Prevention of Future Deaths reports · 2024

Dominic Chapman

Regulation 28 report to prevent future deaths, reference 2024-0309, written 6 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Jun 2024
Reference2024-0309
DeceasedDominic Chapman
CoronerDavid Reid
Coroner areaWorcestershire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

, Director and sole proprietor, Ultra Events Ltd, Unit 15b Sawley 

Park, Nottingham Road, Derby, England, DE21 6AS; 

1  CORONER 

I am David Donald William REID, HM Senior Coroner for Worcestershire. 

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. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 28 April 2022 I commenced an investigation and opened an inquest into the death 
of Dominic Mark Chapman. The investigation concluded at the end of the inquest on 
23 May 2024 

The conclusion of the inquest was that Mr. Chapman “died as the result of an 
accident.” 

4  CIRCUMSTANCES OF THE DEATH 

In answer to the questions “when, where and how did Mr. Chapman come by his 
death?”, I recorded as follows: 

“On 9.4.22 Dominic Chapman sustained a fatal head injury in the course of a charity 
boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester. He 
was taken by ambulance to the Queen Elizabeth Hospital, Birmingham where he 
succumbed to that injury and died on 11.4.22.” 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

1) 

In the course of the inquest I was concerned that criteria set down by Ultra 
Events Ltd. to match opponents for bouts at the charity white collar boxing 
event on 9.4.22, specifically relating to the maximum allowable weight 
difference between boxers, were (a) insufficiently clear, and (b) not always 
applied by the event organiser. I heard evidence that Ultra Events Ltd. have 
since changed the wording of those criteria, but was satisfied that, as now 
drafted, the criteria still lack clarity. 
For example, 
told the inquest that the intention behind the reworded criteria was that: 
(a)  any weight difference between boxers of up to 7kg would be acceptable; 

 ( director and sole proprietor of Ultra Events Ltd. ) 

and 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (b)  any weight difference between boxers in excess of 7kg would have to be 

referred to Ultra Events Ltd.’s head office for approval. 

However, the criteria contained within the new workbook produced by Ultra 
Events Ltd. for use by those training and matching up boxers are not as 
unequivocally clear. For example, the workbook contains the statement: 
“If a match is over 7kg simply explain it on the fight order”. 

I am concerned that instructions about weight differences between boxers 
taking part in charity white collar boxing bouts are important and should be 
unequivocal, and that coaches and event organisers should be clear about 
their responsibilities in this respect. 

2) 

 ( sole director of Ultra 

In his evidence to the inquest, 
Events Midlands Ltd., the franchisee responsible for organising the event on 
9.4.22 ) said that while he left the specifics of the boxers’ 8 week training 
regime to the owner of the gym they used for this purpose “we don’t allow 
sparring until about halfway through training, then body sparring from Week 4, 
and head contact sparring from Week 5.”  
By contrast, the gym owner, 
“For the first week we worked on technique and fitness ( cardio work ); after 2 
weeks, I added a bit of body sparring; after 3-4 weeks we added light sparring 
sessions with shots to the head.” 

, told the inquest: 

Other evidence from a number of the boxers themselves satisfied me that in 
fact the training provided for the event on 9.4.22 did not follow the pattern 
outlined by 

 or anticipated by 

. 

 told the inquest that Ultra Events Ltd. has now produced Training 

Session planning, and that a proposed Training Workbook will require their 
coaches to sign a declaration confirming that they will follow this planning. 
These measures have not yet been brought into force by Ultra Events Ltd., 
and I am concerned that unless and until they are brought into force, there is 
a risk that boxers will not receive the standard of training which Ultra Events 
Ltd. deems safe and appropriate. 

It is currently unclear when these measures will be introduced, and how they 
will be disseminated and enforced so as to ensure that coaches and gyms 
used by Ultra Events Ltd. for charity white collar boxing events follow them to 
the letter.  

3)  After hearing the evidence at inquest I was concerned that Ultra Events Ltd.: 

(a)  does not carry out a satisfactory individualised risk assessment tailored to 

each specific event at each specific venue used by them. I heard 
evidence that, where a venue has previously been used for a white collar 
boxing event, Ultra Events Ltd. will assume that nothing has changed 
since then, and relies on the venue notifying them of any potentially 
relevant changes; 

(b)  does not carry out its own risk assessment for the provision of medical 

cover at its white collar boxing events. I heard evidence from 
that Ultra Events Ltd. requires the companies it uses for medical cover to 
carry their own risk assessments, but does not ask to see or to check 
those risk assessments. This means that there is no effective oversight to 
ensure that the medical cover provided for each individual event at each 
venue is based on a suitable individualised risk assessment. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you, as 
the director and sole proprietor of Ultra Events Ltd., have the power to take such 
action.    

2 

 
 
 
 
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 1 August 2024. 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: 

(a) 
(b)  Tramps Nightclub, Worcester; 
(c)  Worcestershire Regulatory Services. 

, Mr. Chapman’s parents; 

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 

6 June 2024 

David REID 
HM Senior Coroner for Worcestershire 

3

Responses

3 responses 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.

Response from Dcms (PDF)
Minister for Sport, Media, Civil Society and Youth 
Department for Culture, Media and Sport 
1st Floor 
100 Parliament Street 
London SW1A 2BQ 

E: enquiries@dcms.gov.uk  

www.gov.uk/dcms 

 22 November 2024 

Your Ref: 

Our Ref: 

Mr David Reid 
HM Senior Coroner, Worcestershire Coroners Court 

Dear Mr Reid, 

Thank you for your correspondence of 7 June, to the former Secretary of State for Culture, 
Media and Sport, 
Future Deaths Report, following the inquest of Dominic Mark Chapman. I am responding as the 
Minister for Sport, Media, Civil Society and Youth.  

, enclosing a copy of the Reg. 28 Prevention of 

I must apologise for the delay in providing you with a substantive response. As you will 
appreciate, at the time of your report, the then Prime Minister had announced a General 
Election and the Government had entered a period of pre-election sensitivity. 

I was sincerely sorry to hear about this tragic incident and my deepest sympathies are with the 
family and friends of Mr Chapman. 

The safety and wellbeing of everyone taking part in sport is absolutely paramount. There will 
always be risks associated with participating in contact sports, but it is important that robust 
measures are in place to reduce the risk of major injuries and health issues. It is the 
responsibility of individual boxing event organisers to ensure that they protect the safety and 
wellbeing of their participants. 

The Government, Sport England (our arm's-length body for community sport), and the 
governing bodies for boxing, all strongly urge all white collar boxing event organisers to work 
with the sport’s governing bodies to ensure that robust competition standards are in place to 
protect the safety of those who take part. However, as with any private sports organisation, 
there is no obligation for white collar boxing event organisers to affiliate with a governing body.  

In light of safety concerns, such as those highlighted by this tragic case, the Department for 
Culture, Media and Sport’s officials have met with the boxing authorities, the Local Government 
Association and the Home Office (HO) to explore possible options to reduce the risks around 
white collar boxing. 

White collar boxing events take place in venues licensed by local authorities, who undertake 
due diligence of events as part of the licensing process. However, the Licensing Act 2003 
(legislation owned by HO) states that boxing bouts held at venues with audiences under 1,000 
in normal hours do not need to be licensed by the relevant local authority. 

 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 I can confirm that my officials are now preparing a targeted consultation of key stakeholders, 
about possible amendments to the statutory guidance, which will be conducted within the next 
six months.  

Thank you again for your important contribution to this crucial issue. We remain committed to 
working with the sports sector to help ensure the safety of all participants in sport. 

Yours sincerely, 

Minister for Sport, Media, Civil Society and Youth
Response from Ultra Events (PDF)
=

Interested Party
Ultra Events Lid
Fifth

“JL1", “JL2°
23.07.24

Pee

IN THE WORCESTER CORONER'S COURT

INQUEST TOUCHING ON THE DEATH OF MR DOMINIC CHAPMAN

INTERESTED PERSON: ULTRA EVENTS LIMITED

RESPONSE TO REGULATION 28 REPORT
ON BEHALF OF ULTRA EVENTS LIMITED

1. |, EE make this statement on behalf of Uttra Events Limited in
response to 4 Preventing Future Deaths report dated 6 June 2024 prepared
by HM Coroner David Reid following the conclusion of the Inquest touching
on the death of Dominic Chapman.

2. The concerns raised by the leamed Coroner were, to summarise:

a, The criteria set down by Ultra Events Ltd. to match opponents for
bouts, specifically relating to the maximum allowable weight
difference between boxers, were (a) insufficiently clear, and (b) not
always applied by the event organiser, The new wording of the
criteria amended post-inquest still |acks clarity, and the Coroner is
concerned that instructions about weight differences between
boxers taking part in charity white collar boxing bouts are important

and should be unequivocal, and that coaches and event organisers

should be clear about their responsibilities in this respect.

b, It remains unclear when the proposed changes to the training
regime, including introduction of Training Session planning and a
Training Workbook requiring signature from all coaches confirming
that they will follow this planning, will be introduced and how they
will be disseminated and enforced so that they are followed to the

letter.

c. Ultra Events Ltd. does not carry out a satisfactory individualised risk
assessment tailored to each specific event at each specific venue
used by them, and relies upon the venue notifying them of any
potentially relevant changes. In addition, it does not carry out its
own risk assessment for the provision of medical cover at its white
collar boxing events, and does not ask to see or to check risk
assessments carried out by external medical providers. This means
that there is no effective oversight to ensure that the medical cover
provided for each individual event at each venue is based on a

suitable individualised risk assessment

3. The company’s response must be filed by 1 August 2024 and must contain
details of action taken or proposed to be taken, setting out the timetable for

any proposed action or an explanation when no action is proposed.

MATCHING CRITERIA

4. Following this incident, we introduced a system requiring all coaches to
score participants by ability from 1 to 5, and to keep a written record of their

findings.

5. As a result of the evidence heard during the inquest, that system was
formalised into a new workbook that must be signed by coaches and area
representatives. That document was disclosed to the Coroner, family, and
Interested Persons as an exhibit to my witness statement on the final day
of the inquest. Although the changes were welcomed, the learned Coroner
remained concerned about clarity of the wording, specifically the section

which reads “If a match is over 7kg simply explain it on the fight order”.

6. We have therefore amended the wording, and a copy of the new document
is attached as exhibit "JL1". The wording requires all weight discrepancies
of more than 7kgs between boxers to be referred to HQ for approval by
explaining the match-up on the new version of the vest order, a copy of
which has already been provided to the Coroner as an exhibit to the

statement that | filed on the final day of the inquest.
7. If the bout is not approved by HQ, it does not go ahead.

Introduction of Training Planning and Workbook
8. As set out above, the new workbook was introduced immediately. It has
been sent out to all gyms and franchisees, and they have signed and
returned copies for us to retain on file. As such, all gyms have already

signed their agreement to coach within the requirements of the workbook.

9.

10.

+1,

Our Area Representatives attend training regularly to check that
participants are progressing, to record weights, and to assist with matching.
As such, they can see first-hand whether the training is incorporating all the

workbook requirements.

We also operate an exit survey in which all participants are asked to provide
feedback on the event. Any training concerns are discussed with the

coach/training provider to ensure standards are being maintained.

This level of hands-on attendance exceeds the systems used by England
Boxing and the British Boxing Board of Control, neither of which have a

physical presence at training sessions conducted by member gyms.

Risk Assessments

12.

13.

We have always carried out risk assessment for all new venues by
attending them in person. We have also always conducted individualised
risk assessments for each event and, indeed, one was carried out for the
Worcester event that Dominic attended. However, we have traditionally
been reliant upon the venue volunteering details of any changes to their

premises during that process.

Following this inquest, we now pro-actively contact venue owners in
advance of an event to specifically enquire as to any changes that may
have occurred since the last event. If there have been any, the venue is
required to provide us with details of changes so we can formulate a new

risk assessment and, if applicable, a plan.

14.

15.

16.

17.

Medical providers are best placed to carry out risk assessments, as they
are the ones with the specialist knowledge required to ensure safety in their
field of expertise. As such, risk assessing of medical provisions at each

event at each venue remains with the medical provider.

However, we now ask our medical providers to supply us with their event-
specific risk assessment and Medical Plan. Our email explains that they
are required to carry out a thorough assessment of all of the risks which
pertain to this event at particular premises, to an extent that ensures that
they are fully capable of dealing with any medical event, emergency or

otherwise, which may occur.

If that requires them to conduct a site visit, analyse plans, or carry out any

further enquiries, then they are required to do so.

The risk assessment must then be sent to us to be logged with other event

specific paperwork.

General

18.

19.

In the statement that I filed with the Coroner on the final day of the inquest,
| set out a number of other changes that we implemented immediately post-
incident and over the two years since, such as shorter duration of rounds,
more stringent standing 8 counts, and clearer wording in the event

instructions.

| have not dealt with those in this statement as they do not appear as a

cause for concern in the Coroner's Regulation 28 report.

20, | can, however, confirm that those changes will continue to be operated and

refined in the future.

21. | hope that this statement helps the leamed Coroner in understanding
relevant changes made since April 2022.

Statement of Truth

| believe that the facts stated in this witness statement are true. | understand that
proceedings for contempt of court may be brought against anyone who makes, or
causes to be made, a false statement in a document verified by @ statement of
truth without an honest belief in its truth,

Interested Party
Ultra Events Lid

“LT
23.07.24

oe ppo
mul
3

IN THE WORCESTER CORONER'S COURT

INQUEST TOUCHING ON THE DEATH OF MR DOMINIC CHAPMAN

INTERESTED PERSON: ULTRA EVENTS LIMITED

EXHIBIT "JL1"

This is the exhibit *JL1” referred to in the witness statement of [i

Se: : EE i sthatinicnianians
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Response from To Reg.28 Prevention of Future Deaths Report Ultra Events (PDF)
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PROTECTED: TRAINING WORKBOOK

Gym Name *

Gym Address *

Line!

Line 2

Post Code City

United Kingdom v

Country

Gym Email *

Coaches Name(s) * Coaches Email *

Coaches’ responsibilities:

' confirm that | will follow the training guidelines within this document. | understand that participants must complete an absolute bare minimum of 50% of all
training sessions to be able to take part in the event and they should be actively encouraged to complete all sessions.

For the avoidance of doubt, this minimum is 8 out of 16 sessions spread across the 8 weeks.

lagree to use the recommended scoring method and will keep records of matches, including final matching scores ahead of the event, these scores will bo given
to the area rep who will record them on the event fight order.

Rep/Sub-rep responsibilities:

' confirm that all PARQs will be checked and reviewed and that participants will not be allowed to start training until their PARQ is completed and checked and all
participants must complete an absolute bare minimum of 50% of all training sessions to be able to take part in the event.

Where a participant has disclosed prior experience, | confirm that this has been discussed with the coach/coaches and the gym and agreement has been given
for the participant to take part.

Participants will be weighed on week |, week 4 and at the match up night, these figures will be accurately recorded on the register and fight order.

Training Session Planning

The people that take part in UWCB events are beginners, total beginners that have never thrown a punch in most cases.
They will all have a wide variety of fitness levels, All UWCB coaches will have a minimum of 5 years’ experience in combat sports and will be introduced via personal
recommendation. When sparring starts boxers should always spar similar woights.

Learning expectations for the 8 week training programme
At the end of the 8 weeks training programme, all participants should be able to:

Have a high enough fitness level for 3 x 5 minute rounds.
Understand how to move their fect correctly - footwork is key.
Understand how to block and/or parry punches.

How to move in and out of range.

How to throw straight punches.

EVERY SESSION SHOULD INCLUDE:

WARM UP Start with a warm up (once they understand how to move this can progress to shadow boxing).

SESSION Follow 8 weeks plan opposite.

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End with a 20-minute-high intensity fitness session (suggestions are below).

20 MIN HIIT
At the end of every session confirm their learning by asking the group to go over what they have
learnt in that session.
CONFIRM LEARNING
Remember that participants are new to boxing, so the more you explain and check their
understanding, the quicker they will learn.
HOMEWORK TASK Tell them what to do in their spare time (this can be practice technique, attend classes, come to
sparring sessions)
Example 20-minute-high intensity fitness sessions
(These are simply examples)
They should be warm from the technique work
so you can get straight into it.
e  1minute burpee
e@ minute press up
SESSION 1 e@ 1 minute sit up
e 30second rest
@ Repeat 6 times (21 minutes)
e  30second squat thrust
e 30second press up
SESSION 2 e 30second sit up ;
e  30second twist sit up
e Rest 30 second
e Repeat 8 times (20 minutes)
e 40 seconds burpees
SESSION 3 e 20seconds sit ups

Repeat 20 times with no rest

Homework tasks

e Recovery runs ~ 30 minute jog
e Attend extra sessions at gym (fitness, sparring etc)
e Practice lines
e Interval running session ideas
8 Week Training Plan
Focus on Footwork
Show correct stance; feet, chin down etc
WEEK 1
Stepping in and stepping out
Progress to show them how to throw a jab
is bebe
Teach 1-2
WEEK 2

Explain how they generate the power in a back hand (push from toe, push hips through, throw hand etc)
step in 1-2 step out

Dranroce fram waal 9

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WEEK 3

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# twyrwee run ween a
In lines facing each other practice jab & 1-2 punching to gloves

Introduce movement left & right

LL

WEEK 4

Progress from week 3
Show how to parry & block
Gradually introducing more intensity

Here they are learning to block or parry or slip shots they know are coming, so jabs or 1-2’s

WEEK 5

WEEK 6

+

Body Sparring

Progress from week 4

Still in straight lines but now they don’t know what shots are coming (must be straight)
Practise countering (reply within 3 seconds with any 3 punch combo for example)
Here they have effectively started sparring

(Headguards MUST be worn)

This should be light & technical
Participants don’t have conditioned torsos so will easily hurt ribs so this must be built up intensity wise.
(Headguards MUST be worn)

WEEK 7

Progress from week 6

Lead hand to head, anything to body sparring
Progress to open sparring

(Headguards MUST be worn)

ie.

WEEK 8

Session 1 - open sparring

Session 2 - run through what they have learnt and get them mentally ready for what they are about to
do.

Remember a lot of the boxers will be very, very nervous so explaining how they will feel and what will
get them through it on the night will really help them here.

(Headguards MUST be worn)

Matching Process

Fair matches are key to our events. Imagine if your child was boxing, would you be happy with the match given?
To ensure fair matches, the following steps must be taken.

Assessment

All boxers must be assessed across the 8 weeks training period; this assessment involves:

Regularly checking weights (weeks 1, 4 & 8)
Skill assessment.

Fitness assessment.

Sparring appraisal.

All paperwork compiled through training must be retained so that we can explain matches if required to do so, scoring sheets etc.

| nen

Following this assessment, these processes must be used by all UWCB gyms/trainers when matching bouts:

e Fighters ideally matched within 3 kilos.
e 7kilos is the target maximum weight difference, however:

Itis important to remember this is a guide and in white collar boxing there can regularly be bigger weight differences than 7kg and the

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bout still be fair.

If matches fall outside a 7kg weight difference they must be referred to HQ for approval and explained on the fight order.
It's better to have a fair match with a larger than 7kg weight difference than have a stand in.

Anyone boxing over 50 years old MUST be discussed with HQ and their match approved.

Bouts over 95kg can have a larger weight difference.

eeee

Weights should be considered with scores to ensure matches are fair.

Experience must be carefully considered, if someone has boxed or had combat sports experience before take care when matching them
with a first timer.

Whilst ability may appear to be the same the first timer may be more affected by the ‘occasion’, ensure that this is considered.

|

Boxer Ability - Scoring Method

To standardise how we assess participants ability throughout the training programme, the following scoring method should be used at
training sessions and recorded against the participants name on the register. These scores may fluctuate as each participant
progresses through their training and are vital for matching participants fairly for the final event. The participant's final scores must be
recorded against their name and weight in the fight order for the event.

Scores should be used in conjunction with weighs to ensure matches are fair.

You can also use 1+ / 3- etc. This is if you feel participants sit between whole scores.

‘ |

+
Complete novice | Slightly advanced Good | Very good Close to amateur standard

1 2 3

Stand In Boxers

These should be avoided and only realistically used if there is an odd number of boxers.

REMEMBER: The boxers have signed up to raise money for charity, they should have a fair bout and not be embarrassed by a stand in
boxer.

e Stand in’s must be appropriately matched, you cannot simply get a similar weight as their ability may be drastically different!

® Event coordinator MUST brief the stand-in boxers and ensure they ‘look after’ the opponent in case there is an ability
discrepancy (this could happen if the boxer ‘freezes’ as it's their first bout and the stand-in is more comfortable.)

e@ We should let the participant know there will be a stand in as soon as possible.

Declaration
tagreo that | will follow the training and matching process throughout the training period. | confirm that all participants taking part in the final event will complete
the minimum 50% of training sessions.

Where prior experience is disclosed, this has been taken into account and participants were matched fairly in line with the recommended scoring method and
woight considerations.

I confirm | will keep records of matches, and that final participant scores will be given to the area rep ahead of the final event to be included on the fight order
alongside weights.

All PARQs wore received and reviewed prior to each participant starting their training.

Coach/Trainer Name *

Signature *
ar
Date*

10/06/2024

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