26 Nov 2018 Jack Riding · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 6 Failure to ensure prompt access to and deployment of the defibrillator View source Lack of clearly defined first aid training View source Limited risk assessment for medical emergencies on the pitch View source Lack of training and drills for directing emergency services View source Failure to ensure appropriate direction of arriving paramedics View source Lack of a clear timescale for reviewing Health and Safety processes and procedures View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Riding · 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
Jack Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future death.
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. The report was sent to Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prompt access to and deployment of the defibrillator
Wider context from the report “(1) I heard evidence that there was a significant delay in bringing a defibrillator to the pitch where Jack Riding had collapsed. There was a delay of some minutes before the defibrillator was deployed. I make it clear that this could not be said to be a contributing factor in Mr Riding’s death. I have received evidence of the systems in place today for the defibrillator from Goals Soccer Centres plc. It remains a concern to me that when matches are being played that the defibrillator is kept away from the pitch and the deployment of the equipment is dependent on which members of staff are present . I am concerned that any delay in the deployment of this emergency equipment presents a risk of future death .
” 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 Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Lack of clearly defined first aid training
Wider context from the report “(3) I have seen a limited risk assessment to consider what should be done in the case of a medical emergency on the pitch. I have seen no clear indication of the extent and subject matter of any first aid training . I have seen evidence that training has taken place. In the absence of any such evidence I am concerned that a lack of training may present a risk of future death .
” 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 Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Limited risk assessment for medical emergencies on the pitch
Wider context from the report “(3) I have seen a limited risk assessment to consider what should be done in the case of a medical emergency on the pitch . I have seen no clear indication of the extent and subject matter of any first aid training. I have seen evidence that training has taken place. In the absence of any such evidence I am concerned that a lack of training may present a risk of future death.
” 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 Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Lack of training and drills for directing emergency services
Wider context from the report “(2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately. I have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but I have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like . I am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death, any delay of this kind presents a risk of future death.
” 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 Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate direction of arriving paramedics
Wider context from the report “(2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew . I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately . I have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but I have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like. I am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death, any delay of this kind presents a risk of future death .
” 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 Goals Soccer Centres PLC; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear timescale for reviewing Health and Safety processes and procedures
Wider context from the report “(4) I note that Goals Soccer Centres Plc recognise a need to review the Health and Safety processes. They have instructed an Independent Consultant to undertake a review of Health and Safety processes and procedures but with no clear timescale for this review I am still of the view that I am under a duty to prepare this report.
” 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 Install defibrillators across the entire club estate and maintain them in accessible, monitored reception locations.
Verbatim wording from the response “In 2014 Goals proactively initiated a rollout of Defibrillators across all our clubs. This decision was based on our commitment to safeguarding all of our customers and establishing best practice within our industry. After proactively installing defibrillation units in 2014 across our entire estate, they were sited inside the clubhouses. The decision to place the units inside was based upon recommendations made during consultation to ensure the units remain in good working order. Before these units were purchased, we met with the Head Community Liaison officer for the Scottish Ambulance Association (SAA) and consulted with the British Heart Foundation (BHF) for guidance and best practice on the type of equipment and to ensure that we are providing the most appropriate product for our environment.” Source location 2018-0303-Responses
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 Provide Emergency First Aid at Work training to reception staff working at least 16 hours weekly by 31 July 2019 and all qualifying reception staff by 1 January 2020.
Verbatim wording from the response “• By 31st July 2019 any staff member working 16 hours or more on reception will receive the ‘Emergency First Aid at work’ 1-day course covering practical training and assessment, in addition to video training. Course specification Appendix 7.” Source location 2018-0303-Responses
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 Install additional defibrillator location signs at clubhouse and changing-facility exits and individual pitch gates.
Verbatim wording from the response “We do recognise speed is the primary factor in getting the Defibrillator to the point of emergency and knowledge of Defibrillator location is vital for customers (staff are aware of equipment locations as this is included within their induction). We have therefore undertaken an additional audit of Defibrillator locations and signage across all facilities (Appendix 2) and as a result will make the following adjustments:” Source location 2018-0303-Responses
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 Provide General Managers, Regional Managers and Operations Team members with Level 3 First Aid at Work training by 31 July 2019.
Verbatim wording from the response “Since the incident we have committed to significant increases to further enhance the level of training staff receive:” Source location 2018-0303-Responses
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 Provide all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.
Verbatim wording from the response “As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-played by all club staff and refreshed annually. Details of this can be found in the response to the training concern detailed in S5 (3).” Source location 2018-0303-Responses
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 Finalise and implement the Goals Normal Operating Procedures and Emergency Action Plan across all clubs, incorporating emergency response procedures into regional audits.
Verbatim wording from the response “In addition, the subsequent independent review of Health and Safety (commissioned following the incident) has provided a new draft document (Appendix 3) called “Goals Normal Operating Procedures and Emergency Action Plan 2019” which was created on the back of the updated “Goals First Aid risk assessment” (Appendix 9). The “Goals Normal Operating Procedures and Emergency Action Plan 2019” specifically includes (in section 2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it have been agreed and a timeline for rollout across the business is as follows:” Source location 2018-0303-Responses
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 Complete an independent review of health and safety processes and procedures.
Verbatim wording from the response “Coroner Concern S5 (4) I note that Goals Soccer Centres Plc recognise a need to review the Health and Safety processes. They have instructed an Independent Consultant to undertake a review of Health and Safety processes and procedures but with no clear timescale for this review I am still of the view that I am under a duty to prepare this report.” Source location 2018-0303-Responses
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 Circulate the Emergency First Aid Incident Procedure to all clubs to reinforce emergency roles and responsibilities.
Verbatim wording from the response “In addition to First Aid training, all staff are trained in ‘situational awareness’. This training includes medical emergencies. In particular, the training includes directing a member of staff to go and wait for an ambulance at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the casualty. In the case of Jack Riding this didn’t happen and we acknowledge that this part of the emergency was not handled in line with what Goals training. Since the incident, we have immediately circulated the Emergency First Aid Incident Procedure (appendix 13 in our response dated 18th November) to reaffirm the” Source location 2018-0303-Responses
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 Add practical defibrillator training and assessment to the First Aid training syllabus and continue providing it to relevant staff.
Verbatim wording from the response “The final level of in-depth and practical training is provided for all Duty Managers. In 2015 we proactively implemented steps to improve Defibrillator training levels. Until 2018 the First Aid training syllabus did not cover practical training in the use of Defibrillators, however following consultation with our First Aid provider, we added Defibrillator practical training into our First Aid syllabus. At this time this training was not a standard topic within the syllabus of the standard qualification (Level 2 Emergency First Aid at Work QCF). Goals consciously implemented Defibrillator practical training well before this was made mandatory.” Source location 2018-0303-Responses
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 The response disputes that there was a significant delay in accessing or deploying the defibrillator during the incident.
Verbatim wording from the response “We firmly refute that there was a significant delay to the Defibrillator being accessed or used. CCTV footage sent previously (appendix 10 in our response dated 18th November) showed our rapid response time of less than 1 minute from staff receiving the information that the Defibrillator was required and taking it out onto the pitch. Although we do not have exterior CCTV footage to verify timings to and from the pitch, Appendix 1 highlights the distances between pitches and the facility clubhouse and reception which is less than 100m from the clubhouse to the pitch. This distance is much shorter than in many other sports-related leisure” Source location 2018-0303-Responses
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations