Recognition of the disaster
2.4.20 The first essential requirement was that emergency services recognise what had happened with sufficient clarity to mount an appropriate response. It is clear from the documents disclosed to the Panel that there was significant delay before anyone present in an official capacity recognised that they were witnessing the throes of disaster.
2.4.21 Eye-witness accounts confirm that a major factor in this delay was the predisposition of police officers and others to view crowd unrest or perturbation as a sign of actual or impending hooliganism.
2.4.22 Even before the match kicked off, spectators in the central pens protested that they were being crushed intolerably, shouting to the police officers on the perimeter to recognise what was happening and open the small gates in the perimeter fence. They were ignored or told to be quiet.
What happened after 3pm
2.4.23 Lack of recognition of the seriousness of the crush continued as pressure worsened after 3pm. As spectators began to climb the perimeter fence, police attempted to push them back into the pens, misinterpreting their desperate efforts to escape as a pitch invasion, despite the short distance separating them from people already being fatally crushed.
2.4.24 Inevitably, spectators within the pens became frustrated at the inability of police officers only yards away to understand and react to their predicament. Many spectators not yet incapacitated by the crush watched others losing consciousness, and some understandably became angry at the failure of officials to respond appropriately, further reinforcing the police view that this was a disturbance due to bad behaviour.
2.4.25 Although the Match Commander and his colleagues in the Police Control Box were more distant from the central pens, they were well placed to view the crush, with or without video surveillance equipment. They misinterpreted the visual evidence available, first failing to appreciate that the central pens had become seriously overcrowded and then wrongly attributing the signs of unrest and distress to aggressive behaviour and an attempted pitch invasion.
Ambulance Service presence at Hillsborough
2.4.26 That the police were unduly concerned with crowd misbehaviour must be seen within the context of the time and the undeniably poor relationship between the police and football fans.
2.4.27 Yet it is clear from the documentary evidence that recognition of the nature of the disaster was delayed, and the occurrence of serious injuries and fatalities remained unrecognised at 3.06pm when the match was stopped.
2.4.28 However, ambulance officers were present in the stadium specifically in case of a possible disaster, with no remit for crowd control and therefore no reason to be distracted by it. Under an arrangement set up by SYMAS following the fire at Bradford's Valley Parade ground, from 1986 two senior ambulance officers had routinely attended football matches at Hillsborough in case of a major incident.
2.4.29 Their duties included direct liaison from the ground, enabling early assessment and notification of any developing incident. Two stand tickets were provided to SYMAS by Sheffield Wednesday Football Club (SWFC) for league games, but they were not provided for FA Cup games. Nevertheless, Station Officer Paul Eason and Station Officer Patrick Higgins attended with an ambulance and based themselves at pitch level as they were obliged to in the absence of tickets. They were accompanied by two ambulance crew personnel.
Initial SYMAS misinterpretation of the situation
2.4.30 At 3.03pm, the SYMAS officers became aware of crowd unrest on the Leppings Lane terrace, and two minutes later SO Eason went to investigate, accompanied by one of the junior staff. SO Higgins reported to Ambulance Control that there was possible crowd trouble with probable minor injuries but not needing transportation.
2.4.31 SO Eason saw what he believed to be a scuffle on the terrace, with some overspill of spectators onto the pitch, while those still in the pens were becoming agitated. His attention was drawn to an injured spectator on the pitch side of the perimeter fence immediately behind the goal, who was found to have a leg fracture.
2.4.32 The match was stopped at 3.06pm because at least some police officers in the vicinity of the perimeter fence had realised the seriousness of the unfolding disaster. SO Eason and the junior SYMAS officer, however, withdrew to their original position because 'people were getting angry and frustrated and they tended to take out their anger and frustration on those in uniform by hitting out and aiming kicks'.
2.4.33 He failed to appreciate that spectators' frustration had arisen because of their inability to persuade those in uniform of the severity of what was happening. He continued to believe that what he had witnessed through the perimeter fence was a consequence of fighting on the terraces. It is unlikely that the state of mind of those within the pens, where many were struggling to breathe and remain conscious, was helped by the sight of ambulance personnel withdrawing from the area.
2.4.34 Subsequently all four SYMAS staff returned to the Leppings Lane terrace with equipment to treat the individual with a fractured leg bone, and found that the situation had worsened in the intervening two or three minutes. SO Eason stated: 'It was increasingly obvious there were a lot more angry and a lot more injured spectators. [We] were thumped and subjected to verbal abuse. [Two junior ambulance staff] applied a splint to the youth's leg. The situation was becoming increasingly ugly'.
2.4.35 At this point, approximately 3.11pm, seriously injured spectators were being pulled from the central pens and the first resuscitation efforts were initiated by spectators and police. The SYMAS officers still failed to appreciate the extent of the situation at this stage. In response to a request for information by Ambulance Control, timed at 3.11pm, SO Higgins reported 50 to 100 people on the pitch with 'quite a lot that's been squashed forward, probably just winded'.
2.4.36 There is a manuscript addition to SO Eason's statement at this point that 'we realised that there were fatalities and serious injuries', but this later addition is not credible in the light of SO Higgins's observation that the injured were 'probably just winded', or SO Eason's next comment that '[he] wanted now to bring the other vehicle from Middlewood to Leppings Lane as a precaution'. The origin of this manuscript addition is unknown.
2.4.37 At 3.13pm SO Higgins, who had previously been approached by a police officer asking for help in responding to casualties and possible fatalities, reported possible fatalities to Ambulance Control. The response was that 'as many mobiles as we can' would be diverted to the ground.
SYMAS recognition of disaster
2.4.38 Although the transmission from SO Higgins was not a definitive report on the situation, and did not refer to a major incident, it is clear that over the course of the next five minutes SO Eason and he did realise that numerous spectators had suffered serious crush injuries.
2.4.39 SO Eason attempted to make contact with Ambulance Control using his pocket-phone radio, but it would not function in the pitch area. By now, spectators including doctors and nurses and the two junior ambulance staff were attempting to resuscitate numerous casualties on the pitch in front of the Leppings Lane terrace.
2.4.40 SO Eason returned to the ambulance vehicle and radioed Ambulance Control, 'I'd like to declare it as a major incident'. He did not describe the nature of the incident or advise on the most appropriate response, but estimated that between 30 and 50 were injured.
2.4.41 The call was timed at 3.21pm, 15 minutes after the match had been stopped. Even bearing in mind all the difficulties inherent in the initial stages of a disaster identified above, the evident effect on the ambulance staff and their prolonged misinterpretation of why spectators were frustrated, this delay was regrettable, raising significant questions about the professional judgement of senior ambulance staff whose role was to identify and respond to a major incident. Only a few minutes of this delay could be attributed to the undoubted difficulties that affected radio communications.
 Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001.
 Statement of Station Officer Paul Eason, 5 May 1989, YAS000001490001, pp4-6.
 Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, p34.
 Statement of Station Officer Paul Eason, 5 May 1989, YAS000001490001, p6.
 Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, p36.
 Ambulance Control Room Tape Transcripts, 15 April 1989, SYP000014030001, p40.