Concerns raised 5 Failure to implement, disseminate and enforce safe training session planning View source Lack of unequivocally clear weight-difference matching criteria View source Failure to apply weight-difference matching criteria View source Failure to carry out individualised venue risk assessments View source Failure to assess and oversee event medical cover risks View source See 2 more concerns
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AI-generated summary
Dominic Mark Chapman · 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
Dominic Mark Chapman sustained a fatal head injury during a charity boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester on 9 April 2022, and died in hospital on 11 April 2022. The concerns identified included unclear and inconsistently applied criteria for matching opponents by weight, training that did not follow the intended pattern, and inadequate individualised risk assessments for events and medical cover.
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 Ultra Events Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to implement, disseminate and enforce safe training session planning
Wider context from the report “2) In his evidence to the inquest, ████████ ( sole director of Ultra Events Midlands Ltd., the franchisee responsible for organising the event on 9.4.22 ) said that while he left the specifics of the boxers’ 8 week training regime to the owner of the gym they used for this purpose “we don’t allow sparring until about halfway through training, then body sparring from Week 4, and head contact sparring from Week 5.”
By contrast, the gym owner, ████████, told the inquest:
“For the first week we worked on technique and fitness ( cardio work ); after 2 weeks, I added a bit of body sparring; after 3-4 weeks we added light sparring sessions with shots to the head.”
Other evidence from a number of the boxers themselves satisfied me that in fact the training provided for the event on 9.4.22 did not follow the pattern outlined by ████████ or anticipated by ████████ told the inquest that Ultra Events Ltd. has now produced Training Session planning, and that a proposed Training Workbook will require their coaches to sign a declaration confirming that they will follow this planning. These measures have not yet been brought into force by Ultra Events Ltd. , and I am concerned that unless and until they are brought into force, there is a risk that boxers will not receive the standard of training which Ultra Events Ltd. deems safe and appropriate .
It is currently unclear when these measures will be introduced, and how they will be disseminated and enforced so as to ensure that coaches and gyms used by Ultra Events Ltd. for charity white collar boxing events follow them to the letter.
” 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 Ultra Events Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of unequivocally clear weight-difference matching criteria
Wider context from the report “1) In the course of the inquest I was concerned that criteria set down by Ultra Events Ltd. to match opponents for bouts at the charity white collar boxing event on 9.4.22, specifically relating to the maximum allowable weight difference between boxers, were (a) insufficiently clear , and (b) not always applied by the event organiser. I heard evidence that Ultra Events Ltd. have since changed the wording of those criteria, but was satisfied that, as now drafted, the criteria still lack clarity .
For example, ████████ ( director and sole proprietor of Ultra Events Ltd. ) told the inquest that the intention behind the reworded criteria was that:
(a) any weight difference between boxers of up to 7kg would be acceptable;
and
(b) any weight difference between boxers in excess of 7kg would have to be referred to Ultra Events Ltd.'s head office for approval.
However, the criteria contained within the new workbook produced by Ultra Events Ltd. for use by those training and matching up boxers are not as unequivocally clear . For example, the workbook contains the statement: “If a match is over 7kg simply explain it on the fight order”.
I am concerned that instructions about weight differences between boxers taking part in charity white collar boxing bouts are important and should be unequivocal, and that coaches and event organisers should be clear about their responsibilities in this respect.
” 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 Ultra Events Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to apply weight-difference matching criteria
Wider context from the report “1) In the course of the inquest I was concerned that criteria set down by Ultra Events Ltd. to match opponents for bouts at the charity white collar boxing event on 9.4.22, specifically relating to the maximum allowable weight difference between boxers, were (a) insufficiently clear, and (b) not always applied by the event organiser . I heard evidence that Ultra Events Ltd. have since changed the wording of those criteria, but was satisfied that, as now drafted, the criteria still lack clarity.
For example, ████████ ( director and sole proprietor of Ultra Events Ltd. ) told the inquest that the intention behind the reworded criteria was that:
(a) any weight difference between boxers of up to 7kg would be acceptable;
and
(b) any weight difference between boxers in excess of 7kg would have to be referred to Ultra Events Ltd.'s head office for approval.
However, the criteria contained within the new workbook produced by Ultra Events Ltd. for use by those training and matching up boxers are not as unequivocally clear. For example, the workbook contains the statement: “If a match is over 7kg simply explain it on the fight order”.
I am concerned that instructions about weight differences between boxers taking part in charity white collar boxing bouts are important and should be unequivocal, and that coaches and event organisers should be clear about their responsibilities in this respect .
” 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 Ultra Events Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out individualised venue risk assessments
Wider context from the report “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.:
(a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them . I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes ;
(b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events. I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments. This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment.
” 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 Ultra Events Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and oversee event medical cover risks
Wider context from the report “3) After hearing the evidence at inquest I was concerned that Ultra Events Ltd.:
(a) does not carry out a satisfactory individualised risk assessment tailored to each specific event at each specific venue used by them. I heard evidence that, where a venue has previously been used for a white collar boxing event, Ultra Events Ltd. will assume that nothing has changed since then, and relies on the venue notifying them of any potentially relevant changes;
(b) does not carry out its own risk assessment for the provision of medical cover at its white collar boxing events . I heard evidence from ████████ that Ultra Events Ltd. requires the companies it uses for medical cover to carry their own risk assessments, but does not ask to see or to check those risk assessments . This means that there is no effective oversight to ensure that the medical cover provided for each individual event at each venue is based on a suitable individualised risk assessment .
” 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 Amend weight-discrepancy instructions to require HQ approval for matches exceeding 7kg, preventing unapproved bouts from proceeding.
Verbatim wording from the response “6. We have therefore amended the wording, and a copy of the new document is attached as exhibit “JL1”. The wording requires all weight discrepancies of more than 7kgs between boxers to be referred to HQ for approval by explaining the match-up on the new version of the vest order, a copy of which has already been provided to the Coroner as an exhibit to the statement that I filed on the final day of the inquest.” Source location Response from Ultra Events
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 Proactively contact venues about changes before events and use disclosed changes to formulate updated event risk assessments and plans.
Verbatim wording from the response “12. We have always carried out risk assessment for all new venues by attending them in person. We have also always conducted individualised risk assessments for each event and, indeed, one was carried out for the Worcester event that Dominic attended. However, we have traditionally been reliant upon the venue volunteering details of any changes to their premises during that process.” Source location Response from Ultra Events
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 Introduce, distribute and enforce a signed training workbook, with area-representative checks and participant feedback used to monitor compliance.
Verbatim wording from the response “8. As set out above, the new workbook was introduced immediately. It has been sent out to all gyms and franchisees, and they have signed and returned copies for us to retain on file. As such, all gyms have already signed their agreement to coach within the requirements of the workbook.” Source location Response from Ultra Events
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 medical providers to submit event-specific risk assessments and Medical Plans for logging with event paperwork.
Verbatim wording from the response “15. However, we now ask our medical providers to supply us with their event-specific risk assessment and Medical Plan. Our email explains that they are required to carry out a thorough assessment of all of the risks which pertain to this event at particular premises, to an extent that ensures that they are fully capable of dealing with any medical event, emergency or otherwise, which may occur.” Source location Response from Ultra Events
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 Individualised risk assessments were always conducted for each venue and event, including the Worcester event.
Verbatim wording from the response “12. We have always carried out risk assessment for all new venues by attending them in person. We have also always conducted individualised risk assessments for each event and, indeed, one was carried out for the Worcester event that Dominic attended. However, we have traditionally been reliant upon the venue volunteering details of any changes to their premises during that process.” Source location Response from Ultra Events
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 Medical providers remain responsible for risk assessing event medical provision because they possess the necessary specialist expertise.
Verbatim wording from the response “14. Medical providers are best placed to carry out risk assessments, as they are the ones with the specialist knowledge required to ensure safety in their field of expertise. As such, risk assessing of medical provisions at each event at each venue remains with the medical provider.” Source location Response from Ultra Events
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations