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
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Formally respond in writing to future written advice received from Trafford Metropolitan Borough Council.
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Action
Operate quality-assurance compliance checks auditing steward duties, conduct, vomitory protocols and supervisors’ briefings, recording outcomes and providing training where required.
View source
Action
Conduct proactive checks limiting vomitory staffing to two stewards except in exceptional circumstances and positioning them to maximise handrail accessibility during heavy footfall.
View source
Action
Conduct match-by-match proactive and live audits of vomitory steward positioning and compliance with the Stewards Code of Conduct.
View source
Action
Deliver continuing steward briefings with increased emphasis on the Code of Conduct, situational awareness, customer engagement, unimpeded vomitories and accessible handrails.
View source
Action
Deliver detailed positioning guidance to vomitory stewards covering handrail access, movement to clear passage and maintaining awareness during matches.
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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 Manchester United Football Club Limited; 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 Manchester United Football Club Limited; 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 Manchester United Football Club Limited; 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 Manchester United Football Club Limited; 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 Manchester United Football Club Limited; 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 Formally respond in writing to future written advice received from Trafford Metropolitan Borough Council.
Verbatim wording from the response “As noted in paragraph 21.3 of our legal counsel’s closing submissions to the inquest, the letter sent by TMBC to the Club did not ask for a written response, nor was any response subsequently requested by TMBC (with whom we met regularly following receipt of the letter). The Club carefully considered the contents of the letter and carried out such actions as were necessary, whilst continuing to regularly consult and confer with TMBC (including verbal discussions of those recommendations). However, on reflection and having conferred further with TMBC following conclusion of the inquest, we accept that it would have been preferable if there had been a more formal mechanism put in place for discussion of those recommendations and their implementation. In future, should we receive written advice from TMBC we will ensure that this is formally responded to in writing.” Source location 2018-0404-Response-by-MUFC
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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 Operate quality-assurance compliance checks auditing steward duties, conduct, vomitory protocols and supervisors’ briefings, recording outcomes and providing training where required.
Verbatim wording from the response “• As part of this new monitoring and audit process we have introduced new quality assurance compliance check sheets. Head Stewards / Deputies / members of our Safety & Security Team conduct audit checks across the stadium, which involves questions to stewards about their knowledge and understanding of their specific duties, codes of conduct and vomitory protocols. This also includes quality assurance of supervisors’ briefings. Outcomes are recorded on the compliance check sheets, and advice and training is given as required (information on these topics is also contained in Stewards Handbook which is issued to all stewards). The completed sheets are collated and evaluated by senior safety staff and filed post every match.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Conduct proactive checks limiting vomitory staffing to two stewards except in exceptional circumstances and positioning them to maximise handrail accessibility during heavy footfall.
Verbatim wording from the response “• Regular proactive checks have been put in place to ensure that no more than two stewards are present in the vomitory space (save for exceptional circumstances where an additional stewarding presence is required). In periods of heavy footfall, one steward will stay near the head of the vomitory whilst the other will move down inside so as to maximise accessibility of the handrails.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Conduct match-by-match proactive and live audits of vomitory steward positioning and compliance with the Stewards Code of Conduct.
Verbatim wording from the response “Nevertheless, we have fully taken on board the concern which has been raised here. Accordingly, as mentioned above in my opening remarks, we have put into place an additional match-by-match system of proactively checking both stewards’ positioning within vomitories and checking compliance by stewards with the Code of Conduct (including live auditing of both issues throughout each match).” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Deliver continuing steward briefings with increased emphasis on the Code of Conduct, situational awareness, customer engagement, unimpeded vomitories and accessible handrails.
Verbatim wording from the response “• Briefings are continually ongoing to all stewards, which cover their duties, roles and responsibilities. This information is also included in match day briefing notes. Within these briefings, we have increased the focus on the importance of the provisions of the Stewards Code of Conduct. The briefings place particular emphasis on (i) stewards’ awareness of their surroundings and prevailing situation, (ii) customer engagement, (iii) ensuring that vomitories remain unimpeded at all times, and (iv) ensuring availability of handrails for supporters at all times.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Deliver detailed positioning guidance to vomitory stewards covering handrail access, movement to clear passage and maintaining awareness during matches.
Verbatim wording from the response “• In addition, specific steward positioning guidance has been delivered to all stewards who are responsible for vomitory areas which:
o provides guidance to ensure that steward positioning allows supporters to use the handrails and to ensure that the stewards facilitate their use;
o emphasises the need for stewards to continually alert people coming to use the vomitory and to move accordingly to allow space to pass; and
o further emphasises to all stewards that their focus must not be distracted by events taking place on the pitch during the match, in order that they maintain their position and awareness of their surroundings so as to carry out their regulated duties.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Sports Grounds Safety Authority and DDCMS are expected to provide the substantive response on Green Guide content.
Verbatim wording from the response “The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 Club remained satisfied that steward positioning was appropriate, supported by established practice and regulator observation, while issuing guidance to codify it.
Verbatim wording from the response “Again, the content of the Green Guide is a matter for the SGSA. The positioning of the stewarding at Old Trafford stadium is something that SGSA and TMBC have had (and continue to have) many opportunities to observe and advise upon. Neither organisation has ever indicated to the Club that the positioning of the stewards within the vomitories (which is standard practice across most if not all major football stadia) is a cause for concern. Indeed, I understand that at the inquest the evidence from TMBC was that in their opinion stewards need to be located in the position in question for safety reasons; this concurs with our own view and with long-standing practice. However, in view of the concern raised in the Report we have very carefully reviewed the position.” Source location 2018-0404-Response-by-MUFC
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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 vomitory fully complied with the applicable Green Guide requirements at construction, contrary to the concern about inadequate effective width.
Verbatim wording from the response “2. The widths of the staircases (“vomitories”) [sic] 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.” Source location 2018-0404-Response-by-MUFC
Open published response
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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 content of the Green Guide is a matter for the Sports Grounds Safety Authority, not the Club.
Verbatim wording from the response “The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.” Source location 2018-0404-Response-by-MUFC
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations