Jack Riding
26 Nov 2018 · Coroner Joseph Hart · Liverpool & Wirral
The coroner's concerns
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. 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. 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. 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.”