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recurance

Jack Riding

26 Nov 2018 · Coroner Joseph Hart · Liverpool & Wirral

The coroner's concerns

  1. 1. delayed defibrillator deployment

    “I heard evidence that there was a significant delay in bringing a defibrillator to the pitch where [the deceased] had collapsed. There was a delay of some minutes before the defibrillator was deployed. I make it clear that this could not be said to be a contributing factor in Mr [name redacted] death. I have received evidence of the systems in place to deploy the defibrillator from Goals Soccer Centres plc. It remains a concern to me that when matches are being played that the defibrillator is kept away from”
  2. 2. ambulance arrival delay

    “2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the that policy in place is”
  3. 3. insufficient first aid training

    “I have seen a limited risk assessment to consider what should be done in the case of a medical emergency on the pitch. I have seen no clear indication of the extent and subject matter of any first aid training. I have seen evidence that training has taken place. In the absence of any such evidence I am concerned that a lack of training may present a risk of future death.”
  4. 4. delayed health and safety review

    “I note that Goals Soccer Centres Plc recognise a need to review the Health and Safety processes. They have instructed an Independent Consultant to undertake a review of Health and Safety processes and procedures but with no clear timescale for this review I am still of the view that I am under a duty to prepare this report.”

Responses

2018-0303-Responses.pdf ↗· Football Association

Stated action · 1* March 2019

“All Defibrillators will be housed in a location highly visible to the public in our receptions by 1* March 2019. 28 units are already located in a prominent position visible to the public and will remain in place, 18 units will be relocated into more prominent positions for customers with clear Defibrillator signage.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Jack Riding · Recurance