Download the document (1.26 MB) - Hillsborough Independent Panel

M. J. QREQQ, LL.B.
J. J. M. HAWTHORN, M.A.
Our Ref: JH/LF/H359
Malcolm J. Gregg & Co.
Rt Hon Sir Nicholas Lyell QC MP
Office of the Attorney General
9 Buckingham Gate
LONDON
SW1E 6JP
Dear Sir
Solicitors
SECOND FLOOR
CENTURY BUILDINGS
31 NORTH JOHN STREET
LIVERPOOL L2 6RQ
Re: Coroners Act 1988 - Paul Carlile And Others
15th April 1992
Telephone 0 5 1 -2 3 8 8085
Fax No. 0 5 1 -2 3 6 4182
DX 14175
We are instructed by the next of kin of six of those who lost their
lives as a result of the Hillsborough Stadium Disaster on 15th
April 1989. We enclose herewith a Memorial on their behalf together
with two Appendices of supporting material.
We invite you to grant our clients leave under Section 13 (1)(a ) of
the Coroners Act 1988 to apply to the High Court for an Order that
the inquisition be quashed and a fresh inquisition held.
Yours faithfully
Enc.
Uj~ - -
i 607

IN THE MATTER OF THE CORONERS’ ACT 1988
AND IN THE MATTER OF THE DEATHS OF:
PAUL WILLIAM CARLILE
IAN THOMAS GLOVER
RICHARD JONES
MICHAEL KELLY
PETER TOOTLE
KEVIN DANIEL WILLIAMS
TO HER MAJESTY’S ATTORNEY GENERAL:
THE HUMBLE MEMORIAL OF
SANDRA STRINGER AND DONNA CARLILE
(the mother and sister of Paul Carlile)
JOHN AND THERESA GLOVER
(the father and mother of Ian Glover)
JOAN SINCLAIR
(the sister of Michael Kelly)
LESLIE AND DOREEN JONES
(the father and mother of Richard Jones)
PETER AND JOAN TOOTLE
(the father and mother of Peter Tootle)
JAMES STEPHEN AND ANNE WILLIAMS
(the father and mother of Kevin Williams)
Malcolm J. Gregg & Co
Second Floor
Century Buildings
31 North Street
Liverpool
L2 6RG
Solicitors for the Memorialists

IN THE MATTER OF THE CORONERS* ACT 1988
AND IN THE MATTER OF THE DEATHS OF:
PAUL WILLIAM CARLILE
IAN THOMAS GLOVER
RICHARD JONES
MICHAEL KELLY
PETER TOOTLE
KEVIN DANIEL WILLIAMS
TO HER MAJESTY’S ATTORNEY GENERAL:
SHEWETH THAT:
(1) Your Memorialists are:
THE HUMBLE MEMORIAL OF
SANDRA STRINGER AND DONNA CARLILE
(the mother and sister of Paul Carlile)
JOHN AND THERESA GLOVER
(the father and mother of Ian Glover)
JOAN SINCLAIR
(the sister of Michael Kelly)
LESLIE AND DOREEN JONES
(the father and mother of Richard Jones)
PETER AND JOAN TOOTLE
(the father and mother of Peter Tootle)
JAMES STEPHEN AND ANNE WILLIAMS
(the father and mother of Kevin Williams)
(i) Sandra Stringer and Donna Carlile, the mother and sister of Paul
Carlile, deceased.

(ii) John and Theresa Glover, the father and mother of Ian Glover,
deceased.
(iii) Joan Sinclair, the sister of Michael Kelly, deceased.
(iv) Leslie and Doreen Jones, the father and mother of Richard Jones,
deceased.
(v) Peter and Joan Tootle, the father and mother of Peter Tootle,
deceased.
(vi) James Stephen and Anne Williams, the father and mother of Kevin
Williams, deceased.
Between the 18th day of April 1989 and the 28th day of March 1991 an
inquest was held before Doctor Popper, one of Her Majesty’s Coroners,
touching the deaths of the six deceased named hereinbefore and some 89
others who had died as a result of the Hillsborough Stadium disaster on the
15th April 1989.
At the said inquest the jury returned and the Coroner recorded that the six
deceased named hereinbefore had died of multiple crush injuries and the
conclusion of the verdict was accidental death.

Your Memorialists hereby seek your authority under Section 13 of the
Coroners’ Act 1988 to apply to the High Court for an Order quashing the said
inquisition and ordering a fresh inquest. They do so on the grounds that the
said inquest was vitiated by the wrongful rejection of evidence by "irregularity
of proceedings" by "insufficiency of inquiry" and by a failure to direct the jury
correctly as to the verdicts available to them on the facts and in particular the
omission to make any mention at all of the alternative verdicts of "lack of
care", accidental death due to lack of care" and "accidental death aggravated
by lack of care". They further submit that in some cases at least there has
been a subsequent "discovery of new facts or evidence" that justifies the
quashing of the inquisition and the holding of a fresh inquest.
Your Memorialists respectfully refer you to the individual summaries
appended hereto which set out the particular facts of their individual cases.
In what follows your Memorialists will develop some of the points common to
all their submissions which have caused them to seek your authority to apply
to the High Court under Section 13. But they accept that each case will have
to be looked at individually in deciding whether to grant your authority to
some or all of them. All of them complain that the Coroner wrongly failed
to direct the jury as to the verdicts of lack of care or accidental death due to
or "aggravated by lack of care". They do so firstly on the basis that the
negligence of the police in causing the tragedy was self-evident and has
indeed been admitted; this justified leaving the verdict of "lack of care" to the
jury on the basis of the police’s failure to perform their duty of care to the

deceased. But, additionally and in the alternative, they complain that the
Coroner wrongly excluded evidence of lack of care in the emergency services’
and police’s reaction to the deceased’s initial injuries, wrongly insisted on a
cut-off point of 3.15pm for the evidence heard at the main inquest (despite
evidence that the deceased were, or may have been, still alive after that time)
and wrongly failed to direct the jury on the availability of a verdict of
accidental death aggravated by lack of care or lack of care based on the
failure of the various responsible agencies to provide the deceased with
adequate medical attention after they had sustained their original injuries.
BACKGROUND TO THE INQUEST
The inquest arose out of the disaster at Hillsborough Stadium Sheffield which
occurred on 15th April 1989. On that day the semi-final of the Football
Association Cup was arranged to be played at the Stadium between the
Liverpool and Nottingham Forest Football Clubs. What happened next can
be summarised in the words of Lord Keith in his Judgment on the case of
Cooper & Others -v- Wright:
"The South Yorkshire Police Force, which was responsible for crowd control
at the match, allowed an excessively large number of intending spectators to
enter the ground at the Leppings Lane end, an area reserved for Liverpool
Supporters. They crammed into pens 3 and 4, below the West Stand, and in
the resulting crush 95 people were killed and 400 physically injured".

As is recorded in Lord Keith’s Judgment, the South Yorkshire Police have
subsequently admitted that their negligence was responsible for the said
injuries and deaths.
Before the inquest hearing opened on 18th April 1990, there had been an
official inquiry ordered by the Secretary of State for the Home Department
on 17th April 1989. This inquiry was carried out by Lord Justice Taylor with
the help of two assessors. In his Interim Report on the "events at Sheffield
Wednesday Football Grounds on 15th April 1989" which was presented to
Parliament in August 1989, Lord Justice Taylor had established a chronology
of the key events and made certain findings of relevance to this Memorial.
Your Memorialists respectfully summarise the chronology of findings to assist
you by way of background to their complaints about the conduct of the
subsequent inquest. Lord Justice Taylor’s findings can, then, be summarised
as follows, on the basis of his Interim Report:
(i) Before the kick-off of the match, which was scheduled for 3.00pm,
there was a build-up of supporters outside the Leppings Lane
entrance to the grounds which caused pressure and discomfort to
those trying to get into the ground through the turnstiles.
(ii) At 2.52pm Chief Superintendent Duckenfield - who was the police
officer in charge of crowd control at the match decided that, in order
to relieve the pressure at the turnstiles, he would give permission for

the gates to the ground at the Leppings Lane entrance to be opened.
The opening of one of the gates, Gate C, resulted in a sudden influx
of supporters through the tunnel and into the spectators’ pens 3 and
4, building up an intolerable pressure on the supporters at the front
of the pens. This decision to open the gate was found by Lord
Justice Taylor to be a negligent "blunder". He also found that the
police had thereafter further misjudged the situation by failing to
take any steps to divert supporters from pens 3 and 4. He found
that, had this been done, they could have prevented the fatal build­
up of pressure in the pens during the minutes after 2.52pm - which
eventually resulted in the supporters being crushed against the
perimeter wall and the wire mesh of the fence above it. Lord Justice
Taylor also found that the police had made a fatal error in deciding
not to postpone the match, once the problems at the turnstiles
became clear, and that postponement of the match to enable a
slower and more orderly entrance into the ground could also have
averted the resulting disaster.
Lord Justice Taylor found that the pressure on those at the front had
already become intense and life-threatening by 2.59pm, but that the
dangerous situation went "unheeded" and "unremedied" by the
police.
The match kicked-off just before 3pm and shortly after that at

3.04pm a further surge caused by the spectators’ response to a
narrow miss at goal by Beardsley for Liverpool further increased the
pressure on the supporters crushed against the wall at the front. By
then, if not before, many of the supporters had suffered the severe
crush injuries from which they died. The exact time of death was
not established by Lord Justice Taylor since this was clearly not an
essential part of his inquiry’s task.
To the front of the crowd, there was delay by the police in opening
the perimeter gates in pens 3 and 4 to the track which ran alongside
the pitch. These were not open until 3.00pm, and until they were
opened the victims of the crush had no means of escaping from the
pens during the build-up of pressure between 2.52pm and 2.59pm.
It was only after 3.00pm that spectators were able to escape by those
gates onto the track and the pitch.
The match was not stopped until 3.05pm and it was only then that
the gravity of the situation appears to have been appreciated.
There was then a delay in evacuating the casualties from pens 3 and
4 and in responding to the magnitude of the disaster. In particular,
Lord Justice Taylor made the following findings:
(a) Initially no officer took effective charge of the evacuation

of casualties from the pens.
It was not until 3.12pm that chief Superintendent Nesbit
arrived on the pitch and organised a chain of officers to
simplify and expedite the evacuation of casualties from the
pitch.
Though it was not clear when the Major Disaster Plan was
initiated, it was certainly not initiated until 3.06pm
(subsequent evidence suggests that the existence of a major
disaster was not communicated to the ambulance services
for some time).
Ambulances from the South Yorkshire Metropolitan Area
began to arrive at Leppings Lane at 3.13pm and at the
Peniston Road entrance at 3.17pm.
No request for the fire-brigade or for cutting gear was
made until 3.13pm (it would obviously have helped to
evacuate the injured from behind the wiring had the fire-
brigade and cutting equipment been available sooner).
No request for help was broadcast to doctors and nurses in
the grounds until 3.29pm when, according to Lord Justice

Taylor’s findings, "it was too late".
(8) It is plain then that, on the basis of the evidence heard by Lord Justice Taylor
(which to a large extent was reheard by the Coroner and his jury at the
inquest) there was clear evidence that police blunders and negligence was
responsible for the fatal crush which caused the deaths of the deceased. If
then the jury were, as a matter of law, entitled to reflect that negligence in a
verdict (whether of "lack of care" or some other verbal formula falling short
of the gross negligence or recklessness necessary to constitute unlawful killing
by manslaughter), such a verdict should have been left to them on the facts.
(9) Secondly, it is plain that Lord Justice Taylor found some serious deficiencies
in the police response to the plight of the injured once they had sustained
their injuries at some time between 2.52pm and 3.05pm, or even later. It is
true that he had concluded that many of the injuries and deaths were
probably inevitable once the fatal crush had built up. But he recognised that
a quicker response to the emergency by the police to ensure the early
attendance of the emergency services might have saved at least some lives.
These findings did at least raise the further question of whether the cause of
death (i.e. crush injuries) had not in some cases been aggravated by "lack of
care" in the sense of a failure to respond swiftly enough to the plight of the
injured and provide them with the necessary medical care to avert death.
-9-

Lord Justice Taylor did find that "there was insufficiently close co-operation
between the police and the emergency services", and further found that "it is
clear that SYMAS and the Fire Brigade should have been called earlier than
they were". But, in view of his finding as to the "pathetically short period for
which those unable to breathe could survive" he found that it is "improbable
that quicker recourse to the emergency services could have saved more lives".
Moreover, he rejected the criticism that, once they had been called, the St.
John Ambulance Brigade, the Fire Brigade and SYMAS (the South Yorkshire
Metropolitan Ambulance Service) had been slow to respond or inappropriate
in their response or that there was any insufficiency of equipment or lack of
triage. However, it is clear that he did not rule out the possibility that some
lives may have been saved by calling the emergency services in earlier and his
conclusion that in most cases the injuries would have been fatal in any event
after a very short period of crush asphyxia depended on a particular
pathological premise (namely that fatal crush injuries were due to a
continuing pressure which made death inevitable in a matter of minutes)
which has subsequently been challenged and is inconsistent with the fact that
some of the dead appeared to have revived briefly and many of the injured
who got medical attention promptly did survive (See BMJ article dated 30th
November 1991 and annexed hereto). As to his view that the emergency
services could not be validly criticised, this was based on a rejection of the
evidence of two doctors present at the ground with which a jury (had they
been allowed to hear their evidence at the inquest) might not have concurred.

So, despite his reservations about the number of lives that might have been
saved by a swifter response Lord Justice Taylor did make findings which
suggested that the lives of some of the dead might have been saved if there
had been a more timely response by the police to the crisis and if they had
called in the emergency services more quickly. But, as indicated above, there
was additional evidence considered by Lord Justice Taylor, and available to
the Coroner, which went considerably further. This evidence principally
consisted of the statements of two doctors and a nurse who had been present
at the match and attempted to assist and treat the casualties - namely Dr.
Glyn Phillips, Dr. John Ashton and Mr. F.J. Eccleston, a senior nursing
manager.
Dr. Glyn Phillips
Dr. Glyn Phillips has provided a statement to the Coroner, a copy of which
is annexed hereto. In summary, he remarks in his statement how he had been
a spectator at the match, and had experienced the crush as the crowd surged
forward in the pen, and had managed to escape from the pen over the
perimeter fence. He then made various attempts to resuscitate unconscious
spectators lying on the pitch. In one case he succeeded in reviving a spectator
who was lying unconscious by the goal line, cyanosed and pulseless, when he
first came upon him. After some fifteen minutes of cardiac massage and
mouth to mouth resuscitation Dr. Phillips noticed the young man began to
make his own breathing efforts. He got him to an ambulance and told the

ambulance man that he needed an ambulance "now" - but the ambulance man
told him that he couldn’t get the ambulance out. The time, on the basis of
Dr. Phillips’ estimations, must by then have been sometime after 3.21pm. His
evidence is significant in that it demonstrates the possibility that lives could
have been saved with proper emergency help after the crush injuries sustained
at around 3.00pm - 3.04pm. It also indicates that there were matters which
deserve investigation in inquiring as to the cause of death which occurred
after 3.15pm (the "cut-off' point selected by the Coroner). Dr. Phillips’
evidence is also significant in that he called for a ventilator whilst attending
the victim who revived and was told that there was none; and he also asked
for an oxygen cylinder, and was provided with an empty one. This did point
to a significant ‘lack of equipment’ as a problem that may have contributed
to the deaths of some of the deceased.
Dr. John Ashton
Dr. John Ashton, who had attended the match as a spectator with his two
sons and nephew, is a medical practitioner and senior lecturer in Community
Health at University of Liverpool. In a statement dated 19th April 1989 he
gave a detailed account of the events that unfolded from about 3.15pm
onwards which highlighted the serious shortcomings in the response of the
police and the emergency services. His account was as follows:
(a) When he got a view of the pitch shortly before 3.15pm he said:

"There seemed to be a few St. John’s Ambulance people attending
the people who were lying around the pitch and I could see people
lying on the pitch unattended. There was a large line of police
officers across the pitch at the centre circle".
At about 3.15pm he was able to get a better view of what was going
on the pitch and described what he saw as follows:
"The overwhelming impression was of a large and growing number
of casualties and not much response. The supporters were now
impatient and angry at the slowness of the response to the
emergencies. There appeared to be only one or two stretchers on
the pitch and one ambulance was making its way around from the far
corner." He then described how the supporters were chanting for
assistance to be brought to the injured on the pitch and how many
of them began to tear down the advertising boards and organise
themselves into stretcher parties. It was around this time that he
heard the tannoy appeal for doctors to help. This took place at
about 3.29pm.
Dr. Ashton asked several policemen who he could report to to help
and was told they did not know. Finally, a senior police officer
(Inspector Grace) was pointed out to him but he too said that he did
not know who was in charge of emergencies or whom he should

eport to to help.
(d) Dr. Ashton then went out into Leppings Lane at around 3.30pm to
3.35pm and found that there was only one ambulance there.
(e) Dr. Ashton found that there was no triage system in operation to
identify those most in need of medical aid so he organised a triage
system himself as to whom to put in the ambulance.
(f) Dr. Ashton recounted how there was no steady flow of ambulances
until between 3.45pm and 3.50pm. Once they began to arrive he and
a local practitioner worked together sorting out the casualties and
dispatching them in ambulances.
(g) It was not until then that "an anaesthetist arrived from somewhere
and fire engines came with resuscitation equipment, but all of this
was really too late". Dr. Ashton took the view that, by 4.30pm it was
"all over".
(h) Dr. Ashton recorded his view that "on this occasion crowd safety
took second place to crowd control" and that the emergency service
was "woefully inadequate". He recognised the difficulty of assessing
how many lives might have been saved by a more timely response,
but clearly his statement raised this issue most clearly.
-14-

Mr. Eccleston
Mr. Eccleston is a qualified nurse and Senior Nurse Manager who made a
statement dated 18th April 1989 giving his account of the disaster in which he
had been caught up after attending the match as a Liverpool supporter with
his son. In his statement which is appended to this Memorial, he gives an
account of the events which occurred after the match was stopped. His
account of events can be briefly summarised as follows:
(a) He was allowed onto the pitch by a steward when he explained he
was a trained nurse.
(b) He then helped the police pull casualties through the gates of the
pens onto the pitch. The first casualties were conscious and
recovered but they then began to pull out unconscious bodies.
(c) He recalls resuscitating one young man to the point where he
regained consciousness and was able to talk (pages 3-4) and then
taking him on a stretcher to the St. John’s Ambulance room.
(d) Later on at about 15.30 he strove to resuscitate another young man
but "lost the battle for the young man’s life". He records that at that
stage "we still had no equipment of any sort to work with".

It was shortly after 15.30pm that the first ambulances began to make
their way onto the pitch.
He later went to the gymnasium where the space was divided into a
part set aside for the presumed dead and a part for the living. This
was about 15.55pm and the scene was "absolute chaos".
Your Memorialists would particularly draw attention to his
conclusions (6) and (7) which were as follows:
"(6) Observing from the outside it appears to have taken far too
long to decide that it was not a security problem and that
the fans genuinely needed help. Working with and
alongside the individual police officers in the immediate
disaster area, I have enormous praise and admiration for
their efforts. Overall at the scene, however, there appeared
to be a lack of coordination and genuine leadership.
"(7) For an extremely long time we were without any medical
equipment of any description. I still can’t understand why
the local Health Authority’s Major Medical Disaster Team
was not called upon. I understand that all Health
Authorities in this country have a major disaster policy. It
is impossible to accurately estimate the difference this

would have made in saving life. I do however believe that
the Liverpool fans should have been given the chance".
Issues Raised by Evidence Disclosed to Coroner
It is plain then that the general evidence disclosed to the Coroner when he
embarked upon the Inquest proceedings in April 1990 raised at least two
issues that deserved investigation and might result in a verdict that reflected
culpable failure on the part of the police and/or the emergency services:
(i) Firstly there was the negligence of the police in permitting the
situation to develop to a point where the "fatal" pens were so
crowded that the crush injuries resulted which proved fatal to the
deceased.
(ii) Secondly, there was the slow response by the police and emergency
services to the plight of the injured, the evidence that some could
have been saved by a more timely response, and the general
evidence of chaos, lack of leadership, lack of equipment and lack of
ambulances during the crucial time from 3.04pm until 3.30pm and
thereafter.
These were all matters which, it is submitted, require investigation in order
to determine properly "how" the deceased met their deaths, and they made

the Coroner’s subsequent decision to fix a 3.15pm cut-off point unlawful and
unjustifiable. Against that background your Memorialists turn to the conduct
of the Inquest itself.
Opening of Inquest with Jury - 18th April 1990
The Coroner swore in a jury and commenced the inquest before the jury on
the 18th of April 1990. On that occasion the Coroner explained the
procedures that he proposed to adopt to the jury and to the representatives
of your Memorialists’ families. The situation was complicated by the fact that
the Director of Public Prosecutions was still contemplating the initiation of
criminal proceedings against officers of the South Yorkshire Police for their
part in permitting the disaster to occur. The Coroner therefore decided to
open the inquests and hear evidence in the first stage at a series of mini­
inquests which would be confined in their scope to the statutory question of
"who" the deceased was in each case and "when and where" he met his death.
He indicated that he would postpone all wider investigation into the further
question of "how" the deceased came by their deaths - and the extent to which
fault played a part in that causation - until after the Director of Public
Prosecutions had reached a decision on whether to initiate criminal
proceedings. He therefore explained his intentions as follows:
(i) He would firstly hold a series of mini-inquests into the deaths of
each of the deceased confined to the investigation of "who the

decreased was, when he died, as far as it can be established and
where he died, as far as it can be established" (page 10 G-H of
transcript of proceedings on 18th April 1990). At the end of each of
these mini-inquests he would adjourn pending the decision of the
Director of Public Prosecutions on criminal proceedings.
He would not permit any investigation of the wider question of "how"
the deceased met their deaths at these preliminary inquests and "no
criticism or attack on any person or corporations will be permitted
and if a question is asked I will not allow it" (page 128).
The evidence of these mini-inquests would be presented in the form
of "summaries" read out by presenting officers. These "summaries"
would summarise the statements taken from eye-witnesses as to the
movements of the deceased on the day of the disaster, the sightings
made of them at the time of the fatal crush, the finding of their
bodies on the pitch, any attempts at resuscitation made, and the
taking of their bodies to the temporary mortuary in the gym, and the
certification of death. There would be no oral evidence at these
mini-inquests save for the reading out of these summaries, based on
statements taken, by presenting officers and the evidence of
pathologists as to the cause of death (pages 13F - 14F).
The Coroner admitted that he was not complying with the

equirements of Rule 37 of the Coroners’ Rules which lays down the
procedure that must be followed before documentary evidence is put
before an inquest instead of original viva voce evidence (page 17D
18C). In particular, he was not going to summarise the contents of
the summaries and then invite the consent of the interested parties
to this mode of adducing evidence as Rule 37 requires. He justified
this departure from the requirements of Rule 37 on grounds of
practicality.
The mini-inquests of the six young men whose deaths are the subject of this
Memorial took place between the 1st and 4th of May. Detailed accounts are
included in the individual statements relative to the deceased individually
which are appended herewith. But the six mini-inquests had the following
features in common:
(i) At each of them post-mortem evidence was given by pathologists to
the effect that death was due to traumatic asphyxia or crush
asphyxia. Put simply this means that the pressure of the crush of
bodies on them prevented their chests from moving in or out so that
they could not breathe and oxygen was cut off from their vital
organs. As a result they lost consciousness and subsequently died.
In each case, the pathologists claimed that the deceased would have
lost consciousness in a matter of seconds and that they would have
died within a matter of a few minutes.

At each of them the evidence of eye-witnesses relating to the
deceaseds’ movements prior to death, the injuries they sustained,
their condition on being found and the certification of death was
primarily given by way of reading out a documentary ‘summary’
which collated and summarised the statements of the contemporary
eye-witnesses. With few exceptions none of the eye-witnesses gave
oral evidence and the families of the deceased had to rely on the
accuracy of the summary presented in order to gain an account of
the last hours of their sons’ deaths and the circumstances of their
deaths.
In four of the cases there was some evidence that the deceased were
still alive after sustaining their initial crush injuries and for longer
perhaps than had been said seemed to be possible by the
pathologists. These were the cases of Paul Carlile, Ian Glover, and
Kevin Williams and Michael Kelly. Coupled with the evidence that
some of the other victims who survived were found unconscious after
the initial crush but revived by timely medical intervention (see
paragraphs 11-14), this has raised in the minds of the deceaseds’
families the question of whether their lives could have been saved by
a more timely medical response and suitable efforts at resuscitation.
This, in turn, raises the issue of whether the causation of their
deaths was referrable to or "aggravated by" "lack of care" in the
accepted sense of that expression as defined in cases such as ex_

parte Hicks H987) 1 WLR 1524. Similarly in the two cases where
there is no evidence of life after 3.04pm, the cases of Richard Jones
and Peter Tootle, their families are left with reason to suspect that
the deceased may have still been alive and capable of being saved
between the time of the crush and the time when they were certified
dead (at 4.00pm in the case of Richard Jones, and 3.54pm in the
case of Peter Tootle). The evidence relating to the four who showed
signs of life after 3.04pm and may have been alive after 3.15pm and
capable of being saved, will be briefly summarised below.
In respect of three cases of Paul Carlile, Ian Glover and Michael Kelly the
evidence (as fully set out in the families’ individual appended statements) can
be summarised as follows with regard to the question of survival:
(i) Paul Carlile
The evidence of Professor Usher was that Paul Carlile, who was not
in fact certified dead until 4.35pm, would have fallen unconscious
within ten to twenty seconds of sustaining his crush injuries and died
within minutes thereafter. This claim appears to conflict with the
statement of the off-duty nurse Michael Hollinghurst which was
shown to his mother, Sandra Stringer. In that statement, Mr.
Hollinghurst describes how he first became aware of Paul Carlile
when he felt him ‘climbing up his legs’. He was seen to be pulling

himself up by holding onto Mr. Hollinghurst’s trousers. This would
have taken place between 3.03pm and 3.15pm and suggests that Paul
Carlile was alive and conscious when first found by Mr. Hollinghurst.
In the statement Mr. Hollinghurst describes his attempts at
resuscitation, and how he was told to leave the enclosure by a
policeman or ambulance man who said he could achieve no more.
This has raised in his family’s minds the suspicion that Paul Carlile
could have been saved by a more sustained attempt at resuscitation.
It is questionable whether Paul was in fact dead at the point. There
was no electro-cardiogram to test for a pulse (which is extremely low
in traumatic asphyxia cases). Given that he had been conscious
when he was trying to pull himself up, Paul’s family believe that he
might have been saved had Mr. Hollinghurst been allowed to stay
with him longer. They are also very concerned that though he was
one of the first casualties to be taken out through the tunnel to the
Leppings Lane area shortly after 3.15pm, he was, however, never
placed in an ambulance and was still on the ground in that area at
4.35pm when Dr. Monaghan certified him dead. A final matter of
concern raising the question of possible survival is the fact that Mr.
Monaghan requested the use of a machine when attending to Mr.
Carlile. This may suggest that, even then, it was not certain whether
he was dead or not A further point to note is that when Michael
Hollinghurst gave evidence at the resumed inquest none of the
details relating to Paul’s attempts to stand up were raised as an
issue.

Ian Glover
Ian Glover was removed from Pen 3 by two police officers and was
placed on his back on the ground. His brother Joseph attempted
mouth-to-mouth resuscitation but was stopped by a police officer
who pronounced Ian dead and placed a jumper over his face. No
equipment was used to ascertain the presence of a pulse. The
evidence of Professor Usher was that he died of traumatic asphyxia,
and that his injuries would have created unconsciousness within ten
to twenty seconds and made death inevitable within four to six
minutes. This, however, was inconsistent with the evidence of his
brother, Joseph, which was not given orally to the mini-inquest but
indirectly via the Reporting Officer Geraldine Evans. She states (at
page 5B of the mini-inquest transcript for 4th May 1990):
"Sir, I have to include that I have spoken with Joseph this morning
and he wishes to state that in the gymnasium a doctor was present
and when he examined Ian he did in fact find a pulse and attempted
to resuscitate him for about fifteen minutes but was unsuccessful".
It is clear that these attempts at resuscitation would have taken place
during the period between 3.25pm and 3.40pm and suggest the
possibility both that Ian was alive after 3.15pm and that he might
have survived had there been a more timely attempt at resuscitation

y a qualified person. The fact that his face had been covered whilst
he was on the pitch possibly prevented such an attempt.
Michael Kelly
In Michael Kelly’s case the pathologist, Dr. John Clark, gave
evidence at the mini-inquest on the 1st of May 1989 that he died of
crush asphyxia but that the asphyxial changes in him were relatively
mild. There was evidence that he was still alive at 3.08pm (10D of
mini-inquest transcript) which tends to negative any suggestion of
instantaneous unconsciousness and death minutes after. Moreover,
PC Maugham gave evidence that he reached Michael Kelly at some
time around 3.08pm, gave him artificial resuscitation, and carried him
to the Spion Kop End on a hoarding improvised to serve as a
stretcher. That would have been some time around or after 3.15pm
and PC Maugham was quite confident that Michael Kelly was still
alive at that stage. He described how Michael Kelly was still
breathing for himself when he handed him over to the St. John’s
Ambulance Service. Moreover Michael’s Post-Mortem details reveal
no evidence of brain damage and he agreed with Counsel for the
family that he was confident that he "had won through" in Michael
Kelly’s case and resuscitated him. Naturally this evidence, together
with the evidence that Mr. Kelly’s asphyxial changes were relatively
mild, suggested to his family that his death was preventable and that

he only ceased to breathe subsequently and died because of some
shortcomings in the care he received after he was handed over to the
St. John’s Ambulance Service. He was not certified dead until
3.59pm.
Kevin Williams’ Mini-Inquest
At Kevin Williams’ mini-inquest on 2nd May Dr. Slater, the pathologist, gave
evidence that death was due to asphyxia and that his injuries were likely to
have resulted in unconsciousness within seconds and in death within three to
five minutes (page 3B-E). However, evidence was then read out, in the
course of the summary, from two police officers which suggested that he might
still have been alive for some considerable time after he sustained his original
injuries and capable of being saved. The evidence took the following form:
(i) There was first a statement from a PC Bruder which was referred to
in the summary in which he stated that he had come upon Kevin
Williams lying on the ground of the pitch having convulsions (the
rest of his statement in which he referred to Kevin Williams’
vomiting and to him having a pulse was not read out at this hearing
though this clearly provided further evidence that he was still alive).
Clearly this evidence suggested that Kevin Williams was still alive
and moving a considerable time after his original injuries and even
after being moved onto the pitch. This raised the question of

whether he could have been resuscitated though PC Bruder stated
that his own attempts at resuscitation eventually failed and that
Kevin Williams went grey.
However, a further statement was then referred to from a Special
Constable Deborah Martin who had made a statement to the effect
that Kevin Williams was alive and had been briefly resuscitated as
late as about 4pm. In the original, statement she made which was
not read out at the inquest but merely referred to, she said:
"He stopped breathing so I gave him the kiss of life, and heart
massage and a doctor also helped. He started breathing and opened
his eyes, his only word was "Mom" and then he died".
This statement was referred to with some scepticism (page 6F of
transcript and page 7D-E). But clearly it once again raises the
possibility of survival long after 3.15pm (as late as 4pm) and the
question of whether death might have been prevented by more
timely medical intervention. The Coroner was sufficiently concerned
about this evidence to call further evidence on the matter on 4th
May at a resumed mini-inquest into the death of Kevin Williams.

Kevin Williams ("the resumed mini-inquest)
When the mini-inquest was resumed on 4th May the Coroner called further
evidence which was undoubtedly intended to discredit the suggestion that
Kevin Williams had survived for some considerable time after sustaining his
crush injuries and to reassure the family by qualifying and undermining the
testimony of PC Bruder and Special Constable Martin. The further evidence
took the following form:
(i) An Inspector Robert Sawers was called who stated that he had re­
interviewed PC Bruder on 3rd May and that, in the light of the
further questions put to him, PC Bruder now accepted that his
description of the deceased as ‘having convulsions’ should be altered
and the ‘movement’ was best described as a ‘twitch’ (6C). He also
reported that PC Bruder had now qualified his claim to have ‘"felt
a slight pulse" and that he now accepted that "whatever he felt there
he cannot be categoric it was a pulse" (page 6G). He further reports
that PC Bruden now accepted that he had not witnessed Kevin
Williams being sick (page 7b).
(ii) Dr. David Slater, the pathologist, was then recalled. His evidence
was that Kevin Williams’ death was caused by a "very very severe
case of asphyxia" and that there "was four fractures to the voice box".
In his view unconsciousness would have resulted from the crush

injuries within seconds and irrecoverable brain damage death would
have occurred within three to six minutes thereafter but whole body
death may not have resulted until sometime thereafter (pagers 10-
12). This might explain the apparent twitches some considerable
time after he had been taken from the terraces. But he was sure
that Kevin Williams had died before Special Constable Martin
arrived on the scene.
(iii) In addition, a Dr. Ernest Gumpert was called to explain further the
distinctions between brain death and whole body death and to record
his view that Kevin Williams was brain dead before he got out of the
area where he was standing, when he lost consciousness.
Subsequent Developments Regarding Williams’ Inquest
Subsequent investigations have revealed that considerable pressure was put
on both Special Constable Martin and PC Bruder to retract or qualify their
evidence as to the signs of life they described in Kevin Williams. These are
set out more fully in the statement of Kevin Williams’ mother, appended
herewith. But the manner in which the very significant evidence of these two
witnesses was presented to the mini-inquest was highly unsatisfactory. Clearly
the jury and the family should have had the benefit of hearing oral evidence
rather than somewhat misleading second-hand accounts of their original
statements and of the qualifications they had subsequently been persuaded to

make to their original evidence. And clearly the edited version of their
evidence actually presented was, at the very least, not a complete picture of
their eye-witness accounts.
Mini-inquests concerning Richard Jones and Peter Tootle
The mini-inquests into the deaths of Peter Tootle and Richard Jones revealed
no positive evidence of signs of life after they suffered from the crush injuries
which resulted in their deaths. The only evidence in respect of these two
after they suffered their injuries was as follows:
(i) Richard Jones
Richard Jones, who was found to have died of traumatic asphyxia
has been identified standing in enclosure 3 at 2.50pm. The only
evidence of what happened to him after this time came from Police
Sergeant Killoch who disclosed in his summary that sometime later
Police Constable Paul Bromley joined a group of supporters who
were carrying Richard Jones across the pitch to the north stand on
a makeshift stretcher. Once there, the constable attempted to
resuscitate him but was unsuccessful. He then assisted in carrying
Richard Jones into the temporary mortuary where at 4pm he was
certified dead. The very lack of evidence has made his family
concerned that his life might have been saved had there been

suitable medical intervention at an earlier stage. They also raised
with the Coroner their concern to know whether his life could have
been saved had he not been assumed to be dead when taken to the
temporary mortuary but instead taken to hospital and given the
benefit of resuscitation attempts at the hospital. The Coroner dealt
with this by saying at (page 8D of the transcript) that in an ideal
world everybody would have gone to hospital but that this ignored
the practicalities.
Peter Tootle
In the case of Peter Tootle there was very little evidence as to what
happened to him after he fell unconscious from his injuries in the
third enclosure. His friend and companion Colin Frodsham saw a
police officer attempting to resuscitate him for about ten to twenty
seconds when he (Colin Frodsham) recovered consciousness himself.
There is then evidence that at some time between 3.20 and 3.40pm
Police Constable Friend saw Mr. Tootle at the end of the ground
opposite to the Leppings Lane end; he then examined him and
carried him into the temporary mortuary where he was certified dead
at 3.45pm. (Dr. Bull who certified him dead certified a total of 30
victims dead in the space of twenty minutes). His family were
concerned to know whether his life might not have been saved by
more timely intervention by skilled medical help. At the resumed

inquest Mr. and Mrs. Tootle listened to all the evidence but only
heard their son’s name mentioned once as a verdict was attached to
it.
At the conclusion of the mini-inquest, when the Coroner adjourned to await
the result of the Director of Public Prosecution’s decision, the position was
as follows:
(i) Pathologists had given their view that in most cases unconsciousness
had followed within seconds of the crush injuries which eventually
proved fatal and that brain death occurred on average within four to
six minutes thereafter. But clearly, there were some cases (eg
Michael Kelly) where the comparative mildness of the crush injuries
meant that, even if this general rule was correct, it was not
applicable in the individual case.
(ii) On the contrary, eye-witness accounts and those of doctors actually
present at the scene tended to suggest that lives could have been
saved by more prompt medical attention. There were a number of
examples of successful resuscitation when prompt medical attention
had been made available. The report of Lord Justice Taylor had
found that there had at least been delays in summoning the
emergency services. The evidence was very strong that there had
been shortcomings in the response of the emergency services. None

of this evidence had been heard because it was inevitably bound up
with the wider question of "how" the deceased met their deaths and
with questions of fault which the Coroner had excluded from the
mini-inquests.
Your Memorialists all had reason to believe that the delay in calling
the emergency services and the shortcomings in their response may
have played a part in the causation of their relative’s deaths. In four
cases, there was evidence of survival beyond the four to six minute
period given by the pathologist for death to ensue, and in two cases
(Michael Kelly and Kevin Williams) there was positive evidence that
resuscitation had proved temporarily successful. This made it
necessary to investigate whether some failure in medical attention
contributed to the causation of deaths which were not in fact
inevitable.
Most important of all the deceased’s families had been lead to
believe that the question of "how" their relatives met their deaths
would be fully investigated at the resumed inquest. And they
considered that an inquiry into "how" they died that did not extend
to the time of their actual deaths and deal with the preventability of
their deaths by suitable emergency response could hardly be called
adequate.

(24) The Resumed Inquest
In September of 1990 a decision was reached by the Director of Public
Prosecutions not to prosecute anybody in respect of the Hillsborough disaster.
Thereafter, the Coroner decided that the adjourned inquests should be
resumed and completed with a full inquiry into the question of "how".
However he indicated that he would impose a cut-off point of 3.15pm on the
inquest and would hear no evidence as to events after that point. He chose
this cut-off point because that was the time that the first ambulance arrived
on the pitch. The effect of the decision to impose a cut-off point at 3.15pm
was as follows so far as it affected your Memorialists:
(i) I It ruled out any inquiry into the adequacy of the response of the
emergency services and effectively meant that there was no inquiry
into the question of whether the deaths of the individual deceased
might have been prevented by more prompt and adequate medical
intervention.
(ii) It proceeded on the basis that all the deaths of those involved in the
disaster had become inevitable by the time they had sustained the
crush injuries they suffered before or up to 3.04pm or thereabouts,
despite the fact that there was ample evidence to suggest otherwise
which the jury should properly have been permitted to consider.
-34-

(iii) Moreover it meant that there was no evidence of the wider
circumstances surrounding the last minutes of life since there was
considerable evidence that these six deceased were or at least may
have been still alive after 3.15pm. Yet the surrounding
circumstances of what was going on after 3.15pm and before they
were certified dead were not inquired into.
Submissions on 3.15pm Cut-off Point and Ruling
At the outset of the resumed inquest in November 1991 the Coroner heard
submissions from the representative of the families (Mr. King) that he should
not restrict the evidence by reference to a 3.15pm cut-off point and that he
should investigate the question of whether the failure to summon the
emergency services swiftly enough and any failures in their response had
caused or contributed to the causation of the deaths of the deceased. He
rejected these submissions and ruled that the 3.15pm cut-off point would be
observed. It is respectfully submitted that the said decision was unlawful for
the reasons set out in paragraph (24) above and that the consequence was
that the Coroner failed in his duty to inquire "how" the deceased came by
their deaths in the fullest sense and wrongly excluded from the jury’s
consideration what in many cases were the last minutes of the deceased’s
lives. Your Memorialists submit that in the light of all the circumstances set
out above the Coroner thereby gave grounds for the High Court to quash the
inquisition on the basis of "rejection of evidence" and "insufficiency of inquiry"

within the meaning of Section 13(1) of the Coroners’ Act 1988. Your
Memorialists adopt the arguments of their Counsel in his submissions which
are appended herewith in the transcript of the proceedings of that day and
the Coroner’s ruling.
The Coroner then proceeded to hear the evidence of the events of the
Hillsborough Stadium disaster together with his jury. The evidence heard
disclosed that the deaths of the deceased were largely caused by the negligent
failure of the police to control the influx of the crowd into pens 3 and 4, to
prevent the dangerous build-up of pressure in the pens and thereafter, once
the pressure was proving life-threatening, to remedy the situation by
evacuating the crushed supporters onto the pitch and thereby saving their
lives or limiting the number of casualties. The evidence heard also showed
that there had been delay in sending for the ambulances and calling for an
emergency response. On the basis of this evidence alone it is respectfully
submitted that a verdict of "lack of care" or "accidental death" "due to" or
"aggravated by" lack of care should have been left to the jury.
On the 12th of February 1991 Mr. and Mrs. Jones, two of your Memorialists,
wrote to the Coroner asking him to reconsider his decision about the 3.15pm
cut-off point. In their letter they pointed out that there had been a lengthy
delay in removing the casualties from the pens and that the process was not
complete until 3.35pm "a fairly lengthy delay which obviously did nothing to
help their chances of survival". They pointed out that some of the survivors

who had been admitted to hospital with severe injuries had been helped to
recovery later in the day. And they requested that Dr. John Ashton and Dr.
Glyn Phillips should be called to give evidence at the inquest; the Coroner
had already seen these doctors’ statements. The Coroner wrote back
declining to revise his decision on the 3.15pm cut-off point or to call Drs.
Ashton and Phillips to give evidence. In this refusal it is respectfully
submitted that he was once more guilty of an unlawful "rejection of evidence".
The letter sent by the Jones’s and the Coroner’s reply are appended herewith.
At a later stage the Jones’s caused a report by Dr. James Burns, a Home
Office pathologist, to be sent to the Coroner. This report questioned whether
the approach of Professor Usher (and the other pathologists who gave
evidence of the cause of death) had been correct insofar as they suggested
that the crush injuries sustained by the deceased would have proved fatal in
a number of minutes. As Dr. Burns pointed out, the claim was based on the
supposition that the crush injuries were caused by a continuous restriction of
chest movement. In fact it was possible that in many cases the restriction of
chest movement caused by the pressure of the crowd was not continuous but
intermittent and in that case death would not inevitably have occurred before
3.15pm, and there might have been a possibility of recovery if they were
evacuated and given proper attention - if they were unconscious but not yet
brain dead. The Coroner did not admit this further evidence nor did he
review his decision as to the 3.15pm cut-off point in the light of it. In this
decision, again, it is submitted that he erred in law and wrongly rejected
evidence.

(29) Defects of Coroner’s Summing-up
When at the conclusion of the inquest the Coroner summed up he failed to
direct the jury as to the availability of a verdict of "lack of care" or of
combining "lack of care" with "accidental death" in some such formulation as
"accidental death due to lack of care" or "accidental death aggravated by lack
of care". It is respectfully submitted that this was a fatal and unlawful
omission. He had a duty to so direct the jury wherever there was evidence
that a culpable negligence short of the level necessary to justify a verdict of
"unlawful killing" was present and caused or contributed to the death of the
deceased. In the alternative, if this wider submission is not accepted, then it
is respectfully submitted that he did at least have an undoubted duty to direct
the jury as to the availability of a verdict incorporating reference to "lack of
care" if they found that there had been some culpable omission as a result of
which an "opportunity" to render essential medical care and thereby prevent
fatalities had been "lost" (the test of a "lost opportunity to render care" was
laid down in the case of R -v- Southwark Coroner ex parte Hicks (1987) 1
WLR 1624 and is applicable here). On the evidence before the jury, despite
the limitations due to the imposition of the cut-off point, it was open to them
to conclude that, but for the delays in the arrival of the emergency services,
the deceased, or at least some of them, would have survived.
(30) Your Memorialists James and Anne Williams also draw attention to the
further evidence that has come to light since the inquest which is summarised
-38-

in their individual statements. This suggests that the inquest did not get a full
and complete picture of the evidence of PC Bruder and Special Constable
Martin and that the inquest into Kevin Williams’ death should be quashed on
the basis not only of "rejection of evidence" and "irregularity of proceedings"
but also on the basis of the "discovery of new evidence".
(31) Finally, all your Memorialists submit that there has been an "irregularity of
proceedings" in that the Coroner wrongly dispensed with the requirements
of Rule 37 and introduced composite summaries into evidence without going
through the proper formalities for the admission of such documentary
evidence. Alternatively, he was wrong to dispense with oral evidence from
important eye-witnesses who had actually seen some of the deceased in their
last minutes before death and could throw light not only on the actual time
of death but also on the causation of death and its preventability.
(32) Your Memorialists therefore humbly request that you grant leave to them
under Section 13(l)(a) of the Coroners’ Act 1988 to apply to the High Court
for an order that the inquisition be quashed and that a fresh inquisition be
held. Your Memorialists submit together with this Memorial a volume
containing all their individual statements in support of this application and a
second volume containing all the appendices referred to herein.
EDWARD FITZGERALD
DATED this l$*day of April 1992 by Malcolm J. Gregg & Co, Second Floor,
Century Buildings, 31 North Street, Liverpool, L2 6RG.

IN THE MATTER OF THE CORONERS* ACT 1988
ANn TN THE MATTER OF THE DEATHS OF:
PAUL WILLIAM CARLILE
IAN THOMAS GLOVER
RICHARD JONES
MICHAEL KELLY
PETER TOOTLE
KEVIN DANIEL WILLIAMS
TO HER MAJESTY’S ATTORNEY GENERAL:
THE HUMBLE MEMORIAL OF
SANDRA STRINGER AND DONNA CARLILE
(the mother and sister of Paul Cariile)
JOHN AND THERESA GLOVER
(the father and mother of Ian Glover)
JOAN SINCLAIR
(the sister of M ichael Kelly)
LESLIE AND DOREEN JONES
(the father and mother of Richard Jones)
PETER AND JOAN TOOTLE
(the father and mother of Peter Tootle)
JAMES STEPHEN AND ANNE WILLIAMS
(the father and mother of Kevin Williams)
Malcolm J. Gregg & Co
Second Floor
Century Buildings
31 North Street
Liverpool
L2 6RG
Solicitors for the Memorialists