14 Oct 2019 César Cuauhtémoc González Barrón · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to ensure first aider knowledge of ambulance-summoning arrangements View source Failure to provide ambulance crews with correct venue access directions View source Lack of designated monitoring of performers’ wellbeing and consciousness View source Failure to communicate the nature of an emergency when summoning first aiders View source Failure to guide and assist first aiders responding to emergencies View source Failure to ensure first aider identification of venue staff during emergencies View source Failure to initiate CPR when cardiac arrest is identified View source Failure to provide a competent handover to ambulance services View source Failure to ensure timely availability of a defibrillator at the emergency location View source Failure to brief first aiders on venue emergency arrangements View source Lack of incident command during emergency response View source Ineffective delivery of chest compressions View source See 9 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
César Cuauhtémoc González Barrón · 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
César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.
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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure first aider knowledge of ambulance-summoning arrangements
Wider context from the report “2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it.
She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance.
She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ambulance crews with correct venue access directions
Wider context from the report “3. In the event, the instructions given to the London Ambulance Service did not include the direction to drive round to the rear entrance and so valuable minutes were lost as the paramedics made their way from front to rear on foot outside the building.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of designated monitoring of performers’ wellbeing and consciousness
Wider context from the report “1. When Mr González Barrón lost consciousness, there was a delay before it was recognised that this was not part of the performance.
He was 51 years old and undergoing very vigorous exertion, but there was nobody at the wrestling match tasked specifically with ensuring that he was well and that, for example, he had not lost consciousness .
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the nature of an emergency when summoning first aiders
Wider context from the report “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened . She had no understanding of the nature of the emergency .
The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going.
The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to guide and assist first aiders responding to emergencies
Wider context from the report “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened. She had no understanding of the nature of the emergency.
The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going.
The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure first aider identification of venue staff during emergencies
Wider context from the report “6. When Mr González Barrón collapsed, the scene was chaotic. No person took charge. There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance , for example, in retrieving her equipment. She was distracted by the noise and comment of those around.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate CPR when cardiac arrest is identified
Wider context from the report “5. When the first aider arrived at Mr González Barrón's side, she cut off his face mask. Though she was told immediately by someone she thought to be a doctor that Mr González Barrón was not breathing and had no pulse, she did not start cardiopulmonary resuscitation (CPR) .
She did hand over her pocket mask and oropharyngeal airways, and she did go to retrieve emergency equipment from the first aid room 15-20 seconds away, but she could not remember in court if she fetched the defibrillator on her first or second return to the first aid room.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a competent handover to ambulance services
Wider context from the report “8. The handover to LAS was confused, with mixed messages as to whether the automated external defibrillator had delivered a shock or not. No person took charge of a competent handover to LAS.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely availability of a defibrillator at the emergency location
Wider context from the report “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened. She had no understanding of the nature of the emergency.
The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going.
The first aider did not take the defibrillator with her when she first went to the ring , she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it .
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to brief first aiders on venue emergency arrangements
Wider context from the report “2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it .
She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance.
She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of incident command during emergency response
Wider context from the report “6. When Mr González Barrón collapsed, the scene was chaotic. No person took charge . There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance, for example, in retrieving her equipment. She was distracted by the noise and comment of those around.
” 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 Roundhouse Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective delivery of chest compressions
Wider context from the report “7. The chest compressions in progress when the London Ambulance Service (LAS) arrived were ineffective .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations