21 Dec 2018 Richard John Whale · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Failure of club stewards to comply with the steward code of conduct View source Lack of guidance on steward placement to keep handrail access clear View source Lack of regular audits of steward compliance with the Code of Conduct View source Failure of staircase width standards to account for steward deployment View source Lack of mechanisms for discussing and monitoring implementation of recommendations View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Richard John Whale · 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
Richard John Whale died at Salford Royal Hospital after suffering a head injury in a fall down the exit stairs at Old Trafford football ground. The concerns included stewards impeding the exit and obstructing access to handrails, inadequate guidance on steward placement, non-compliance with the stewards’ code of conduct, and a lack of evidence of regular audits. There was also no mechanism to discuss or monitor whether recommendations issued after his death had been followed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of club stewards to comply with the steward code of conduct
Wider context from the report “4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on steward placement to keep handrail access clear
Wider context from the report “3. The green guide does not give guidance as to placement of stewards or suggest best practice to avoid stewards blocking access to the handrails. It was accepted during the course of the inquest that the role and placement of stewards was vital to ensuring the safety of the public at football matches.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of regular audits of steward compliance with the Code of Conduct
Wider context from the report “4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of staircase width standards to account for steward deployment
Wider context from the report “2. The widths of the staircases (“vomitories”) is set in the Green Guide. Those widths take into account the handrails but not the inevitable reduction in width that takes place when stewards are deployed into them. In effect, the vomitories are significantly narrower at points than the suggested widths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of mechanisms for discussing and monitoring implementation of recommendations
Wider context from the report “1. The Local Authority had issued a list of recommendations to the club after the death of Mr Whale. There was no mechanism in place for discussion of those recommendations or to ensure that they had been followed or if not followed discussion for reasons.
” Open source report
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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 Continue regulatory monitoring of sports-ground safety and take action when necessary.
Verbatim wording from the response “Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.” Source location 2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
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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 Publish the sixth edition of the Green Guide with expanded guidance on vomitories, steward positioning, widths, control measures, and steward training.
Verbatim wording from the response “The SGSA has since published the latest 6th edition of the Green Guide in October 2018. This latest edition expands upon the guidance in the 5th edition and includes specific guidance on vomitories and the positioning of stewards (section 9.8), vomitory widths (section 9.9) and vomitory control measures (section 9.10). It recognises that the width of a vomitory, and of gangways leading to a vomitory, are key control measures (section 9.9). Furthermore, Chapter 4 highlights that safety at sports grounds relies to a great extent upon the deployment of an appropriate number of well trained and suitably equipped stewards, with section 4.6 outlining stewards’ duties and section 4.10 detailing current stewards training and assessment processes. The new edition of the Green Guide has informed the SGSA’s engagement with Trafford MBC and MUFC.” Source location 2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
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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 Amend Green Guide section 9.8e to specifically address spectator access to handrails during vomitory ingress and egress.
Verbatim wording from the response “In light of the concerns you have raised the SGSA is amending the Green Guide so that section 9.8e makes a specific reference to access to handrails in the context of vomitories and the positioning of stewards. The relevant extract is below, with the proposed new wording shown in italics:” Source location 2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
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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 Liaise with Trafford MBC and MUFC and monitor steward behaviour and safety arrangements at Old Trafford.
Verbatim wording from the response “The SGSA is aware of the incident leading to the death of Mr Richard Whale in December 2017. Since the incident took place, the relevant SGSA Inspector has been liaising closely with both Trafford Metropolitan Borough Council (MBC) and MUFC, most recently in November 2018. This liaison has focused on ensuring that lessons are learned from the incident and are being applied by the club and the local authority, particularly in relation to the ongoing provision of suitably qualified and trained stewards at Old Trafford. There has been monitoring of stewards’ behaviour in and around vomitories, especially during ingress and egress.” Source location 2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
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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 The SGSA considers Trafford MBC and MUFC’s identified safety issues and steps taken to address them sufficient, subject to ongoing monitoring.
Verbatim wording from the response “Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.” Source location 2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Open published response
Concerns raised 10 Failure of Tour Operators to collaborate and share health and safety information View source Failure to provide carbon monoxide detectors in accommodation with individual gas appliances View source Lack of a central register and up-to-date energy-source and service-history information for holiday premises View source Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises View source Delegation of health and safety checks to inexperienced and overworked Tour Representatives View source Failure to provide clear traveller information about carbon monoxide dangers and safeguards View source Lack of robust internal health and safety management, supervision, support and training View source Lack of publicly accessible accommodation health and safety inspection reports View source Lack of suitably qualified specialist health and safety inspections at holiday accommodation View source Failure to carry out annual accommodation safety audits View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christianne Shepherd and Robert Shepherd · 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
Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure of Tour Operators to collaborate and share health and safety information
Wider context from the report “2. In most situations a hotel, apartment or other holiday premises will be used by more than one Tour Operator. In this event a system should be devised for Tour Operators to work in collaboration with communicate and actively share information pertaining to Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carbon monoxide detectors in accommodation with individual gas appliances
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises.
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation , which has individual gas appliances , whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of a central register and up-to-date energy-source and service-history information for holiday premises
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises
Wider context from the report “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises .
That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Delegation of health and safety checks to inexperienced and overworked Tour Representatives
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task . The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear traveller information about carbon monoxide dangers and safeguards
Wider context from the report “7. All holiday brochures and travel promotional literate and Health and Safety information should be written in clear, easy to understand language and should make specific reference to the dangers of carbon monoxide poisoning , and make reference to safeguards that travellers should adopt .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of robust internal health and safety management, supervision, support and training
Wider context from the report “6. Within the structure and hierarchy of every provider of hotels, apartments and holiday premises there should be a robust internal structure for a system of management, supervision support and training in respect of Health and Safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of publicly accessible accommodation health and safety inspection reports
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible . In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Lack of suitably qualified specialist health and safety inspections at holiday accommodation
Wider context from the report “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety . Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks , the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Digital, Culture, Media and Sport; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out annual accommodation safety audits
Wider context from the report “1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations