Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0102, written 24 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2023 |
|---|---|
| Reference | 2023-0102 |
| Deceased | Richard Hill |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: - Bill Sweeney, Chief Executive Officer, Rugby Football Union Rugby House Twickenham Stadium 200 Whitton Road Twickenham Middlesex TW2 7BA 1 CORONER I am Peter Nieto, Area Coroner for the coroner 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 10 May 2022 I commenced an investigation into the death of Richard James HILL, referred to as Richard for the purposes of the inquest, aged 24. The investigation concluded at the end of the inquest on 13 March 2023. The conclusion of the inquest was that Richard’s death was alcohol related. 4 CIRCUMSTANCES OF THE DEATH Richard died on 30 April 2022 at a sports and recreation club where his rugby club was holding its annual awards ceremony. Richard had been drinking alcohol all day and at the event and by 21:23 when he collected his trophy he was clearly showing the effects of alcohol inebriation and this was apparent to people at the event, including club members. About thirty minutes later he was unable to walk and had reduced responsiveness and he had to be carried to an outside bench. When it was realised that he was possibly critically unwell an ambulance was called, although medically trained attendees at the club event had started to provide resuscitative interventions, including use of a defibrillator which identified there was no shockable rhythm. Paramedics attended but intensive resuscitation was sadly unable to revive Richard and he was pronounced dead at the scene. Richard was known to drink heavily when out with friends and at social events. The court heard evidence from Richard's brother that Richard's alcohol consumption appeared to increase following the death of a close friend in January 2022. After Richard's death, as part of post-mortem examination, blood and urine samples were sent for toxicological testing. Toxicology identified a very high level of alcohol in Richard's system, at a level capable of causing death due to alcohol toxicity. Cocaine was also identified in Richard's system but was not considered to be contributory to his death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: - The inquest heard evidence that some people, probably including Richard, were drinking alcohol from trophy cups at the rugby club event and that these were being topped up by various people in the course of the evening, such that the trophy cups contained mixed Regulation 28 – After Inquest Document Template Updated 30/07/2021 drinks. Post-mortem toxicological analysis of Richard’s blood and urine demonstrated a toxic level of alcohol in his system, and he had been drinking alcohol all day, including prior to the event. The inquest heard evidence that excess alcohol consumption is likely a problem across all male sports. The rugby club had received educative/campaign material from the Rugby Football Union (RFU) on issues including mental health but not specifically concerning alcohol misuse and alcohol awareness. The club is a local grassroots club, effectively run by volunteers, and it seems to me that the RFU might consider providing guidance and educative material around alcohol use that would potentially be welcome and utilised by affiliate grassroots rugby clubs and could have a positive impact on harmful drinking. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 19, 2023. 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 Ashbourne Rugby Union Football Club (licensee of the Ashbourne Recreation Ground) (parents of Richard) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 24 March 2023 Peter Nieto Area Coroner Derby and Derbyshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
England
Rugby
.
-
Rugby Football Union
Rugby House. Twickenham Stadi um
zoo Whitton Road, Twickenham TW2 7BA
T, 0o871 222 2120 F 020 8892 9816
england.rug by.com
Mr Peter Nieto,
Norfolk Coroner's Service
County Hall
Martineau Lane
Norwich
NRI 2DH
16 May 2023
Dear Mr Nieto,
Report dated 24 March 2023
Thank you for your report dated 24 March 2023 following an inquest into the tragic death of
a Mr Richard Hill.
The Rugby Football Union ("RFU") was saddened to learn of Mr Hill's death, and it wishes to
express its deepest sympathy to Mr Hill's friends and family for their loss.
The RFU was not invited to participate in the inquest, however we understand from your
report that you consider "the RFU might consider providing guidance and educative material
around alcohol use that would potentially be welcome and utilised by affiliate grassroots
rugby clubs which you believe could have a positive impact on harmful drinking".
The RFU is committed to the promotion of good health in all respects, and it supports the
principle of responsible drinking. The RFU provides advice and guidance to community clubs
on issues relating to the supply of alcohol/licencing, health, safety, and wellbeing, and it
recommends Codes of Conduct for members of clubs to promote responsible behaviour.
Responsible drinking practices are also covered, where applicable, in the RFU's Safeguarding
Guidance. All resources can be accessed for free on the RFU's website.
The RFU's RugbySafe programme, is an innovative and overarching player safety and
wellbeing programme which provides resources for everyone involved in rugby. As it is
recognised that issues relating to excessive alcohol consumption can sometimes be connected
to mental wellbeing these issues are raised within the RugbySafe programme to promote
awareness. The RFU partners with Simplyhealth and mental health charity Looseheadz to
promote an open discussion around all relevant issues. Resources are available for free on the
RFU website.
The RFU has previously partnered with the charity Drinkaware to help promote its message
of responsible drinking, and it will continue to work with partners to contribute to the societal
discussion on these issues. It is of course recognised that playing sport, including rugby, has
recognised physical benefits for participants, as well as a positive impact on mental wellbeing.
Rugby Football Union a society established under the Co-operative and Community Benefit Societies
Act 2014 with registered number IP27981R whose registered office is at the above address.
Based on the information provided to us, and taking into account pre-existing work in relevant
areas, the RFU proposes to take no additional specific action at this stage but we will keep this
under review. The RFU is however willing to consider materials around alcohol awareness
which may contribute to the societal conversation on these issues and the promotion of good
health generally, including via its community game updates which are communicated
regularly to clubs and participants.
Should you wish to discuss these matters further, please do not hesitate to contact
Legal Director at the RFU.
,
Yours sincerely,
Chief Executive Officer
Rugby Football Union
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