The Hillsborough inquests: Lessons learned

Background

On 26 April 2016, following a hearing of just over two years, the jury of the Hillsborough inquest concluded that the 96 Liverpool FC supporters who lost their lives at Hillsborough were unlawfully killed.

The 2014 inquests commenced after the verdicts of the original inquests were quashed on application to the High Court following a report by the Hillsborough Independent Panel in 2012. In the application to the court, the jurisdiction of coroners to hold a further inquest where it is necessary or desirable in the interests of justice was considered.

Jurisdiction to quash an earlier inquest lies with the High Court, who outlined the reasons for which they considered that the original inquests should be quashed. Although substantial progress has undoubtedly been made in the field of coroners’ inquests since the original Hillsborough inquests some points can be taken from their flaws.

Limitation of evidence

A key failing in the original inquests was a decision by the coroner that no evidence relating to events beyond 15:15 on the day of the disaster would be heard. This decision had a number of damaging consequences:

• there was no investigation of whether some of those who died might have survived if they had been rescued quickly;
• there was no consideration of omissions in the rescue process;
• there was no investigation of whether deficiencies in police control might have aggravated the level of police culpability; and
• there may have been a level of culpability in the emergency services.

The impact of the coroner’s decision in this respect was profound, leading to an incorrect conclusion of accidental death. This serves as a reminder that the need for a thorough investigation must be put before administrative convenience.

Editing witness documentation

Perhaps the most damning flaw in the original inquests was that the jury was not made aware of the full extent of the amendments and alterations to police statements. The court noted that around 116 of 164 police statements were amended to conceal critical evidence.  

The editing of police statements not only played an important role in the need for further inquests, but blighted the inquest process over many years. Ultimately, in the best interests of justice, the nature and impact of the amendments came to light.

Tampering with evidence does sometimes occur. The extent to which this influenced the verdicts of the original inquests highlights the vital importance of the proper documentation and recording of evidence.

Misguided focus

At the original inquests evidence relating to the intoxication of football fans was given particular importance.

In April 2016 the jury was asked: “Was there any behaviour on the part of football supporters which may have caused or contributed to the dangers situation at the Leppings Lane turnstiles?”

They returned a verdict of “No.”

The incorrect assessment that drunkenness played a role in the disaster illustrates the harm of making assumptions. Assumption should not too readily be drawn without a thorough analysis of the evidence.

Positive lessons

Although it may have taken 27 years, the 2014 inquiries provided a transparent investigation of the Hillsborough disaster.

The inquests were of a complex nature, with somewhere close to one million pages of documents disclosed over a two-year period. The nine men and women who sat on the jury heard a total of 267 days of evidence, a period during which they analysed a mass of complex information - proof that a jury does have the capacity to hear lengthy and complicated cases.

At the outset of the inquiries the coroner made clear that given the high profile nature of the inquest it was vulnerable to being damaged by the publication of information on social media. Despite this the inquest proceeded successfully, showing that the potential dangers of publicity and social media can be controlled even in modern times of advanced technology.

Moving forward

The Hillsborough inquests illustrate the importance that inquests have not only for families, but for the wider public interest affected by such disasters. They show that although the process of an inquest is often drawn-out, inquests can provide vindication for those that need it.

Key points for healthcare organisations:

• Be careful when suggesting amendments or additions to a witness’s statement; it’s important that it’s their statement, not yours.
• Make sure you preserve evidence; what you think are the most important documents and records may not necessarily be, so it is best to keep as much as you can.
• High profile inquests can be harmed by social media. The chances of this happening can be mitigated by warning those at risk of releasing information proactively. If you are worried about adverse comments on social media affecting the inquest, see our article on the perils of social media for what action you can take.
• Although inquests can be arduous, they can also be important in identifying key areas for improvement. Invest the time now to try and prevent the same set of circumstances at a later date.