Edward Bilbey

Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Secretary of State for Digital, Culture, Media and Sport
2 ……………………………………
3 ……………………………………

1 CORONER

I am Robert HUNTER, Senior Coroner for the area of Derby and Derbyshire

2 CORONER’S LEGAL POWERS

I 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 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.

4 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.

5 CORONER’S CONCERNS

The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern)

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.

6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to
take such action, either by primary or secondary legislation.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,

 namely by 05 May 2021.

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.

8 COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Parents of Mr Bilbey, and The Childrens Commissioner for England.
……………………………………………………………………………………………………………………

and to the Local Safeguarding Board (where the deceased was less than 18).

I have also sent it to

……………………………………………………………………………………………………………………

who may find it useful or of interest.

I 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.

9

Robert HUNTER
Senior Coroner for
Derby and Derbyshire
Dated: 10 March 2021

Rt Hon Oliver Dowden CBE MP

dS Secretary of State for Digital,

Rae Culture, Media and Sport
4th Fl

Department for 100 Parliament Street

Digital, Culture London SW1A 2BQ

Media & Sport

www.gov.uk/dcms
enauiries@dcms.gov.uk

Dr Robert Hunter
HM Senior Coroner

Rose Hill

Chesterfield ~
$40 1LP G May 2021

OL Dt he

| am writing to you in response to the regulation 28 report dated 10 March 2021,
following the inquest into the death of Edward Lewis Bilbey. | am sorry to hear about
the tragic circumstances of this case.

There will always be risks associated with participating in sport, but it is vital that
robust measures are in place to reduce the risks of major or catastrophic injuries and
that procedures are in place to protect athletes’ health. Sports must put the safety of
their participants first.

The government is wholly committed to doing all it can to ensure children and young
people can participate in sport in safe and secure environments. My department is
currently engaging across sports to address the issues of concussion and dementia.
| have held a number of meetings with current and former athletes, as well as sport
national governing bodies, to understand how government intervention could bring
about positive change for athletes’ safety.

My department works closely with Sport England and the NSPCC’s Child Protection
in Sport Unit to review and strengthen safeguarding provision wherever necessary.

The Child Protection in Sport Unit (CPSU) is the lead body for advice and standards
on safeguarding in sport in England. {t works with sports to build capacity around
safeguarding children and young people.

All organisations in receipt of public funding from Sport England and UK Sport have
been required to meet the standards set out in the Code for Sports Governance
since April 2017. The Code contains specific obligations around safeguarding,

including a requirement for national governing bodies to adhere to the Standards for
Safeguarding and Protecting Children in Sport, which are issued by the CPSU. The
CPSU undertakes an annual review of NGBs funded by Sport England to assess .
their safeguarding policies and procedures. The results of these reviews are used
internally within sports to strengthen practice.

Given these existing measures, we do not currently intend to bring forward any
further sport-specific legislation. However, we will continue to work closely with our
safeguarding partners to ensure that provision is reviewed and strengthened
wherever necessary.

My department will work with Sport England and England Boxing to review and
address the specific concerns raised in these reports.

With regard to wider safeguarding concerns, the government welcomed the launch

of the Whyte Review which is looking into allegations of mistreatment within the sport
of gymnastics. My department will follow the Whyte Review and its findings closely.

roe

Rt Hon Oliver Dowden CBE MP
Secretary of State for Digital, Culture, Media and Sport

IN THE CHESTERFIELD CORONER'S COURT

INQUEST TOUCHING UPON THE
DEATH OF EDWARD LEWIS BILBEY

Date: 14 —- 20 December 2020

Interested Party: England Boxing

RESPONSE TO REGULATION 28 REPORT
TO PREVENT FUTURE DEATHS

Coroner: Dr Robert Hunter, Senior Coroner
Area: Derby/Derbyshire

Reg 28 Report Date: 10 March 2021

Response Date: 5 May 2021

Coroner’s Concerns

The Regulation 28 Report identified the following concerns:

1. England Boxing did not have in place adequate and enforceable child protection and
safeguarding measures;
2. England Boxing did not have in place any policy or procedure for checking and enforcing

compliance with its safeguarding or child protection procedures.

The following points were noted during the Inquest as relevant evidence in support of the concerns

raised above:

1. The club’s registered Welfare Officer had left the club three years prior, but his name
remained registered on “The Vault” system held and maintained by England Boxing;

2. There was nothing to demonstrate that the name or contact details of the registered
Welfare Officer were displayed prominently at the club;
3. There was a level 2 coach registered on The Vault but the witness’s testimony stated that

he was not involved in training activities at the club.

England Boxing’s Response

HM Coroner will be aware that the tragic event which gave rise to the Inquest and the Coroner’
subsequent concerns occurred on 24 March 2017. Between that date and the Inquest, England
Boxing, as organising body for amateur/Olympic boxing in England, identified and implemented
remedial action which it was believed would increase safety and awareness in sport carried out
within EB’s remit. Work required in order to carry out other actions identified was dependent upon

information revealed during the Inquest itself and, as such, have been completed since.

ACTIONS COMPLETED PRIOR TO INQUEST

Rule Book - At the time of this incident, the rules and regulations governing amateur/Olympic
boxing in England were located in various publications available from different sources, which
made identifying and applying specific rules unnecessarily cumbersome. They were also, to some
extent, based upon regulations imposed by other international bodies, meaning that clubs had to
sift through information which did not apply on a local/regional level in order to find information
relevant to them. Since 2018 we have collated all the information on rules and regulations
regarding competitive boxing and codified them into one publication. The resultant England Boxing

Rule Book can be found on our website and is available for open-access viewing.

Website — Since 2018, the England Boxing website has been overhauled in order to provide
greater clarity on regulation and policy. The structure is now much easier to follow and relevant
publications are easily accessible. All guidance available on the website has been scrutinised and
updated where appropriate.

Policies — We have drafted the following policy documents, which were missing at the time of this
incident:

e Emergency Action Plan For a medical Emergency involving boxer.
e Emergency Action plan for a medical emergency involving an official or spectator that
requires the ring side doctor.

The policies codify who has responsibility for each aspect of the emergency procedure to ensure
that specialist medical attention is available as quickly as possible. They also link to the new Rule

Book, which provides greater clarification on the roles and responsibilities at a bout or competition.

Permit Regulations: Bouts have never been allowed to go ahead without a permit issued by the
relevant England Boxing region. However, the regulations regarding the issuing of permits were
comprehensively updated in 2019. The new regulations set out in detail the accountability of bout
organisers, ensures the suitability of the venue (with reference to the new Emergency Plans) and
requires that appropriate safety, security and medical provisions are in place. Permits will not be
issued unless all of those requirements have been met.

Coach / Official Training: Since 2017 we have comprehensively restructured our coaching
courses. We have now introduced a refresher course for level one coaches which must be
undertaken every three years to ensure that coaches stay up to date. Coaches who do not attend

refresher training are decertified.

Coaches may only progress to a level 2 status by holding a level 1 certification for a minimum of 12
months and registering up to date safeguarding, first aid and DBS certifications on The Vault, so

that we can ensure policies have been adhered to.

Training for those officiating at bouts has also been expanded and developed, including training
courses for Supervisors, which sets out their responsibilities for implementing the Emergency
Plans in the event of an emergency event.

Campaigns: Following this incident, we initially raised awareness within our Member community
of the benefits of ensuring that Automatic Emergency Defibrillators are available within Member
clubs, along with how funding can be secured in order to do so. That allowed a transitional period
for clubs to put in place any initiatives they may have required. Following that initial period,
England Boxing took the step of making the installation of AEDs a mandatory requirement by June
2021. This date may be delayed slightly due to the pandemic, but a deadline will remain in place.

Safeguarding: Whilst required before this, since May 2018 all prospective coaches have to attend
an approved safeguarding course prior to issue of their coaching licence. Without it the licence will
not be issued. This is in addition to enhanced DBS checks. More recently, we have engaged the
services of a prominent QC to review our safeguarding procedures and policies and amend them

where necessary. As a result, Regional and Club Welfare Officers are also now required to attend

regular safeguarding update courses and training. Regional Welfare officers also need to

undertake the enhanced “Time to Listen Course”.

Club membership requires the presence of a registered level 1 and level 2 Coach, a committee,
and a designated Welfare Officer. Clubs must also adopt England Boxing’s Safeguarding Policy.
Details of the above information must be registered on “The Vault”. New applications are supplied
to England Boxing centrally, with the relevant Region dealing with renewals. A Regional
representative will then conduct a visit to the club in order to carry out physical checks on the
facilities, whilst the Registrar will check the relevant paperwork and membership requirements
before approving the club for the season.

Vault: At the time of this incident “The Vault’ system was in its infancy and its benefits and
capabilities were not utilised to the full. Since then, the system has expanded in use and
registrations are actively tracked, ensuring accountability. Prior to the introduction of The Vault
club membership was administered regionally and, upon centralisation of the process, training and
instruction was provided to Registrars in each region. They were responsible for confirming the
necessary qualifications were in place for the coaches and club before approving the application,
but it has become apparent that there was some variation in some of the club facility requirements

between regions (but not coaching qualifications).

In November 2106, the Coach education system was also centralised. Any new Coach registering
with England Boxing is input into The Vault database by staff based in Sheffield, who check and
cross-reference the training, safeguarding, first-aid, and DBS certification to ensure validity. We
also introduced a new policy for dealing with any concerns regarding any items on the database.
When the Coach renews membership, the England Boxing region in which they are based checks
the updated certifications.

The new club and individual membership criteria are displayed on the England Boxing website to
provide access to clear advice regarding membership, which is now consistent nationwide and
unaffected by regional variances.

ACTIONS TO BE TAKEN

Independent Inquiry: Immediately following this incident, England Boxing identified a number of
issues which required analysis and action. As set out above, many of those were implemented

prior to the Inquest. However, although the Court will note that post-incident meeting minutes

identified the need for an independent organisational inquiry, the decision was made to postpone
that process until the Inquest had taken place. That would ensure that there was no risk of
interference with investigations being conducted by the Police in the course of the Coroner’s
Inquest and would allow the independent inquiry’s remit to be dictated or molded by the Inquest

findings.

Following completion of the Inquest, England Boxing is now in the process of setting up an
independent inquiry, the chair of which will be appointed by “Sports Resolutions”, a body separate
distinct to England Boxing. The terms of reference are still being finalised, but the overarching aim
will be to investigate the points raised in the Inquest, in particular the two points of concern which
appear in the Regulation 28 Report. The inquiry will identify the respective responsibilities of the
Regions and England Boxing centrally to oversee adherence to regulations and policies both at the
time of this incident and subsequent to it and will determine whether those responsibilities were
and are being met. Some of the regulations and policies which will be investigated relate to the
process used in the registration of clubs to “The Vault’, along with how that information is cross-
referenced and checked regionally. The inquiry’s findings will then inform what changes will be
required to ensure that policies and procedures are not only in place, but actively adhered to by

member clubs.

It is anticipated that the report will be completed by the end of 2021 with any learning notes or
recommendations being implemented throughout 2022.

| would like to thank the Coroner on behalf of England Boxing for conducting a thorough
investigation into this important matter, which has allowed us to make wholesale improvements to
our organisation of Olympic Boxing in England. That will, in turn, ensure safety measures are
implemented and observed throughout each Region, keeping boxers and those who attend bouts
as safe as possible.

Capacity: CEO, England Boxing

Dated: 4 “7 Lod