Investigation and inquest
On 11/11/2020 I commenced an investigation into the death of Edward Lewis BILBEY aged 17. The investigation concluded at the end of the inquest on 23 December 2020. The conclusion of the inquest was:
I a Cardiac arrest
I b Combined effects of an inherited heart condition, myocardial fibrosis and metabolic disturbance caused by intense physical training and rapid weight loss by dehydration.
Narrative Conclusion : Edward Lewis Bilbey, in preparation for a boxing competition, died as a result of an undiagnosed heart condition in combination with a metabolic disturbance resulting from intense physical training and rapid weight loss and dehydration. His death was in part contributed to by a failure to have adequate safeguarding and child protection measures in place to prevent him from doing so.
Circumstances of the death
Edward Lewis Bilbey died on the 24th March 2017 at Kings Mill Hospital after collapsing in a boxing ring, preceded by a period of intensive training.
Coroner’s concerns
Boxing England, A National Governing Body did not have in place any systems to monitor and enforce compliance with Child Protection and Safeguarding issues. Given the media coverage of issues with Child Protection and Safeguarding with British Gymnastics and British Athletics I am concerned that this is endemic amongst Sporting National Bodies.