Jack Riding · Prevention of Future Deaths report

On 21st August 2018 the Coroner commenced an investigation into the death of Jack Riding.
The inquest concluded on the 31st October 2018. The conclusion of the Coroner was one of death from natural causes.

There had been a number of issues raised in the course of the inquest but Goals Soccer Centres plc had been represented by the local manager Mr Simpkin and before I concluded whether I was under a duty to prepare this report I asked for further information and any representations. I made it clear in open court that I was contemplating such a report and asked that ████████ convey that message.

On August 13th 2018 Jack Riding was playing football when he collapsed. He suffered from a complex heart condition and in the particular circumstances of this case little could be done to assist him.

Jack Riding collapsed and became unresponsive as a genetic heart condition had caused his heart to stop whilst playing football on the 13th August 2018. Resuscitation attempts were started almost immediately by bystanders. Paramedics arrived about ten minutes later and Jack was conveyed to University Hospital Aintree where it was ascertained that he had suffered severe hypoxia to his brain. Despite treatment and resuscitation attempts Jack was declared dead at University Hospital Aintree on the 15th August 2018

(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.

(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.

(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.

(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.