Chapter 8: The Coroner's inquiry: from the immediate aftermath to the preliminary hearings


2.8.1 As discussed in Part 1, the Hillsborough inquests were controversial in their organisation, conduct and outcome. The South Yorkshire West District Coroner, Dr Stefan Popper, considered that the medical evidence determined that all who died received their fatal injuries from a common cause - the crush on the terraces. He repeatedly compared the deaths at Hillsborough with deaths in a car crash. In determining 'how' people died, therefore, he focused on the circumstances of the crush rather than the effectiveness of rescue and resuscitation attempts.

2.8.2 Many bereaved families, however, rejected Dr Popper's reasoning and proposed that consideration of the effectiveness of emergency response and the treatment administered immediately to the dying were key elements in establishing the circumstances in which their loved ones died.

2.8.3 They were critical of the Coroner's unprecedented decision to record and publish blood alcohol levels of those who died and to rely on statements gathered by the West Midlands Police (WMP) who had serviced Lord Justice Taylor's Home Office Inquiry and the criminal investigation.

2.8.4 Families were concerned also about the limitations of procedures adopted at the preliminary inquests (mini-inquests) at which evidence could not be examined and WMP officers presented summaries of statements as fact before the jury. This denied the opportunity to test the accuracy of the evidence. Yet the bereaved families agreed to the mini-inquests on the advice of their solicitors (Hillsborough Steering Committee).

2.8.5 Part 1 also establishes what was known about the 'generic' stage of the inquests, resumed once the decision had been taken that there would be no criminal prosecutions. The families' concerns here focused on the Coroner's decision not to hear evidence beyond 3.15pm, and his rationale for this decision.

2.8.6 There was, and remains, considerable concern that some of those who died were alive at 3.15pm and lived for a considerable time. Failure to intervene, lack of response or inappropriate response, such as being laid in a position that compromised their recovery (by airway obstruction) could have contributed to their deaths. The evidence confirming that their concerns were well-founded is set out in Chapters 4 and 5.

2.8.7 The sequence in which the evidence was presented at the inquests, and the imbalance in the examination of the evidence by lawyers representing the interested parties, was considered by families and their lawyers to have had a negative impact on the jury. The subsequent Judicial Review focused particularly on irregularity of proceedings and insufficiency of inquiry. The case for new inquests was rejected.

2.8.8 Other chapters consider the above issues and examine the rationale behind the Coroner's decisions: his initial response to the disaster in the immediate aftermath; the significance of parallel investigations for the coronial inquiry; the background to and conduct of the mini-inquests and the generic inquest; the aftermath of the inquests; the judicial review and the continuing controversy about the inquests.

2.8.9 They focus on the issues of procedural irregularity and perceived insufficiency of inquiry. This is particularly significant because since the Hillsborough inquests coroners and juries have been encouraged to use discretion to return narrative verdicts or add narrative comment to tightly prescribed verdicts in certain circumstances.

2.8.10 While the issue of the 3.15pm cut-off is discussed in detail in Chapter 10 and the significance and reliability of the medical evidence, particularly the pathology and the recording of blood alcohol levels, are considered in Chapter 5, they have a bearing on the coronial issues considered in this chapter. The first section, however, addresses the role and function of inquests.