Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0142, written 14 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2025 |
|---|---|
| Reference | 2025-0142 |
| Deceased | Alexander Eastwood |
| Coroner | Michael Pemberton |
| Coroner area | Manchester (West) |
| Category | Child Death (from 2015) |
| 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 before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Department For Culture, Media And Sport 1 CORONER I am Michael James Pemberton, HM Assistant Coroner for the coroner area of Manchester (West). 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 05 July 2024 I commenced an investigation into the death of Alexander Robert EASTWOOD aged 15. The investigation has not yet concluded, and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH On 29 June 2024, Alexander Eastwood participated in a kickboxing competition in Wigan. He wore safety equipment including a head guard, and gloves. The fight lasted 3 x 2 minute rounds. At the end of the contest, he appeared unwell and became unresponsive apparently suffering a seizure. Medical assistance at the match was summoned and paramedics were called. He was taken by ambulance to Wigan Royal Albert & Edward Infirmary where a CT scan showed he had a significant bleed on the brain. He was transferred to the Royal Manchester Children’s Hospital in a critical condition and underwent surgery to relieve intracranial pressure, but unfortunately further bleeds developed and despite maximal medical intervention he deteriorated and was declared deceased on 2 July 2024. 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: 1. During the current course of investigation, it is apparent that there is no guidance or regulation of contact sports involving children’s participation. 2. This is important, because no base line or minimum standards of what safeguarding or necessary risk management is set out for those who plan or organise an ‘official’ or ‘unofficial’ match where physical force may be used between or against a child participant. 3. Under current circumstance, arrangements for each, and every contact sport contest involving a child, is left to the judgement of an organiser who may have recourse to principles provided by a sports association, if the match is to meet official status. If a match is unofficial or unsanctioned, there is no guideline of what minimum standards Regulation 28 – After Inquest Document Template Updated 30/07/2021 must be met to provide safeguarding for a child participant. 4. This includes a. no minimum standard of what medical support may be required, b. maximum rounds or periods of rest c. welfare checks on participants being undertaken. d. no risk assessment and critical incident plan 5. In the current investigation, these concerns relate to the sport of Kick Boxing, but the identified issues appear to be of wider significance in terms of ‘contact ‘ sports involving children. 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 9 May 2025. 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 Hurricane Combat & Fitness Kickboxing GB I have also sent it to UK Sport Children’s Commissioner for England 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 Dated: 14 March 2025 Michael James Pemberton Assistant Coroner for Manchester (West) 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.
y Secretary of State for Culture, Media and Sport i 1st Floor 100 Parliament Street Department Londen SW1A 280 for Culture, E: enquiries @dems.gov.uk Media & Sport wwow.govukddcms 3 May 2025 Michael James Pemberton Assistant Coroner for Manchester (West) HM Coroner's Court and Office for Po Manchester West Paderborn House Howell Croft North Bolton BL1 1QY Thank you for your letter of 14 March 2025 enclosing a copy of the Regulation 28 Report to Prevent Future Deaths of Alexander Robert Eastwood. | would like to extend my deepest sympathies to Alexander’s family and friends. As part of his legacy, | confirm we are doing everything possible to ensure children can enjoy sport safely. You raised a number of concerns about the current system and | am keen to consider how best to address them. | am mindful that the government does not, and should not, regulate sport directly. However, | am concerned that the current system, which allows individual clubs to decide whether to affiliate to a National Governing Body and their associated standards, does not offer sufficient protection to children and parents. While resources are available to those who choose to use them, | have tasked my Department with exploring ways to urgently improve the safety and welfare of children in martial arts and ensure it is always a priority. | will also ask Sport England to work with the Martial Arts Safeguarding Group and other relevant combat sport stakeholders on this. | am particularly keen that we ensure that parents and children who are currently participating in competitions understand the difference between competitions that are regulated and those that aren't. | would be happy to update you on progress once we have received and considered your final report. In the meantime, | have asked my officials to explore different options and report back to me. at ir: DA 3 YY Ss 2 M5, oi | am clear that there is more we can do to protect and empower parents and children participating in sport. | am proactively seeking the views and experiences of the family, and | am so grateful to you for raising this with me. No family should have to endure the pain and loss Alexander’s family have experienced and | am determined that from this tragedy, there must emerge a better system. Yours sincerely, Secretary of = a —_ Media and Sport at Moy, 205/p, OS O40 s 2 2 sap
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