PFD report

Richard John Whale · Prevention of Future Deaths report

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Issued 21 Dec 2018•Manchester South

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
5

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
15

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure of club stewards to comply with the steward code of conduct
  2. Lack of guidance on steward placement to keep handrail access clear
    Part of recurring concern: Inadequate handrail safety on steps and access ramps
  3. Lack of regular audits of steward compliance with the Code of Conduct
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.12

  1. Action

    Require the Club to respond to future recommendations or requests within specified timescales and review actions where necessary.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 21 December 2018.
  2. Action

    Include observations of the Club’s monitoring of stewarding behaviour in future match-day safety audits.

    Stated by Trafford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 21 December 2018.
  3. Action

    Continue regulatory monitoring of sports-ground safety and take action when necessary.

    Stated by Department for Digital, Culture, Media and SportStated completedThe respondent said that this action was complete when they made their response on 21 December 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    Responsibility for deciding whether to implement the informal recommendations rested with the Club.

    Stated by Trafford Borough CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 club stewards to comply with the steward code of conduct

Wider context from the report

“4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Lack of guidance on steward placement to keep handrail access clear

Wider context from the report

“3. The green guide does not give guidance as to placement of stewards or suggest best practice to avoid stewards blocking access to the handrails. It was accepted during the course of the inquest that the role and placement of stewards was vital to ensuring the safety of the public at football matches. ”

Is this part of a recurring concern?

Yes — Inadequate handrail safety on steps and access ramps.

Open source report

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

Lack of regular audits of steward compliance with the Code of Conduct

Wider context from the report

“4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 staircase width standards to account for steward deployment

Wider context from the report

“2. The widths of the staircases (“vomitories”) is set in the Green Guide. Those widths take into account the handrails but not the inevitable reduction in width that takes place when stewards are deployed into them. In effect, the vomitories are significantly narrower at points than the suggested widths. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Lack of mechanisms for discussing and monitoring implementation of recommendations

Wider context from the report

“1. The Local Authority had issued a list of recommendations to the club after the death of Mr Whale. There was no mechanism in place for discussion of those recommendations or to ensure that they had been followed or if not followed discussion for reasons. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 the Club to respond to future recommendations or requests within specified timescales and review actions where necessary.

Verbatim wording from the response

“In addition, the Council have now requested that the Club responds to any future recommendations or requests within a specified time frame with a review of all actions where it is considered necessary. This positive approach has been welcomed by the Club and has been implemented with immediate effect.”

Source location

2018-0404-Response-by-Trafford-Council
Page 2 · response
Published 21 December 2018

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

Include observations of the Club’s monitoring of stewarding behaviour in future match-day safety audits.

Verbatim wording from the response

“Following the conclusion of the inquest, Council Officers and the regional Sports Ground Safety Authority Inspector have met with the Club to discuss the concerns raised during the inquest. During these discussions, the Club explained the actions they have taken to address the recommendations highlighted in the letter from the Council, and they have also explained that they are undertaking additional awareness training for stewards and monitoring of stewards' behaviour whilst carrying out their duties at the stadium. Council officers undertaking future match-day audits at the Club will include observations of the monitoring of stewarding behaviour by the Club.”

Source location

2018-0404-Response-by-Trafford-Council
Page 2 · response
Published 21 December 2018

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

Continue regulatory monitoring of sports-ground safety and take action when necessary.

Verbatim wording from the response

“Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.”

Source location

2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Page 1 · response
Published 21 December 2018

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

Publish the sixth edition of the Green Guide with expanded guidance on vomitories, steward positioning, widths, control measures, and steward training.

Verbatim wording from the response

“The SGSA has since published the latest 6th edition of the Green Guide in October 2018. This latest edition expands upon the guidance in the 5th edition and includes specific guidance on vomitories and the positioning of stewards (section 9.8), vomitory widths (section 9.9) and vomitory control measures (section 9.10). It recognises that the width of a vomitory, and of gangways leading to a vomitory, are key control measures (section 9.9). Furthermore, Chapter 4 highlights that safety at sports grounds relies to a great extent upon the deployment of an appropriate number of well trained and suitably equipped stewards, with section 4.6 outlining stewards’ duties and section 4.10 detailing current stewards training and assessment processes. The new edition of the Green Guide has informed the SGSA’s engagement with Trafford MBC and MUFC.”

Source location

2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Page 2 · response
Published 21 December 2018

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

Amend Green Guide section 9.8e to specifically address spectator access to handrails during vomitory ingress and egress.

Verbatim wording from the response

“In light of the concerns you have raised the SGSA is amending the Green Guide so that section 9.8e makes a specific reference to access to handrails in the context of vomitories and the positioning of stewards. The relevant extract is below, with the proposed new wording shown in italics:”

Source location

2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Page 2 · response
Published 21 December 2018

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

Liaise with Trafford MBC and MUFC and monitor steward behaviour and safety arrangements at Old Trafford.

Verbatim wording from the response

“The SGSA is aware of the incident leading to the death of Mr Richard Whale in December 2017. Since the incident took place, the relevant SGSA Inspector has been liaising closely with both Trafford Metropolitan Borough Council (MBC) and MUFC, most recently in November 2018. This liaison has focused on ensuring that lessons are learned from the incident and are being applied by the club and the local authority, particularly in relation to the ongoing provision of suitably qualified and trained stewards at Old Trafford. There has been monitoring of stewards’ behaviour in and around vomitories, especially during ingress and egress.”

Source location

2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Page 1 · response
Published 21 December 2018

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

Formally respond in writing to future written advice received from Trafford Metropolitan Borough Council.

Verbatim wording from the response

“As noted in paragraph 21.3 of our legal counsel’s closing submissions to the inquest, the letter sent by TMBC to the Club did not ask for a written response, nor was any response subsequently requested by TMBC (with whom we met regularly following receipt of the letter). The Club carefully considered the contents of the letter and carried out such actions as were necessary, whilst continuing to regularly consult and confer with TMBC (including verbal discussions of those recommendations). However, on reflection and having conferred further with TMBC following conclusion of the inquest, we accept that it would have been preferable if there had been a more formal mechanism put in place for discussion of those recommendations and their implementation. In future, should we receive written advice from TMBC we will ensure that this is formally responded to in writing.”

Source location

2018-0404-Response-by-MUFC
Page 3 · response
Published 21 December 2018

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

Operate quality-assurance compliance checks auditing steward duties, conduct, vomitory protocols and supervisors’ briefings, recording outcomes and providing training where required.

Verbatim wording from the response

“• As part of this new monitoring and audit process we have introduced new quality assurance compliance check sheets. Head Stewards / Deputies / members of our Safety & Security Team conduct audit checks across the stadium, which involves questions to stewards about their knowledge and understanding of their specific duties, codes of conduct and vomitory protocols. This also includes quality assurance of supervisors’ briefings. Outcomes are recorded on the compliance check sheets, and advice and training is given as required (information on these topics is also contained in Stewards Handbook which is issued to all stewards). The completed sheets are collated and evaluated by senior safety staff and filed post every match.”

Source location

2018-0404-Response-by-MUFC
Page 2 · response
Published 21 December 2018

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

Conduct proactive checks limiting vomitory staffing to two stewards except in exceptional circumstances and positioning them to maximise handrail accessibility during heavy footfall.

Verbatim wording from the response

“• Regular proactive checks have been put in place to ensure that no more than two stewards are present in the vomitory space (save for exceptional circumstances where an additional stewarding presence is required). In periods of heavy footfall, one steward will stay near the head of the vomitory whilst the other will move down inside so as to maximise accessibility of the handrails.”

Source location

2018-0404-Response-by-MUFC
Page 2 · response
Published 21 December 2018

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

Conduct match-by-match proactive and live audits of vomitory steward positioning and compliance with the Stewards Code of Conduct.

Verbatim wording from the response

“Nevertheless, we have fully taken on board the concern which has been raised here. Accordingly, as mentioned above in my opening remarks, we have put into place an additional match-by-match system of proactively checking both stewards’ positioning within vomitories and checking compliance by stewards with the Code of Conduct (including live auditing of both issues throughout each match).”

Source location

2018-0404-Response-by-MUFC
Page 4 · response
Published 21 December 2018

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

Deliver continuing steward briefings with increased emphasis on the Code of Conduct, situational awareness, customer engagement, unimpeded vomitories and accessible handrails.

Verbatim wording from the response

“• Briefings are continually ongoing to all stewards, which cover their duties, roles and responsibilities. This information is also included in match day briefing notes. Within these briefings, we have increased the focus on the importance of the provisions of the Stewards Code of Conduct. The briefings place particular emphasis on (i) stewards’ awareness of their surroundings and prevailing situation, (ii) customer engagement, (iii) ensuring that vomitories remain unimpeded at all times, and (iv) ensuring availability of handrails for supporters at all times.”

Source location

2018-0404-Response-by-MUFC
Page 2 · response
Published 21 December 2018

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

Deliver detailed positioning guidance to vomitory stewards covering handrail access, movement to clear passage and maintaining awareness during matches.

Verbatim wording from the response

“• In addition, specific steward positioning guidance has been delivered to all stewards who are responsible for vomitory areas which: o provides guidance to ensure that steward positioning allows supporters to use the handrails and to ensure that the stewards facilitate their use; o emphasises the need for stewards to continually alert people coming to use the vomitory and to move accordingly to allow space to pass; and o further emphasises to all stewards that their focus must not be distracted by events taking place on the pitch during the match, in order that they maintain their position and awareness of their surroundings so as to carry out their regulated duties.”

Source location

2018-0404-Response-by-MUFC
Page 2 · response
Published 21 December 2018

Open published response

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

Responsibility for deciding whether to implement the informal recommendations rested with the Club.

Verbatim wording from the response

“the Club, and it did not stipulate any legal contraventions which the Club should action or that any action should be taken within a specified timescale. The responsibility, therefore, was with the Club as to whether or not the recommendations were implemented.”

Source location

2018-0404-Response-by-Trafford-Council
Page 2 · response
Published 21 December 2018

Open published response

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 club safety arrangements and Council engagement mechanisms were considered sufficient to address the recommendations.

Verbatim wording from the response

“It was within this remit that the Council undertook an investigation into the accident to Richard John Whale. The investigation found that the Club had satisfactory arrangements in place at the time of the accident in relation to maintaining the safety of spectators at the ground, and that there was no evidence available which would warrant any formal action under the Health and Safety at Work etc Act 1974.”

Source location

2018-0404-Response-by-Trafford-Council
Page 1 · response
Published 21 December 2018

Open published response

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 SGSA considers Trafford MBC and MUFC’s identified safety issues and steps taken to address them sufficient, subject to ongoing monitoring.

Verbatim wording from the response

“Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.”

Source location

2018-0404-Response-by-Department-for-Digital-Culture-Media-and-Sport
Page 1 · response
Published 21 December 2018

Open published response

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 Sports Grounds Safety Authority and DDCMS are expected to provide the substantive response on Green Guide content.

Verbatim wording from the response

“The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.”

Source location

2018-0404-Response-by-MUFC
Page 3 · response
Published 21 December 2018

Open published response

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 Club remained satisfied that steward positioning was appropriate, supported by established practice and regulator observation, while issuing guidance to codify it.

Verbatim wording from the response

“Again, the content of the Green Guide is a matter for the SGSA. The positioning of the stewarding at Old Trafford stadium is something that SGSA and TMBC have had (and continue to have) many opportunities to observe and advise upon. Neither organisation has ever indicated to the Club that the positioning of the stewards within the vomitories (which is standard practice across most if not all major football stadia) is a cause for concern. Indeed, I understand that at the inquest the evidence from TMBC was that in their opinion stewards need to be located in the position in question for safety reasons; this concurs with our own view and with long-standing practice. However, in view of the concern raised in the Report we have very carefully reviewed the position.”

Source location

2018-0404-Response-by-MUFC
Page 3 · response
Published 21 December 2018

Open published response

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 vomitory fully complied with the applicable Green Guide requirements at construction, contrary to the concern about inadequate effective width.

Verbatim wording from the response

“2. The widths of the staircases (“vomitories”) [sic] is set in the Green Guide. Those widths take into account the handrails but not the inevitable reduction in width that takes place when stewards are deployed into them. In effect, the vomitories are significantly narrower at points than the suggested widths.”

Source location

2018-0404-Response-by-MUFC
Page 3 · response
Published 21 December 2018

Open published response

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 content of the Green Guide is a matter for the Sports Grounds Safety Authority, not the Club.

Verbatim wording from the response

“The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern. As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.”

Source location

2018-0404-Response-by-MUFC
Page 3 · response
Published 21 December 2018

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.3

  1. 1

    Review Council policies and procedures, including an appraisal of the Coroner’s concerns.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2018.
  2. 2

    Review, enhance and independently validate the match-day slips, trips and falls risk assessment, including spectator and steward impediment risks and associated controls.

    Stated by Manchester United Football Club LimitedStated completedThe respondent said that this action was complete when they made their response on 21 December 2018.
  3. 3

    Keep the additional spectator-safety measures under continuous review in consultation with Trafford Metropolitan Borough Council and the Sports Grounds Safety Authority.

    Stated by Manchester United Football Club LimitedStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    No formal enforcement action was taken because available evidence did not warrant action under the Health and Safety at Work etc. Act 1974.

    Stated by Trafford Borough CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Review Council policies and procedures, including an appraisal of the Coroner’s concerns.

Verbatim wording from the response

“Further, as part of our commitment to safety at sports ground duties, the Council is currently reviewing its policies and procedures and will include an appraisal of the Coroner’s concerns as part of this review.”

Source location

2018-0404-Response-by-Trafford-Council
Page 2 · response
Published 21 December 2018

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

Review, enhance and independently validate the match-day slips, trips and falls risk assessment, including spectator and steward impediment risks and associated controls.

Verbatim wording from the response

“Following the conclusion of the inquest into Mr Whale’s death in November 2018, we have implemented the following additional steps in close consultation with TMBC and the SGSA:”

Source location

2018-0404-Response-by-MUFC
Page 1 · response
Published 21 December 2018

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

Keep the additional spectator-safety measures under continuous review in consultation with Trafford Metropolitan Borough Council and the Sports Grounds Safety Authority.

Verbatim wording from the response

“As noted above, we continue to strive to improve our spectator safety measures. We are therefore keeping all of the above under continuous review in close consultation with TMBC and SGSA.”

Source location

2018-0404-Response-by-MUFC
Page 2 · response
Published 21 December 2018

Open published response

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

No formal enforcement action was taken because available evidence did not warrant action under the Health and Safety at Work etc. Act 1974.

Verbatim wording from the response

“It was within this remit that the Council undertook an investigation into the accident to Richard John Whale. The investigation found that the Club had satisfactory arrangements in place at the time of the accident in relation to maintaining the safety of spectators at the ground, and that there was no evidence available which would warrant any formal action under the Health and Safety at Work etc Act 1974.”

Source location

2018-0404-Response-by-Trafford-Council
Page 1 · response
Published 21 December 2018

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

Data last updated 7 September 2026