Chapter 5: Medical evidence: the testimony of the dead

Cause of death

2.5.15 As required in England and Wales, recording of cause of death allows for a chain of up to three conditions, the first of which is the 'immediate cause of death' and the last being the 'underlying cause of death'. They might be common if only one cause is listed. It is also possible to note 'associated conditions' which contributed, but did not lead directly, to death.

2.5.16 The immediate cause of death was given as traumatic asphyxia[5] in 68 cases and as crush asphyxia in 14. Most forensic pathologists would regard the terms 'traumatic asphyxia' and 'crush asphyxia' as interchangeable, although some may seek to draw a distinction between a single impact or compression causing traumatic asphyxia, and a more gradual compression causing crush asphyxia.

2.5.17 This approach was taken, for example, by Mr James Wardrope, Accident and Emergency Consultant at the Northern General Hospital Sheffield, and his colleagues in describing the outcome of treatment of those admitted to hospital following the disaster.[6]   

2.5.18 However, it is clear from the answers given repeatedly to questions during the inquests that the pathologists drew no such distinction and regarded the two terms as synonymous. For example, Professor Alan Usher, the senior pathologist at the Medico-Legal Centre was explicit in his evidence: 'Traumatic asphyxia, which we talked about yesterday, is sometimes crush asphyxia for obvious reasons and some of the pathologists have used that term and some have used traumatic asphyxia. There is no difference'.[7] 

2.5.19 Other immediate causes of death recorded were inhalation of stomach contents[8] (6), inhalation of stomach contents together with traumatic asphyxia (1), respiratory failure[9] (2), cerebral anoxia[10] (1), pyelitis[11] and bronchopneumonia[12] (1), cardiorespiratory arrest[13] (2), and shock and haemorrhage[14] (1).

Traumatic asphyxia

2.5.20 The underlying cause of death shows an even greater preponderance of traumatic asphyxia (73) and crush asphyxia (17) - 90 in total (one jointly with inhalation of stomach contents). Of the remaining six, the underlying cause of death was given as inhalation of stomach contents in three, traumatic pulmonary contusions[15] in two, and transection of the aorta[16] in one. In four of these six where neither traumatic nor crush asphyxia was the underlying cause, one or other was given as an associated cause contributing to death.

2.5.21 Thus in only two cases does neither traumatic nor crush asphyxia appear on the certificate. In these, respiratory failure due to traumatic pulmonary contusions associated with fractured rib and pulmonary lacerations was recorded. Even when the cause of death was certified as shock and haemorrhage due to transection of the aorta, one of the most rapid causes of sudden death, traumatic asphyxia was given as an associated cause contributing to death.

The 'mini-inquests'

2.5.22 The issue of traumatic asphyxia recurred consistently during the preliminary hearings into each individual death ('mini-inquests'). The pathologist who carried out the post mortem was invited to agree that, as a result of traumatic asphyxia, loss of consciousness would have occurred rapidly, within seconds, and that death would have followed within a few minutes at most.[17]

2.5.23 In each case, the pathologist accepted this interpretation. This was emphasised to the families as a matter of comfort, but it also established an unvarying pattern of death, a matter of importance to the Coroner in his approach to the inquests. Subsequently, when aspects of the conduct of the inquests were challenged through Judicial Review, he prepared a statement of evidence explaining his decisions.

2.5.24 His initial draft stated: 'In every one of the 95 cases the uncontested evidence of the pathologists was that the pathological cause of death was traumatic asphyxia and that within a matter of seconds the individual would have been unconscious and unaware of anything further and would have died within a matter of minutes thereafter'.[18] Subsequently, 'in every one of the 95 cases' was amended to 'in the majority of the cases' and presented as the final version.[19] 
2.5.25 While this insistence on a single unvarying pattern of rapid death may have been motivated, at the time of the mini-inquests, by a desire to ease the emotional burden on relatives, it was a crucial factor in the imposition of the 3.15pm cut-off. Consequently, as shown in Chapter 10, evidence concerning events after that time was not considered at the generic stage of the inquests, a cause of significant distress to relatives. 

2.5.26 The Coroner argued that the outcome for each of those who died was determined entirely by events before 3.15pm, and that no new significant event could have intervened in the chain of causation of death beyond that time:

As a marker I picked the arrival of the first ambulance on the pitch which was timed at 3.15pm because on the overwhelming pathological evidence available to me, by that time permanent irreversible damage would have already occurred.[20] 

2.5.27 This view of the rapidly fatal and irreversible nature of traumatic asphyxia also influenced LJ Taylor, who concluded that the potential impact of the emergency services was limited: 'in view of the nature and extent of the crushing, the time when police rescue began and the pathetically short period for which those unable to breathe could survive, it is improbable that quicker recourse to the emergency services would have saved more lives'.[21]  

2.5.28 However, the portrayal of an unvaryingly rapid and inevitable death was not supported by the post mortem findings in a substantial number of cases. Two principal findings emerged from the Panel's review of all of the post mortem reports.

[5] Asphyxia is a lack of oxygen in the body, often due to a problem with breathing. Traumatic asphyxia is a lack of oxygen due to compression of the chest preventing breathing, and often obstructing the blood flow back to the heart.
[6] Wardrope J, Ryan F, Clark G et al. The Hillsborough Tragedy. British Medical Journal 1991; 303: 1381-1385. Available on the Panel's website at HOM000038420001.
[7] Inquest transcript in respect of Stephen Francis O'Neill, 14 May 1990, SYC000109290001, p7.
[8] Obstruction of breathing due to the effect of stomach contents on the airways if regurgitated and inhaled.
[9] Inability of the lungs to function adequately, particularly to supply oxygen to the bloodstream.
[10] Lack of oxygen affecting the brain.
[11] Inflammation of the upper part of the urinary system, particularly due to infection.
[12] Infection of the lungs and the airways leading to them.
[13] Cessation of heartbeat and breathing, for example due to the brain ceasing to function.
[14] Blood circulation inadequate due to loss of blood.
[15] Bleeding into the substance of the lung due to injury, for example from pressure on broken ribs.
[16] Complete division of the main blood vessel leading from the heart.
[17] For example, at the inquest in respect of Peter McDonnell, 20 April 1990, SYC000109440001, p7.
[18] Draft Affidavit by Dr Popper, undated, SPP000002120001, p7.
[19] Affidavit by Dr Popper, undated, SYC000001290001, p12.
[20] Affidavit by Dr Popper, undated, SYC000001290001, p14.
[21] Interim Report of the Inquiry into the Hillsborough Disaster (Taylor Report), HOM000011140001, p59.