Hillsborough report: Key findings
The Hillsborough disaster occurred when 96 Liverpool fans died after they were crushed within Sheffield Wednesday's stadium during the 1989 FA Cup semi-final with Nottingham Forest.
The fans who died had been in two pens of the Leppings Lane terrace. Each pen was separated by fences, including an overhanging barrier designed to prevent pitch invasions. Each pen had a small locked gate that opened onto the pitch.
The report, compiled by the Hillsborough Independent Panel, said that despite obvious signs of distress, it was a while before the police fully reacted and launched attempts to rescue those who were being crushed.
"It is evident… that the safety of the crowd admitted to the terrace was compromised at every level: access to the turnstiles from the public highway; the condition and adequacy of the turnstiles; the management of the crowd by South Yorkshire Police (SYP) and the Sheffield Wednesday FC (SWFC) stewards; alterations to the terrace, particularly the construction of pens; the condition and placement of crush barriers; access to the central pens via a tunnel descending at a 1 in 6 gradient; emergency egress from the pens via small gates in the perimeter fence; and lack of precise monitoring of crowd capacity within the pens.
"These deficiencies were well known and further overcrowding problems at the turnstiles in 1987 and on the terrace in 1988 were additional indications of the inherent dangers to crowd safety. The risks were known and the crush in 1989 was foreseeable."
"The flaws in responding to the emerging crisis on the day were rooted in institutional tension within and between organisations.
"This was reflected in: a policing and stewarding mindset predominantly concerned with crowd disorder; the failure to realise the consequences of opening exit gates to relieve congestion at the turnstiles; the failure to manage the crowd's entry and allocation between the pens; the failure to anticipate the consequences within the central pens of not sealing the tunnel; the delay in realising that the crisis in the central pens was a consequence of overcrowding rather than crowd disorder.
"The SYP decision to replace the experienced match commander… just weeks before an FA Cup semi-final, has been previously criticised. None of the documents disclosed to the panel indicated the rationale behind this decision."
CUSTOMS AND PRACTICES
"Throughout the 1980s there was considerable ambiguity about South Yorkshire Police's and Sheffield Wednesday FC's crowd management responsibilities within the stadium. The management of the crowd was viewed exclusively through a lens of potential crowd disorder, and this ambiguity was not resolved despite problems at previous semi-finals. SWFC and SYP were unprepared for the disaster that unfolded on the terraces on 15 April 1989."
THE EMERGENCY RESPONSE
"Not only was there delay in recognising that there were mass casualties, the major incident plan was not correctly activated and only limited parts were then put into effect. As a result, rescue and recovery efforts were affected by lack of leadership, co-ordination, prioritisation of casualties and equipment.
"The emergency response to the Hillsborough disaster has not previously been fully examined, because of the assumption that the outcome for those who died was irretrievably fixed long before they could have been helped.
"It is not possible to establish whether a more effective emergency response would have saved the life of any one individual who died. Given the evidence disclosed to the panel of more prolonged survival of some people with partial asphyxiation, however, a swifter, more appropriate, better-focused and properly equipped response had the potential to save more lives."
THE MEDICAL EVIDENCE
"During the inquest, the coroner ruled that there should be a cut-off of 3.15pm on the day in relation to medical evidence, arguing that the fate of all those who died after this point had already been determined by earlier events.
"The panel's access to all of the relevant records has confirmed that the notion of a single, unvarying and rapid pattern of death in all cases is unsustainable. Some of those who died did so after a significant period of unconsciousness during which they might have been able to be resuscitated, or conversely may have succumbed to a new event such as inappropriate positioning.
"It is not possible to establish with certainty that any one individual would or could have survived under different circumstances. It is clear, however, that some people who were partially asphyxiated survived, while others did not. It is highly likely that what happened to these individuals after 3.15pm was significant in determining that outcome. On the basis of this disclosed evidence, it cannot be concluded that life or death was inevitably determined by events prior to 3.15pm, or that no new fatal event could have occurred after that time."
DEFLECTION OF BLAME
"It is evident from the disclosed documents that from the outset SYP sought to establish a case emphasising exceptional levels of drunkenness and aggression among Liverpool fans, alleging that many arrived at the stadium late, without tickets and determined to force entry.
"Eight years after the disaster it was revealed publicly for the first time that statements made by SYP officers were initially handwritten as 'recollections', then subjected to a process of 'review and alteration' involving SYP solicitors and a team of SYP officers.
"Some 116 of the 164 statements identified for substantive amendment were amended to remove or alter comments unfavourable to SYP."
The panel also looked at the allegations of blame levelled against Liverpool fans in some newspapers, including The Sun.
"The documents disclosed to the panel show that the origin of these serious allegations was a local Sheffield press agency informed by several SYP officers, an SYP Police Federation spokesperson and a local MP.
"They also demonstrate how the SYP Police Federation, supported informally by the SYP chief constable, sought to develop and publicise a version of events that focused on several police officers' allegations of drunkenness, ticketlessness and violence among a large number of Liverpool fans. This extended beyond the media to Parliament.
"Yet, from the mass of documents, television and CCTV coverage disclosed to the panel there is no evidence to support these allegations other than a few isolated examples of aggressive or verbally abusive behaviour clearly reflecting frustration and desperation."