Recurring concern

Unreliable Welfare Officer contact arrangements

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First reported 31 May 2019•Latest report 10 Mar 2021

Definition

What this concern includes

Includes failures in Welfare Officer contact arrangements, including maintaining current appointments and contact details, prominently displaying or otherwise communicating them, providing cover or alternative contact when the primary officer is unavailable, and ensuring people seeking welfare or safeguarding support can reach the responsible function.

Not included

Excludes general safeguarding, welfare-support or safeguarding-training deficiencies where Welfare Officer contact arrangements are not the identified unsafe condition.
Excludes failures in the substantive investigation or management of a welfare concern after a current and accessible Welfare Officer has been reached.
Excludes generic contact-directory, communication or staffing deficiencies unless they directly impair access to the Welfare Officer function.
Excludes unrelated care, clinical, police or emergency contact processes without an explicitly comparable Welfare Officer arrangement.

Reports: 2
Individual concerns: 3
Date range: 2019–2021
Stated actions: 5

Reports 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.

Department for Digital, Culture, Media & Sport (2017 to 2023)1

England Boxing Limited1

Surrey Police1

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.

10 Mar2021
Derby and Derbyshire
Concerns raised2
1. Failure to maintain current Welfare Officer registration records
2. Failure to display current Welfare Officer contact details prominently at clubs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Require clubs to maintain specified coaches, a committee and Welfare Officer, adopt the safeguarding policy, and undergo membership and facility checks before seasonal approval.
  Stated by England BoxingStated completed
2. Action
  Expand The Vault to actively track registrations and centralise checks of coach qualifications, safeguarding, first-aid and DBS certifications.
  Stated by England BoxingStated completed
3. Action
  Set up an independent inquiry into safeguarding, club registration and oversight responsibilities, with terms of reference informed by the Inquest.
  Stated by England BoxingStated in progress
1. Action
  Work with Sport England and England Boxing to review and address concerns raised in the reports.
  Stated by Department for Digital, Culture, Media and SportStated planned
AI-generated summary

Edward Lewis BILBEY · 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

Edward Lewis Bilbey died at Kings Mill Hospital on 24 March 2017 after collapsing in a boxing ring following intensive training. The inquest found that his death resulted from an undiagnosed heart condition combined with metabolic disturbance associated with intense physical training and rapid weight loss by dehydration. The report raised concerns that Boxing England lacked systems to monitor and enforce child protection and safeguarding compliance, and that this issue might be more widespread among national sporting bodies.

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 maintain current Welfare Officer registration records
Wider context from the report
“At Mr Bilbey’s club the registered Welfare Officer had left the club three years prior to Mr Bilbey’s death. However, his name was at the time registered on ‘The Vault’ held and maintained by England Boxing. From the evidence heard at inquest there no thing to demonstrate that the name of the Welfare officer and his contact details were displayed prominent in the club. In fact those details were not displayed at all. There was a registered level 2 couch registered on ‘The Vault’. However, in evidence the witness stated under oath that he did not undertake any training or coaching activities at the club. ”
Source location
Edward Lewis BILBEY · 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 display current Welfare Officer contact details prominently at clubs
Wider context from the report
“At Mr Bilbey’s club the registered Welfare Officer had left the club three years prior to Mr Bilbey’s death. However, his name was at the time registered on ‘The Vault’ held and maintained by England Boxing. From the evidence heard at inquest there no thing to demonstrate that the name of the Welfare officer and his contact details were displayed prominent in the club. In fact those details were not displayed at all. There was a registered level 2 couch registered on ‘The Vault’. However, in evidence the witness stated under oath that he did not undertake any training or coaching activities at the club. ”
Source location
Edward Lewis BILBEY · 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
Require clubs to maintain specified coaches, a committee and Welfare Officer, adopt the safeguarding policy, and undergo membership and facility checks before seasonal approval.

Verbatim wording from the response
“Club membership requires the presence of a registered level 1 and level 2 Coach, a committee, and a designated Welfare Officer. Clubs must also adopt England Boxing’s Safeguarding Policy. Details of the above information must be registered on “The Vault”. New applications are supplied to England Boxing centrally, with the relevant Region dealing with renewals. A Regional representative will then conduct a visit to the club in order to carry out physical checks on the facilities, whilst the Registrar will check the relevant paperwork and membership requirements before approving the club for the season.”

Source location
2021-0068-Response-from-England-Boxing-Redacted
Page 4 · response
Published 12 March 2021
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
Expand The Vault to actively track registrations and centralise checks of coach qualifications, safeguarding, first-aid and DBS certifications.

Verbatim wording from the response
“Vault: At the time of this incident “The Vault” system was in its infancy and its benefits and capabilities were not utilised to the full. Since then, the system has expanded in use and registrations are actively tracked, ensuring accountability. Prior to the introduction of The Vault club membership was administered regionally and, upon centralisation of the process, training and instruction was provided to Registrars in each region. They were responsible for confirming the necessary qualifications were in place for the coaches and club before approving the application, but it has become apparent that there was some variation in some of the club facility requirements between regions (but not coaching qualifications).”

Source location
2021-0068-Response-from-England-Boxing-Redacted
Page 4 · response
Published 12 March 2021
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
Set up an independent inquiry into safeguarding, club registration and oversight responsibilities, with terms of reference informed by the Inquest.

Verbatim wording from the response
“Independent Inquiry: Immediately following this incident, England Boxing identified a number of issues which required analysis and action. As set out above, many of those were implemented prior to the Inquest. However, although the Court will note that post-incident meeting minutes”

Source location
2021-0068-Response-from-England-Boxing-Redacted
Page 4 · response
Published 12 March 2021
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
Work with Sport England and England Boxing to review and address concerns raised in the reports.

Verbatim wording from the response
“My department will work with Sport England and England Boxing to review and address the specific concerns raised in these reports.”

Source location
2021-0068-Response-from-DCMS-Redacted
Page 2 · response
Published 12 March 2021
Open published response
31 May2019
Berkshire
Concerns raised1
1. Unavailability of Welfare Officer contact when the primary Welfare Officer is off duty
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide secondary Welfare Officer cover for absences and list relevant support contacts at the front of each Duty of Care Risk Assessment.
  Stated by Surrey PoliceStated completed
AI-generated summary

Joshua Oliver Maxwell Blackham · 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 Blackham, a 30-year-old police officer, was found hanged on 29 November 2016 after his suspension from duty and amid increasing personal pressures, including relationship breakdown, financial concerns and concerns about contact with his daughter. The report raised concerns about inadequate welfare-officer training, insufficient information sharing, lack of arrangements for welfare contact when the officer was unavailable, and shortcomings in the NHS mental-health support for which Joshua had been referred.

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
Unavailability of Welfare Officer contact when the primary Welfare Officer is off duty
Wider context from the report
“5. Any new arrangement should make allowances for contact with a Welfare Officer where the primary Welfare Officer is off duty. ”
Source location
Joshua Oliver Maxwell Blackham · Prevention of Future Deaths report
Page 3 · 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
Provide secondary Welfare Officer cover for absences and list relevant support contacts at the front of each Duty of Care Risk Assessment.

Verbatim wording from the response
“5. Having a secondary (back up) WO who has been included in the revised process to ensure that there is suitable cover for annual leave or other absence. Contact details of all relevant persons supporting the particular officer/staff member will be listed at the front of the DOCRA.”

Source location
2019-0182-Response-by-Surrey-Police
Page 3 · response
Published 14 August 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to maintain current Welfare Officer registration records

Failure to display current Welfare Officer contact details prominently at clubs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Unavailability of Welfare Officer contact when the primary Welfare Officer is off duty

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 4

Actions described in response 1