Recurring concern

Failure to tailor safety arrangements to individual entertainment events and venues

First to latest report 25 Nov 2021 — 6 Jun 2024

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 2

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

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

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

6 Jun2024
Worcestershire
Concerns raised2
1. Failure to carry out individualised venue risk assessments
2. Failure to assess and oversee event medical cover risks
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department for Digital, Culture, Media and Sport
Ultra Events Ltd
Stated actions 2
1. Ultra Events Ltd
  Proactively contact venues about changes before events and use disclosed changes to formulate updated event risk assessments and plans.
2. Ultra Events Ltd
  Require medical providers to submit event-specific risk assessments and Medical Plans for logging with event paperwork.
Respondent positions 3
1. Department for Digital, Culture, Media and Sport
  Individual boxing event organisers are responsible for protecting participants’ safety and wellbeing.
  Redirects responsibility
1. Ultra Events Ltd
  Individualised risk assessments were always conducted for each venue and event, including the Worcester event.
  Disputes the concern
2. Ultra Events Ltd
  Medical providers remain responsible for risk assessing event medical provision because they possess the necessary specialist expertise.
  Redirects responsibility
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
25 Nov2021
Newcastle upon Tyne
Concerns raised1
1. Failure to provide venue-specific entertainment safety policies and warnings
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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