PFD report

Mark Townsend · Prevention of Future Deaths report

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Issued 13 Oct 2025•South Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised1

  1. Failure of stewards to know the location of the nearest radio
    Part of recurring concern: Unreliable on-site emergency medical and first-aid response arrangements
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Continue testing and exercising emergency procedures, including radio and communications systems.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  2. Action

    Continue steward training on radio locations and immediate communication during medical emergencies.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  3. Action

    Continue enhanced pre-match briefings addressing radio accessibility and how to obtain help.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The brief delay was non-causative and does not indicate that the stadium’s radio arrangements are unsafe or unsuitable.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of stewards to know the location of the nearest radio

Wider context from the report

“Accepting staff are required to roam to deal with their duties, this position was not in line with those outlined on a map of radio locations produced to the Court. The CCTV footage shows the following events: • A West Bromwich Albion supporter spoke to a steward to raise the alarm. The steward initially climbed up the stairs to speak to supporters. • That steward signalled to a second steward to raise the alarm. • The second steward began to descend the stairs. • The first steward then began to descend the stairs. • Stewards one and two conversed with a group of other stewards at the bottom of the stairs leading to the W vomitory. • A steward then moved from the group of stewards the bottom of the stairs leading to the W vomitory and ran towards the group of stewards and steward supervisors at the bottom of the stairs leading to the X vomitory following which the call for medical assistance was made by a supervisor. The Court found that the actions of the stewards in moving to the bottom of the stairs leading to the W vomitory, before running towards the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, demonstrated that they did not know where to find a member of staff with a radio. The time between the second steward arriving at the group of people at the bottom of the stairs leading to the W vomitory, and the time the steward arrives at the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, was 20 seconds with the radio call being made 11 seconds later. The Court found this period of time did not cause or contribute to Mark’s death, but has concerns that delays caused by stewards not being aware where the nearest radio is could cause delays in summoning medical help in the future, and that may give rise to a risk of future deaths. ”

Is this part of a recurring concern?

Yes — Unreliable on-site emergency medical and first-aid response arrangements.

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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

Continue testing and exercising emergency procedures, including radio and communications systems.

Verbatim wording from the response

“As a club we host and participate in large scale multi-agency emergency response training including large scale emergency incident scenarios. As part of this training radio and communications systems are trialled and tested.”

Source location

Response from Sheffield Wednesday Football Club
Page 4 · response
Published 20 October 2025

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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

Continue steward training on radio locations and immediate communication during medical emergencies.

Verbatim wording from the response

“Stewards receive advance briefing information in the days prior to any match with information sent to them via an app. On matchdays stewards receive stand briefings from their supervisor/stand managers which are in turn informed by briefings given to those leaders by the Chief Steward, Safety Officers and medical leads. Briefings include ‘How to get help’ incorporating locations of radios, location of emergency phones, location of first aid responders and location of Fire Marshals.”

Source location

Response from Sheffield Wednesday Football Club
Page 4 · response
Published 20 October 2025

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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

Continue enhanced pre-match briefings addressing radio accessibility and how to obtain help.

Verbatim wording from the response

“Stewards receive advance briefing information in the days prior to any match with information sent to them via an app. On matchdays stewards receive stand briefings from their supervisor/stand managers which are in turn informed by briefings given to those leaders by the Chief Steward, Safety Officers and medical leads. Briefings include ‘How to get help’ incorporating locations of radios, location of emergency phones, location of first aid responders and location of Fire Marshals.”

Source location

Response from Sheffield Wednesday Football Club
Page 4 · response
Published 20 October 2025

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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

Regularly review radio positioning and distribution using operational experience.

Verbatim wording from the response

“The location of radio holders is planned and mapped. The location of radio holders is disseminated to stewards through their training, briefings and during emergency training scenarios.”

Source location

Response from Sheffield Wednesday Football Club
Page 3 · response
Published 20 October 2025

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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 brief delay was non-causative and does not indicate that the stadium’s radio arrangements are unsafe or unsuitable.

Verbatim wording from the response

“SWFC respectfully notes that the substantive findings of the inquest were positive in relation to the Club's safety arrangements and response to this incident and that there were no causative failings on the part of the Club. The inquest’s findings demonstrated that a radio call was made 63 seconds after a steward was first notified of the medical incident and a paramedic arrived with Mr Townsend approximately 3 minutes later, 1 minute 20 seconds after Mr Townsend’s cardiac arrest. The speed of the resultant medical response was found to have been in line with what might be expected had Mr Townsend suffered a cardiac arrest in a clinical hospital setting.”

Source location

Response from Sheffield Wednesday Football Club
Page 1 · response
Published 20 October 2025

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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

Leaving static unattended radios around the stand is not considered practical or safe; the emergency telephone is the static contact method.

Verbatim wording from the response

“incidents that might occur and so that radios can be moved into position to deal with developing situations. Stand Managers and Steward Supervisors liaise with one another to ensure that a radio holder presence is always maintained on the lateral walkway even if one of them is called away to attend to an incident. It is not considered practical or safe to leave static unattended radios around the stand. The emergency telephone serves as the static means of contacting the control room.”

Source location

Response from Sheffield Wednesday Football Club
Page 4 · response
Published 20 October 2025

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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

Existing radio provision, training, procedures, inspections and emergency telephones are considered an effective and adequate response to communications risks.

Verbatim wording from the response

“The location of radio holders is planned and mapped. The location of radio holders is disseminated to stewards through their training, briefings and during emergency training scenarios.”

Source location

Response from Sheffield Wednesday Football Club
Page 3 · response
Published 20 October 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Continue sharing safety learning and best practice with other venues and stakeholders.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2025.
  2. 2

    Continue dialogue with regulatory bodies to ensure radio arrangements remain fit for purpose.

    Stated by Sheffield Wednesday Football Club Limited (in AdministrationStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2025.

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

Continue sharing safety learning and best practice with other venues and stakeholders.

Verbatim wording from the response

“Notwithstanding the points set out above, SWFC takes the coroner's concerns seriously and is committed to continuous improvement and learning in all aspects of ground safety. The Club will continue to take the following steps which also were in operation prior to Mr Townsend’s death:”

Source location

Response from Sheffield Wednesday Football Club
Page 6 · response
Published 20 October 2025

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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

Continue dialogue with regulatory bodies to ensure radio arrangements remain fit for purpose.

Verbatim wording from the response

“Our safety arrangements are subject to scrutiny from the Sports Ground Safety Authority, including through regular matchday inspections. We are also subject to appropriate licensing scrutiny from our Local Authority. As a club we also actively participate in our local Safety Advisory Group. All of these bodies are able to raise concerns in respect of any safety issues but we have not been notified of any relevant concern as to our existing radio systems.”

Source location

Response from Sheffield Wednesday Football Club
Page 4 · response
Published 20 October 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026