The panel today released the following summary of its report to the media:
The documents disclosed to the Panel endorse Lord Justice Taylor's key finding that the main reason for the Hillsborough disaster was a 'failure in police control'. Yet they also reveal multiple failures within organisations that compromised crowd safety. The evidence shows conclusively that Liverpool fans neither caused nor contributed to the deaths of 96 men, women and children.
Announcing the results of its two year review of all documents relating to the disaster, the Independent Panel's report adds significantly to public understanding of the tragedy and its aftermath.
Introducing the report to the Hillsborough families at the Anglican Cathedral in Liverpool, Bishop James Jones, the Bishop of Liverpool and Chair of the Panel said:
"For nearly a quarter of a century the families of the 96 and the survivors of Hillsborough have nursed an open wound waiting for answers to unresolved questions. It has been a frustrating and painful experience adding to their grief.
"In spite of all the investigations they have sensed that their search for truth and justice has been thwarted and that no-one has been held accountable.
"The documents disclosed to and analysed by the Panel show that the tragedy should never have happened. There were clear operational failures in response to the disaster and in its aftermath there were strenuous attempts to deflect the blame onto the fans. The Panel's detailed report shows how vulnerable victims, survivors and their families are when transparency and accountability are compromised.
"My colleagues and I were from the start of our work impressed by the dignified determination of the families."
The Panel's research and analysis of the documents begins with a near disaster at the 1981 FA Cup semi-final when crushing in the well known bottleneck at the turnstiles led to the opening of a gate thus transferring the crush onto the terraces and many injuries.
Following that near tragedy, ground modifications actually increased the dangers at the Leppings Lane end of the stadium. There were further problems at FA Cup semi-finals in 1987, at the turnstiles and on the terrace in 1988. The documents show that the risks were known and that the tragedy in 1989 was foreseeable.
The documents disclosed to the Panel reveal that the flaws in responding to the emerging crisis on the day were rooted in institutional tension within and between organisations reflected in: a policing and stewarding mind-set predominantly concerned with crowd disorder; the failure to realise the consequences of opening exit gates to relieve congestion at the turnstiles; the failure to manage the crowd's entry and allocation between the pens; the failure to anticipate the consequences within the central pens of not sealing the tunnel; the delay in realising that the crisis in the central pens was a consequence of overcrowding rather than crowd disorder.
For the first time, the documents reveal the extent of the shortcomings in the emergency response including the ambulance service's failure to implement the major incident plan fully.
Documents disclosed to the Panel also reveal that the original pathologists' evidence of a single unvarying pattern of death is unsustainable. This assumption was the basis for Coroner's imposition of a 3.15pm cut-off on evidence to the inquests. It led to the mistaken belief than an effective emergency services' intervention could not have saved lives. The Panel's disclosure confirms that in some cases death was not immediate and the outcome dependent on events after 3.15pm.
Close analysis of the documents demonstrates that the weight placed on blood alcohol levels was inappropriate, fuelling persistent and unsustainable assertions about drunken fan behaviour not supported by evidence of moderate patterns of drinking not unremarkable for a leisure event.
It is evident from analysis of the various investigations that from the outset South Yorkshire Police (SYP) sought to deflect responsibility for the disaster onto Liverpool fans, presenting a case that emphasised exceptional levels of drunkenness and aggression among Liverpool fans, alleging many arrived at the stadium late, without tickets and determined to force entry. Beyond police accounts, there is no evidence of substance to support this view. The documents reveal an investigation by the Health and Safety Executive which found that severely restricted turnstile access, poor condition of the terrace, inadequate safety barriers and virtually no means of escape rendered the Leppings Lane terrace - especially the central pens - structurally unsafe.
Despite the range of parallel investigations into the disaster and the length of the inquests, the Panel's Report raises profound concerns about the conduct and appropriateness of the inquests. These concerns include the decision to hold part of the inquests, for individual families, without the opportunity to examine evidence presented to the jury as factual and to hold a generic stage as a 'rerun' of the Taylor Inquiry.
The Panel's analysis revisits the review and alteration of police statements showing clearly the extent to which substantive amendments were made by the South Yorkshire Police to remove or alter comments unfavourable to the police management of and response to the unfolding disaster. It also shows for the first time that South Yorkshire Metropolitan Ambulance Service documents were subject to a similar process.
In the days after the disaster serious allegations were printed, particularly in the Sun newspaper, about the behaviour of Liverpool fans. The documents disclosed to the Panel show that the origin of these serious allegations was a local Sheffield Press Agency informed by several senior SYP officers, an SYP Police Federation spokesperson and a local MP. The Police Federation, supported informally by the SYP Chief Constable, sought to develop and publicise a version of events derived in police officers' allegations of drunkenness, ticketless fans and violence. This extended beyond the media to Parliament. From the mass of documents, television and CCTV coverage disclosed to the Panel there is no evidence to support these allegations other than a few isolated examples of aggressive or verbally abusive behaviour clearly reflecting frustration and desperation. The vast majority of fans on the pitch assisted in rescuing and evacuating the injured and the dead.
The Panel's Report is based on research and analysis of over 450,000 pages of documents made available by over 80 organisations and individuals in the first such disclosure exercise in this country. Part 1 of the Report establishes what was known about the disaster before the Panel began its work. Part 2 comprises twelve chapters and presents 150 substantive issues that add to public understanding. Part 3 makes recommendations for a permanent archive of the documents, including the continuation of the public website which is being switched on today.
Bishop James Jones paid tribute to the individual families and to the established representative groups. The need for full disclosure came to the fore in 2009 when the Hillsborough Family Support Group met the then Home Secretary who, together with the then Secretary of State for Culture Media and Sport, took the decision to appoint the Hillsborough Independent Panel. Bishop James said that:
"The Panel produces this Report without any presumption of where it will lead. But it does so in the profound hope that greater transparency will bring to the families and to the wider public a greater understanding of the tragedy and its aftermath. For it is only with this transparency that the families and survivors, who have behaved with such dignity, can with some sense of truth and justice cherish the memory of their 96 loved ones."