Hillsborough: pathology review set up to assess medical failures of first inquiry
The Home Office has announced a review of failures in the original medical examinations of people killed at Hillsborough, which led to the first inquest finding that their injuries were irreversible by 3.15pm on the day of the disaster.
The pathology review, chaired by the forensic science expert Glenn Taylor, has been set up in response to one of 25 recommendations in a 2017 report by Bishop James Jones. Jones was chair of the Hillsborough Independent Panel, which in 2012 published damning criticisms of the original pathology, and his 2017 report, following the new inquests, was aimed at avoiding any repeat of the injustice suffered by the bereaved families.
The original pathology evidence on the deaths of the then 95 people in the lethal crush at the FA Cup semi-final between Liverpool and Nottingham Forest on 15 April 1989 led the coroner at the first inquest, Dr Stefan Popper, to rule that no evidence after 3.15pm would be heard. That meant no inquiry was conducted into the chaotic South Yorkshire police and South Yorkshire metropolitan ambulance service (SYMAS) response to the crush.
Bereaved families were incensed at the “3.15 cutoff”, and maintained it as a core element of their campaign for justice, which finally led to the original inquest and its 1991 accidental death verdict being quashed 21 years later, in 2012.
The Hillsborough Independent Panel stated in its 2012 report that a detailed review of the pathology evidence “casts significant doubt” on the original findings that the victims died very quickly from irreversible injuries. Dr Bill Kirkup, the panel’s medical expert, said that 41 of the people who died “had the potential to survive” after the disaster.
The inquests held in 2014-16 included detailed new pathology by consultant doctors, who concluded that many of the victims died a considerable time after 3:15pm. The jury found that the then total of 96 people – the Liverpool supporter Tony Bland died of his injuries in 1993 after four years on life support – had been unlawfully killed due to the gross negligence manslaughter of the police officer in command, Ch Supt David Duckenfield. The jury also determined that there was a “lack of [police] coordination, communication, command and control” in the response, and that SYMAS officers “failed to ascertain” that a crush was happening, and call a major incident.
The new review began in July, with Taylor asked to “take heed of the failures in the pathology … identified at the final inquests”. His terms of reference also include assessing the risk of the same failures being repeated following a future disaster, whether enough safeguards are in place now and doctors are sufficiently accountable, and whether lessons learned from the Hillsborough disaster can be built into pathology practice. His report is expected next summer.
Hillsborough families have criticised the government for not yet acting on any other recommendations in Jones’s 2017 report, and are calling for a “Hillsborough law”, to which Labour has committed. Jones’s recommendations included that bereaved families should have public funding for legal representation at inquests where public bodies are represented, and a “duty of candour” for police officers. In July 2021 Andrew Devine, 55, died 32 years after suffering severe and irreversible brain damage at Hillsborough. A coroner ruled that he was unlawfully killed, making him the 97th victim of the disaster.