Richard Whale

Rt Hon Jeremy Wright QC MP 

Secretary of State for Digital, Culture, 
Media and Sport 
4th Floor 
100 Parliament Street 
London SW1A 2BQ 

www.gov.uk/dcms 
enquiries@culture.gov.uk 

TO2019/01903/DC 
11 February 2019 

Alison Mutch OBE 
HM Senior Coroner 
Manchester South 
Coroner’s Court 
1 Mount Tabor Street 
Stockport   SK1 3AG 

Dear Ms Mutch, 

Thank you for your letter of 21 December 2018, enclosing your Regulation 28 Report on the 
death of Mr Richard Whale on 11 December 2017 following an incident at Old Trafford, the home 
ground of Manchester United FC (MUFC). 

The Sports Grounds Safety Authority (SGSA) is the UK Government’s expert body on sports 
ground safety.  It has a statutory responsibility to regulate local authorities in their oversight of 
safety at all football grounds in the Premier League and the English Football League, as well as 
at Wembley and the Principality Stadium. It also issues licences to these stadia to enable them to 
admit spectators. 

The SGSA is aware of the incident leading to the death of Mr Richard Whale in December 2017. 
Since the incident took place, the relevant SGSA Inspector has been liaising closely with both 
Trafford Metropolitan Borough Council (MBC) and MUFC, most recently in November 2018. This 
liaison has focused on ensuring that lessons are learned from the incident and are being applied 
by the club and the local authority, particularly in relation to the ongoing provision of suitably 
qualified and trained stewards at Old Trafford. There has been monitoring of stewards’ behaviour 
in and around vomitories, especially during ingress and egress. 

Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that 
both organisations have identified the relevant spectator safety issues arising from the incident, 
and that each has taken appropriate steps to address these issues. The SGSA will continue to 
monitor and take action as necessary, as part of its ongoing regulatory remit.   

I note your report references the SGSA’s Guide to Safety at Sports Grounds (the “Green Guide”). 
I agree with your finding that it does not include explicit “guidance as to the placement of 
stewards or suggest best practice to avoid stewards blocking access to the handrails”.  The 5th 
edition of the Green Guide, the current edition at the time of the incident, did include guidance on 
handrails and stairways at 8.81, 8.92, 9.9a3 and 9.9e4, with paragraph 9.9e emphasising that 

1 Guidance	
  at	
  8.8	
  states,	
  “Handrails	
  for	
  stairways	
  and	
  ramps:	
  As	
  stated	
  in	
  Section	
  8.6,	
  a	
  handrail	
  is	
  provided	
  for	
  people	
  to	
  grasp,	
  
for	
  guidance	
  or	
  support.	
  If	
  the	
  handrails	
  are	
  to	
  serve	
  only	
  as	
  handrails	
  for	
  stairways	
  or	
  ramps	
  –	
  that	
  is	
  they	
  are	
  not	
  barriers	
  as	
  
described	
  in	
  Section	
  8.7b	
  -­‐	
  the	
  design	
  should	
  meet	
  the	
  following	
  requirements:	
  [including]	
  a.	
  Handrails	
  of	
  the	
  same	
  height	
  should	
  
be	
  provided	
  on	
  both	
  sides	
  of	
  stairways,	
  landings	
  and	
  ramps…” 
2 Guidance	
  at	
  8.9	
  states,	
  “In	
  order	
  to	
  ensure	
  free	
  flow	
  of	
  people,	
  and	
  avoid	
  crowd	
  pressures	
  building	
  up,	
  the	
  head	
  of	
  each	
  
stairway	
  should	
  be	
  designed	
  so	
  that	
  flow	
  onto	
  the	
  stairway	
  is	
  uniform	
  across	
  its	
  width.” 
3 Guidance	
  at	
  9.9a	
  states,	
  “If	
  passage	
  through	
  the	
  vomitory	
  is	
  by	
  steps,	
  the	
  design,	
  dimensions,	
  barriers	
  and	
  handrails	
  should	
  
meet	
  the	
  requirements	
  for	
  stairways	
  (see	
  Chapter	
  8).” 

 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
                     
 Department for Digital, Culture, Media & Sport 

during ingress and egress stewards should position themselves to ensure the unimpeded 
passage of spectators who wish to leave. However, the 5th edition was not explicit about 
spectator access to handrails on egress.   

The SGSA has since published the latest 6th edition of the Green Guide in October 2018. This 
latest edition expands upon the guidance in the 5th edition and includes specific guidance on 
vomitories and the positioning of stewards (section 9.8), vomitory widths (section 9.9) and 
vomitory control measures (section 9.10).  It recognises that the width of a vomitory, and of 
gangways leading to a vomitory, are key control measures (section 9.9). Furthermore, Chapter 4 
highlights that safety at sports grounds relies to a great extent upon the deployment of an 
appropriate number of well trained and suitably equipped stewards, with section 4.6 outlining 
stewards’ duties and section 4.10 detailing current stewards training and assessment processes.  
The new edition of the Green Guide has informed the SGSA’s engagement with Trafford MBC 
and MUFC. 

In light of the concerns you have raised the SGSA is amending the Green Guide so that section 
9.8e makes a specific reference to access to handrails in the context of vomitories and the 
positioning of stewards. The relevant extract is below, with the proposed new wording shown in 
italics: 

“Management should ensure that no spectators or non-essential staff are allowed to stand in 
vomitories during an event. 

Similarly, during ingress and egress, stewards should position themselves to ensure the 
unimpeded passage of spectators. Stewards should not prevent spectators being able to access 
any handrails present. This is essential towards the end of an event (or a significant part of an 
event) in order to prevent overcrowding, to avoid impeding those spectators who wish to leave, 
and to ensure spectator safety.” 

I hope this reassures you that suitable guidance is in place for sports grounds and that necessary 
remedial action, overseen by the SGSA, is being taken by Trafford MBC and MUFC to avoid a 
repetition of the incident which resulted in the tragic death of Mr Whale.   

Yours sincerely, 

Rt Hon Jeremy Wright QC MP 
Secretary of State for Digital, Culture, Media and Sport 

4 Guidance	
  at	
  9.9e	
  states,	
  “Management	
  should	
  ensure	
  that	
  no	
  spectators	
  or	
  non-­‐essential	
  staff	
  are	
  allowed	
  to	
  stand	
  in	
  
vomitories	
  during	
  an	
  event.	
  	
  Similarly,	
  during	
  ingress	
  and	
  egress,	
  stewards	
  should	
  position	
  themselves	
  to	
  ensure	
  the	
  unimpeded	
  
passage	
  of	
  spectators.	
  	
  This	
  is	
  essential	
  towards	
  the	
  end	
  of	
  an	
  event	
  (or	
  significant	
  part	
  of	
  an	
  event)	
  in	
  order	
  to	
  prevent	
  
overcrowding	
  and	
  not	
  to	
  impede	
  those	
  spectators	
  who	
  wish	
  to	
  leave.”

RECEIVED
29 JAN 2619

t

HM Senior Coroner
Coroner’s Court

1 Mount Tabor Street
Stockport

SK1 3AG

BY RECORDED DELIVERY

25 January 2019

Dear Ms Mutch

RE: Richard John Whale
Your ref: 8927/CLB

On behalf of Manchester United Football Club Limited (the “Club”), | write in response to your
Regulation 28 Report (the “Report”) dated 21 December 2018. | note that the Report has also been
sent to Trafford Metropolitan Borough Council (“TMBC”) and the Department for Digital, Culture,
Media & Sport (“DDCMS”), each of whom | understand will also be submitting their own response to
the Report.

Opening remarks

Before turning to the specific matters raised in the Report, let me first reiterate that everyone at
Manchester United is deeply saddened by the death of Mr Whale. The club continues to extend its
sincere condolences to his family.

The health, safety and security of all supporters and visitors at Old Trafford is of utmost importance
to Manchester United and we go to great lengths to ensure our procedures are audited, monitored
and adhered to at all times. We work with independent safety inspectors from the local authority
(TMBC), national stadium safety inspectors (the Sports Ground Safety Authority, “SGSA”), and
external safety auditors to ensure the correct procedures are administered.

We believe that the club operates its health, safety and security arrangements to an exceptionally
high standard and in full compliance with the law; this is reflected in the consistently excellent
feedback we have received from the regulators. However, we are not complacent in this regard and
we constantly seek to learn and to improve our procedures. We therefore welcome the
observations in the Report on opportunities for further risk reduction.

Following the conclusion of the inquest into Mr Whale’s death in November 2018, we have
implemented the following additional steps in close consultation with TMBC and the SGSA:

e The match-day slips/trips/falls risk assessment has been further reviewed, updated and
enhanced with input and advice from TMBC. It has also been externally validated by an
independent health and safety consultant. This now includes the potential risks arising from
‘impediments caused by the presence of spectators, staff and stewards’. The risk controls
have also been expanded to include the briefings, training and guidance being provided to
stewards and the ‘real time’ monitoring and auditing that is taking place as described further

MANCHESTER UNITED FOOTBALL CLUB LIMITED

Sir Matt Busby Way, Old Trafford, Manchester M16 ORA
Telephone: 0161 868 8000. Facsimile: 0161 868 8804. www.manutd.com
Registered In England No, 95489. VAT No. GB 561 0952 51

below. In addition, the risk assessment also includes reference to steward vigilance,
customer engagement and steward positioning on vomitories.

e Briefings are continually ongoing to all stewards, which cover their duties, roles and
responsibilities. This information is also included in match day briefing notes. Within these
briefings, we have increased the focus on the importance of the provisions of the Stewards
Code of Conduct. The briefings place particular emphasis on (i) stewards’ awareness of their
surroundings and prevailing situation, (ii) customer engagement, (iii) ensuring that
vomitories remain unimpeded at all times, and (iv) ensuring availability of handrails for
supporters at all times.

e Inaddition, specific steward positioning guidance has been delivered to all stewards who are
responsible for vomitory areas which:

© provides guidance to ensure that steward positioning allows supporters to use the
handrails and to ensure that the stewards facilitate their use;

Oo emphasises the need for stewards to be continually alert to people coming to use
the vomitory and to move accordingly to allow space to pass; and

© further emphasises to all stewards that their focus must not be distracted by events
taking place on the pitch during the match, in order that they maintain their position
and awareness of their surroundings as to carry out their regulated duties.

e Regular proactive checks have been put in place to ensure that no more than two stewards
are present in the vomitory space (save for exceptional circumstances where an additional
stewarding presence is required). In periods of heavy footfall, one steward will stay near the
head of the vomitory whilst the other will move down inside so as to maximise accessibility
of the handrails.

e As part of this new monitoring and audit process we have introduced new quality assurance
compliance check sheets. Head Stewards / Deputies / members of our Safety & Security
Team conduct audit checks across the stadium, which involves questions to stewards about
their knowledge and understanding of their specific duties, codes of conduct and vomitory
protocols. This also includes quality assurance of supervisors’ briefings. Outcomes are
recorded on the compliance check sheets, and advice and training is given as required
{information on these topics is also contained in Stewards Handbook which is issued to all
stewards). The completed sheets are collated and evaluated by senior safety staff and filed
post every match.

All of the above was fully in place prior to the Boxing Day fixture, and is in addition to our already
rigorous and extensive spectator safety measures.

As noted above, we continue to strive to improve our spectator safety measures. We are therefore
keeping all of the above under continuous review in close consultation with TMBC and SGSA.

Response to the specifics of the Report

The Report (at section S) lists four specific matters of concern. We respond to each of these as
follows:

1. The Local Authority had issued a list of recommendations to the club after the death of Mr
Whale. There was no mechanism in place for discussion of those recommendations or to ensure that
they had been followed or if not followed discussion for reasons.

As noted in paragraph 21.3 of our legal counsel’s closing submissions to the inquest, the letter sent
by TMBC to the Club did not ask for a written response, nor was any response subsequently
requested by TMBC (with whom we met regularly following receipt of the letter). The Club carefully
considered the contents of the letter and carried out such actions as were necessary, whilst
continuing to regularly consult and confer with TMBC {including verbal discussions of those
recommendations). However, on reflection and having conferred further with TMBC following
conclusion of the inquest, we accept that it would have been preferable if there had been a more
formal mechanism put in place for discussion of those recommendations and their
implementation. In future, should we receive written advice from TMBC we will ensure that this is
formally responded to in writing. We also understand from TMBC that any future correspondence
from them which calls for a reply from the Club will be appropriately time-lined to ensure an
auditable response trail (an approach with which we agree).

2. The widths of the staircases (“vomiteries” [sic]) is set in the Green Guide. Those widths take into
account the handrails but not the inevitable reduction in width that takes place when stewards are
deployed into them. In effect, the vomiteries are significantly narrower at points than the suggested
widths.

The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely
with the DDCMS to provide a substantive response to this concern. As noted and accepted during
the inquest, the vomitory in question fully complies with the requirements of the Green Guide as
applicable at the time of construction.

3. The green guide does not give guidance as to placement of stewards or suggest best practice to
avoid stewards blocking access to the handrails. It was accepted during the course of the inquest
that the role and placement of stewards was vital to ensuring the safety of the public at football
matches.

Again, the content of the Green Guide is a matter for the SGSA. The positioning of the stewarding at
Old Trafford stadium is something that SGSA and TMBC have had (and continue to have) many
opportunities to observe and advise upon. Neither organisation has ever indicated to the Club that
the positioning of the stewards within the vomitories (which is standard practice across most if not
all major football stadia) is a cause for concern. Indeed, | understand that at the inquest the
evidence from TMBC was that in their opinion stewards need to be located in the position in
question for safety reasons; this concurs with our own view and with long-standing practice.
However, in view of the concern raised in the Report we have very carefully reviewed the

position. We remain satisfied that the positioning of stewards is appropriate, and as noted above
we have issued detailed positioning guidance to all stewards deployed in vomitories in light of the
findings at the inquest which explicitly codifies existing good practice.

4. It was accepted by MUFC that the club stewards were not complying with the code of conduct
relating to stewards although one was trained and one was undergoing training. A Supervisor was

also supervising them. There was no evidence of regular audits of stewards and their compliance
with the Code of Conduct.

The Club is naturally disappointed that the two stewards in question exhibited lapses in behaviour
which were not in compliance with the Code of Conduct. As noted at paragraph 24 of our legal
counsel’s closing submissions to the inquest (and confirmed by Mr Phil Rainford in his evidence), the
Club’s stewarding arrangements are very regularly audited from a health, safety and security
perspective. In the 12 month period immediately prior to the inquest, the Club was inspected or
audited from a health, safety and security perspective by TMBC on at least five occasions, SGSA on at
least four occasions, the Safety Advisory Group on one occasion and external independent safety
and security auditors on one occasion (which included viewing two matches). None of these
regulators, inspectors or auditors advised the Club of any issue relevant to the inquest relating to
stewarding arrangements, including the positioning of stewarding in the vomitories.

Nevertheless, we have fully taken on board the concern which has been raised here. Accordingly, as
mentioned above in my opening remarks, we have put into place an additional match-by-match
system of proactively checking both stewards’ positioning within vomitories and checking
compliance by stewards with the Code of Conduct (including live auditing of both issues throughout
each match).

| trust that the above response addresses the issues raised in the Report. Should you have any
queries regarding the above, please do not hesitate to contact me.

Yours sincerely

bs Shas”

GROUP MANAGING DIRECTOR
MANCHESTER UNITED FOOTBALL CLUB LIMITED

Alison Mutch OBE 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Ms Mutch, 

Re: Richard John WHALE 

Corporate Director, Place 
Trafford Council 
Trafford Town Hall, Talbot Road 
Stretford, Manchester, M32 OTH 

Email 

Telephone 0161 912 4265 
www.trafford.gov.uk  

Your Ref: 8927/CLB 

Date 8 February 2019 

Thank you for your letter dated 21st December 2019 which contained a Regulation 28 Report 
to Prevent Future Deaths.   

Trafford Council are aware that the jury conclusion into the death of Richard John Whale was 
one of accidental death, with contributed factors relating to impedance and lack of awareness 
of the stewards, obstruction of access to both handrails by stewards, and lack of awareness 
by the stewards of their surroundings. 

In terms of the matters of concern relevant to the Local Authority (Trafford Council) Point 5 (1) 
namely (italics): 

The Local Authority had issued a list of recommendations to the club after the death of Mr 
Whale. There was no mechanism in place for discussion of those recommendations or to 
ensure that they had been followed or if not followed discussions for reasons. 

the Council’s response is as follows: 

The Council has a dual regulatory role in relation to sports grounds safety. Firstly, under The 
Safety at Sports Ground Act 1975, the Council is responsible for issuing the General Safety 
Certificate and enforcement of the conditions. In issuing a General Safety Certificate, the 
Council has to be satisfied that appropriate policies and procedures are in place to ensure the 
reasonable safety of all people who attend a sports ground. Secondly, the Council is the 
relevant enforcing authority in relation to the Health and Safety at Work etc. Act 1974, 
including the investigation of accidents that are reported to the local authority under the 
Reporting of Injury, Disease and Dangerous Occurrences Regulations 2013.  

It was within this remit that the Council undertook an investigation into the accident to Richard 
John Whale. The investigation found that the Club had satisfactory arrangements in place at 
the time of the accident in relation to maintaining the safety of spectators at the ground, and 
that there was no evidence available which would warrant any formal action under the Health 
and Safety at Work etc Act 1974.  

Following the outcome of the investigation, a letter was sent to the Club outlining three 
recommendations. This was an informal letter highlighting good practice recommendations to 

 
 
 
 
   
 
  
 
 
 the Club, and it did not stipulate any legal contraventions which the Club should action or that 
any action should be taken within a specified timescale. The responsibility, therefore, was with 
the Club as to whether or not the recommendations were implemented. 

However, it is anticipated that these recommendations would have been picked up and 
highlighted through a number of existing mechanisms which allow for discussions to take 
place between the Council, the Club and other interested parties. This is primarily done 
through meetings of the Safety Advisory Group, where issues relating to sports grounds safety 
are discussed. The Council also have regular engagement with the Club where necessary, 
such as in response to any match-day incidents, and undertake proactive match-day 
monitoring audits where issues relating to safety are discussed.  

Following the conclusion of the inquest, Council Officers and the regional Sports Ground 
Safety Authority Inspector have met with the Club to discuss the concerns raised during the 
inquest. During these discussions, the Club explained the actions they have taken to address 
the recommendations highlighted in the letter from the Council, and they have also explained 
that they are undertaking additional awareness training for stewards and monitoring of 
stewards' behaviour whilst carrying out their duties at the stadium.  Council officers 
undertaking future match-day audits at the Club will include observations of the monitoring of 
stewarding behaviour by the Club.  

In addition, the Council have now requested that the Club responds to any future 
recommendations or requests within a specified time frame with a review of all actions where 
it is considered necessary. This positive approach has been welcomed by the Club and has 
been implemented with immediate effect.  

Further, as part of our commitment to safety at sports ground duties, the Council is currently 
reviewing its policies and procedures and will include an appraisal of the Coroner’s concerns 
as part of this review.   

Yours Faithfully, 

Corporate Director, Place