“You don’t expect to go to a football match and die”

During the FA Cup semi-final between Liverpool and Nottingham Forest on 15 April 1989 at the Hillsborough stadium in Sheffield, an avoidable disaster led to the deaths of 97 men, women and children.

The investigations exposed many failures in crowd management and emergency planning at a major sporting event. This article outlines the key human factors that contributed to this disaster.

It is now accepted that several public authorities attempted to create an altered account of what actually happened; hiding their own failures, and at the same time directing blame for the disaster onto the people who died or were injured. Those false narratives were amplified through the media from day one, and continued for many years.

“The failures of police communication and spread of misinformation and lies after Hillsborough caused enormous distress to many people and still echo today” (Joint statement from the National Police Chiefs’ Council and the College of Policing, January 2023)

The allegations reported by media outlets at the time significantly added to the anguish of survivors and the bereaved. The treatment of these families by the media is perhaps unique in the aftermath of a major disaster.

The crush at the turnstiles

As fans approached the ground, there was a crush in the confined concourse areas just before the Leppings Lane turnstiles. Both fans and police became trapped, helping people to climb over the turnstiles and passing children to safety on the shoulders of adults. People were distressed, screaming and panicking; some people fainted. There was obvious relief from fans as they eventually passed through towards the ground.

To ease pressure at these turnstiles, an exit gate was opened (Gate C), rapidly admitting a large number of people (approx. 2000 fans). There was some delay in opening this gate, due to police concerns that they would lose control over who was admitted. The decision-making of police in the control box was prioritising an expected public order situation, not crowd safety.

Police officers outside the ground were relieved that opening Gate C reduced the crush at the turnstiles. They understood that it had been a serious situation. Little did they know that this simply transferred the bottleneck from the turnstiles to inside the ground.

“A river of people”

As large numbers of fans now passed through the Gate C, they emerged directly opposite the tunnel under the West Stand at the Leppings Lane Terrace. This is a classic example of how human behaviour is “nudged” by the environment. This route appeared to fans (who were largely unfamiliar with the ground) to be the one that they should follow. Here, the two crowded central sections or “pens” behind the goal (pens 3 and 4), with a combined capacity of 2,100, became seriously overfilled.

There were two alternative routes, either side of this tunnel, that many fans didn’t notice. Signposting in the area was poor, it being described as a “bewildering complex” (Taylor, 1990). Relieved to have escaped the crush at the turnstiles, many people walked towards the tunnel straight ahead, and into the daylight.

More and more fans entered these two central pens, which were soon holding more than double their capacity. The statements of survivors make difficult reading and so I include very few details here. Fans described not being able to move their arms, nor able to move their bodies. People were crushed together, and against the fencing. People felt that they were going to die, and they were packed tightly against people who had already died. They were fighting for their lives, but had nowhere to go.

On the pitch, the game had started. Police officers facing the overcrowded pens didn’t immediately open the locked gates onto the pitch, despite fans begging and screaming at them for help. Some reports describe how fans attempting to climb the perimeter fence to escape the crush were forced back into the pens by police. The situation was misinterpreted as attempts at a pitch invasion. Reinforcements were called for, and all police officers were directed to the pitch.

“Realisation came at different moments to different officers in different places” (Taylor Interim Report, para 71).

Fatal consequences

As a result of the crush in the Leppings Lane Terrace, 95 people lost their lives on 15 April 1989. Hundreds more suffered severe injuries. Four years later, a seriously injured fan died when he was taken off life support, and another person died in 2021 as a result of injuries from the day. In total, 97 people died as a result of the disaster, aged between 10 and 67 years.

Several people who survived the disaster have since died by suicide, and many who witnessed the events have suffered throughout their lives. Given the large number of deaths, the ripple effect into communities is significant.

The investigations and Inquests

The understanding of what happened at Hillsborough (and why) is an extreme example of the complexity of investigation and legal processes. At the end of this article I have provided a brief timeline of key investigations and reports into the disaster that span several decades.

The Inquests into the deaths (April 1990 to March 1991) concluded verdicts of “accidental death” for all those who died, and this was supported by a scrutiny of evidence, led by Lord Justice Stuart-Smith (Feb. 1998). The Coroner limited any evidence to events that occurred before 3.15pm, assuming that anyone who died had sustained irreversible injuries by that time. This cut-off prevented any assessment of the emergency response and rescue, which caused great concern amongst bereaved families. Given correct resuscitation, it is thought possible that some of those who died may have survived.

The Hillsborough Independent Panel (2012) concluded that some public authorities had altered accounts of events, and so doubt was cast over these Inquests. Many statements of South Yorkshire Police (SYP) officers went through an extensive process of review and alteration:

“Some 116 of the 164 statements identified for substantive amendment were amended to remove or alter comments unfavourable to SYP” (Hillsborough Independent Panel, p.23).

The statements of South Yorkshire Metropolitan Ambulance Service also went through a similar process.

As a result of this Independent Panel, the original Inquests were overturned and fresh Inquests were conducted (March 2014 to April 2016). These returned new verdicts of “unlawful killing”.

There were private prosecutions by families in 2000 that resulted in no convictions. A trial of the senior police officer (the Match Commander) for gross negligence manslaughter in 2019 resulted in acquittal. At a trial in 2021 relating to perverting the course of justice, the judge ruled that there was no case to answer and the case against three defendants was dismissed.

At the time of writing (July 2025) a final report by the Independent Office for Police Conduct (IOPC) is yet to be published.

“Ninety-seven men, women and children were unlawfully killed. Police failures were the main cause of the tragedy and police failures have continued to blight the lives of family members ever since” (Joint statement from the National Police Chiefs’ Council and the College of Policing, January 2023)

Initial response to the emergency

The senior police officer in charge of the event saw fans on the perimeter track. He thought that this was a pitch invasion and communicated this to officers, instructing them to the area, along with dog handlers. As police arrived at the crowded pens, it was clear to them that this was not a pitch invasion or crowd violence. They reported in their statements arriving to see a large number of people either dead or dying. Together with spectators, the police tried to pull people over the fences, or to pull down fences with their bare hands.

The game was halted by the referee at 3.06pm, when a police officer ran to him.

Few of the police officers were prepared for such a disaster; some were frozen, clearly in shock at the scenes unfolding before them. Police and fans dragged people from the pens, and administered life support as best they knew how. Fans were frantically searching for their friends and family.

“rescue and recovery efforts were affected by lack of leadership, coordination, prioritisation of casualties and equipment” (Hillsborough Independent Panel, p.11).

There was no systematic assessment or triage in place, and there was a lack of basic medical equipment. Some of those who died might have been able to be resuscitated. While unconscious, some fans may have been placed into a position that further obstructed their airway.

The injured and the dying were carried across the pitch to exits. Advertising boards were ripped from the track to use as stretchers.

Despite this being a major sporting event, the main official medical assistance present consisted of volunteers, some of them young cadets. The NHS Ambulance Service had four representatives at the match, with one ambulance outside the ground – although more arrived within minutes of being called.

Previous similar events

In 1971, a crush on the exit gangway at a Rangers-Celtic match at the Ibrox Park stadium, Glasgow, led to the loss of 66 lives. At the Heysel Stadium in Brussels, at a final between Liverpool and Juventus in 1985, 38 people died in a crush and hundreds more were injured.

There have also been previous incidents of overcrowding at the Hillsborough stadium. In 1981 at the FA Cup semi-final there was similar congestion at the Leppings Lane turnstiles and overcrowding on the concourse, leading to crush injuries to fans on the Leppings Lane terrace. As with the 1989 disaster, Gate C was opened to relieve the crush and a major tragedy was avoided. The Match Commander in 1989 was not aware of the serious crushing incident in 1981. There was also overcrowding at Hillsborough in the previous year, in 1988.

Contributory causes: A human factors review

At the most basic level, the disaster happened because pens 3 and 4 became grossly overcrowded. The influx of people through Gate C increased the pressure in these areas significantly. A difficult layout outside the ground, a large number of fans having to gain access through few turnstiles, and a lack of filtering prior to the entrance gates, led the Taylor Report to conclude that the police lost control of the crowd.

“The main problem was simply one of large numbers packed into the small area outside the turnstiles” (Taylor Interim Report, para 208)

Design of the grounds: Approach to the turnstiles

A combination of issues contributed to the initial crush at the turnstiles. The design issues included an insufficient number of turnstiles, a limited waiting area outside, and the labelling of the turnstiles was too low to be visible through a crowd (leading to people presenting at the wrong gate). I note that guidance on preventing congestion at the entrances to football grounds dates back as far as 1924.

It was foreseeable that a large number of people would arrive at the turnstiles in a short period of time. However, this was not planned for.

Design of the grounds: Containment and segregation

Due to a few incidents of hooliganism at football matches, crowd control focussed on “containment”. Reports into controlling football crowd behaviour led to the installation of high fences to prevent sideways movement (segregating home and away supporters), together with perimeter fencing to prevent fans from gaining access to the pitch.

Once through the turnstiles, fans were then left to their own devices – all pens were open at once and each pen was to “find its own level”. There were no stewards to guide or filter the spectators. Photographs of the day show that even though there was serious congestion in pens 3 and 4, other pens were sparsely occupied. The high fences were effective at preventing sideways movement across the terrace, as designed.

The perimeter gates (onto the pitch) were not designed as exits, but as access for medical emergencies involving an individual. They were inadequate to support a mass evacuation onto the pitch. Once the seriousness of the situation was understood, fans were so tightly packed it was difficult for the police to pull people out through these narrow gates.

The plans for evacuation (e.g., fire, bomb threat) involved use of the tunnel, or along the back of the terraces. Neither of these options was viable in a serious overcrowding situation.

Design of the grounds: Technical change

Following the 1981 overcrowding incident, the Hillsborough grounds were modified and altered on several occasions, including installation of the lateral fences to create pens. However, designated turnstiles for each pen were not installed, so there was no means of counting or controlling the number of fans in each pen.

The alterations were not considered when establishing a safe capacity in the central pens.

The impact of opening Gate C

The decision to open this gate addressed the imminent problem (to reduce crushing at the turnstiles). However, there was little consideration of where these people would go when the gate was opened. This had a direct bearing on the disaster.

The police control room (having a direct view of the pens and knowledge of the crowds at the turnstiles) did not warn or consult other key stakeholders (including the Police Ground Commander, the Chief Steward at the Leppings Lane area, or the Club control room). The officers on the concourse area were not aware of the crowding in pens 3 and 4.

It appears that the possibility of overcrowding was not considered by those in control. The Match Commander making the decision to open Gate C did not instruct staff to steer the large influx of people to the wing pens.

“Failure to give that order was a blunder of the first magnitude” (Taylor Interim Report, para 227)

At previous semi-final matches in 1987 and 1988, police officers cordoned off the entrance to the tunnel to divert fans to the side pens. (Although senior officers denied knowledge of this practice, Jones Report, 2012).

Postponement of kick-off

Kick-off was planned for 3pm. From the crowd still outside the grounds, and the slow throughput of the turnstiles, a decision could have been taken to postpone the start of the game (as has happened previously for similar reasons). A request for such postponement had actually come from police officers close to the crowds. Taking this decision would have likely reduced the pressure to gain entry before 3pm.

“Faced with a situation which was becoming dangerous, crowd safety should have been [the] paramount consideration. Kick-off should have been delayed” (Taylor Interim Report, para 227)

An “era of hooliganism”

In the years prior to the disaster, hooliganism strongly influenced police strategy. It led to a focus on a small number of troublemakers, at the expense of safety of the majority. The mindset was crowd control, not crowd safety. This focus on preventing public disorder through incorrect mental models, assumptions and expectations, led to poor decisions.

The instructions to officers prior to the match did not mention overcrowding, but included emphasis on possible pitch invasions and a prohibition on opening gates in the perimeter fence. Evidence from officers revealed that even when they saw fans in distress, they were concerned about disciplinary action if they opened the gates without authorisation. Delays in recognising there was a problem and in taking action “caused vital time to be lost” (Taylor Interim Report, para 249).

“The anxiety to protect the sanctity of the pitch has caused insufficient attention to be paid to the risk of a crush due to overcrowding” (Taylor Interim Report, para 264)

Mistaking the struggles in pens 3 and 4 as an attempt at a pitch invasion influenced police behaviour. The senior officer, when seeing fans on the perimeter track, sent officers with instructions to deal with a pitch invasion.

Culture and complacency

Poor conditions for spectators at football matches was the norm. Many grounds are old and have basic facilities, particularly in terraces where fans would stand in all environments, often without cover. There was insufficient concern for the safety and well-being of spectators across the sport.

The Final Taylor Report also suggested that complacency (“it couldn’t happen here”) was an issue across many clubs. It referred to their thinking that as disaster has not occurred on previous occasions, it wouldn’t happen this time. Unfortunately, Taylor found this reasoning was prevalent at other clubs even after Hillsborough.

“So, although the operational errors on 15 April were special to one ground and one day, the lack of precautions against overcrowding was not unique. I do not believe that sufficient safety measures were being applied at all other grounds. The lesson here is that Hillsborough should not be regarded as a freak occurrence, incapable of happening elsewhere. All those responsible for certifying, using and supervising sports grounds should take a hard look at their arrangements and keep doing so. Complacency is the enemy of safety” (Taylor Final Report, para 25)

Roles and responsibilities

The police considered that their role was one of public order. The most senior police officer (wrongly) believed that crowd management and the prevention of overcrowding was “the responsibility of the club”. Written and verbal instructions to police officers made no reference to the avoidance or detection of overcrowding.

The Independent Panel reports on several occasions the “difficult” relationship following the 1981 incident, between the owners of the stadium (Sheffield Wednesday Football Club) and the South Yorkshire Police (referred to as “institutional tension”).

Leadership

The most senior police officer at the event, the Match Commander, had recently been promoted and inexperienced in this role. The Taylor Inquiry is heavily critical of their leadership before and during the event – relating to the police planning, misjudging the build-up at the turnstiles, lack of communications and direction, and a failure to take control of the developing disaster. A lack of leadership impacted on the initial rescue efforts. The balance between the prevention of crowd disorder and maintenance of public safety was inappropriate.

The Taylor Report also comments on the behaviours of senior officers during the Inquiry, that they were defensive and evasive:

“Neither their handling of problems on the day nor their account of it in evidence showed the qualities of leadership to be expected of their rank” (Taylor Interim Report, para 264)

Communications

The Superintendent responsible for policing the outside of the stadium had no knowledge of the uneven distribution of fans in the terraces, and the Chief Superintendent inside the stadium had no knowledge of the extreme overcrowding outside the grounds.

Several police officers along the perimeter fencing realised what was happening and attempted to use radios to contact the police control room, seeking permission to open the gates and allow fans to escape onto the pitch. However, no reply was received.

The police radio system was intermittently faulty at key points during the disaster and prevented officers at the turnstiles, in the ground, and in the control box from communicating effectively. This impacted on the ability to gain awareness of the situation and take command. Even so, the Inquiry is critical of the lack of communication between those responsible for policing.

It’s unclear from the statements whether permission was granted to open to perimeter gates, but they were opened by police officers when the extent of the situation became clear.

Final thoughts

As with many other disasters, there were previous similar events. Over the years, eight official reports had covered crowd safety at UK football grounds. The lessons and recommendations from previous disasters didn’t prevent 95 people dying from overcrowding in full view of those responsible for ensuring that such an event did not happen. Many of the deficiencies at Hillsborough were known issues.

The suffering of bereaved families has been compounded by failures over decades to both uncover and acknowledge the truth of what happened on that day. As the legal journey appears to be over for the families, they are campaigning for a proposed “Hillsborough law” which will increase transparency and support following future disasters.

I also note that lessons from Hillsborough and the experiences of bereaved families has had a positive benefit in other inquests; from individual deaths to major disasters such as Grenfell.

Related articles

Further resources

BBC Radio 4, The Report: Hillsborough, 4 October 2012. (28 Minutes)

The investigations

1. Public Inquiry, led by Lord Justice Taylor (Interim Report published August 1989 and Final Report published January 1990)
   • Main cause was a failure of police control
2. Inquests into the deaths (April 1990 to March 1991)
   • Verdicts of “accidental death” for those who died
3. Scrutiny of evidence, led by Lord Justice Stuart-Smith (Feb. 1998)
   • Nothing significant to add to the Taylor Report or Inquests
   • No basis to re-open previous inquiries
4. Hillsborough Independent Panel, chaired by James Jones, Bishop of Liverpool (Sept. 2012)
   • Followed the disclosure of new documents relating to the disaster
   • Reviewed 450,000 pages of evidence not previously available
   • Some public authorities had altered accounts of the events
   • Cast doubt over the previous Inquests
5. Operation Resolve (2013 to March 2022)
   • The actions of all organisations involved in the disaster and the lead up to it
6. Independent Office for Police Conduct (IOPC) investigation (2012 onwards)
   • Focuses on police actions in the aftermath of the disaster
   • To establish whether any police officer may have committed a criminal offence
   • To determine possible cases of misconduct or gross misconduct
7. Fresh inquests (March 2014 to April 2016)
   • Verdicts of “unlawful killing” for those who died
   • Numerous failings by the police and other emergency services
   • Design and layout of the stadium contributed to the crush
   • Fans did not cause or contribute to the disaster
8. Report on experiences of families, led by James Jones, Bishop of Liverpool (Nov. 2017)
   • Proposals for how official inquiries are conducted
9. National Police response to the Jones Report (Jan. 2023)
   • Apologies and recognition of police failures
   • Actions taken to embed learnings in police processes
10. Government response to the Jones Report (Dec. 2023)
    • Outlines actions taken and intended actions
    • Hillsborough Charter to support bereaved families
11. Independent Office for Police Conduct (IOPC) investigation (TOR updated, June 2024)