Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0512, written 13 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2025 |
|---|---|
| Reference | 2025-0512 |
| Deceased | Mark Townsend |
| Coroner | Tanyka Rawden |
| Coroner area | South Yorkshire (West) |
| Category | Other 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 THIS REPORT IS BEING SENT TO: Sheffield Wednesday Football Club, Hillsborough Stadium, Sheffield S6 1SW. 1 CORONER I am Tanyka Rawden, Senior Coroner for the Coroner area of South Yorkshire (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 7 October 2024 I commenced an investigation into the death of Mark Townsend aged 56. The investigation concluded at the end of the inquest on 10 October 2025. The conclusion of the inquest was that Mark died due to natural causes. 4 CIRCUMSTANCES OF THE DEATH On 28 September 2024 Mark Townsend attended the Hillsborough Stadium in Sheffield to watch a football match between West Bromwich Albion and Sheffield Wednesday. Approximately twenty minutes into the game Mark said he was hot. As the second goal was scored, Mark sat down and fell to his side. Mark went into cardiac arrest and was assisted by an off-duty doctor and an off-duty paramedic before a paramedic from the contracted medical provider arrived. Mark was taken to the Northern General Hospital in Sheffield where he died. The medical cause of death was: 1a. Acute myocardial infarction. 1b. Coronary artery disease. 2. Hypercholesterolaemia. 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 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 Court heard evidence and viewed CCTV footage which showed that at the point where a steward became aware medical assistance was required, the nearest member of staff with a radio was at the top of a set of metal stairs, near to the bottom of the stairs leading to the X vomitory. Accepting staff are required to roam to deal with their duties, this position was not in line with those outlined on a map of radio locations produced to the Court. 1 The CCTV footage shows the following events: A West Bromwich Albion supporter spoke to a steward to raise the alarm. The steward initially climbed up the stairs to speak to supporters. That steward signalled to a second steward to raise the alarm. The second steward began to descend the stairs. The first steward then began to descend the stairs. Stewards one and two conversed with a group of other stewards at the bottom of the stairs leading to the W vomitory. A steward then moved from the group of stewards the bottom of the stairs leading to the W vomitory and ran towards the group of stewards and steward supervisors at the bottom of the stairs leading to the X vomitory following which the call for medical assistance was made by a supervisor. The Court found that the actions of the stewards in moving to the bottom of the stairs leading to the W vomitory, before running towards the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, demonstrated that they did not know where to find a member of staff with a radio. The time between the second steward arriving at the group of people at the bottom of the stairs leading to the W vomitory, and the time the steward arrives at the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, was 20 seconds with the radio call being made 11 seconds later. The Court found this period of time did not cause or contribute to Mark’s death, but has concerns that delays caused by stewards not being aware where the nearest radio is could cause delays in summonsing medical help in the future, and that may give rise to a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 8 Decemebr 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: The family of Mark Townsend via their representative. The Sports Ground Safety Authority. 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 2 your response, about the release or the publication of your response by the Chief Coroner. 9 13 October 2025 3
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.
Sheffield Wednesday Football Club (In Administration) Response to Prevention of Future Deaths Report Issued by HM Senior Coroner for South Yorkshire (West), Ms Tanyka Rawden Date: 8 December 2025 Re: Prevention of Future Deaths Report – Mr Mark Townsend For the attention of HM Senior Coroner for South Yorkshire (West), Ms Tanyka Rawden: Sheffield Wednesday Football Club (“SWFC”) writes in response to your Prevention of Future Deaths Report dated 13 October 2025 concerning the tragic death of Mr Mark Townsend on 28 September 2024. SWFC wishes to repeat its sincere condolences to Mr Townsend's family and all those affected by his sad death. The Club takes the safety and welfare of all persons attending Hillsborough Stadium with the utmost seriousness and has carefully considered the concern raised in your report. SWFC respectfully notes that the substantive findings of the inquest were positive in relation to the Club's safety arrangements and response to this incident and that that there were no causative failings on the part of the Club. The inquest’s findings demonstrated that a radio call was made 63 seconds after a steward was first notified of the medical incident and a paramedic arrived with Mr Towsend approximately 3 minutes later, 1 minute 20 seconds after Mr Townsend’s cardiac arrest. The speed of the resultant medical response was found to have been in line with what might be expected had Mr Townsend suffered a cardiac arrest in a clinical hospital setting. The inquest also heard evidence that Hillsborough Stadium is regularly and routinely inspected by the Sports Ground Safety Authority, is licensed by the Local Authority and is subject to scrutiny by a multidisciplinary Safety Advisory Group. Not only have none of these bodies ever raised an issue with regard to the robustness of the existing radio system, the Sports Ground Safety Authority also informed the inquest that it endorsed SWFC’s approach to radio infrastructure. We have again reviewed the footage to consider the actions of the steward who relayed information about the medical incident to a radio holder. We note that following her discussion with steward colleagues, they then began to make their way towards Mr Townsend whilst she proceeded towards the radio holder. The conversation between the stewards was found to have lasted no more than 20 seconds and was determined not to Page 1 of 7 have been causative of or contributory towards Mr Tonwsend’s death even on a more than minimal basis. The inquest also established that SWFC complies with all relevant safety guidance and that the arrangements at Hillsborough Stadium voluntarily exceed what is required by the guidance and licensing conditions. Current Measures at SWFC We have comprehensively reviewed our current arrangements for radio availability, visibility and ensuring that stewards are aware of where to locate radios. Our existing measures include: Radio Availability On matchdays in the West Stand and immediate surrounding areas there are 13 radios available. Radio holders (8) in the West Stand are: • 2 x Steward Supervisors (Upper Tier) • 2 x Steward Supervisors (Lower Tier) • 1 x Stand Managers • 2 x Fire Marshalls (Upper Tier) • 1 x Fire Marshall (Lower Tier) Radio Holders (5) in the direct vicinity of the West Stand are: • 1 x Chief Steward (South-West Corner) • 1 x Medical Co-ordinator (Control Room) • 2 x Response Team Manager (South-West and North-West Corners) • 1 x Gate Steward On match days there are approximately 120 radios in use on site at Hillsborough Stadium. For a full capacity game, SWFC would provide approximately 300 stewards (in excess of the 205 stewards required by our safety certificate). Therefore the ratio of radios is more than one radio to every three stewards. There is also a static emergency telephone located in the West Stand First Aid Room located in the rear concourse. Page 2 of 7 Visibility of Radio Holders Radio-holders are made visible and distinguishable as follows: • Steward Supervisors and Stand Managers wear high visibility orange jackets • Fire Marshals wear high visibility red jackets • Response team managers wear high visibility yellow jackets with blue vests • The Chief Steward and Medical Co-ordinator wear high visibility yellow jackets with • black detail Individuals’ roles are also marked on the front and rear of their jackets. Location of Stewards and Radios Stewards are strategically located around the West Stand. On the upper tier the 2 Steward Supervisors, 2 Fire Marshalls and 1 Stand Manager are positioned on the horizontal walkway spanning the width of the stand. This allows them to move laterally across the stand and select and ascend any of the vertical stairways easily. This position also provides them with good visibility of the upper tier sections and an ability to liaise easily with fire and medical professionals who also take up positions or mobilise along the horizontal walkway. The horizontal walkway is kept clear at all times and the first two rows of seats are netted off so that there is no crowd impingent on this area meaning that radio holders maintain good visibility, lines of sight and freedom of movement. Radio holders on the horizontal walkway are also readily visible to fans and stewards in the upper stand who can easily descend and move to their location. The concourse behind the stand (accessible from the upper tier staircases via vomitoria) is equipped with a First Aid Room with a static emergency phone with a direct line to the stadium control room. The location of radio holders is planned and mapped. The location of radio holders is disseminated to stewards through their training, briefings and during emergency training scenarios. Stewards are also trained and regularly briefed on the location of the static emergency telephone and its use as a failsafe. Whilst the position of radio holders is mapped for the start of every match they are able to move and dynamically respond to any issues which might arise on the day. Whilst this means that radios will not always remain in their mapped location at all times, it is felt to be more important that radio holders retain an ability to respond to the wide range of Page 3 of 7 incidents that might occur and so that radios can be moved into position to deal with developing situations. Stand Managers and Steward Supervisors liaise with one another to ensure that a radio holder presence is always maintained on the lateral walkway even if one of them is called away to attend to an incident. It is not considered practical or safe to leave static unattended radios around the stand. The emergency telephone serves as the static means of contacting the control room. Briefing and Training Stewards receive advance briefing information in the days prior to any match with information sent to them via an app. On matchdays stewards receive stand briefings from their supervisor/stand managers which are in turn informed by briefings given to those leaders by the Chief Steward, Safety Officers and medical leads. Briefings include ‘How to get help’ incorporating locations of radios, location of emergency phones, location of first aid responders and location of Fire Marshals. Supervisors also receive local training on the use of radios and the Club’s radio systems and undertake 72 hours of guided training as part of their Level 3 certification in Spectator Safety (RQF). As a club we host and participate in large scale multi-agency emergency response training including large scale emergency incident scenarios. As part of this training radio and communications systems are trialled and tested. Oversight and Regulation Our safety arrangements are subject to scrutiny from the Sports Ground Safety Authority, including through regular matchday inspections. We are also subject to appropriate licensing scrutiny from our Local Authority. As a club we also actively participate in our local Safety Advisory Group. All of these bodies are able to raise concerns in respect of any safety issues but we have not been notified of any relevant concern as to our existing radio systems. We comply with and in many areas exceed the recommended safety arrangements set out in the Green and Purple Guides, including on communications systems. Benchmarking Against National Standards SWFC has written to key stakeholders to compare the Club's radio arrangements with what is expected and practised at sporting and public events up and down the country. We have consulted with the following by setting out our club’s current arrangements and requesting their input: Page 4 of 7 • The Sport Ground Safety Authority • Sheffield City Council / Safety Advisory Group • The English Football League • Nine EFL Clubs located in Yorkshire The SGSA have responded to the consultation and have not made any comments, recommendations, advice or areas for improvement. The EFL have responded to the consultation and have not made any comments, recommendations, advice or areas for improvement. The Local Authority / SAG have responded to the consultation and have not made any comments, recommendations, advice or areas for improvement. They have stated that supervisors are required to be mobile in order to perform their duties adequately and that The clubs who responded to the consultation indicated that the arrangements for radios were at least consistent with their own. Some clubs have indicated an intention to review their own practices having learned from the arrangements in place at SWFC. The only specific recommendation or suggestion for SWFC to amend its own arrangements was: • Placing a radio at each corner or the pitch; this is in fact already in place as radio- holding response managers are located in these positions. The Reality of Live Event Management SWFC respectfully submits that sporting and public events are, by their nature, staffed by human beings whose behaviour in the moment may create delays measured in seconds for a wide range of reasons, despite comprehensive training, clear procedures, and robust systems. Factors that can contribute to brief delays include: • The need to assess the situation before acting • Communication between team members to ensure appropriate response and deployment • The time required to physically move through crowded areas • The need to balance multiple priorities in a dynamic environment • Human reaction times and decision-making processes Page 5 of 7 The Club's radio provision arrangements are: • Compliant with all applicable regulations and guidance • Approved and licensed by the SGSA, LA, and SAG • Subject to regular inspection without adverse findings • Consistent with or exceeding arrangements at comparable venues • Supported by comprehensive training and procedures In the context of live event management, where thousands of people attend matches and stewards must respond to a wide range of incidents, a response time of 63 seconds to initiate a radio call for medical assistance represents an effective and well-functioning system. SWFC's Response to the PFD Report Notwithstanding the points set out above, SWFC takes the coroner's concerns seriously and is committed to continuous improvement and learning in all aspects of ground safety. The Club will continue to take the following steps which also were in operation prior to Mr Townsend’s death: • Steward training on radio locations and the importance of immediate communication in medical emergencies • Enhanced pre-match briefings specifically addressing radio accessibility • Continued dialogue with regulatory bodies to ensure arrangements remain fit for purpose • Regular review of radio positioning and distribution based on operational experience • Sharing of learning and best practice with other venues and stakeholders • Regular testing and exercising of emergency procedures SWFC is deeply saddened by the death of Mr Mark Townsend and extends its heartfelt sympathies to his family. The Club is grateful for the thorough investigation conducted by the coroner and notes the positive findings regarding SWFC's safety arrangements and the non-causative nature of any delay in this case. Whilst SWFC acknowledges the coroner's view that more can be done to ensure stewards know where to find radios, the Club respectfully feels that the evidence demonstrates a robust, well-regulated system that functions effectively and is consistent with arrangements at sporting and public events nationwide. The brief delay in this case – measured in seconds and found to be non-causative – does not indicate an unsafe or unsuitable set of safety arrangements. Page 6 of 7 SWFC remains committed to the highest standards of safety and will continue to work collaboratively with all stakeholders to ensure that Hillsborough Stadium remains a safe environment for all who attend. Yours sincerely Stadium Operations Manager For and on behalf of Sheffield Wednesday Football Club Limited (in Administration) Page 7 of 7
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