hillsboroughIn a previous posting here I discussed the failures of the ambulance service at Hillsborough. In this blog I want to consider the conduct of the Yorkshire Ambulance Service (YAS) at the recently concluded Inquests into the deaths of 96 Liverpool football club supporters. It seems to me that their conduct, along with that of organisations like South Yorkshire Police raises important issues about how public authorities should conduct themselves during Inquiries and Inquests. In particular it is my contention that such organisations need to turn their backs on what has been described as ‘institutional denial’ and adopt instead policies of openness and transparency. Failure to do so means that the chances are that lessons from previous errors and failures are less likely to be learned.
We might even call this change ‘Hillsborough Law’.

Yorkshire Ambulance Service did not exist at the time of the Hillsborough Disaster in 1989. It was only created in 2006 following the merger of a number of regional ambulance services including the now infamous South Yorkshire Metropolitan Ambulance Service [SYMAS] which failed so badly on the day of the disaster.

When the report of the Hillsborough Independent Panel was published in September 2012 the then Chief Executive of YAS, David Whiting issued the following statement:

First and foremost, on behalf of the Trust, I would like to extend my sympathy to the bereaved families of the 96 Liverpool supporters who lost their lives as a result of the Hillsborough tragedy on 15th April 1989. I understand this will be a very difficult time for the many people who remain affected by the tragedy, including a number of our current and former staff… . The trust remains committed to openness in the process and we welcome and fully accept the findings highlighted within the Panel’s report. I sincerely apologise for the shortcomings identified in the report relating to the way in which the incident was managed in its early stages.  Twenty-three years on from the Hillsborough tragedy, the ambulance service is very different…

It’s not often anyone has a bad word to say about the ambulance service and no doubt most people at the time will have taken Mr Whiting’s fine words at face value. So when YAS was granted Interested Person status for the new inquests no one could imagine that they would wish in any way to go behind their apparently sincerely meant statement of regret. They had accepted that SYMAS had failed, at least in the early stages of the emergency response. By 2012 SYMAS no longer existed and YAS was simply a successor organisation. YAS had no legitimate interest in seeking to explain the failures of SYMAS in the wake of the disaster. They could legitimately have been expected to have come to the Inquests and made it clear they did not intend in any way to detract from their apology.

In the event the jury’s conclusions in respect of SYMAS were that there were errors or omissions by SYMAS which caused or contributed to the loss of lives in the disaster. By way of additional comments the jury added: ‘SYMAS officers at the scene failed to ascertain the nature of the problem at Leppings Lane. The failure to recognise and call a major incident led to delays in responses to the emergency.’

As if to emphasise their contrition, immediately after the jury had delivered those conclusions YAS again apologised, this time in the words of Rod Barnes, the new Chief Executive who had taken over during the Inquests. The YAS statement said: ‘We fully accept the jury’s conclusions that after the crush began to develop there were mistakes made by the ambulance service; lives could have been saved on 15th April 1989 had the emergency response been different.’  Then, seemingly in anticipation that the conduct of YAS at the inquests might be about to attract criticism, they added: ‘As one of the successor organisations of SYMAS, we had a responsibility to ensure a full and fair evaluation of their response. We have done our best to make sure all relevant evidence about the ambulance service response has been put before the Court, placed in context and properly explored in an open way.’

That last sentiment will have a particularly hollow ring to anyone who listened to the case being put on behalf of YAS during the Inquests.

As anyone in court could attest YAS continually acted contrary to their previous apology. They began by denying they had failed, then, when their own witnesses accepted they had failed their counsel continued to try to downplay the admitted errors. YAS’s approach seemed essentially to be trying to resurrect the old and discredited 3.15pm cut-off point and to suggest that any failings made no difference to the outcome. The approach taken by YAS not only increased the length of the hearings but added significantly to the distress suffered by the families.

No one is suggesting that Interested Parties (IPs) do not have the right to defend themselves from undue criticism.   The families had no difficulty with any IP fighting their corner to avoid unjustified criticism. But where that organisation has already made admissions as to its failures and apologised that organisation cannot then conduct itself in Inquests in wholesale disregard of the apologies it has made.

Readers will already have detected in YAS’s conduct unhealthy parallels with the behaviour of South Yorkshire Police (SYP) who similarly made apologies and then ignored them in the Inquests. I have previously written about the conduct of SYP at the Inquests here.

The questions remain therefore in the light of the statements and apologies made by YAS both before and after the Inquests: why did YAS try falsely to blame the fans for impeding the rescue effort? why did YAS try to pretend the failures by SYMAS on the day were not responsible for the high number of deaths? and why in particular did YAS instruct their lawyers to intervene repeatedly during the final pathology phase of the Inquests in an attempt to suggest that all the 96 were either dead or beyond assistance by shortly after 3pm?

Blaming the supporters
Given the offensive launched at the Inquests by the match commanders with wholesale blame being alleged against the supporters all the other institutional IPs knew full well the likely impact of joining in.  The extent of the attack on supporters by YAS was not on the same scale as the match commanders but the impact was the same.  Here was another institution seeking to avoid taking responsibility by blaming the most vulnerable group present on the day, namely the victims and survivors of the disaster.

Examples include allegations of hostility from the crowd, entirely refuted by the CCTV footage of the rescue effort and claims that fans impeded the rescue effort which is a bit rich coming from an organisation that was conspicuous by its absence from the Hillsborough pitch. It was even suggested that the fact it was fans who moved the dead and injured across the pitch was something the ambulance service was not responsible for. It had evidently slipped the mind of counsel for YAS that without the heroic effort of fans, most of whom had only just escaped the crush themselves, there was little likelihood of anyone else carrying the casualties across the pitch, especially not from SYMAS. What legitimate interest did the Chief Executive of YAS in 2014/16 have in instructing his counsel to conduct his case in this way?

Going behind the apologies
Both Station Officer Eason, one of the senior ambulance officers on the ground before the disaster and the Chief of SYMAS Albert Page made significant concessions in their evidence that the response to the disaster by SYMAS was poor and inadequate. Despite this, counsel for YAS repeatedly questioned witnesses suggesting that such concessions were only a reflection of hindsight and not criticisms of the organisation on the day. Other witnesses who were critical of the SYMAS response were challenging in an apparent attempt to minimise criticism of the organisation despite these concessions and the apology issued in 2012.

Liaison between SYP and SYMAS
As one would expect, the major incident plans of both SYP and SYMAS emphasised the importance of early liaison between the emergency services.   On behalf of the families it had been repeatedly suggested that one of the obvious benefits of early liaison would have been that the police could have assisted SYMAS staff by ensuring that a large area of the pitch was kept free of people to enable the injured to be treated and their life chances assessed. This idea was treated with near derision by counsel for YAS who asked a senior SYMAS officer how he imagined his directing police officers would have been received, inviting the reply that he did not think the police would take orders from him. Why would counsel acting for YAS and instructed by its Chief Executive have tried to rubbish the perfectly sensible idea that the two emergency services needed to liaise and that if they had arrangements could easily have been made that might have resulted in fewer deaths?

‘Even if, which is not admitted, we were rubbish, it didn’t matter anyway’
A particularly distasteful aspect of the case presented by YAS at the Inquests amounted to suggesting that even if, contrary to their first line of defence, the jury thought that SYMAS had failed to respond to the unfolding disaster in anything like an adequate fashion, it didn’t really matter because there was nothing that even the best response could have corrected and anyway most of the deceased were dead at a very early stage.

To this end, during the expert overview at the start of phase 2 (the movements of the 96 individuals who died) YAS sought to establish that the time between respiratory arrest in the crush and cardiac arrest was likely to be so short that any failures by SYMAS would not have made any difference. During phase 2 YAS’s questioning of witnesses was designed to emphasise that death was likely to have occurred at an early stage of the crush.

During the individual pathology hearings YAS intervened in almost every one of the 96 cases.  The same line was repeated endlessly to seek to diminish SYMAS’s responsibility. So it was suggested that the lack of medical equipment, for which SYMAS was largely responsible, made no difference to the outcome.   Witnesses were questioned to emphasise that even good quality CPR was usually not successful and therefore lack of it in other cases made no difference.

Intervening in almost all of the 96 cases in this way did nothing to advance a legitimate case for YAS and it seems extraordinary that the Chief Executive should have instructed his counsel to conduct the case in the way it was.

Time for ‘Hillsborough Law’
This is why I believe that it is essential that public organisations such as the police and ambulances service but also local authorities whose whole raison d’etre is service to the public must be required to exercise openness and candour. The current practice of institutional denial is unacceptable. Such conduct delays justice and adds further to the distress of the families of the bereaved and all for no good or sufficient reason given that the organisation has previously admitted its failures and apologised. The same expectation would also apply to bodies such as football clubs, which whilst they may be private rather than public entities, nonetheless derive significant income from inviting large numbers of members of the public into their stadia and to whom they owe a duty of care for their safety and comfort. Again such organisations should be required to act with frankness and transparency and not denial.

It’s not enough that the lessons of the disaster itself should be learned, although hopefully they were learned a long time ago now and most football stadia are very different places to what they were in 1989. But is seems pretty clear that in other ways lessons have not been learned by the authorities who ostensibly exist in order to serve the public but all too often seem to put their own institutional reputation before their duty to the public. It would be a fitting tribute to the dead and injured of the Hillsborough disaster and the families who fought so long and so valiantly to get justice if this case saw an end to cover-ups and denials and a recognition by public authorities and other institutions that they must be open and transparent in the future. When they make mistakes however serious they may be the onus must be on them to own up. Only that way can we really be sure these institutions do learn the lessons of their mistakes. If “Hillsborough Law” achieved that, it would be a very welcome reform.