The new inquests into the deaths of the 96 Liverpool supporters who died at Hillsborough on April 15th 1989 are taking place at Birchwood Park in Warrington and are being heard by retired Court of Appeal judge Sir John Goldring, who has been made an assistant coroner for the purpose.
Anne Williams died in 2013 following a battle with cancer.
The court will be hearing evidence about the day of the disaster and how people died - please be aware this may be distressing
Please respect the coroner's instructions and do not comment about witnesses or evidence on social media - read more
That is all of the evidence for today.
The court will resume at 10am tomorrow.
Nick Brown asks questions on behalf of the family.
Dr Cary says if a brain had cerebral oedema - which would develop in someone who survived more than an hour after the crush - it would be described as more severely swollen than Stephen’s brain was.
He says from a pathological point of view there is no evidence of prolonged survival.
The original post mortem recorded the cause of death as inhalation of stomach contents due to crush asphyxia.
Dr Cary says inhalation of stomach content can occur during resuscitation.
He says there was no description of food material in the air passages or lungs.
He says: “I felt, on the basis of the factual evidence contained within the post mortem report, there wasn’t really any solid evidence of inhalation of stomach contents.”
There were some haemorrhages reported in the lungs.
Dr Cary said they may be a manifestation of asphyxia.
Dr Cooper says he doesn’t think the pathology can help narrow the time frame from 3.03pm to 4.05pm.
The report recorded a large bruise to the back of the head, but the skull was intact.
Dr Cooper says: “Clearly there has either been a bash to the head or the head has been pushed very hard against something.”
He says it may have caused the swelling of the brain.
The pathologists agree that compression asphyxia is the cause of death.
Pathologists Dr Cary and Dr Cooper answer questions about Stephen.
Dr Cooper says the description of the face in the post-mortem is consistent with an asphyxial process but somewhat short of the typical findings of traumatic asphyxia.
Dr Cary says the pinpoint haemorrhages are described as being particularly associated with the eyes.
The report recorded a cluster of bruises on the inner right arm and a number of bruises on the inner left arm.
The initial post mortem said they appeared to be the result of gripping.
Dr Cary agrees they are consistent with someone being gripped in life.
He says: “I think with other cases we have been quite cautious to say when that gripping is likely to have occurred.
“Obviously the presence of bruising implies that the circulation is still functioning, but there may have been gripping during the course of the crush, there may have been gripping during recovery from the pen and we are not able to distinguish between those two possibilities.”
The brain was described as congested and swollen and was recorded as 1,800g - which is heavier than expected.
Dr Cary says the description said it was slightly swollen.
He says: “That, plus the congestion, would mean this may simply be a brain that has swollen a bit because of the process of asphyxia and blood being forced back up the circulation and into the head.”
Nick Brown asks questions on behalf of Stephen’s family.
Dr Soar says one of the possibilities is that Stephen was unconscious when treated on the pitch.
He agrees that we don’t know what time before 3.30pm Stephen was retrieved from the pen, how long CPR was given and there is no description of a check for a pulse.
Mr Brown suggests that the best opportunity for successful intervention might have been before Stephen was retrieved from the pen.
Dr Soar says it would depend on his exact condition.
Jenni Richards asks questions on behalf of the ambulance service.
Dr Soar agrees it is most likely that Stephen was in cardiac arrest when resuscitation attempts were made.
He confirms he was most likely in cardiac arrest when carried across the pitch, so lying on his back wouldn’t have affected the outcome.
Dr Soar confirms that Mr Crookes’ evidence shows no checks before CPR started and no response to CPR.
He says it is likely Stephen was likely to be unconscious when he was given CPR.
He says: “I think it is most likely that he wasn’t breathing and possibly didn’t have a pulse, but we don’t have any AV evidence, we don’t have any good evidence of a formal verification of the absence of signs of life at the end of that period of CPR.
“So I wouldn’t be absolutely certain that at the end he was in cardiorespiratory arrest.
“Although that would be my highest probability of his likely condition.”
He says the timeframe for Stephen’s death is between 3.03pm and 4.05pm.
Footage from 3.29pm to 3.30pm shows Stephen being carried across the pitch.
A coat is covering his face and upper torso.
Mr Smart said he had a recollection of a St John Ambulanceman treating Stephen.
He said he went to help others and then came back and helped to carry Stephen on a hoarding.
He remembered a tunic being placed over Stephen.
Stephen was confirmed dead at 4.05pm.
Ms Lambert says the court heard from a number of witnesses.
Mr Smart said he helped carry a casualty believed to be Stephen through gate three and laid him on the pitch.
He said the casualty was blue and looked dead.
He said a St John Ambulance man took over attempts to resuscitate him.
Ms Lambert said police officer Robert Crookes described seeing Stephen being carried from the pen and giving CPR with Mr West.
He said they went at it “hell for leather” and initially thought he was coming round because they saw his chest rise.
They carried on with CPR until they decided it was no use.
Dr Soar agrees there only seems to have been a visual check of Stephen.
He says you would expect to see the chest rise during mouth-to-mouth.
Mr Crookes said he couldn’t recall anyone checking for a pulse before CPR was stopped but he thought one of them would have.
He said when they stopped CPR Stephen was placed in the recovery position.
But he said that wasn’t because they thought he was breathing.
He was placed on a board and Mr West then covered Stephen with his jacket.
Mr Crookes said he thought Stephen was taken and placed outside the gym.
He didn;t see anyone performing checks on Stephen at that time.
The court is shown photos timed at about 3.03pm.
Stephen is seen at the front of the pen and is upright with his eyes partially open.
Another photo is shown and Stephen’s eyes are closed and he is possibly grimacing.
Dr Soar says he has gone through a number of photos from around this time.
He says: “They do point to Stephen being alive at that time.”
He says he appears affected by the crush at that time.
Dr Soar answers questions about Stephen.
Ms Lambert says Stephen and friends Anthony Burrows and Anthony Smith arrived in Sheffield at about 1pm.
They got to the ground at about 2.30pm and entered through gate C after the second opening at 2.52pm.
Mr Smith said they went down the tunnel and were pushed onto the terrace in a surge.
Mr Smith said they had some discussion about whether to go back and into pen four but there was a sudden surge and he didn’t see Mr Burrows or Stephen again.
Mr Burrows said they went through the tunnel and moved into pen three.
He said the pen was full with intense pressure and he was forced to about halfway down.
He said he turned to Stephen and Mr Smith and said they should go to the right.
They tried but weren’t able to.
Ms Lambert says footage at 2.56pm shows Stephen and Mr Burrows making their way across pen three.
The court will now hear evidence about Stephen Copoc.
He was 20 when he died.
The family said Stephen began studying birds when he was about 12 and would go fishing at Speke Hall.
He studied for a City and Guilds in botany and horticulture and could name any flower or plant.
He started working in Calderstones Park and then became a gardener at Sudley Hall in Mossley Hill.
Dr Cooper says the report showed a brain weight which was within the normal range.
Some swelling, causing coning to the lower brain, was recorded but Dr Cooper says he doesn’t think that was plausible given the weight.
Some bruising of the heart was recorded.
Dr Cary says: “Consistent with an asphyxial process, but if there was genuine bruising of the muscular wall of the heart, then this could have occurred either during the crush or during resuscitation.”
The pathologists agree the cause of death was compression asphyxia.
Dr Cooper says: “There may well have been a contribution because of pressure on the neck, but compression asphyxia covers it.”
Ms Lambert asks about the timeframe for death of between 3.05pm and 3.40 or 3.45pm.
Dr Cary and Dr Cooper agree with that time frame.
The report recorded fractures on both sides of the hyoid bone - a horseshoe shaped bone in the neck.
There was also evidence of bleeding which had occurred before death.
The post-mortem recorded fractures to the thyroid cartilage - which Dr Cary says is on either side of the voice box and near the hyoid bone.
Dr Cary says: “Something has compressed the neck and it has caused injury on the outside and it has also caused injury on the inside.
“The line or abrasion or grazing going from side to side would lend itself very well to some sort of linear object that the neck had been forced up against.”
He says he thinks it is a reasonable conclusion that the injuries happened during life.
Ms Lambert says expert Prof Birchall was asked to comment on whether the injuries might have stopped Kevin murmuring the word ‘mum’.
He said he didn’t think they would have affected that.
Dr Cary says he agrees that the injury would not have stopped Kevin talking.
Prof Birchall said the injuries may have made Kevin’s breathing noisy.
Dr Cary says that is possible but the intensive care experts have given evidence on that.
He says it is likely the injury was sustained during the crush.
We’re back in court now.
Pathologists Dr Nat Cary and Dr Nigel Cooper answer questions about Kevin’s post-mortem report.
Dr Cary says the external examination shows signs consistent with an asphyxial process of death.
He says: “It has many of the elements of the classic traumatic asphyxia case.
“However the case is made slightly more complicated by injuries, both externally and internally, in relation to the neck, so there may have been a major component of neck compression rather than just truncal compression.”
He says the pallor of the face might mean Kevin’s face was pressed against an object.
The report recorded an abrasion on the right side of the chin.
Dr Cary demonstrates where on the chin it was.
On the left side of the chin there was an abrasion, slightly lower than the other injury.
There were also two abrasions at the front of the neck, over the voicebox.
The court will now break for lunch and will resume at 2pm, when pathologists will give evidence about Kevin.
Ms Lambert asks more questions.
Dr Soar agrees that he is not putting the time of death back to the start of the CPR attempt at the Kop end of the pitch because of Mr Bruder’s evidence of Kevin showing .
Ms Lambert says: “The best opportunity for survival on the narrative that the jury have heard would have been if the CPR had been given at the Leppings Lane end of the pitch?”
Dr Soar says: “That’s correct.”
He adds: “Early treatment doesn’t necessarily mean survival..”
Mr Weatherby asks about the pictures of Kevin taken between 3.05pm and 3.06pm.
Dr Soar agrees Kevin’s head does not appear slumped in the two photos and his head is in a different position in the two pictures.
In a report Dr Soar said the fact Kevin was upright in the photo suggested he was still alive in the pictures.
He says that was supported by the evidence of supporters.
He says one of the witnesses describes Kevin going down onto his knees and his head moving.
He says: “So if he was moving his head after the photograph was taken, that would imply to me he was alive.”
Dr Soar says there is a high degree likelihood Kevin was in cardiac arrest after CPR done by Mr Bruder and Mr Towler.
He says it is unlikely that he was alive at the point he was in the gym with Ms Martin at about 4pm.
Mr Weatherby asks if he can exclude the possibility that Kevin was alive.
Dr Soar says if he was in cardiac arrest when he was taken to the gym he couldn’t have been alive.
In a report he said: “Although we think it is very unlikely, we cannot exclude what special constable Martin witnessed and mistook as Kevin saying mum was an aganol breath.
“These can occur when the heart has just stopped.”
Dr Soar says he thinks it is most likely that Kevin was already in cardiac arrest at the end of the CPR attempt at the Kop end of the pitch.
Dr Soar says the neck injury Kevin suffered did not appear to hinder him being given mouth-to-mouth in the photos he had seen.
He says: “We don’t think the neck injury prevented resuscitation on the pitch.”
Mr Weatherby asks if the time frame for Kevin’s death could be between 3.05pm and 3.06pm to 10-15 minutes after CPR started around the Kop end of the pitch.
That would be at about 3.40pm to 3.45pm.
Pete Weatherby asks questions on behalf of Kevin’s family.
Dr Soar agrees there is nothing inconsistent between the evidence of Mr Towler and Mr Bruder, because Mr Bruder saw Kevin’s head twitching before Mr Towler arrived.
Mr Weatherby says: “Putting it together, here we have not a medic, but an off-duty emergency services person , viewing the scene and identifying three separate signs of life.”
He adds: “You, looking at this from a medical perspective, would put some store in those as being signs of life?”
Dr Soar says: “Yes I would say that was plausible.”
He says looking at the photos the CPR seems of a high standard.
He agrees that assuming Mr Bruder saw signs of life, that would indicate either Kevin had gone into cardiac arrest very shortly beforehand, or was going into cardiac arrest or was about to go into cardiac arrest.
He says: “So earlier than that would be a critical period in terms of treatments.”
Ms Richards says Kevin’s post mortem recorded fractures of the neck.
Dr Soar says there was evidence of marks on his neck and the possibility of fractures on his voicebox, although the pathologists will give more evidence on that.
He says unless the voicebox was completely blocked the injuries described wouldn’t have stopped Kevin breathing.
Dr Soar says Mr Rankin’s evidence would be consistent with Kevin being in cardiac arrest - if accurate.
He says he thinks Mr Prescott described being an observer and allowing others to do assessments and treatment, although he described Mr Bruder saying he found a pulse.
He says Mr Towler was a senior divisional superintendent for St John Ambulance so he would expect him to have knowledge and assessment of CPR.
He says Mr Bruder’s evidence of seeing Kevin twitch could mean cardiorespiratory arrest had just occurred or was about to occur.
Jenni Richards, on behalf of the ambulance service, asks questions.
Dr Soar says the photos of Kevin in the pen, on their own, aren’t clear enough for him to reach conclusions about his precise condition.
He says he noted that Mr Craighill, the police officer, might have placed his hand on Kevin’s neck at the Leppings Lane end to check for a pulse, but he can’t be certain of that.
He says the thumps given by Mr Craighill rarely work and are no longer in guidance.
He says he can’t express any confident conclusions about Kevin’s condition after Mr Craighill treated him.
Ms Richards asks about the description of Kevin’s skin colour by people who carried him across the pitch.
He says skin colour is unreliable because it is subjective.
Dr Soar says both Mr Towler and Mr Bruder give evidence of a good duration of CPR for Kevin.
He says both descriptions describe there being no response.
Ms Lambert says there is no precise time for Debra Martin’s involvement with Kevin, but it might be around 3.45pm.
She asks about Ms Martin’s evidence of Kevin saying ‘mum’.
She says: “Do you think that is medically plausible?”
Dr Soar says: “No, and it is something that Prof Nolan and I have discussed at length.
“We don’t think it is plausible to be deeply unconscious for that duration and then to restore an adequate level of breathing and oxygen level and blood pressure for the brain to then regain adequate consciousness to then say a single word and then for that process to reverse again.
“So we don’t have a medical explanation for that.”
He says he doesn’t think it is plausible that Ms Martin felt a pulse after the CPR from Mr Towler and Mr Bruder.
He says that is because there had been a trial of competently performed CPR and no pulse was detected, apart from the faint pulse Mr Bruder described at the start.
Dr Soar says: “A weak pulse would imply a low blood pressure or a low cardiac output.”
Ms Lambert asks about the photos of Mr Bruder giving CPR.
He describes them as showing “textbook, exemplary” mouth-to-mouth.
He says: “From that sequence of photos, it does appear that he knew what he was doing in terms of giving mouth-to-mouth breaths.”
Dr Soar says after CPR there is evidence from three witnesses that there was no response to the CPR.
Mr Prescott and Mr Towler said a doctor then joined them.
Ms Lambert asks if Kevin went into cardiac arrest during that time.
Dr Soar says: “He could have gone in when the CPR started, so at the time those twitches were seen, and I’m confident that at the end - by the time they finished their 10 to 15 minutes of CPR, there are no signs of life reported by three individuals, so yes, he was in cardiac arrest.”
He confirms that the likely survival rate for someone receiving CPR outside hospital at the time of cardiac arrest was only about 2%.
He agrees that it seems Kevin didn’t fall into that 2%.
Dr Soar confirms the men who carried Kevin across the pitch only did a visual assessment of him.
He says all he can say with any certainty is that Kevin was deeply unconscious at that point.
Ms Lambert asks about the twitches Mr Bruder described seeing.
Dr Soar says: “Twitches of the head to me imply movement, and to have any movement, that does imply there is some blood flow to the brain.
“Whether that is because the heart has just recently stopped, about to stop or there’s a very weak heartbeat or the fact there’s been recent CPR and the brain is now running out of oxygen, it is difficult to say.
“But it is possibly a sign of life.”
He accepts the footage doesn’t suggest recent CPR.
He says: “He noticed them twice, so there is, you know, two episodes of movement that he sees of the head.”
He says: “They could mean the heart is beating or has just stopped beating.”
Ms Lambert says Mr Bruder described feeling a slight pulse in the neck.
Dr Soar says: “The rang of explanations are, yes, there was a weak heartbeat, and that would go with the twitching, or he thought there was a weak heartbeat and we know pulse checks aren’t always reliable, and they are the main two.”
He adds: “I think his assessment to then carry on CPR was appropriate, in that he did say it was weak.”
Dr Soar confirms Kevin was alive between 3pm and 3.03pm.
He says he can be certain that Kevin was “deeply unconscious” when removed from the pen.
Ms Lambert asks about the thumps to the chest Mr Craighill gave.
Dr Soar says: “If the heart stopped, if you thump it early enough after it stops, it may start beating again, but in practice it rarely works.”
He adds: “We can say that there was clearly no response to those punches in terms of Kevin responding physically.
“So again,k that’s another sign that he was deeply unconscious and unresponsive.
“But in terms of other vital signs, it’s not entirely clear.”
He says: “There’s a possibility he wasn’t breathing and didn’t have a pulse, but I can’t say that with any certainty.”
Ms Lambert says Debra Martin, a special constable, said she saw Kevin being carried on a hoarding at the Kop end.
She said she felt a feeble pulse and was sure she saw his chest rise.
She said she gave mouth-to-mouth in the gym.
She then picked him up, he opened his eyes, he said mum and then closed his eyes and went limp.
Ms Martin said she tried to revive him again and after a few minutes was told to stop.
In her first statement she recorded that she gave Kevin the kiss of life in the gym and he opened his eyes and said mum.
She said it was an oversight that in that statement she didn’t mention finding a pulse in Kevin’s neck.
In a second statement she didn’t mention Kevin breathing, opening his eyes, having a pulse or saying mum.
She said that statement was inaccurate and had been drafted by another person, Julie Appleton.
In an interview she gave to the Cook Report in 1994 she said she felt a “flutter” when checking for a pulse in Kevin’s neck.
She said she tried to do CPR on the pitch.
Ms Lambert says Kevin was confirmed dead by a doctor at 4.06pm.
Ms Lambert says John Towler, a divisional superintendent for St John Ambulance, said Kevin was very white and not moving.
He said Kevin didn’t have a pulse and wasn’t breathing.
He said he was told that by a fan but was sure he would have checked that himself before starting chest compressions.
In his 1989 statement he said he checked for a pulse and couldn’t find one.
He said he would have checked the neck for about a minute for a pulse.
He said he and Mr Bruder performed CPR.
He said they were trained to check for a pulse every three minutes and he thought he would have done that automatically.
He said if anyone had said they could find a pulse he would have checked for himself and would have stopped chest compressions if he had found one.
He said some fluid was coming from Kevin’s mouth.
He said a woman who was a doctor took over chest compressions and after five minutes said “you’re not getting anywhere”.
We’re back in court now and Ms Lambert continues reminding the court of Mr Bruder’s evidence about Kevin at the Kop end of the pitch.
He said he checked Kevin’s neck for a pulse.
He said he felt a slight pulse.
He said he was “absolutely positive” that he checked the correct part of the neck and did feel a slight pulse.
He said it was not strong enough to put Kevin into the recovery position and he thought without CPR Kevin might die.
Ms Lambert says police officer Mr Sawers and pathologist Dr Slater gave evidence about Mr Bruder’s statements but Mr Bruder was adamant he found a pulse.
He said he started mouth to mouth while Mr Towler gave chest compressions.
The court is shown photos from 3.32pm to 3.33pm.
Mr Bruder is shown giving mouth-to-mouth.
Mr Bruder said he noticed Kevin’s ribcage was prominent.
He remembered the ambulance driving onto the pitch.
Ms Lambert says that was at 3.35pm.
He said he sent Mr Towler to flag down the ambulance but it didn’t stop.
Mr Bruder said after five minutes Kevin started to go great.
He said a St John volunteer who was a woman took over chest compressions.
He said after CPR the female St John volunteer said Kevin had gone.
He said he wouldn’t have left Kevin if he wasn’t confident he had died.
He didn’t record any assessment to confirm Kevin had died.
The court is going to have a short adjournment while the problem is dealt with.
There is a pause as the court transcript has stopped working.