drunkenness in the crowd.

The report dismissed the theory, put forward by South Yorkshire Police, that fans attempting to gain entry without tickets or with forged tickets were contributing factors.

Emergency response

Taylor concluded that in responding to the disaster there had been no fault on the part of the emergency services (St John Ambulance, South Yorkshire Metropolitan Ambulance Service and fire brigade).

Police evasion

Taylor concluded his criticism of South Yorkshire Police by describing senior officers in command as "defensive and evasive witnesses" who refused to accept any responsibility for error: "In all some 65 police officers gave oral evidence at the Inquiry. Sadly I must report that for the most part the quality of their evidence was in inverse proportion to their rank". Further stating: "South Yorkshire Police were not prepared to concede they were in any respect at fault in what occurred. ... [T]he police case was to blame the fans for being late and drunk, and to blame the Club for failing to monitor the pens. ... Such an unrealistic approach gives cause for anxiety as to whether lessons have been learnt".

Effect on stadiums in Britain

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The Taylor Report had a deep impact on safety standards for stadiums in the UK. Perimeter and lateral fencing was removed and many top stadiums were converted to all-seated. Purpose-built stadiums for Premier League and most Football League teams since the report are all-seater. Chester City F.C.'s Deva Stadium was the first English football stadium to fulfil the safety recommendations of the Taylor Report, with Millwall F.C.'s The Den being the first new stadium to be built that fulfilled the recommendations.

In July 1992, the government announced a relaxation of the regulation for the lower two English leagues (known now as League One and League Two). The Football Spectators Act does not cover Scotland, but the Scottish Premier League chose to make all-seater stadiums a requirement of league membership. In England and Wales all-seating is a requirement of the Premier League and of the Football League for clubs who have been present in the Championship for more than three seasons. Several campaigns have attempted to get the government to relax the regulation and allow standing areas to return to Premiership and Championship grounds.

Stuart-Smith scrutiny

In May 1997, when the Labour Party came into office, Home Secretary Jack Straw ordered an investigation. It was performed by Lord Justice Stuart-Smith. The appointment of Stuart-Smith was not without controversy. At a meeting in Liverpool with relatives of those involved in Hillsborough in October 1997, he flippantly remarked "Have you got a few of your people or are they like the Liverpool fans, turn up at the last minute?" He later apologized for his remark, saying it was not intended to offend. The terms of reference of his inquiry were limited to "new evidence", that is "...evidence which was not available or was not presented to the previous inquiries, courts or authorities." Therefore, evidence such as witness statements which had been altered were classed as inadmissible. When he presented his report in February 1998, he concluded that there was insufficient evidence for a new inquiry into the disaster. In paragraph 5 of his summary, Lord Justice Stuart-Smith said:

I have come to the clear conclusion that there is no basis upon which there should be a further Judicial Inquiry or a reopening of Lord Taylor's Inquiry. There is no basis for a renewed application to the Divisional Court or for the Attorney General to exercise his powers under the Coroners Act 1988. I do not consider that there is any material which should be put before the Director of Public Prosecutions or the Police Complaints Authority which might cause them to reconsider the decisions they have already taken. Nor do I consider that there is any justification for setting up any further inquiry into the performance of the emergency and hospital services. I have considered the circumstances in which alterations were made to some of the self-written statements of South Yorkshire Police officers, but I do not consider that there is any occasion for any further investigation.

Importantly, Stuart-Smith's report supported the coroner's assertion that evidence after 3:15 pm was inadmissible as "that by 3:15 pm the principal cause of death, that is, the crushing, was over." This was controversial as the subsequent response of the police and emergency services would not be scrutinized. Announcing the report to the House of Commons, Home Secretary Jack Straw backed Stuart-Smith's findings and said that "I do not believe that a further inquiry could or would uncover significant new evidence or provide any relief for the distress of those who have been bereaved." However, the determination by Stuart-Smith was heavily criticized by the Justice Minister, Lord Falconer, who stated "I am absolutely sure that Sir Murray Stuart-Smith came completely to the wrong conclusion". Falconer added: "It made the families in the Hillsborough disaster feel after one establishment cover-up, here was another."