Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0048, written 15 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2018 |
|---|---|
| Reference | 2018-0048 |
| Deceased | Charlie Craig |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Other related deaths · Child Death (from 2015) |
| 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: Ms Julie Harrington, Chief Executive, British Cycling, Stuart Street, Manchester M11 4DQ. CORONER | am Chris Morris, Area Coroner, for the Coroner area of South Manchester 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 INVESTIGATION and INQUEST On 29" March 2017, Alison Mutch OBE, Senior Coroner for Manchester South opened an inquest into the death of Charlie Benjamin Craig, who was aged 15 when his death was confirmed at Stepping Hill Hospital, Stockport on 21% January 2017. The investigation concluded at the end of the inquest which | heard on 13" and 14" February | 2018. The conclusion of the inquest was that Master Craig died as a consequence of damage to his heart resulting from a number of myocardial infarctions. It is likely that these | myocardial infarctions occurred as a result of an abnormal physiological response to adrenaline and noradrenaline produced by the body during intense exercise. At the end of the inquest, | recorded a narrative conclusion to this effect. 4 | CIRCUMSTANCES OF THE DEATH Charlie Craig was an elite cyclist, and a member of the Apprenticeship stage of British Cycling’s World Class Programme. Master Craig appeared to be generally in excellent health, and in particular did not at any stage report any signs or symptoms which would ordinarily be suggestive of any problems with his heart. Master Craig was found unresponsive in his bed on the morning of 21% January 2017, having last been seen by his family, apparently fit and well, the previous evening. A post mortem examination (part of which included examination of Master Craig’s heart by a specialist cardiac pathologist) concluded that Charlie Craig died as a result of: 1a) Idiopathic myocardial infarction; | Il) Gastrointestinal bleeding. 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. | 7 6 | ACTION SHOULD BE TAKEN — COPIES and PUBLICATION The MATTERS OF CONCERN are as follows. — It was confirmed during the inquest that British Cycling does not currently undertake any health assessments or medical screening prior to accepting young riders onto the Apprenticeship stage of the World Class Programme. The evidence before the court was that this approach differs from that of some other UK sporting bodies running comparable programmes for young athletes, who undertake medical screening as a matter of routine. A consultant cardiologist gave evidence in the course of the inquest to the effect that medical screening can play an important role in identifying cardiac abnormalities in asymptomatic young people. In my opinion action should be taken to prevent future deaths and | believe you have 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 12" April 2018. |, 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. | have sent_a copy of my report to the Chief Coroner and to the following Interested Persons aaa parents of the deceased. | have also sent a copy to UK Sport who may find it useful or of interest. | 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. Chris Morris Area coy) 15.02.2018 i Ne
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.
Mary
<7 HSBC UK
BRITISH
CYCLING
ICEIVED
11 APR 2016
British Cycling
Stuart Street
Manchester M11 4DQ
T: +44 (0) 161 274 2000
F: +44 (0) 161 274 2001
britishcycling org.uk
Mr Chris Morrison
Area Coroner
Coroner's Court
1 Mottram Street
Mount Tabor
Stockport
SK1 3AG
10 April 2018
Dear Mr Morrison
REGULATION 28: REPORT TO PREVENT FUTURE DEATH: CHARLIE BENJAMIN CRAIG
(DECEASED)
Thank you for your Report dated 15 February 2018 made under paragraph 7, schedule 5, of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013 ("Report"), which has bean made following the inquest touching the death of
Charlie Craig which was heard at Stockport Coroner's Court on 13% and 14" February 2018.
We have set out below our response to the Report addressing the matters of concem raised in
the Report, namely that British Cycling does not currently undertake any health assessments
or medical screening prior to accepting young riders onto the apprentice stage of the World
Class Programme ("WCP”).
Great Britain Cycling Team (“GBCT") WCP
As you are aware the GBCT operates a performance pathway which nurtures promising talent
ultimately leading to participation on the WCP. The performance pathway is broken down into
an apprentice stage for riders between the ages of 14 and 16, the junior academy for riders
between the ages of 16 and 18, the senior academy for riders between the ages of 18 and 23
and the podium stage for riders aged 21 upwards.
In the apprentice stage the training is regionalised and riders are not subject to a full time
training program and in fact only train with the GBCT for, on average, 15 to 20 days per year.
As riders progress through the various stages the training becomes more extensive and Is
centralised in Manchester.
GBCT medical assessment
At present, on joining the apprentice stage, riders are required to complete a health
questionnaire. As riders progress through the stages and the training becomes more intense,
so doss the medical review which includes a full medical screening including cardiac screening
in the form of an ECG, followed by an echocardiogram where abnormalities are detected on
the ECG.
HSBC <> UK LORDERY < uk sport PONbenY WS Pe Baie
‘The Brilish Cycling Federation trading as ‘Britith Cycling’ is © company timited by Guarentee Registered in England No 1642494 Registered Cilice: Britith Cycting Federation, Stuart Street, Manchester 411 4D.
«f HSBC UK
BRITISH
CYCLING
British Cycling
Stuart Street
Manchesler M14 40Q
T: +44 (0) 181 274 2000
F: +44 (0) 161 274 2001
britishcycling.org.uk
Review of medical screening on the GBCT
The type of testing envisaged as a possibility by the Coroner has in fact been under research
since last September when a new Head of Medical Services was appointed and British Cycling
believes that this testing will meet what is envisaged by the Coroner's report.
Since his appointment the new Head of Medical Services has been working with some of the
UK's leading sports cardiology experts at Liverpool John Moores University to produce new
GBCT cardiac screening guidelines ("Guidelines") covering all athletes on the WCP together
with those at apprentice level. The recommendations for Guidelines are due lo be submitted
for review by the GBCT Senior Leadership Team by 16 Apri! 2018, following which the
Guidelines will be implemented across the WCP and those at apprentice level.
The screening of individuals below the age of 16 has previously been a contentious area across
all sports, as due to the developmental changes in the heart which are still taking place at this
age ECG monitoring can produce false positive ECG findings. However, the latest professional
consensus at the UK Cardiology in British Sport Symposium (23 March 2018) is that screening
at this age can be statistically relevant.
[tis proposed that under the Guidelines, as a minimum, apprentice riders will not be allowed to
participate in the performance pathway until ihey have:
@. Satisfactorily completed a health questionnaire and any areas of concern have been
addressed by the GBCT medical team,
b. provided a fitness to participate certificate from their General Practitioner, and
c. provided evidence that cardiac screening has been undertaken in the form of an ECG,
and where abnormalities are detected on the ECG, evidence has been obtained that a
satisfactory echocardiogram has been completed. Any abnormalities found at the time
of screening will trigger referral to a sports cardiologist for further action, Including
decisions on further participation on the performance pathway.
We trust that the above addresses the matters of concern raised in the Report; however, should
further information be required please do not hesitate to contact us.
Yours sincerely
tulle Harrington
Chief Executive
British Cycling
HSBC €}UK nae vB uk sport PORDESY 05 SP Baleo
‘The British Cycling Federation trading as ‘British Cycling’ ts a compamy timnited by Guarentee. Registered In England No, 2042494 Regittered Office: Beitish Cycting Federation, Stusrt Street, Manchester M11 400:
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