Adam Johnson

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IN THE MATTER OF ADAM ROBERT JOHNSON (DECEASED) 

RESPONSE TO THE SENIOR CORONER’S REGULATION 28 REPORT OF 3 

NOVEMBER 20231 

1. 

This Response is filed on behalf of the Elite Ice Hockey League (“EIHL”). 

2. 

The  Senior  Coroner  South  Yorkshire  (West)  (“the  Senior  Coroner”)  commenced  an 

investigation into the death of Adam Robert Johnson on 1 November 2023. 

3. 

On 3 November 2023 the Senior Coroner issued a Report to Prevent Future Deaths under 

Regulations  28  and  29  of  the  Coroners  (Investigations)  Regulations  2013  and  under 

paragraph 7, schedule 5 of the Coroners and Justice Act 2009. 

4. 

The EIHL is a Properly Interested Person for the purposes of the investigation and inquest. 

5. 

The  EIHL  is  to  respond  to  the  Senior  Coroner’s  Regulation  28  report  by  29  December 

2023. 

6. 

The EIHL is a commercial organisation which manages the highest level of professional 

ice  hockey  in  the  UK.    There  are  presently  10  teams  in  the  EIHL,  including  the 

Nottingham Panthers and the Sheffield Steelers. 

7. 

The  National  Governing  Body  for  the  sport  of  ice  hockey  in  the  UK  is  Ice  Hockey  UK 

(“IHUK”).  The International Ice Hockey Federation (“IIHF”) is the worldwide governing 

body. 

8. 

Adam Robert Johnson was a professional ice hockey player.  On 28 October 2023 he was 

playing for the Nottingham Panthers in a game against the Sheffield Steelers at the Utilita 

1 Served on the EIHL on 14 November 2023 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Arena, Sheffield.  During the game, Mr Johnson sustained an incised wound to the neck 

caused by impact with the skate of another player.  He died as a result of his injuries. 

9. 

The Senior Coroner identified a risk that future deaths will occur.  The Matters of Concern 

are as follows: 

“The International Ice Hockey Federation (“IIHF”) recommends that neck guards 

or protectors are worn, but there is no requirement for ice hockey players over the 

age of 18 to wear equipment designed to protect the neck. 

“In  due  course  the  inquest  will  consider  whether  the  use  of  a  neck  guard  or 

protector  could  have  prevented  Mr  Johnson’s  death.    At  this  stage  in  my 

investigation  however,  I  am  sufficiently  concerned  that  deaths  may  occur  in  the 

future if neck guards or protectors are not worn”. 

10. 

The IIHF Rulebook for 2023/24 says this: 

“Rule 9.5 – Protective Equipment: 

Equipment must conform to safety standards and be used only to protect Players, 

not to enhance or improve playing ability or to cause injury to an opponent. 

All players are strongly recommended to wear equipment made of cut resistance 

material for their safety. 

For all players in the senior competition category it is strongly recommended 

to wear a neck laceration protector in a proper way and that is not modified 

or damaged. 

“Rule 9.12 – Neck Laceration Protector2 

All players are recommended to properly wear a neck laceration protection. This 

protective device is recommended to cover as large of an area as possible on the 

player. 

2 Different, more prescriptive rules provide for U18s etc.  For the purposes of this Response, only the rule for adult 
games is set out. 

 
 
 
 
 
 
 
 
 
 
 11. 

EIHL follows the IIHF Rulebook for the purposes of games played under its auspices. 

12. 

Since  the  inquest  was  opened,  matters  have  moved  on.    On  4  December  2023,  the  IIHF 

issued the following statement: 

“The IIHF Council, on recommendation from its Medical Committee, has decided 

to  mandate  the  use  of  a  neck  laceration  protector,  specifically  designed  for  this 

purpose, at all levels of IIHF competitions. The neck laceration protectors are now 

mandatory for the senior categories in addition to the U20 and U18 categories, for 

which neck laceration protectors had already been enforced as per  IIHF Official 

Rule Book.   

“The  exact  date  this  mandate  will  go  into  effect  for  the  senior  categories will  be 

determined  by  the  supply  situation.  The  IIHF  remains  in  close  contact  with  its 

suppliers to ensure they are able to respond to the current high demand.   

“Until  the  rule  officially  goes  into  effect,  the  IIHF  continues  to  strongly 

recommend that neck laceration protectors are worn by all players performing in 

an IIHF competition”. 

https://www.iihf.com/en/news/56022/iihf_mandates_neck_laceration_protection_at_all_le 

13. 

Following the IIHF statement, the EIHL issued the following: 

“The Elite Ice Hockey League remains committed to player safety as our top priority, and 

we  continue  to  work  with  players,  officials,  clubs,  and  relevant  authorities  to  enhance 

this.” 

“Since the tragic loss of Adam, we have continued to follow the International Ice Hockey 

Federation  Council  guidance  and  strongly  recommended  the  use  of  neck  laceration 

protectors.  In  light  of  the  Federation’s  decision  to  mandate  the  use  of  neck  laceration 

 
 
 
 
 
 
 protectors  for  its  competitions,  the  Elite  Ice  Hockey  League  will  consider  how  best  to 

implement  this  mandate  and  provide  further  updates  to  players,  officials  and  Clubs  as 

soon as possible and importantly when supply issues have been determined.” 

14. 

It  being  noted  that  nearly  all  players  in  the  EIHL  have  used  neck  protection  since  28 

October 2023, it has now been resolved as follows: 

(i) 

The use of neckguards is to be mandated for all players in the EIHL from 1 January 

2024 in training, pre-game and in game; 

(ii) 

A temporary rule change has been put in place to sanction non-compliance pending 

the provision of the full rule change from the IIHF. 

15. 

Accordingly: 

(i) 

Action has been taken to protect the necks of ice hockey players in the EIHL; 

(ii) 

The timetable for action is set out above. 

16. 

The  issue  of  whether  the  use  of  neck  guards  or  protectors  would  have  prevented  Mr 

Johnson’s death will be the subject of evidence at the inquest. 

Dated this 22nd day of December 2023 

Served by Horwich Farrelly Solicitors

Mrs Tamika Rawden 
HM Senior Coroner South Yorkshire (West) 
The Medico-Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

29 December 2023 

Dear Mrs Rawden, 

Re: Adam Robert Johnson (deceased) 

Thank you for your letters with reference to Adam Robert Johnson, and for sharing the 
information available to you at that time. We are happy to assist you at this time with the 
following information, as requested. 

Regulations around neck laceration protection
The relative rarity of this type of injury means that there is relatively little research on the topic. 
The International Ice Hockey Federation (IIHF) maintain records of injuries at all their 
Championship events; their registry records one neck laceration (of minor severity) in the 7,000 
games for which records are held; this equates to an estimated risk to an individual player of 
one injury (of any severity) for every 300,000 games they play. 

The IIHF rulebook for 2023-24, which applies to all parts of the sport in the UK, contains the 
following references to neck protection: 

“Rule 9.5 – Protective Equipment: 
Equipment must conform to safety standards and be used only to protect Players, not to 
enhance or improve playing ability or to cause injury to an opponent. All players are 
strongly recommended to wear equipment made of cut resistance material for their 
safety. For all players in the senior competition category it is strongly recommended to 
wear a neck laceration protector in a proper way and that is not modified or damaged. 

“Rule 9.12 – Neck Laceration Protector 
All players are recommended to properly wear a neck laceration protection. This 
protective device is recommended to cover as large of an area as possible on the player. 

“A Goalkeeper may attach a throat protector to the chin of their facemask. It must be 
made of a material that will not cause injury. 

Players who play in senior categories but are of the age as “Under 20” and “Under 18” 
categories must wear the appropriate protective equipment of these U20 and U18 
categories in accordance with the specific rules.” 

Rules 202.5 and 202.6 require all players in the U20 and U18 age categories 
respectively “to wear, in a proper way, a neck laceration protection. It is recommended 
that this protective device covers as much of the players body as possible.”. Rule 102.6 
extends this requirement to the Women’s U18 category. 

England Ice Hockey Limited
Ice Sheffield, Coleridge Road, Sheffield, England S9 5DA 
Company No: 3730185 Registered in England & Wales 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On 4 December 2023, the IIHF released a statement mandating neck laceration protection at all 
levels of IIHF competition, acknowledging the exact date for the imposition of the mandate 
would be under review given the high demand and supply issues of the neck laceration 
protector. 
(https://www.iihf.com/en/news/56022/iihf_mandates_neck_laceration_protection_at_all_le). 

Neck laceration protection
The current international standard covering the design and construction of neck laceration 
protectors (ISO 10256-5:2017) is essentially unchanged since it was first introduced; it is 
currently under review, with key stakeholders within the global ice hockey community actively 
engaged in its revision. 

English Ice Hockey Association response 
On 30 October 2023, the English Ice Hockey Association (EIHA) along with Ice Hockey UK 
(IHUK) and Scottish Ice Hockey (SIH), released a statement recognising the need for short, 
medium and long term action in response to Adam Johnson’s death. The statement confirmed 
that neck laceration protectors would be strongly recommended at all levels with immediate 
effect and become compulsory from 1 January 2024 at all levels of ice hockey in the UK. The 
statement can be found here: https://englandicehockey.com/eiha-update-player-safety/ 

A further update, a copy of which is attached for your convenience, will be published on 30 
December 2023 to confirm the mandate, with the exception of Recreational Hockey (the 
community level of the sport) where the supply of neck laceration protectors has meant that the 
strong recommendation has been extended until 1 April 2024. 

EIHA, along with IHUK and SIH, are committed to undertaking a player safety equipment review 
and procedures for ensuring player safety at all levels of the sport in the UK. 

Governance structure of Ice Hockey in the UK
The International Ice Hockey Federation (IIHF) is the worldwide governing body for the sport, 
under whose jurisdiction we fall. 

Ice Hockey UK (IHUK) is the recognised National Governing Body across the UK, with overall 
responsibility to the IIHF for the conduct of the sport, and with operational responsibility for 
delivery of the GB National Team programme, representing the sport at international level. 
There are a number of constituent member organisations who fall under the overall umbrella of 
IHUK. 

The Elite Ice Hockey League (EIHL) is a commercial organisation who manage the top-level of 
professional ice hockey in the UK; this is the league in which Adam was playing at the time of 
his untimely death. The EIHL hold operational responsibility for the conduct of the sport in their 
league, within the rules laid down in the IIHF rulebook. 

The English Ice Hockey Association (EIHA), now known as England Ice Hockey, is responsible 
for the organisation and delivery of the sport in England and Wales, at all other levels. Scottish 
Ice Hockey (SIH) undertakes this role for Scotland and Northern Ireland. 

England Ice Hockey Limited
Ice Sheffield, Coleridge Road, Sheffield, England S9 5DA 
Company No: 3730185 Registered in England & Wales 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We trust this clarifies the existing situation and organisational responsibilities for the time being 
and is helpful to you. We remain available to assist you in your investigations in any way. 

Yours sincerely, 

Vice Chair 

England Ice Hockey Limited
Ice Sheffield, Coleridge Road, Sheffield, England S9 5DA 
Company No: 3730185 Registered in England & Wales 

3

Neck Laceration Protector Mandate 

On 30th  October 2023, England Ice Hockey along with Ice Hockey UK (IHUK) and Scottish 
Ice Hockey (SIH), released a statement recognising the need for short, medium and long 
term action in response to the tragic death of Adam Johnson. 

Further to this statement, England Ice Hockey can confirm the short term action of the 
mandating of neck laceration protectors (neck guards) which comes into effect from 1st 
January 2024 as instructed below. 

Ref: IIHF Rule 9.12 Neck Laceration Protectors 

In October 2023 Ice Hockey UK (IHUK), England Ice Hockey (EIH) and Scottish Ice Hockey 
(SIH) issued updated safety information on the wearing of neck laceration protectors 
(commonly referred to as neck guards) by all players. Unless engaged in activities already 
covered by IIHF regulations, this confirms that IIHF Rule 9.12 on Neck Laceration Protectors 
will be enforced in the UK from 1st  January 2024. In brief, the instruction outlines that: 

•  neck guards must be worn by all players for all on-ice activities. For the avoidance of 

doubt, this includes on ice training as well as games/tournaments; 

•  players should regard a neck guard as a normal item of protective equipment when 

on the ice (playing or training); 

•  as with any other protective equipment, neck guards must be worn without alterations 

• 

and as directed by the manufacturers’ specification. 
It is strongly recommended that coaches wear a neck laceration protector whilst on 
the ice. 

Neck guards must meet the safety standard ISO 10256-5:2017 and/or BNQ 9415-970/2008. 

Equipment must conform to safety standards and be used only to protect skaters, not to 
enhance or improve playing ability or to cause injury to an opponent. 

Parental, guardian or any written consent requesting dispensation for a player not to wear a 
neck guard will not be accepted in any form of ice hockey in the UK. 

This mandate applies to all players and coaches in all forms of ice hockey within the United 
Kingdom, with the exception of Recreational Hockey where an extension to the mandated 
wearing of neck guards has been agreed due to supply issues (the strong recommendation 
remains in place at this level only). The mandate will apply for Recreational Hockey on the 
1st  April 2024, subject to the supply situation, however it will remain under review and we 
reserve the right to bring the mandate into force sooner. 

These instructions apply during any on-ice activity. Any individual taking responsibility for 
players should take all reasonable steps to ensure that this requirement is followed at all 
times. 

IHUK, EIH and SIH asks that the mandate is communicated to all players and parents / 
guardians (where U18), and reiterates that players are not allowed to take part in any on-ice 
activity without wearing appropriate neck laceration protection. With the assistance of clubs 
and leagues, the wearing of neck guards by players is now standard practice in ice hockey 
throughout the UK.

Regus House 
Malthouse Avenue 
Cardiff Gate Business Park 
Cardiff 
CF23 8RU 

24 December 2023 

Mrs Tanyka Rawden 
HM Senior Coroner South Yorkshire (West) 
Office of HM Coroner 
The Medico-Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

Dear Mrs Rawden, 

Re:  Adam Robert Johnson (Deceased) 

We have now had an opportunity to review the Prevention of Future Deaths Report issued by the 
Senior Coroner on 03 November 2023. 

We can confirm that the International Ice Hockey Federation (“IIHF”) is the worldwide governing body 
for Ice Hockey, under whose jurisdiction Ice Hockey UK (“IHUK”) falls.  IHUK in turn operates as the 
national governing body for the sport within the UK. 

The IIHF, on recommendation from its Medical Committee, has now decided to mandate the use of a 
neck laceration protector (or “neck guard”), specifically designed for this purpose, at all levels of IIHF 
competitions - 
https://www.iihf.com/en/news/56022/iihf_mandates_neck_laceration_protection_at_all_le.  IHUK, 
whose rule jurisdiction only covers the GB National teams, mandated neck guards for Senior Men and 
Women with immediate effect on 30 October 2023 - https://www.icehockeyuk.co.uk/player-health-
safety-wellbeing-review-and-action-plan.  This was in addition to the existing mandate for the U16, 
U18 and U20 categories, as official IIHF categories the latter two were already covered as per IIHF 
Official Rule Book. 

IHUK does not have jurisdiction to implement changes within the Elite Ice Hockey League (“EIHL”) 
rules which Adam Johnson was playing within at the time of the incident, nor the English Ice Hockey 
Association (“EIHA”, now known as England Ice Hockey or “EIH”), both parties named as Properly 
Informed Persons on the Regulation 28:  Report to Prevent Future Deaths.  The EIHL and EIH will be 
able to separately advise as to how they intend to address the decision taken by IIHF. 

Yours sincerely, 

Chair, Ice Hockey UK 
For and on behalf of Ice Hockey UK Ltd 

Limited by Guarantee 
Registered in England 

VAT No: 728 6456 03 
Company Reg No:  3800672