Jack Riding

TheFA

FAO: Mr Joseph Hart

Her Majesty’s Assistant Coroner
Liverpool and the Wirral

C/o Jacqueline A Horner
Coroner's Investigation Officer

PRIVATE AND CONFIDENTIAL
24" January 2019
Dear Sirs

Inquest touching upon the death of Mr. Jack Riding —- Her Majesty’s Coroner Regulation 28
report (“the Report”)

We write in relation to the above matter and further to our previous correspondence dated 14"
January 2019.

Firstly, The Football Association once again wishes to express our sincere condolences on the
passing of Mr Riding.

Having given further consideration to the matters raised within Her Majesty's Coroner’s Report, we
believe it would be beneficial for us to review a copy of the Independent Consultant review of the
health and safety processes and procedures at Goals Soccer Centre Plc (“Goals”), as alluded to in
paragraph 4 of the ‘Coroner's Concerns’ section of the Report.

Having not been party to the inquest proceedings, we believe that having sight of this document
may better inform us about the circumstances of Mr Riding’s death and potentially assist us in
providing a more helpful response to Her Majesty's Coroner.

As such, we would be grateful if Her Majesty's Coroner would kindly provide us with a copy of the
review document, once it has been completed. We would be grateful for a short extension of 7 days
from the time that we receive a copy of the review document, by which to provide our response.

Patron The FA Group Postal Address T +4470) 800 169 1463
| Bogces Bis Meyers: Tan Grane wm uae F 800 169 1864
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CONNECTED BY bazahy kG Registration. 77797

The FA takes the matters raised in Her Majesty’s Coroner's Report seriously and we look forward to
providing a substantive response in due course.

We can be of any further assistance, please do not hesitate to contact us.

We look forward to hearing from you in due course.

Yours faithfully,

The Football Association
Email:

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5-A-SIDE. THE WAY IT SHOULD BE.

Goals Soccer Centres pic
Orbital House

Peel Park

East Kilbride

Mr. Joseph Hart
Coroners Officer
Gerard Majella Courthouse,
Boundary Street,
Liverpool,
15" January 2019

Dear Mr Hart
lam writing in response to your Regulation 28 Report of 26" November 2018.
Please find attached our comprehensive response to the Coroner’s concerns as specified in your document.

| have been CEO of Goals since April 2018 and want to stress that Health and Safety is a high priority for our
business. We have recently created a Health and Safety sub-committee to the PLC Board which will oversee
all of our activities in this area. It will have the same status as other sub-committees such as the Audit or
Remuneration Committees. | will be Chairing this committee.

| also want to stress that, even before | joined, Goals has always taken a proactive role in staying ahead of
current regulation in this area. This is true in our early adoption of Defibrillators across all of our centres as
well as adding training on these units into standard first aid training. Our approach to locating the units is in
line with other institutions such as major gyms and the FA’s new football hubs and was decided after
significant consultation.

However, we are not complacent and understand that there is always room for improvement and areas
where we should learn and make things better. We have detailed a number of such areas in our response.

We are keen to make sure we handle medical emergencies as affectively as possible and would welcome any
further suggestions you might have in this regard.

| hope you find our response comprehensive and easy to follow. If you have any questions or comments
please contact me directly. Furthermore, | would welcome the opportunity to discuss our response in person
with the Coroner, if appropriate.

| look forward to hearing from you

Yours sincerely

Andy Anson
CEO

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5-A-SIDE. THE WAY IT SHOULD BE.

Dear Mr Hart

RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS, SECTION 5 CORNORNERS CONCERNS

Following the Coroner’s Report sent to Goals Soccer Centres PLC (‘Goals’) on 28"" November 2018, please
find below the Coroner’s concerns with our formal response to each them.

Coroner Concern 55 (1) | heard evidence that there was a significant delay in bringing a Defibrillator to the
pitch where Jack Riding had collapsed. There was a delay of some minutes before the Defibrillator was
deployed. | make it clear that this could not be said to be a contributing factor in Mr Riding’s death. | have
received evidence of the systems in place to deploy the Defibrillator from Goals Soccer Centres plc. It remains
a concern to me that when matches are being played that the Defibrillator is kept away from the pitch and
the deployment of the equipment is dependent on which members of staff are present. ! am concerned that
any delay in the deployment of this emergency equipment presents a risk of future death.

55 (1) Response

In 2014 Goals proactively initiated a rollout of Defibrillators across all our clubs. This decision was based on
our commitment to safeguarding all of our customers and establishing best practice within our industry.
After proactively installing defibrillation units in 2014 across our entire estate, they were sited inside the
clubhouses The decision to place the units inside was based upon recommendations made during
consultation to ensure the units remain in good working order. Before these units were purchased, we met
with the Head Community Liaison officer for the Scottish Ambulance Association (SAA) and consulted with
the British Heart Foundation (BHF) for guidance and best practice on the type of equipment and to ensure
that we are providing the most appropriate product for our environment. The rollout of the Defibrillators
was undertaken based on best-practice advised during the consultation with the SAA and BHF and we
adopted their expert advice.

As a result of the advice received, the conscious decision was made by Goals to house the Defibrillators in
reception area’s which are constantly manned by staff, while the facility is open. In addition, the Defibrillators
could also be observed and monitored. We were advised that external unit placements are susceptible to
vandalism and damage and were clearly advised not to place units outside. To keep in full working order,
outside units would need to be wall mounted and lockable and keys would still be held inside at reception or
within the site which would further delay access to the Defibrillator when collecting the key and unlocking
the equipment for use. After further review and consultation with other new 5-a-side and fullsize facility
developments, it is clear that the units are still being placed inside including at the FA’s new hubs in Liverpool
and across the UK, for example at Heron Eccles opening late 2018 in Liverpool.

We firmly refute that there was a significant delay to the Defibrillator being accessed or used. CCTV footage
sent previously (appendix 10 in our response dated 18" November) showed our rapid response time of less
than 1 minute from staff receiving the information that the Defibrillator was required and taking it out onto
the pitch. Although we do not have exterior CCTV footage to verify timings to and from the pitch, Appendix
1 highlights the distances between pitches and the facility clubhouse and reception which is less than 100m
from the clubhouse to the pitch. This distance is much shorter than in many other sports-related leisure

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facilities. The Defibrillator unit was with Duty Manager Nicole Johnston on the pitch ready to be deployed
when necessary. There were several minutes when the Defibrillator was on the pitch while Nicole was
speaking to the 999 call operative taking CPR instructions. When instructed, the unit was on and ready for
use and produced a single shock after which the Ambulance Crew took over.

All Goals staff members are trained in the use of the Defibrillator so any staff member on duty is able to
operate a unit when necessary. Staff training is detailed further in our response to the coroner’s concern

detailed in S5 (3).

We do recognise speed is the primary factor in getting the Defibrillator to the point of emergency and
knowledge of Defibrillator location is vital for customers (staff are aware of equipment locations as this is
included within their induction). We have therefore undertaken an additional audit of Defibrillator locations
and signage across all facilities (Appendix 2) and as a result will make the following adjustments:

1) All Defibrillators will be housed in a location highly visible to the public in our receptions by 1°* March
2019. 28 units are already located in a prominent position visible to the public and will remain in
place, 18 units will be relocated into more prominent positions for customers with clear Defibrillator
signage.

2) All exit doors from our clubhouse/changing facilities to pitches and all individual pitch gates will have
additional Defibrillator location signs placed by 1** March 2019.

Coroner Concern $5 (2) | heard evidence that there was a significant delay in the ambulance personnel
getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. | saw some
CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. | have read the
representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of
emergency services, but it remains a concern to me how it is ensured the that policy in place is followed to
ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed
appropriately. | have seen Appendix 2 of the response of Goals Soccer Centres Pic which sets out that the
personnel at Goals, Liverpool North have been made aware of the new policy but | have seen insufficient
evidence of programmes of training to be carried out in the future, or of training drills, or the like. | am
concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death,
any delay of this kind presents a risk of future death.

$5 (2) Response

In addition to First Aid training, all staff are trained in ‘situational awareness’. This training includes medical
emergencies. In particular, the training includes directing a member of staff to go and wait for an ambulance
at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the
casualty. In the case of Jack Riding this didn’t happen and we acknowledge that this part of the emergency
was not handled in line with Goals training. Since the incident, we have immediately circulated the
Emergency First Aid Incident Procedure (appendix 13 in our response dated 18*" November) to reaffirm the

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procedure and to ensure all clubs are compliant in understanding their roles and responsibilities during an
emergency incident in the immediate short term.

In addition, the subsequent independent review of Health and Safety (commissioned following the incident)
has provided a new draft document (Appendix 3) called “Goals Normal Operating Procedures and Emergency
Action Plan 2019” which was created on the back of the updated “Goals First Aid risk assessment” (Appendix
9). The “Goals Normal Operating Procedures and Emergency Action Plan 2019 specifically includes (in section
2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it
have been agreed and a timeline for rollout across the business is as follows:

Phase Action Completion Date

Phase 1: Final review of new documentation and sign off by Head of Corporate 31/01/2019
Operations and PLC Health & Safety Committee

Phase 2: Standard documentation sent to clubs for specific club detail input and to be 15/02/2019
returned and reviewed by Head of Corporate Operations

Phase 3: “Goals Normal Operating Procedures and Emergency Action Plan 2019” 01/03/2019
Final detail agreed by Goals Senior Management team and implemented across
all clubs

Phase 4: Regional Manager audits are to be re-reviewed and the new documentation 28/02/2019

and actions implemented into the Regional Manager club audits

As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-
played by all clubs and refreshed annually. Details of this can be found in the response to the training concern
detailed in $5 (3).

Coroner Concern $5 (3) | have seen a limited risk assessment to consider what should be done in the case of
a medical emergency on the pitch. | have seen no clear indication of the extent and subject matter of any
First Aid training. | have seen evidence that training has taken place. In the absence of any such evidence |
am concerned that a lack of training may present a risk of future death.

S5 (3) Response

All Goals staff have received Emergency First Aid, Health and Safety and Defibrillator training which broadly
consists of 4 tiers of job-specific training in the form of: Induction training, Defibrillator video training, e-
learning and practical training.

The first phase of training is compulsory and provided during all staff job inductions. The inductions cover
site specific locations of First Aid equipment, Defibrillators, First Aid kits and essential site information.

Further to induction, all staff undertake video training on using a Defibrillator provided by our Defibrillator
provider, Lifepak. This provides training in operational use of the units. The content of the 13-minute video

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training can be found via a link in our company H&S policy (Appendix 5, page 16). The training is refreshed
every 6 months (Appendix 4 signed shows latest staff refreshers).

In addition to Induction and video training, all staff including Receptionists, Bar staff, Maintenance staff and
Car Park Security complete bespoke e-learning in Health and Safety Level 2 and Emergency First Aid via our
e-learning provider Flow Hospitality. The course specification can be found in Appendix 6 which in Summary
covers dealing with emergency situations, primary & secondary surveys, basic life support (CPR) and the
recovery position.

The final level of in-depth and practical training is provided for all Duty Managers. In 2015 we proactively
implemented steps to improve Defibrillator training levels. Until 2018 the First Aid training syllabus did not
cover practical training in the use of Defibrillators, however following consultation with our First Aid provider,
we added Defibrillator practical training into our First Aid syllabus, At this time this training was not a
standard topic within the syllabus of the standard qualification (Level 2 Emergency First Aid at Work QCF).
Goals consciously implemented Defibrillator practical training well before this was made mandatory. The
qualification was updated in January 2018 to include practical training and assessment in the use of
Defibrillator, which we continue to provide, specifically covering First Aid skills in cardiopulmonary
resuscitation (CPR) and use of an automated external Defibrillator (AED) (Further content of the training can
be found in Appendix 7).

We have held 18 Emergency ‘First Aid at Work’ qualification courses in the past 24 months and Appendix 8
shows 172 staff First Aid trained to this level with practical Defibrillator training, valid for 3 years.

Since the incident we have committed to significant increases to further enhance the level of training staff
receive:

¢ By 31st July 2019, All General Managers, Regional Managers and Operations Team members will
complete the Level 3 ‘First Aid at work’ (18 hours) (They previously were required to complete the
‘Emergency First Aid at Work’ course 6 hours). Course specifications Appendix 7.

¢ By 31st July 2019 any staff member working 16 hours or more on reception will receive the
‘Emergency First Aid at work’ 1-day course covering practical training and assessment, in addition to
video training. Course specification Appendix 7.

e By 1* January 2020 all reception staff (regardless of hours worked) with 1 years’ service will receive
the ‘Emergency First Aid at work’ 1-day course covering practical training and assessment, in addition
to video training. Course specification Appendix 7.

To support the new Emergency Action Plan and Serious First Aid Incident Procedures, we are implementing
scenario-based training to deal specifically with emergency First Aid procedures with the following rollout
plan:

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Phase Action Completion Date
Phase 1: Create club-based scenario and First Aid incident on the pitch training and 31/03/2019
video roles & responsibilities for the Goals e-learning platform
Phase 2: Create scenario-based training to emulate Emergency First Aid procedures 31/03/2019
in each club with all staff members and implement an annual refresher
Phase 3: Roll out video & scenario-based training to all staff to complete in the 2nd 31/08/2019
Defibrillator refresher training
Phase 4: — Regional Manager audit to be re-reviewed and new training to be checked 28/02/2019
as part of new Regional Manager audit procedure

The video training course will be accessed via the Goals e-learning platform in time for the second running
of the 2019 Defibrillator refresher training, along with on-site situational role-play training which all staff
members will be required to undertake.

Coroner Concern $5 (4) | note that Goals Soccer Centres Plc recognise a need to review the Health and Safety
processes. They have instructed an Independent Consultant to undertake a review of Health and Safety
processes and procedures but with no clear timescale for this review | am still of the view that | am under a
duty to prepare this report.

S5 (4) Response The Independent Consultant Health and Safety review is now complete (Appendix 3) and
the timescales for the rollout of the new documentation training and subsequent actions and procedures are
highlighted in the responses to the Coroner concerns in $5 3 & 4, above.

Appendices, referenced in document:

Number Document

Liverpool North Pitch overview

Goals Defibrillator Audit

Goals NORMAL OPERATING PROCEDURES AND EMERGENCY ACTION PLAN 2019
Defibrillator Refresher Training

Goals Health and Safety Policy November 2018

Goals e-learning Training

Goals Qualification Overview

Goals First Aiders

Goals First Aid Risk Assessment December 2018

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We hope this response adequately addresses your concerns. We are happy to discuss this in more detail at
your convenience and would welcome the opportunity to meet in-person.

Yours sincerely,

Head of Corporate Operations

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GOALSFOOTBALL.CO.UK Bet