Football fans who could have survived the Hillsborough disaster were not treated by hospital doctors and left in a temporary mortuary for at least 10 minutes before a medic checked they were no longer alive.
The hospital that led the medical response to the tragedy struggled with shortages of life-saving drugs and equipment and a lack of staff when it was deluged with scores of victims on 15 April 1989.
The problems meant that several victims taken from the Hillsborough football ground to Sheffield's Northern General Hospital were declared dead when they arrived. Health chiefs subsequently concentrated on the achievements of staff in coping with the crisis reporting that: "The hospital responded exceptionally well."
The hospital's performance will be placed under scrutiny when new inquests into the 96 deaths begin next year. Maria Eagle, Labour MP for Garston and Halewood, said yesterday: "While the number of casualties was such that there were clearly going to be great difficulties, the idea of not trying to resuscitate people and sending them straight to the mortuary is shocking."
Documents released by the Hillsborough Independent Panel reveal that James Wardrope, the consultant in charge at the hospital's A&E department on the day, said: "Patients with no cardiac output who were having active cardio pulmonary resuscitation had been sent to the resuscitation room to try to restart the heart." However, the policy changed at about 3.45pm. His witness statement said: "We were still receiving many seriously ill patients and about this point I took the decision to send patients who had no cardiac output direct to the mortuary."
Although those sent to the mortuary had already been declared dead by doctors, another statement said Mr Wardrope later asked a colleague to go and "check that the patients we were sending there were dead". She proceeded to certify 11 people dead in barely 15 minutes. Thirteen people were brought to the hospital in cardiac arrest, but none survived. There was only "definite evidence" of resuscitation attempts for fewer than half of them, according to Mr Wardrope's witness statement.
Referring to medical records and post-mortem evidence, he states that in a number of cases no attempts had been made to try to restart their hearts. In other cases, there was no evidence in medical notes to show that any attempts had been made to resuscitate them. One teenage boy had probably been taken to the resuscitation room but "in view of the large number of patients present at the time, resuscitation attempts were not taken any further".
A confidential staff debriefing on 28 April 1989 revealed serious shortcomings in the casualty department. These included an "initial shortage of doctors" and a "shortage of nursing staff experienced in resuscitation". It concluded that Hillsborough was a "severe test" of the hospital's major incident plan and warned: "Although the Northern General Hospital can be justifiably proud of its response to the incident at Hillsborough, it should be realised that there was a very fine dividing line between coping extremely well, as we did, and chaos." A statement by Dr Edward Walker, an anaesthetist who treated patients that day, claimed "the lack of available cardiac monitors was detrimental to some patients" and that doctors "encountered a shortage of basic cardiac arrest drugs".
The official version of events contained barely any reference to major problems. The Sheffield Health Authority's 1989 report on the Northern General Hospital's role stated: "The hospital responded exceptionally well." The only hint of difficulties was a passing mention on the "considerable pressure" on hospital staff, and a reference to unspecified "problems". Dr Bill Kirkup, the Hillsborough Independent Panel's medical expert, said the public face of the medical response had been "sanitised".
He said: "The reason it was sanitised was not because their performance was poor, but because they thought that if they explained the realities of dealing with a major incident of this scale they would get unwarranted criticism. In too many places there is a culture where the first reaction is 'How can we cover this up?'. I think that is what the hospital did – it said as little as it could to try to avoid unwarranted criticism. They should have been more open about the difficulties they faced, which were understandable."
A spokesperson for Sheffield Teaching Hospital NHS Foundation Trust said: "The speed of arrival of large numbers of critically ill patients was highly unusual …. Despite this, extra staff arrived quickly and drugs and additional equipment were obtained as soon as possible …. Every patient who was brought to A&E was triaged according to major incident procedures. Sadly, there were some... who had no clinical signs of life .… The report of the Hillsborough Independent Panel stated that both main Sheffield hospitals provided prompt and effective treatment."