Recurring concern

Unreliable emergency arrangements for organised public events

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First reported 14 Jan 2015•Latest report 10 Apr 2025

Definition

What this concern includes

Includes failures of emergency arrangements dedicated to organised public events, including venue-specific briefings for first aiders, marshals and participants, procedures for summoning or directing emergency services, and arrangements for pausing or managing event activity to allow emergency access.

Not included

  • Excludes generic event regulation, licensing or overall event governance where no operational emergency-arrangements deficiency is identified.
  • Excludes ordinary safety briefings unrelated to emergency response or emergency access.
  • Excludes failures of emergency-service dispatch, ambulance capacity or clinical treatment after responders have been contacted.
  • Excludes generic communication, staffing or training deficiencies unless they directly impair emergency arrangements for an organised public event.
Reports
4

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
1

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.

Department for Digital, Culture, Media and Sport1
Department of Health and Social Care1
First Aid Cover Ltd1
Health and Safety Executive1
Leeds City Council1
The Roundhouse Trust1
White Branch Live 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. Sunderland

    AI-generated summary

    Mr Joel Kenneth Ineson · 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

    Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.

    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

    Lack of emergency plans for organised open water swimming events

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    César Cuauhtémoc González Barrón · 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

    César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.

    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 ensure first aider knowledge of ambulance-summoning arrangements

    Wider context from the report

    “2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it. She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance. She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building. ”

    Source location

    César Cuauhtémoc González Barrón · 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 communicate the nature of an emergency when summoning first aiders

    Wider context from the report

    “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened. She had no understanding of the nature of the emergency. The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going. The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it. ”

    Source location

    César Cuauhtémoc González Barrón · 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 guide and assist first aiders responding to emergencies

    Wider context from the report

    “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened. She had no understanding of the nature of the emergency. The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going. The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it. ”

    Source location

    César Cuauhtémoc González Barrón · 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 ensure first aider identification of venue staff during emergencies

    Wider context from the report

    “6. When Mr González Barrón collapsed, the scene was chaotic. No person took charge. There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance, for example, in retrieving her equipment. She was distracted by the noise and comment of those around. ”

    Source location

    César Cuauhtémoc González Barrón · 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 brief first aiders on venue emergency arrangements

    Wider context from the report

    “2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it. She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance. She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building. ”

    Source location

    César Cuauhtémoc González Barrón · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. West Yorkshire Eastern

    AI-generated summary

    Joshua Lee Edwards · 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

    Joshua Lee Edwards, aged 19, became unwell in Leeds after taking ecstasy and cocaine and died in hospital on 15 May 2017 despite treatment. The ambulance was delayed by road closures for the Leeds 10K run, and concerns were raised that repeated calls from police did not lead to escalation and that ambulance crews were unclear about crossing road-closure signs in an emergency.

    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 road signs that preserve emergency vehicle access at designated crossing points

    Wider context from the report

    “(4) Road closure signs at such designated crossing points should be replaced by signs indicating ‘Access to emergency vehicles only’ or equivalent wording. ”

    Source location

    Joshua Lee Edwards · Prevention of Future Deaths report
    Page 1 · 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 ensure public-event personnel and participants are informed about emergency vehicle crossings

    Wider context from the report

    “(3) In the preparation for such public events, the organisers should be required to brief their Marshalls that at specified crossing points, the event may require to be halted momentarily to allow emergency response vehicles to cross. In short, that an emergency may take precedence. Participants in the event should also be forewarned of the possibility of this occurring. ”

    Source location

    Joshua Lee Edwards · Prevention of Future Deaths report
    Page 1 · 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 maintain emergency vehicle access during public events

    Wider context from the report

    “(1) The ambulance despatched to the scene encountered roads closed for the Leeds 10K run that day. It then navigated a route around the course, thus encountering a delay in reaching the casualty. The Police Officers at the scene telephoned three times to ask where the ambulance was but this did not result in the situation being escalated in the control room at Yorkshire Ambulance Service. ”

    Source location

    Joshua Lee Edwards · Prevention of Future Deaths report
    Page 1 · 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

    Continually review event road closures to ensure they remain appropriate, minimal and safe.

    Verbatim wording from the response

    “Whilst some road closures are inevitable with the events in the city, we are also continually reviewing these to make sure they are appropriate, kept to a minimum and are as safe as possible.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 3 · response
    Published 2 March 2019

    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

    Replacing road-closure signs could weaken their prohibition and create safety risks; existing signs should remain under current legislation with controlled emergency access measures.

    Verbatim wording from the response

    “Road closure signs during events are placed for the safety of event participants and road users alike. In the current climate of vehicle incursion we would not seek to weaken their prohibition of vehicles by allowing anyone to confuse or misinterpret the message to suggest that any form of access is permitted. In doing so there will always be road users who interpret the signs to their advantage. In discussions with emergency services and traffic regulation colleagues I feel it is preferable to maintain the road closure signing as it is set out in the Traffic Signs Regulations and General Directions legislation and take other measures such as those described above. This will provide authority to those who legitimately need access in a controlled way. This will ensure that any delays to genuine emergencies are minimised and the safety of the event participant is not compromised.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 3 · response
    Published 2 March 2019

    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

    Existing event management plans, designated crossing points and trained marshals sufficiently address emergency vehicle access and temporary event stoppages.

    Verbatim wording from the response

    “Every major event such as the half-marathon and Leeds 10k run includes an Event Management Plan which sets out the process for emergency responses, emergency vehicle access and the training of Marshalls. Emergency routes are agreed with emergency services during the planning for each event. Specific locations to cross the routes are designated. These are used wherever possible. Other locations can be used under the control of Event Control. All road closure points are staffed with marshals capable of assisting access and halting events in the case of an emergency.”

    Source location

    2018-0335-Response-by-Leeds-City-Council
    Page 2 · response
    Published 2 March 2019

    Open published response

  4. Inner South London

    AI-generated summary

    Max Carlton-Smith · 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

    Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

    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

    Barricading of rave venues against police and other emergency access

    Wider context from the report

    “The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did. ”

    Source location

    Max Carlton-Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026