PFD report

Faye Allen · Prevention of Future Deaths report

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Issued 29 Apr 2019•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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised1

  1. Ambiguity in staffing-level guidance for medical-area resources at events
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.3

  1. Action

    Make necessary changes to the guidance following stakeholder consultation.

    Stated by National Ambulance Resilience UnitStated plannedThe respondent said that this action was planned when they made their response on 29 July 2019.
  2. Action

    Draft amendments to clarify emergency-plan guidance and address the report’s specific concerns.

    Stated by National Ambulance Resilience UnitStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
  3. Action

    Complete a national review of emergency-plan guidance, including Annex B provisions.

    Stated by National Ambulance Resilience UnitStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Event organisers are responsible for assessing risks and ensuring adequate medical provision during event set-up, operation and breakdown.

    Stated by Health and Safety ExecutiveRedirects 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

Ambiguity in staffing-level guidance for medical-area resources at events

Wider context from the report

“During the course of the inquest the issue of the availability of paramedics and other medical assistance was considered. The inquest was referred to the National Ambulance Service Guidance for preparing an Emergency Plan specifically Annex B which feeds into the Purple Guide. The annex and its tables set out staffing levels that are recommended for different event types. However, it became clear during the evidence that the recommended levels of staffing could be interpreted in different ways and that for example first aiders deployed in areas other than the medical cabin area were being counted as part of the resource. This meant that staff directly deployed to deal with medical issues in the medical area could vary widely and be significantly below the numbers set out in the tables. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Make necessary changes to the guidance following stakeholder consultation.

Verbatim wording from the response

“• The next stage will be for that draft text to go out to consultation with relevant stakeholders. We will then make the necessary changes and aim to publish a revised version of the guidance before the end of September 2019.”

Source location

2019-0147-Responses
Page 1 · response
Published 29 July 2019

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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

Draft amendments to clarify emergency-plan guidance and address the report’s specific concerns.

Verbatim wording from the response

“• My Compliance & Quality Team have drafted a number of amendments to be included within the guidance document to add clarity and address the specific concerns raised within the Regulation 28 report findings.”

Source location

2019-0147-Responses
Page 1 · response
Published 29 July 2019

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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

Complete a national review of emergency-plan guidance, including Annex B provisions.

Verbatim wording from the response

“To date, the following work has been completed.”

Source location

2019-0147-Responses
Page 1 · response
Published 29 July 2019

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

Event organisers are responsible for assessing risks and ensuring adequate medical provision during event set-up, operation and breakdown.

Verbatim wording from the response

“The key to any event is the pre-preparation and assessment of risk and this will include the medical provision. The purple guide is a live event specific document whereas the NARU document is for a wider focus of events. The numbers and arrangements of medical provision will depend on several factors such as crowd size, expected crowd behaviour, expected drug/alcohol use and venue size (e.g. a Warehouse venue will require different planning and medical provision to that of a large festival site). It is for the organiser to”

Source location

2019-0147-Responses
Page 2 · response
Published 29 July 2019

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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.4

  1. 1

    Send the coroner’s comments on emergency planning and the response letter to relevant local authorities.

    Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 29 July 2019.
  2. 2

    Raise the coroner’s concerns with entertainment-industry representatives.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
  3. 3

    Brief NHS England on the report findings and planned corrective actions.

    Stated by National Ambulance Resilience UnitStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
  4. 4

    Consult relevant stakeholders on the drafted guidance amendments.

    Stated by National Ambulance Resilience UnitStated plannedThe respondent said that this action was planned when they made their response on 29 July 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    First Aid at Work Regulations 1981 apply only to employees, not specifically to first-aid provision for members of the public.

    Stated by Health and Safety ExecutiveDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Local authorities are responsible for enforcing health and safety law at individual events within their geographical areas.

    Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Send the coroner’s comments on emergency planning and the response letter to relevant local authorities.

Verbatim wording from the response

“HSE has raised your concerns with representatives from the entertainment industry. We will also arrange for your comments regarding general emergency planning procedures in place at this event, along with a copy of this letter to be sent to relevant Local Authority bodies, who have licensing and enforcement responsibilities for such activities.”

Source location

2019-0147-Responses
Page 3 · response
Published 29 July 2019

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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

Raise the coroner’s concerns with entertainment-industry representatives.

Verbatim wording from the response

“HSE has raised your concerns with representatives from the entertainment industry. We will also arrange for your comments regarding general emergency planning procedures in place at this event, along with a copy of this letter to be sent to relevant Local Authority bodies, who have licensing and enforcement responsibilities for such activities.”

Source location

2019-0147-Responses
Page 3 · response
Published 29 July 2019

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

Brief NHS England on the report findings and planned corrective actions.

Verbatim wording from the response

“• I have briefed our parent body, NHS England, on your report findings and our planned actions.”

Source location

2019-0147-Responses
Page 1 · response
Published 29 July 2019

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

Consult relevant stakeholders on the drafted guidance amendments.

Verbatim wording from the response

“• The next stage will be for that draft text to go out to consultation with relevant stakeholders. We will then make the necessary changes and aim to publish a revised version of the guidance before the end of September 2019.”

Source location

2019-0147-Responses
Page 1 · response
Published 29 July 2019

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

First Aid at Work Regulations 1981 apply only to employees, not specifically to first-aid provision for members of the public.

Verbatim wording from the response

“Festival organisers have responsibilities under Section 3 of the Health and Safety at Work etc. Act 1974 (HSWA) to ensure, so far as is reasonably practicable, the safety and health of members of the public affected by their business. HSE guidance strongly recommends guidance that employers include non-employees in the first aid provisions; however, the specific requirements of the First Aid at Work Regulations 1981 apply only to the provision of first aid for employees.”

Source location

2019-0147-Responses
Page 2 · response
Published 29 July 2019

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

Local authorities are responsible for enforcing health and safety law at individual events within their geographical areas.

Verbatim wording from the response

“The Health and Safety Executive (HSE) leads on national occupational health and safety policy for the entertainments and leisure sector, whilst Local Authorities are responsible for enforcing the law at individual events, such as festivals, in their geographical area. In addition to health and safety law, some events may also require licences from local authorities.”

Source location

2019-0147-Responses
Page 2 · response
Published 29 July 2019

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