Nearly half of the Hillsborough victims could have been saved but a string of blunders by police and ambulance crews meant they were left to die slowly on the pitch.
The hard-hitting report into the 1989 disaster in which 96 Liverpool fans were killed found 41 of them had pulses and were breathing long after the crush.
But life-saving equipment remained in ambulances outside the ground banned by police from entering as they thought frantic supporters were fighting.
And dithering 999 crews failed to put into action a major incident plan that could have established if any of the ?seriously injured fans were still alive.
But a ruling in 1991 by controversial coroner Dr Stefan Popper who insisted all the victims were dead by 3.15pm led to the belief medical intervention would have made no difference.
It meant the chaotic role of the emergency services in the disaster was never examined and has for 23 years been effectively ignored.
Now angry families are demanding Dr Popper’s accidental death verdicts be ripped up and another inquest ordered.
Dr Bill Kirkup, part of the investigatory Hillsborough panel, yesterday revealed the shocking truth about fans being left to die on the pitch.
He said: “In total, 41 had evidence that they had potential to survive after 3.15pm. What I can’t say is how many of them could, in actuality, have been saved. But I can say is that, ?potentially, it was in that order of magnitude.”
The report revealed that in 31 of the dead, the heart and lungs continued to function after the crush and in 16 of those it was for a prolonged period.
There were indications some may still have been alive up until 4pm.
And the report criticised the coroner’s 3.15pm cut-off. It added: “It led to the mistaken belief that an effective emergency services intervention could not have saved lives.
“The panel’s disclosure confirms that in some cases death was not immediate and the outcome depended on events after 3.15pm.”
The revelations were greeted by dismay by victims’ relatives, who have been left traumatised by the bombshell news their loved ones could have been saved.
Margaret Aspinall, who lost son James, 18, said: “I find it very difficult.
“When the families heard when that came out today, some of them passed out. It’s a very painful thing to hear.
“I haven’t really thought about it because if we do our emotions will take over. We said to each other when we came here, ‘Could James have been one of them? Could Sarah [Hicks] or Vicky [Hicks]?’
“We don’t know who it is yet and we’ve got to face who they are.”
Bishop of Liverpool James Jones added: “For nearly a quarter of a century the families of the 96 and the survivors of Hillsborough have nursed an open wound waiting for answers to unresolved questions.
“It has been a frustrating and painful experience adding to their grief. The documents show the tragedy should never have happened. There were clear operational failures in response to the disaster and in its aftermath there were strenuous attempts to deflect the blame onto the fans.
“The panel’s report shows how vulnerable victims, survivors and their families are when transparency and accountability are compromised.”
The damning report was revealed to families at Liverpool’s Anglican Cathedral. It was outlined in the Commons yesterday by David Cameron and determined “institutional tension” between police and partner organisations led to senior officers becoming obsessed with the prospect of fan disorder rather than maintaining crowd safety at the Sheffield ground’s Leppings Lane pens.
Trevor Hicks, who lost two daughters Vicki, 15, and Sarah, 19, in the disaster, vowed the families would now press for criminal action against those involved in the disaster.
“The truth is out today, justice starts tomorrow,” he said.
And he condemned the authorities for the shocking “depths of depravity” in the way the police tried to blame the fans after the disaster.
Stephen Wright, who lost 17-year-old brother Graham in the tragedy, struggled to contain his emotion as he said: “Today, my brother was up there mouthing the words, ‘Thank you’.
“We have been fighting for 23 years for him and never given up on him.
“If you knew the truth, like we did, you’d never stop either. And we’ve been proved right.”
Liverpool Walton MP Steve Rotheram last night revealed around 70 of the Hillsborough families still furious with Dr Popper’s inquest verdicts are demanding they be quashed and will apply to the High Court for a new hearing into the deaths.
He added: “It’s not just about the 41 people after the cut off time, it’s everyone, the ruling of accidental death is a complete insult to the families of the 96.”
He went on: “How can you have 96 accidental deaths in the same place at the same time? It doesn’t make sense.”
Mr Cameron told the Commons he had instructed attorney general Dominic Grieve to establish whether the High Court should be petitioned for the original inquest to be quashed so that a new one could be held into the deaths.
The law allows for a fresh hearing to be held if the applicant can show fraud, rejection of evidence, irregularity of proceedings or discovery of new facts or evidence.
Sheila Coleman, of the Hillsborough Justice Campaign, said: “The attorney general needs to surely, with the evidence presented to him today and the evidence previously presented, must quash the inquest verdicts in all cases.
“With the clear evidence that fans could have been saved he needs to give all of those 96 victims their right under law, the right to a fair hearing. It needs a full inquiry into how they died.”
Dr Popper was condemned for his findings at the time that effectively turned the spotlight away from the response of the emergency services.
But alarm bells about Sheffield Wednesday’s Hillsborough stadium were ignored for at least eight years before the disaster, the report also revealed.
There was a near-fatal crush at an FA Cup semi-final in 1981. And the ground had problems with turnstiles, fan monitoring in the Leppings Lane pens, emergency escape plans and the condition of crush barriers.
Turnstile trouble delayed the 1987 FA Cup semi and there was a crush at the same tie a year later. But despite the problems, bosses failed to act.
The report found poor safety standards at the ground and cost-cutting played a major part in the 1989 tragedy before Liverpool’s FA Cup semi clash with Nottingham Forest.
The panel said: “The risks were known and the crush in 1989 was foreseeable.”
Hillsborough had failed to meet minimum safety standards since 1978 but the report said the club’s “primary concern was to limit costs”.
The panel said Wednesday had denied knowledge of crowd-related problems at the 1987 and 1988 semis.
Way is open for criminal prosecution
The damning report opens the way for criminal charges against those responsible for the tragedy and the cover-up.
Legal experts believe the CPS could bring misconduct in a public office and perverting the course of justice charges. Both carry maximum sentences of life.
Sheila Coleman, of the Hillsborough Justice Campaign, said: “All the evidence today shows that South Yorkshire Police lied and operated a cover-up.”
Top lawyer Michael Mansfield QC, who has been advising the families, said: “There was no safety certificate. That is the beginning of serious negligence.
“It isn’t just the police, Sheffield Wednesday and the Sheffield authorities need to answer some questions.”
Tory MP Robert Buckland added: “Officers involved in the cover-up who changed 164 statements could be charged with perverting the course of justice.”
South Yorkshire Chief Constable David Crompton pledged to cooperate, saying criminal acts must be prosecuted.