Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0300, written 19 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Oct 2017 |
|---|---|
| Reference | 2017-0300 |
| Deceased | Jakub Moczyk |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
LIFESHIELD MEDICAL SERVICES LTD
FALAISE
MAIN ROAD
GREAT YARMOUTH
NR29 3LW
1 | CORONER
| am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 | INVESTIGATION and INQUEST
On 23 November 2016 | commenced an investigation into the death of JAKUB DAWID
MOCZYK, AGE 22 YEARS. The investigation concluded at the end of the inquest on 13
OCTOBER 2017. The conclusion of the inquest was Medical Cause of Death: 1a)
Traumatic Brain Injury; and Conclusion: MISADVENTURE.
4 | CIRCUMSTANCES OF THE DEATH
Mr Moczyk was taking part in a boxing match at The Atlantis Arena on 19 November
2016. In round 3, he received a blow to the head and fell to the ground. Mr Moczyk was
unresponsive and was taken to the James Paget University Hospital. He did not regain
consciousness and died from his injuries on 21 November 2016.
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
In my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(1) Not all boxers were fully checked prior to the fight taking place, including the
deceased's opponent {aged 17 years). The medics did not notice he had not been fully
examined.
(2) The medics did not make the referee/promoter aware that not all the boxers had
returned to complete their medical examination before the boxing had started.
(3) During the 2 round the deceased’s opponent gagged/vomited on 2 occasions. The
referee stopped the fight and counted to 8 on both occasions. The medics did not
examine the boxer and advise as to his fitness to continue fighting, but relied on the
referee to make the decision as to whether the fight should continue. It was known by
the medics that the referee was not medically qualified. The medics were aware the
referee was also the opponent's own trainer. It was said in response to questioning in
this respect, that the referee could be expected to know the boxer and whether he was
fit to continue fighting. No account was taken that the referee/trainer may prefer the
boxer to continue fighting rather than to stop the fight.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 8 December 2017. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
and
via his solicitor, EEEERt Belmores
Great Yarmouth Borough Council via their solicitor,
| am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
19 October 2017
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Lifeshield Medical Services Ltd Falaise Main Road, Ormesby, Great Yarmouth, Norfolk NR29 3LW 16" November 2017 Reply to regulation 28 report. Dear Jacqueline Lake, In answers to your questions Paragraph 5 1 We couldn't exam all the fighters when even though we had asked several times for the list of who was fighting we were not given one so it was impossible for us to know other than the ones that did not come back for the blood pressure to be taken. 2. You are saying we did not inform the referee or promotor that not everyone had had medicals this is incorrect we had informed both of them we also told | ES had fighters there. 3. Referees will have first aid training. It is up to the referee and the corner men to make decisions or ask for advice. This was not ask for. It is up to the referee in all boxing events including British Boxing Association. We have no power whatsoever which we would like to have. Due to our new policies for boxing most promotors do not want them so we are not covering boxing. We did want to bring in random drug testing and head scanning before and after matches plus the list below out of the promotors only one has agreed to everything other than the scanning. The rules No medical no fight failed medical no fight _ failed drug test no fight These rules cannot be overruled. We also carry our own paperwork for medicals even if they supply their own. These people and promoters do not want rules and regulations if they did they would be a member of one of the associations. If they are in force they will go underground and they do not have to have medical cover because of not being a part of association. Just an added extra just to bring to your attention nothing to do with this report. The very last boxing match we covered there were children as young as 6 years old boxing advertised as skill bouts. Yours Sincerely
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