Chapter 5: Medical evidence: the testimony of the dead

What was already known

2.5.1 Evidence relating to the cause of death was central to the 95 'mini-inquests' conducted by the South Yorkshire West District Coroner, Dr Stefan Popper, alongside the summaries from West Midlands Police about the place of death. Three features recurred across the medical and pathological evidence given to the inquests.

2.5.2 First, traumatic asphyxia was a central feature, in most cases as the underlying cause of death. Second, in their evidence the pathologists presented a common account that consciousness would have been lost within a matter of seconds and irreversible brain damage would have occurred in minutes.

2.5.3 Taken together, these features presented an unvarying picture of a uniform, rapid process that led inevitably to death once an irresistible pressure had built up within the central pens. As such, as discussed in Chapter 10, it underpinned the Coroner's decision to impose a 3.15pm cut-off on evidence presented at the generic stage of the inquests.
 
2.5.4 The third recurring feature was the emphasis attached to alcohol, as the blood alcohol level of the deceased was read to the court at the start of each 'mini-inquest' and immediately reported in the media.

2.5.5 The disclosed documents add significant new information on each of these crucial aspects of the medical evidence. The first part of this chapter considers the evidence available from systematic review of the pathology reports. The second part highlights the significance of the Coroner's exceptional decision to take blood alcohol samples from the deceased, and how the results were presented.

Pathology 

2.5.6 The investigation into the deaths included a post mortem examination of each body. This was carried out under the jurisdiction of the Coroner for the district in which the deaths occurred, in this case the South Yorkshire West District Coroner, Dr Popper. It is usual to conduct post mortem examinations when deaths occur that cannot be attributed reliably to natural causes.

2.5.7 Yet Dr Popper's contemporaneous notes indicate that this was not a foregone conclusion: 'I considered the need for post mortem in these cases, bearing in mind that visual inspection indicated that a probable conclusion would be Traumatic Asphyxia and bearing in mind that many of the deceased were young people'.[1]  

2.5.8 It is instructive that as early as the morning of Sunday 16 April 1989, within 24 hours of the disaster and before any post mortems had been conducted, the Coroner had surmised that the probable cause of death was traumatic asphyxia for all 94 people who, at that time, had died.  It was a conclusion of sufficient certainty that he questioned the need for post mortem examinations.

Arrangements for post mortems

2.5.9 Yet, on balance, Dr Popper decided that post mortems were required and all would take place at the Medico-Legal Centre in Sheffield, in as short a time as practicable. To expedite the process, additional pathologists attended the Medico-Legal Centre, and nine pathologists carried out 94 post mortem examinations over two days.

2.5.10 Two people died later, one following two days in hospital and a second in 1993, after being in a persistent vegetative state since the disaster. These two post mortems were carried out by different pathologists, the latter under the jurisdiction of the West Yorkshire Coroner, as he had died in Airedale Hospital.

2.5.11 The arrangements for the post mortem examinations were in accordance with legal requirements and with standard practice, although to a demanding timescale. The reason for this haste is not clear from the documents. Nor is the reason for the other outstanding feature, the unusual direction that blood be taken from all of the deceased at post mortem to determine a blood alcohol level.

2.5.12 From subsequent statements[2] it is clear that this directive was decided by Dr Popper before the post mortem examinations began, and it is clear from the post mortem records that the directive was followed in each of the 94 post mortems on those who died, regardless of age. In addition the documents confirm that a blood alcohol level was estimated in the 95th, a boy of 14 who died in hospital two days after the disaster, using a sample taken previously.[3]

2.5.13 Blood alcohol levels are routinely checked in those driving or piloting motor vehicles, railway trains, ships and aircraft involved in fatal incidents, but not in mass disaster victims.

Post mortem reports

2.5.14 The Panel regards the records of the post mortem examinations as confidential to the family concerned and not for public disclosure.  Its terms of reference, however, require a report on the overall content of material shared with the Panel.  All post mortem reports were scrutinised in detail by a medically qualified Panel member, and are described in aggregate here.[4] The results show some striking features, considered under four headings: cause of death; traumatic asphyxia and venous compression; cerebral oedema; and implications of post mortem reports.

[1] File note by Dr Popper, 16 April 1989, SYC000001360001, p245.
[2] Inquest transcript, opening statement by the Coroner, 18 April 1990, SYC000109270001, p31.
[3]  Inquest transcript, 1 May 1990, SYC000109960001, p8.
[4] In view of the specialist nature of some of the pathology the overall findings were discussed with an independent expert forensic pathologist, and the Panel is grateful for his helpful advice.