Chapter 5: Medical evidence: the testimony of the dead

Conclusion: What is added to public understanding

  • In the great majority of cases, the cause of death given after post mortem examination was either traumatic asphyxia or crush asphyxia, each regarded as synonymous terms. The disclosed documents show that this corresponded to an assumption made by the Coroner and formed before the post mortems were conducted.
  • The detailed review of all post mortem reports casts significant doubt on the single unvarying pattern, described consistently during the 'mini-inquests', of traumatic asphyxia causing unconsciousness within seconds, followed inevitably by death within a few minutes. 
  • There was clear evidence from the post mortem reports that 28 of those who died did not have traumatic asphyxia with obstruction of the blood circulation, and asphyxia may have taken significantly longer to be fatal. There was separate evidence that in 31 the heart and lungs had continued to function after the crush, and in 16 of these this was for a prolonged period. (These numbers cannot  be added to the 28 as some featured in both groups.)
  • It was asserted repeatedly, by the Coroner, by the High Court in the Judicial Review proceedings and by the Stuart-Smith Scrutiny, that the effects of asphyxia were irreversible by the time each of those who died was removed from the pens. Yet individuals in each of the groups now identified could have had potentially reversible asphyxia. Resuscitation of an unconscious person with a heartbeat is much more likely to be successful than if cardiac arrest has already occurred, as was previously assumed. While they remained unconscious, these individuals were vulnerable to a new event, particularly further airway obstruction from inappropriate positioning.
  • It is not possible to establish with certainty that any one individual would or could have survived under different circumstances. It is clear, however, that some people who were partially asphyxiated survived, while others did not. It is highly likely that what happened to these individuals after 3.15pm was significant in determining that outcome. On the basis of this disclosed evidence, it cannot be concluded that life or death was inevitably determined by events prior to 3.15pm, or that no new fatal event could have occurred after that time.
  • Disclosed documents provide no rationale for the Coroner's exceptional decision to take samples for blood alcohol measurement from all of the deceased.
  • The implicit and explicit use of a blood alcohol level of 80mg/100ml as a marker was unjustified. This level has relevance to the rapid response times of individuals in charge of motor vehicles, but none to people attending a leisure event.
  • Analysis of the data demonstrates that the attempt to draw statistical correlation between the time of arrival and alcohol level was fundamentally flawed in six respects, and no such link could be deduced.
  • The weight placed on alcohol levels, particularly in the Coroner's summing up at the inquests, was inappropriate and misleading. The pattern of alcohol consumption among those who died was unremarkable and not exceptional for a social or leisure occasion.
  • A document disclosed to the Panel has revealed that an attempt was made to impugn the reputations of the deceased by carrying out Police National Computer checks on those with a non-zero alcohol level.
  • The disclosed documents show that blood alcohol levels were tested in some survivors who attended hospital, as well as in all those who died. There is no record of these tests or their results in the medical notes of survivors, and in some there was no apparent medical reason for the test. The extent of this testing remains unknown.
  • There was no evidence to support the proposition that alcohol played any part in the genesis of the disaster and it is regrettable that those in positions of responsibility created and promoted a portrayal of drunkenness as contributing to the occurrence of the disaster and the ensuing loss of life without substantiating evidence.