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The Hillsborough Independent Panel found that up to 41 of the dead might have survived if they had received adequate emergency care. Only one ambulance was allowed through on to the pitch and the authorities were simply too slow to react. Fresh inquests into the deaths of the football fans and criminal investigations of those responsible for Britain's worst sporting disaster are now expected to take place.
The panel's investigation into the disaster at Hillsborough Stadium, published yesterday, revealed that South Yorkshire Police carried out a systematic cover-up to exonerate senior officers and took part in a smear operation to put the blame on fans for being drunk and violent. Hundreds of witness statements from officers on duty were significantly altered, including 116 which criticised the match-day police operation and its leadership.
Coroner Stefan Popper sanctioned the taking of blood samples from the dead to establish alcohol levels, the panel said, and the Police National Computer was used to check the pasts of some victims in an effort to "impugn the reputation of the deceased".
In the Commons, David Cameron delivered an unequivocal apology to the families of the victims and those who survived the disaster and who have campaigned tirelessly to uncover the truth.
More than 450,000 pages of documents examined by the nine-strong panel revealed for the first time the failure of the emergency response to the unfolding tragedy and the shortcomings of ambulance services on the day of the match.
Trevor Hicks of the Hillsborough Families Support Group, who lost his two teenage daughters in the crush, said relatives would now seek the prosecution of those responsible. "The truth is out today, justice starts tomorrow," said Mr Hicks.
The families stood and applauded the panel led by the Rt Rev James Jones, the Bishop of Liverpool, after hearing details of its findings. Panel member Raju Bhatt said the Attorney General, Dominic Grieve, was now in possession of fresh information which was "crying out" to be re-examined.
Mr Cameron said it was now down to Mr Grieve to decide whether to refer the matter of the disputed accidental death inquest verdicts back to the High Court. Mr Grieve said he was now considering the new evidence.
The Prime Minister told MPs the families and survivors had been victims of a "double injustice" for which he was "profoundly sorry". They had endured "the injustice of the appalling events – the failure of the state to protect their loved ones and the indefensible wait to get to the truth. And the injustice of the denigration of the deceased – that they were somehow at fault for their own deaths."
The original inquests imposed a cut-off time of 3.15pm on the day of the match, assuming everyone was dead by that point, and limiting the scope of the investigation to events before that time. But the report concluded this "severely limited examination of the rescue, evacuation and treatment of those that died". This could potentially lead to the overturning of the original verdicts.
Medical evidence contained within the post-mortem reports found that 41 individuals had potentially "reversible asphyxia" while others who were left unconscious might have died because they did not receive adequate care. "A swifter more appropriate response had the potential to save more lives," the report concluded.
David Crompton, Chief Constable of South Yorkshire Police, said those that had broken the law should be prosecuted. He apologised on behalf of his force which he said had made "grave errors".
"In the immediate aftermath, senior officers sought to change the record of events. Disgraceful lies were told which blamed the Liverpool fans for the disaster," he said.
David Whiting, chief executive of Yorkshire Ambulance Service, also apologised on behalf of the organisation while Sheffield Council expressed regret over inadequate checks at Hillsborough which meant the club hosted the match despite failing to meet minimum safety standards.
The report found that the tragedy was "foreseeable" and that crowd safety had been "compromised at every level". Sheffield Wednesday's primary consideration was the cost of bringing the ground up to date following a near tragedy there in 1981.
Margaret Aspinall, chairwoman of the Hillsborough Families Support Group, whose son James died, said the families had trusted the panel all along and thanked the members for their work and for "exonerating" the fans. She added: "They have made our city proud today but most importantly they have made the 96 rest in peace for the first time in all those years."
15.4.89: What really happened
1. The panel found that the safety of the crowd was "compromised at every level". Hillsborough's deficiencies were well known since a previous crush in 1981 but the stadium still failed to meet minimum standards under the Safety of Sports Grounds Act 1975 after inadequate inspections.
2. Relationship between Sheffield Wednesday Football Club (SWFC) and South Yorkshire Police had broken down over who was to blame for safety and crowd control at the stadium. SWFC failed to act on ground change advice because of concerns over costs.
3. Fire service had raised concerns over emergency evacuation procedures particularly at inadequate perimeter fence gates. Steep gradient of tunnel leading into stand also breached safety recommendations.
Build-up
1. Police replaced previous match commander with "minimally experienced" Chief Superintendent David Duckenfield 21 days before match "without explanation".
2. Ambulance and fire service did not attend pre-match meeting.
3. Crush outside the ground not caused by fans arriving late, as was claimed. Turnstiles were inadequate to stop build up. Police had no communication between events inside and outside ground.
Emergency response
1. Reaction of emergency services has never previously been fully examined. The panel found that the South Yorkshire Metropolitan Ambulance Service Ambulance Service (SYMAS) officers were slower than police to respond to emergency despite being closer to crush.
2. Absence of leadership and basic triage equipment among emergency service crews. Situation remained chaotic for an hour after crush began. SYMAS subsequently gave "misleading" responses to criticism of their actions.
The inquest
1. Notion of "single, unvarying and rapid pattern of death in all cases" – the finding of the original inquest – was "unsustainable".
2. Panel ruled that 41 victims had the potential to survive after the 3.15pm cut-off point imposed by the coroner. Thirty one victims had heart and lung function after the crush.
3. 3.15pm cut off "severely limited examination of the rescue, evacuation and treatment of those who died".
4. After 3.15, unconscious victims remained vulnerable to airway obstruction because of inappropriate positioning,, which was never examined due to coroner's ruling.
5. Weight placed on fans' alcohol consumption at inquest was "inappropriate and misleading".
The aftermath
1. 116 police officers' statements were "substantially altered" to remove criticism. 164 statements were altered.
2. Sheffield news agency White's filed unfounded allegations over ticketless fans' drunken and violent behaviour which led to notorious Sun story "The Truth". The claims, which then appeared in other media outlets, were based on testimony from four police sources and MP Irvine Patnick.
3. Cabinet documents reveal that the Prime Minister, Margaret Thatcher, expressed concern over "broad thrust" of Taylor report into tragedy which contained "devastating criticism of the police".
