Recurring concern

Failure to tailor safety arrangements to individual entertainment events and venues

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First reported 25 Nov 2021•Latest report 6 Jun 2024

Definition

What this concern includes

Includes failures in the dedicated safety-management process for entertainment events to identify venue-specific risks and tailor policies, risk assessments, warnings and related protective arrangements to each individual event and venue.

Not included

  • Excludes generic event governance, licensing or regulatory oversight where no failure to tailor safety arrangements to a specific entertainment event and venue is identified.
  • Excludes failures limited to emergency response, medical cover, security, staffing or equipment where the event- and venue-specific safety-arrangement condition is not also asserted.
  • Excludes routine entertainment provision or ordinary venue hazards without a deficient event-specific safety control.
  • Excludes generic risk-assessment failures unrelated to entertainment events or their venues.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2021–2024

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Bounce Til I Die1
Department for Digital, Culture, Media and Sport1
Ultra Events Ltd1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Worcestershire

    AI-generated summary

    Dominic Mark Chapman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dominic Mark Chapman sustained a fatal head injury during a charity boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester on 9 April 2022, and died in hospital on 11 April 2022. The concerns identified included unclear and inconsistently applied criteria for matching opponents by weight, training that did not follow the intended pattern, and inadequate individualised risk assessments for events and medical cover.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out individualised venue risk assessments

    Wider context from the report

    “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.: (a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them. I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes; (b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events. I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments. This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment. ”

    Source location

    Dominic Mark Chapman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess and oversee event medical cover risks

    Wider context from the report

    “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.: (a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them. I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes; (b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events. I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments. This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment. ”

    Source location

    Dominic Mark Chapman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Proactively contact venues about changes before events and use disclosed changes to formulate updated event risk assessments and plans.

    Verbatim wording from the response

    “12. We have always carried out risk assessment for all new venues by attending them in person. We have also always conducted individualised risk assessments for each event and, indeed, one was carried out for the Worcester event that Dominic attended. However, we have traditionally been reliant upon the venue volunteering details of any changes to their premises during that process.”

    Source location

    Response from Ultra Events
    Page 4 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require medical providers to submit event-specific risk assessments and Medical Plans for logging with event paperwork.

    Verbatim wording from the response

    “15. However, we now ask our medical providers to supply us with their event-specific risk assessment and Medical Plan. Our email explains that they are required to carry out a thorough assessment of all of the risks which pertain to this event at particular premises, to an extent that ensures that they are fully capable of dealing with any medical event, emergency or otherwise, which may occur.”

    Source location

    Response from Ultra Events
    Page 5 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individual boxing event organisers are responsible for protecting participants’ safety and wellbeing.

    Verbatim wording from the response

    “The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will always be risks associated with participating in contact sports, but it is important that robust measures are in place to reduce the risk of major injuries and health issues. It is the responsibility of individual boxing event organisers to ensure that they protect the safety and wellbeing of their participants.”

    Source location

    Response from DCMS
    Page 1 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individualised risk assessments were always conducted for each venue and event, including the Worcester event.

    Verbatim wording from the response

    “12. We have always carried out risk assessment for all new venues by attending them in person. We have also always conducted individualised risk assessments for each event and, indeed, one was carried out for the Worcester event that Dominic attended. However, we have traditionally been reliant upon the venue volunteering details of any changes to their premises during that process.”

    Source location

    Response from Ultra Events
    Page 4 · response
    Published 14 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Medical providers remain responsible for risk assessing event medical provision because they possess the necessary specialist expertise.

    Verbatim wording from the response

    “14. Medical providers are best placed to carry out risk assessments, as they are the ones with the specialist knowledge required to ensure safety in their field of expertise. As such, risk assessing of medical provisions at each event at each venue remains with the medical provider.”

    Source location

    Response from Ultra Events
    Page 5 · response
    Published 14 June 2024

    Open published response
  2. Newcastle upon Tyne

    AI-generated summary

    Neil James STEWART · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil James Stewart travelled to Amsterdam in November 2017 and, on 18 November 2017, entered the Noordzeekanaal after jumping from a party boat; his body was recovered on 3 December 2017. The concerns addressed written safety policies and warnings for guests, venue-specific risks, and clarity about safety responsibilities between entertainment providers and venue organisers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide venue-specific entertainment safety policies and warnings

    Wider context from the report

    “(2) Create/adopt a written policy/protocol for providing services (entertainment) at a venue that is associated with risks unique/specific to that venue which should include bespoke warnings/guidance to be given to clients who attend. ”

    Source location

    Neil James STEWART · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026