16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 9
Action
Launch a dedicated referee learning-management system to track completion and communicate directly with referees.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2026. View source
Action
Amend downloadable club and venue resources to improve AED location awareness, preparedness, maintenance and access.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2026. View source
Action
Undertake a feasibility study on phased requirements for SCA-trained coverage at football games and use its findings to inform long-term proposals.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2026. View source
Action
Promote the SCA module through websites, social media, newsletters, referee communications and County Football Association asset packs.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2026. View source
Action
Add the SCA module to Advanced Trauma Medical Management in Football training.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2026. View source
Action
Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2026. View source
Action
Increase football-match AED availability and provide free AED training covering use, storage, registration and checking.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2026. View source
Action
Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
Stated completedThe respondent said that this action was complete when they made their response on 27 April 2026. View source
Action
Reintegrate the SCA module into EE Playmaker and notify affected learners that completion is required to retain certification.
Stated plannedThe respondent said that this action was planned when they made their response on 27 April 2026. View source See 6 more actions
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AI-generated summary
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” 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 Launch a dedicated referee learning-management system to track completion and communicate directly with referees.
Verbatim wording from the response “19. The FA intends to launch a new Learning Management System for referees in August 2026. The use of a dedicated platform will enable greater tracking of training completion statistics for referees (as distinct from other participants) and this will also provide a platform by which The FA will be able to communicate directly with referees and therefore provides an additional opportunity to promote completion of the SCA module.” Source location Response from The FA
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 Amend downloadable club and venue resources to improve AED location awareness, preparedness, maintenance and access.
Verbatim wording from the response “27. In addition to the information about use of a defibrillator in the SCA module, The FA has a separate Emergency Action Planning Module which is available online free of charge. This contains information about the location and use of AEDs at football grounds. Following the issuance of the Report, the FA has amended its downloadable resources to support preparedness and familiarity with defibrillators across each club and venue. The amended resources (such as “How To Use An AED” and “Your Club’s Nearest AED”) support club staff in identifying the location of each defibrillator and prompt thinking about maintenance and access. The resources emphasise that no harm can be caused by the application of an AED and that it will not shock unless required.” Source location Response from The FA
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 Undertake a feasibility study on phased requirements for SCA-trained coverage at football games and use its findings to inform long-term proposals.
Verbatim wording from the response “21. The FA has committed to undertaking a feasibility study in the coming season to examine strategies that could lead to every game being attended by at least one individual who has completed the SCA module. The feasibility study will consider the practicability and efficacy of a phased approach to the introduction of mandating training for certain categories of participants.” Source location Response from The FA
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 Promote the SCA module through websites, social media, newsletters, referee communications and County Football Association asset packs.
Verbatim wording from the response “The FA will actively promote the SCA module on The FA and England Football websites and across its social media platforms before the start of the 2026/2027 grassroots season to encourage engagement. The FA has 262,000 social media followers and England Football has 2.3 million social media followers. There are an average of 542,000 monthly active users on thefa.com and 583,000 monthly active users on EnglandFootball.com.
iv. The FA will include information about the SCA module and risks of SCA in its Clubs and Leagues newsletter, to be sent on Friday 26th June, asking recipients to encourage everyone involved in their respective clubs and leagues to complete the free SCA module. The Clubs and Leagues newsletter is sent to an audience of 132,700 contacts at affiliated clubs and leagues;” Source location Response from The FA
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 Add the SCA module to Advanced Trauma Medical Management in Football training.
Verbatim wording from the response “10. The SCA module is mandated across the medical pathway from Level 1 to Level 4. While it is difficult to ascertain precise statistics, there have been more than 430,000 completions of FA medical courses since 2021 (more than 300,000 are completion of IFAiF). From 19 May 2026,” Source location Response from The FA
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 Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
Verbatim wording from the response “13. Following the Inquest, the FA has undertaken a review of its IFAIF course and the SCA module to ensure learning from best practice guidelines and this case are fully reflected in the content delivered. A member of the FA’s Medical Team was a contributor to the Resuscitation Council UK ‘Resuscitation on the Field of Play’ Guidelines and the new ‘Resuscitation in Community Sports: A National Best Practice Guide’ (dated April 2026).” Source location Response from The FA
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 Increase football-match AED availability and provide free AED training covering use, storage, registration and checking.
Verbatim wording from the response “26. While the Resuscitation Council UK do not recommend formal training for the use of a defibrillator and the HSE removed approval for formal training in October 2013, the FA took proactive steps to increase the presence of defibrillators (or “AEDs”) at football matches and to ensure participants were appropriately trained in how to use an AED, how to store it, register it and check it. For example, The FA participated in three AED roll-outs and provided free AED training courses, delivered by The FA’s IFAiF and EFAiF tutors, to all those in receipt of an AED (paid for by FA Education).” Source location Response from The FA
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 Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
Verbatim wording from the response “18. The FA has also taken steps to ensure that learning from this case is incorporated into delivery of training by tutors across all in-person courses. Tutors have been advised to promote the relevant points and asked to show a video distinguishing normal breathing from abnormal breathing/agonal breathing at every face-to-face course.” Source location Response from The FA
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 Reintegrate the SCA module into EE Playmaker and notify affected learners that completion is required to retain certification.
Verbatim wording from the response “9. The SCA training module is also an essential component of ‘EE Playmaker by England Football’ (“EE Playmaker”). EE Playmaker is a free online entry level football course for those interested in a more active role in grassroots football. Between January 2026 and June 2026, the SCA module was temporarily signposted for completion by participants as part of EE Playmaker rather than being integrated into the module itself. However, the SCA module will be fully integrated back into EE Playmaker from 12 June 2026. Over 12,000 learners who had either completed or enrolled on EE Playmaker between January 2026 and June 2026 have been contacted by The FA and informed that they are required to complete the SCA module in order for their EE Playmaker certificate to remain valid.” Source location Response from The FA
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 FA cannot appropriately train participants to override or disregard emergency call handlers’ instructions about using defibrillators.
Verbatim wording from the response “24. In Adam’s case, the 999 call handler advised those administering first aid not to utilise the defibrillator which was present at the scene. This is a challenging factor for The FA to address, as it would not be appropriate for The FA to train participants to override or disregard the instructions of call handlers. On 31 January 2024 there was a defibrillator available at the pitch, staff were aware of the location of the defibrillator and there was no delay in obtaining it. The witnesses present at the hearing explained that they would have used the device as and when instructed by the call handler.” Source location Response from The FA
Open published response
18 Mar 2022 Emiliano Raul Sala · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Risk of future deaths from illegal flights View source Failure of relevant organisations to communicate illegal-flight risks to their members View source Insufficient CAA powers for investigating and enforcing aviation regulation breaches View source Lack of effective public guidance about illegal flights and their risks View source See 1 more concern
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.
×
AI-generated summary
Emiliano Raul Sala · 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
Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.
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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Risk of future deaths from illegal flights
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights , and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant organisations to communicate illegal-flight risks to their members
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members , and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations . I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role .
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 The Football Association; that does not assign responsibility.
PFD Monitor interpretation Lack of effective public guidance about illegal flights and their risks
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public , especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them . I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Open source report
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 The Football Association; 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 The Football Association; 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 The Football Association; 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 The Football Association; 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 The Football Association; 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 The Football Association; 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations