No one was in charge of casualties in the makeshift morgue at Hillsborough, a Sheffield doctor has told the new inquests into the tragedy.
Dr Nicholas Kearsley, a Sheffield United fan, was a GP at the time of the 1989 tragedy which left 96 Liverpool fans dead.
He was not working and had gone to watch the FA Cup Semi Final with another doctor.
Dr Kearsley said: “There was nobody there to give instructions or direction, as far as I was aware.”
At around 3.04pm when Peter Beardsley hit the crossbar the medic saw fans climbing over the fences and thought there was a pitch invasion.
After the match was stopped he and his friend went to ask if they could help.
Dr Kearsley said there did not appear to be anyone in charge of the relief and resuscitation efforts in the gym where injured fans were being taken.
Asked how the casualties were positioned, he said: “Quite a few of them were lying on their back, or looked like they were lying on their back, I think they were positioned lying on their back.
“They weren’t in the resuscitation position.”
He said people being left on their backs might have meant the difference between life and death.
Dr Kearsley said apart from relatives and friends there did not seem to be many people tending to them.
“There were a lot of people, mainly young people, who looked awful,” he said.
“They looked grey, they looked pale, they looked blue and they looked extremely unwell, or certainly a number of them looked extremely unwell.”
■ This year’s Hillsborough Memorial Service takes place at Anfield on Wednesday, April, 15.