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

Hillsborough, the Coroner and the immediate aftermath

2.8.23 At 4.16pm on 15 April 1989 Dr Popper received a telephone call from a police officer informing him of a major disaster at Hillsborough.[4] He understood that a stand had collapsed and there were 74 fatalities. He contacted the assistant coroner and the senior pathologist at Sheffield's Medico-Legal Centre, Professor Alan Usher, who already had been telephoned by the South Yorkshire Police (SYP).

2.8.24 The immediate plan was to move bodies from the stadium to the Medico-Legal Centre. Dr Popper arrived at the Medico-Legal Centre at approximately 5.40pm and met pathologists including Professor Usher. They discussed identification procedures and Professor Stephen Jones, who had experience in the immediate aftermath of a previous disaster, established an identification check-list. The Medico-Legal Centre was to be used as 'it was thought that we had sufficient capacity for all the dead'.

2.8.25 As detailed in Chapter 4, the disclosed documents reveal that Dr Popper met Detective Chief Superintendent Terence Addis of SYP in the Hillsborough gymnasium, along with Professor Jones, Professor Usher and another pathologist, Dr David Slater, and took the decisions that determined where the bodies would be held, how they would be identified and how the investigation of their deaths would proceed.

2.8.26 At this point Dr Popper 'considered the need for post mortem ... 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'.

2.8.27 Having consulted with Professor Usher and others, he took the decision that 'despite' his hesitation 'it would be advisable ... to have a post mortem'. This would 'exclude any problems should there be any civil litigation with regard to say life expectancy or if there should be any criminal proceedings arising out of this matter'. Thus, 'in view of the nature of this disaster, the definitiveness of a post-mortem, the civil and criminal aspects of the matter, and the provisions of the Coroners Act ... and the desirability of having definitive diagnoses ... it would be inappropriate in this case not to proceed with a post mortem'.

2.8.28 The pathologists discussed the post mortems, and organised technicians and timetables on the basis of a three-session day. At some point during this period (when is not clear from his notes) Dr Popper decided with the pathologists that a sample of blood would be taken at each post mortem to determine the blood alcohol level of the deceased.

2.8.29 The consequences of this decision and how the results were portrayed are considered in detail in Chapter 5.  Dr Popper appears to have made no record at the time of the reason for this decision, a matter of concern for bereaved families. Dr Popper subsequently addressed the issue.[5] Asked why blood alcohol samples had been taken and recorded, he was clear: 'The answer is because I authorised it'.

2.8.30 Pressed for a more detailed justification for taking blood alcohol samples, Dr Popper stated that on the night of the disaster, while he 'realised that the vast majority were in fact extremely young ... once I had made up my mind that we wanted alcohol levels done, I said we were doing them for all, irrespective of other considerations'.[6]  

2.8.31 At that time 'I did not know ... whether or not alcohol would be relevant' but that the 'levels might have been such that the cause of death might have been due to that'. Regarding age he stated that, 'youth these days is no guarantee that alcohol is not ingested'. He concluded: 'I felt it was a justifiable investigation given where it happened and all the circumstances surrounding it'. He continued 'the alcohol level was something which sprang to mind as something which could possibly be relevant'.

2.8.32 On 16 April Dr Popper noted a telephone conversation with David Purchon, Director of Health and Consumer Services, Sheffield City Council, during which it was anticipated that an outside police force would be appointed to investigate the disaster.[7] At this point Det C/Supt Addis remained responsible for liaising between SYP and the Coroner. Mr Purchon and Dr Popper discussed the release of 'physical evidence' from the stadium, specifically the broken barrier, an obvious focus of investigation.

2.8.33 Dr Popper stated that they 'would have to wait a little while before we could release items from the ground and that [the investigating] force might have different views from Mr Addis as to the suitability of releasing the articles'. Mr Purchon 'assumed he would want the things in their laboratory by the end of this week'.

2.8.34 Also on 16 April, at a meeting of senior SYP officers, the Chief Constable commented 'at this stage we will continue with the enquiry as we would be conducting a Coroner's enquiry and simply gathering all the evidence together, instead of pursuing priorities and aspects where the responsibility/blame lies'.[8] 

2.8.35 At a later meeting that day involving a larger group of officers it was stated that the SYP's initial inquiry would be divided: 'one enquiry will be for the Coroner ... The other enquiry is the one we are gathered here today to discuss, for it may be in the fullness of time that this enquiry will be taken away from us'.[9]

[4] File note, 'SLT/JT. HILLSBOROUGH DISASTER 15.4.89', 15 April 1989, SYC000001360001, pp240-249.
[5] Inquest transcript, 18 April 1990, SYC000109270001, p31.
[6] Inquest transcript, 18 April 1990, SYC000109270001, p55.
[7] File note, 'SLT/JT, HILLSBOROUGH DISASTER 16.4.1989', 16 April 1989, SYC000001360001, p239.
[9] 'SOUTH YORKSHIRE POLICE BRIEFING 12 NOON SUNDAY 16.4.1989', 16 April 1989, SYP000010040001 , p9.