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eport to to help.<br />

(d) Dr. Ashton <strong>the</strong>n went out into Leppings Lane at around 3.30pm to<br />

3.35pm and found that <strong>the</strong>re was only one ambulance <strong>the</strong>re.<br />

(e) Dr. Ashton found that <strong>the</strong>re was no triage system in operation to<br />

identify those most in need of medical aid so he organised a triage<br />

system himself as to whom to put in <strong>the</strong> ambulance.<br />

(f) Dr. Ashton recounted how <strong>the</strong>re was no steady flow of ambulances<br />

until between 3.45pm and 3.50pm. Once <strong>the</strong>y began to arrive he and<br />

a local practitioner worked toge<strong>the</strong>r sorting out <strong>the</strong> casualties and<br />

dispatching <strong>the</strong>m in ambulances.<br />

(g) It was not until <strong>the</strong>n that "an anaes<strong>the</strong>tist arrived from somewhere<br />

and fire engines came with resuscitation equipment, but all of this<br />

was really too late". Dr. Ashton took <strong>the</strong> view that, by 4.30pm it was<br />

"all over".<br />

(h) Dr. Ashton recorded his view that "on this occasion crowd safety<br />

took second place to crowd control" and that <strong>the</strong> emergency service<br />

was "woefully inadequate". He recognised <strong>the</strong> difficulty of assessing<br />

how many lives might have been saved by a more timely response,<br />

but clearly his statement raised this issue most clearly.<br />

-14-

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