2.10.1 The Coroner's decision to impose a restriction on evidence presented to the jury at the inquests became public knowledge after the completion of the 'mini-inquests' and immediately prior to the resumption of the inquests in generic form. Of the Coroner's decisions this restriction was, and remains, of profound concern to the bereaved families. Yet, as revealed in Chapter 9, it was a restriction agreed by lawyers representing the bereaved.
2.10.2 While controversial among the bereaved families, the restriction was not challenged by way of judicial review at the time of the inquests on the advice of Counsel. It was a prominent issue in the subsequent judicial review of the inquests and was revisited by the Stuart-Smith Scrutiny.
2.10.3 The complexity, enormity and exceptional demands of the work faced by the Coroner - with a duty to inquire into the deaths of 95 people - was daunting. That there were so many witnesses, CCTV and film footage and photographs compounded the challenge of selecting and prioritising evidence from the mass of statements and material gathered. For the Coroner, it also created an unprecedented difficulty in planning the scope of evidence presented at inquests.
2.10.4 At the conclusion of the mini-inquests families raised concerns with their legal representatives and the Coroner, Dr Stefan Popper, about 'sufficiency of inquiry' because of the limitations placed on the presentation and examination of evidence put to the jury. This chapter focuses on a central issue - the introduction at the generic hearing of a 3.15pm cut-off.
2.10.5 Dr Popper's rationale for imposing this restriction on evidence continues to be misunderstood or misrepresented. Most significant has been the false assumption that he proposed that in all cases death had occurred before 3.15pm. This was not the case.
2.10.6 Put simply, his position was that those who died received the injuries that caused their death before 3.15pm, even if they lived beyond that time. His logic was that in each case there was no 'intervening act' (novus actus interveniens) that contributed to death. This rationale, however, also suggested that whatever the interventions, or lack of interventions, as part of the emergency response each death was unavoidable once 3.15pm had been reached.
2.10.7 The documents considered in Chapter 5 contain clear medical evidence that a significant number of those who died may have been alive after removal from the pens. These individuals might have survived given appropriate and timely intervention, but remained vulnerable while unconscious to the effects of a new event such as being positioned incorrectly or inhaling stomach contents.
Restriction on the scope of the mini-inquests
2.10.8 It is also clear from the documents discussed in Chapter 4 that the delivery of appropriate and timely intervention was significantly hampered by lack of coordination of the emergency response, lack of prioritisation of casualties and shortage of basic equipment. The question of how to consider evidence relating to efforts made to care for and resuscitate those who died confronted the Coroner. As discussed previously, Dr Popper attempted to resolve this by resuming the inquests on a limited basis as a series of individual hearings for each of the deceased.
2.10.9 In a note of a conversation with Detective Chief Inspector Kevin Tope from the West Midlands Police (WMP) investigation team, Dr Popper observed that WMP wanted to establish 'at what point the evidence' at each mini-inquest 'would stop'. Dr Popper noted his reply, that it would extend 'probably up to the temporary mortuary but obviously if there were any particular difficulties we would do our best to try and answer the questions as far as we could'. DCI Tope commented that 'on the whole the evidence went beyond' the temporary mortuary, 'right up to identification and the Medico-Legal Centre'.
2.10.10 In the immediate aftermath the 'scope' of the investigation had also exercised South Yorkshire Police (SYP). On 26 April 1989 a meeting of the SYP team responsible for coordinating the collation of officers' recollections or 'self-prepared statements' established that the SYP investigation would be 'internal, narrow in scope, as evidence gathering not investigation, and, finally, as secondary to the West Midlands enquiry'.
2.10.11 Chief Superintendent Terry Wain, the briefing officer, stated: 'I would like you to stress to each of these officers that our enquiry is concerned only with the incident itself not the actions taken in respect of the aftermath'. The 'enquiry is to consider the events leading up to the decision to stop the game and nothing thereafter' (emphases in original).
2.10.12 The scope of the SYP 'evidence gathering' was further developed at a meeting on the same day that included the SYP solicitor, Peter Metcalf and Counsel, Bill Woodward QC. Deputy Chief Constable Peter Hayes stated that the 'scope of the enquiry' had 'focused on a time up to about 3.15, or 3.30'. He asked if this should be extended 'at this stage to focus on consequences'. Counsel replied 'Yes, I think so, why did somebody not do something might be a question? Why did someone die when they needn't have done? It's those sorts of questions that we need to be aware of'.
2.10.13 Thus it was against this background that the mini-inquests were held covering the 'who', 'when' and 'where' details of each person who died including the pathology evidence and the medical cause of death. As stated previously, although the scope of enquiry at this stage covered the period beyond 3.15pm, the situational evidence was summarised, presented by WMP officers and not subject to cross-examination.
2.10.14 For many families the expectation was that questions, concerns and inaccuracies not addressed at the mini-inquests would be resolved at the generic hearing, particularly issues pertaining to the effectiveness of the emergency response and whether lives could have been saved.
 File notes of conversation between Dr Popper and DCI Tope (WMP), 6 March 1990, SYC000001390001, p45.
 Briefing for officers coordinating the collation of self-prepared statements from police officers on duty at FA Cup Semi-Final at Hillsborough - 15 April 1989, 26 April 1989, SYP000097200001, p4.
 Minutes of meeting with Counsel, 26 April 1989, SYP000096360001, p99.