The Hillsborough inquests commenced on March 31, 2014 and are the subject of reporting restrictions that have been imposed by the Attorney General's office. Liverpool Football Club is respectful of these restrictions and will therefore only be making available updates from other media channels for the duration of the inquest.

Courtesy of Press Association

April 1

The Hillsborough disaster is "seared into the memories of the very many people affected by it", a coroner has told jurors at the fresh inquests into the deaths of the 96 football fans who died. In an opening statement, Lord Justice Goldring explained the tragedy was "the worst ever disaster at a British sports stadium", when hundreds of people were hurt and dozens killed in a "terrible crush".

Among the different questions the jury will have to consider is whether a decision to promote chief superintendent David Duckenfield, who was in charge on match day, was the right choice, the coroner said.

Before the jury of seven women and four men was sworn in, names of each of the 96 victims of the disaster were read aloud.

Against a backdrop of a reverent silence, relatives wept quietly as each name was slowly read to the jury by counsel to the inquests, Christina Lambert QC, whose voice cracked as she progressed through the roll-call.

The disaster unfolded on April 15 1989 during Liverpool's FA Cup semi-final against Nottingham Forest as thousands of fans were crushed on the ground's Leppings Lane terrace.

Lord Justice Goldring said: "The disaster is seared into the memories of the very many people affected by it, most notably of course the families of the 96 people who died."

The coroner told the jury the findings in the original inquests were quashed in December 2012.

"A new inquiry was needed, we are conducting the new or fresh inquiry," he said. "In doing so we are not concerned with whether what was decided at the previous inquiries was right or wrong."

More than 400 people were taken to hospital with injuries, 95 fans were killed and the 96th died later.

Taking the jury through different areas of evidence, Lord Justice Goldring said Mr Duckenfield had only been promoted to his role on March 27.

He was given responsibility for Hillsborough over a more experienced officer, the jury was told, despite his speciality being criminal investigations rather than public order.

Lord Justice Goldring told the jury: "Whether that was a sensible decision may be something for you to have to consider."

Briefly outlining the events of the day, the coroner said: "Around the time of the kick-off, a terrible crush developed in two pens, within the standing terrace at the west end of the stadium - the Leppings Lane end. That's where the Liverpool fans were standing."

He went on: "The pressure in the pens built up. Many of those in the pens suffered terrible crushing injuries."

Explaining the role of the jury during the inquest, Lord Justice Goldring said jurors would have to consider "whether opportunities were lost which might have prevented the deaths or saved lives".

He added: "It's important you approach these inquest hearings with an open mind."

Quoting from previous comments made on the fresh inquests, the coroner said: "While searching fearlessly for the truth, we should avoid this hearing degenerating into the kind of adversarial battle which looking back on it scarred the original inquests."

Lord Justice Goldring stressed that there would be a great deal of interest around the forthcoming 25th anniversary of the disaster.

"It is natural and right that the press will want to report events marking the anniversary and the inquests in the context of the anniversary," he said. "It would be unrealistic to tell you not to read newspapers or watch the news on television."

The inquest will not sit in the week of the anniversary, the coroner said.

Lord Justice Goldring said that witnesses' memories may have faded in the two and a half decades that have passed.

"Because these events happened very nearly 25 years ago, memories will inevitably have faded," he said.

Jurors were taken through a list of key individuals including police, fire, ambulance and council staff, as well as the match referee and managers of the teams playing on the day, Liverpool and Nottingham Forest.

After showing jurors diagrams and photographs of the stadium, Lord Justice Goldring said Hillsborough had seen a previous crushing incident in 1981, in which 38 people were injured.

The crush was relieved when gates in the fence between the terrace and the pitch were opened, the inquest heard.

After the incident, the central pen in the Leppings Lane terrace was given a capacity of 2,200, the jurors were told, but there was no means of counting how many people went into a particular pen.

Four years later, capacity figures were set for two pens behind the goal, which some experts will tell the jury were "substantially too high", the coroner said.

They were secured with gates that could only be opened from the pitch side, the coroner said.

Going through the history of the stadium, which was built in 1899 but has been through many changes since, Lord Justice Goldring told the jury about reports of crushing in 1988, one year before the disaster.

He said: "On April 9 1988 - in other words about a year before the disaster - Hillsborough hosted an FA Cup semi-final between Liverpool and Nottingham Forest.

"Some fans who attended the match later gave accounts of there being pressure and crushing within the Leppings Lane terraces.

"There were no reports of serious injuries."

Authorities regarded the match as a success, the court heard.

"They later modelled their plan for 1989 on the event in 1988," the coroner added.

Lord Justice Goldring said it would be for the jury to decide if authorities were correct to regard the 1988 semi-final as a success.

Before the 1989 semi-final, secretary of Liverpool Peter Robinson suggested that the club's supporters should not be allocated the Leppings Lane end for a second year, because fewer cheap standing tickets were available to fans.

This was rejected by police, who felt the system used in 1988 was more effective for managing the arrival of supporters, the court heard.

On the day of the match, police could only judge how full the pens in the terraces were becoming by looking at CCTV, the jury heard.

There were counters on the banks of turnstiles but this did not record how many people were going into each pen, the court was told.

Lord Justice Goldring said: "What the monitoring system could not say was how many people had gone into pens three and four, or whether the maximum capacity of these pens had been reached. To know that would require police officers or stewards at the tunnel entrance with handheld counting devices, and that did not happen on April 15 1989.

"That meant that those in the control room could only decide how full the pens were by looking down or making use of the CCTV system and forming an impression of how crowded pens three and four seemed to be."

He also said that on the day of the disaster, some police officers had found themselves unable to get through when using their mobile radios, or they could not be heard.

Lord Justice Goldring then outlined evidence surrounding the events of April 15, adding that "different witnesses view these events from very different perspectives".

The coroner said the weather on the day of the match was "very good" and a capacity crowd of 54,000 was expected.

"The numbers of people arriving grew as the day went on and the kick-off time of 3pm approached," he said.

The coroner told the jury that many fans did not go directly to the ground but socialised elsewhere in the town.

He said there remain "different and varying accounts" of the behaviour of supporters in the town.

Lord Justice Goldring went on: "Some witnesses, including a number of police officers, have given accounts complaining of bad behaviour.

"Many others describe the atmosphere as good-natured.

"In any case, there were relatively few arrests."

The court heard that police officers were not under instruction to monitor the numbers going towards different entrances or regulate the numbers going towards the tunnel into the ground.

Between 2.15pm and 2.30pm, the number of fans approaching the Leppings Lane stand increased.

"It was forming into a mass of people," the coroner said. "The pressure was building up."

Superintendent Bernard Murray, who advised Mr Duckenfield, was becoming "increasingly concerned" about the press of supporters outside the turnstiles, the coroner said.

"The pressure was becoming very heavy," he said. "Space was limited. Fans were keen to get into the ground in time for kick-off."

Lord Justice Goldring said the crush was worse near the turnstiles, adding that some of those coming through the turnstiles were "winded and distressed".

Superintendent Roger Marshall, who was responsible for the Liverpool fans' section, was becoming "very worried" and at around 2.47pm requested that exit gates A, B and C should be opened to permit people to enter the ground to "ease the pressure", the coroner said.

Around 150 fans were able to get in when one of the exit gates was temporarily opened to eject a supporter, he added.

Mr Duckenfield took "some minutes" to make a decision, the jurors were told, and Mr Marshall later made a second request to open the exit gates.

By the time of his third request, he warned that "somebody would be killed if the gates weren't opened", Lord Justice Goldring told the court.


Mr Duckenfield eventually decided to open the gates, although he chose not to delay kick off because he thought it was too late.

The jury was told he said: "If there is likely to be a serious injury or death I've no option but to open the gates. Open the gates."

In the five minutes that one of the three gates was opened, some 2,000 supporters entered the stadium, the court heard.

There are contrasting accounts of the behaviour of fans outside the venue, the jury was told, with some saying that they were deliberately pushing to get in, and some were drunk.

However the coroner continued: "By contrast many of the supporters describe a group of ordinary supporters who were keen to get into the match and found themselves in an intolerable crush, sometimes with little choice but to move forward in the hope of escaping the crush.

"You will hear a range of accounts and form your own views. You will also have to consider whether such problems as you see there were should have been foreseen by the police and others in their planning for the match."

He said they will have to consider various questions, such as whether the order to open the gates should have been given, whether pens three and four were crowded at the time, and whether anything more should have been done to stop a dangerous situation developing.

But Lord Justice Goldring warned: "In answering those and other questions beware the wisdom of hindsight. Beware too of applying the standards of 2014 to events which happened in 1989. Consider the situation which faced the officers on the afternoon of April 15 1989."

Lord Justice Goldring said that as the fans entered the ground, the tunnel into the Leppings Lane stand became more crowded.

The coroner said: "As supporters moved down the tunnel, those in front were driven forward. People have spoken of pressure like a train moving them onwards. Some described being lifted off their feet.

"The influx of fans in the tunnel increased the overcrowding in the two central pens."

He told the jury the mesh perimeter fence prevented the pressure being relieved.

"Those at the front were being pressed up against it," Lord Justice Goldring said. "Many fans were in serious distress."

The coroner summarised the accounts of a Police Constable Smith, who described "shouting and screaming".

The police officer attempted to make contact with the police control room to obtain authorisation to open the gates on to the pitch, but he was not able to get through, the court heard.

The officer decided to open the gates anyway, but this did not relieve the pressure, the coroner said.

Another officer described a "river of people" entering the central pens, the jury was told.

"The crush in the pens, particularly at the front, was intolerable," the coroner said.

At 3.04pm, Liverpool player Peter Beardsley struck the crossbar on the Nottingham goal at the other end of the pitch, Lord Justice Goldring said.

"The crown in pens three and four surged forward as fans tried to see what was happening at the far end," the coroner said. "That surge contributed to the crushing of fans towards the front."

A crush barrier broke in one of the pens, the jury was told.

Mr Greenwood ran on to the pitch between 3.05pm and 3.06pm to stop the match, the court heard.

Between 3pm and 3.20pm police and ambulance staff at the ground "began to appreciate the disaster which was unfolding", the coroner said.

Lord Justice Goldring said: "The events developed quickly. At first, many involved didn't understand they were facing a major disaster."

The court heard that one of the initial calls by police control to ambulance control said that there was "pushing and shoving" and that "a few ambulances" might be needed, although this was quickly changed to a request for a fleet, which was initially refused.

Ambulance staff also failed to walk through fans who were at the side of the pitch and therefore did not see how many people were "in danger and distress", the court heard.

By 3.12pm fans began to be pulled out of pen three and ambulance station officer Paul Eason told control he wanted to declare a major incident, although the coroner said the major incident procedures were not fully enacted.

Jurors were shown photographs of the pitch during the disaster, with crowds of fans pouring on to the grass.

Ambulance staff did not set up a triage system, used to assess how seriously people are hurt, the court heard.

Lord Justice Goldring said: "To establish a system of triage, if they considered it, the ambulance personnel would have had to at an early stage take control of the situation by declaring a major incident and creating a clear area within the pitch in which to assess and treat casualties.

"You may well need to consider whether they could and should have done that and if so what difference, if any, it would have made to the care of the seriously injured who later died. You may also need to consider what steps the police could or should have taken to assist with the situation at this point."

At 3.15pm, Mr Duckenfield told the-then chief executive of the Football Association Graham Kelly that one of the three gates that had been opened was forced.

This claim was repeated in a radio interview by Mr Kelly, and then picked up by several media outlets.

The coroner said: "There is no question of Gate C having been forced.

"This early account resulted in some seriously inaccurate reporting of events. You will want to consider why chief superintendent Duckenfield said what he did."

The hearing was adjourned until tomorrow.