Jack Riding

Dear Sirs Inquest touching upon the death of Mr. Jack Riding Her Majesty'$ Coroner Regulation 28 report ("the Report") We write in relation to the above matter and further to our previous correspondence dated 14th January 2019. Firstly; The Football Association once again wishes to express our sincere condolences on the passing of Mr Riding: given further consideration to the matters raised within Her Majesty's Coroner's Report; we believe it would be beneficial for Us to review a copy of the Independent Consultant review of the health and safety processes and procedures at Goals Soccer Centre Plc ("Goals"), as alluded to in paragraph 4 of the 'Coroner's Concerns' section of the Report. Having not been party to the inquest proceedings, we believe that sight of this document may better inform Us about the circumstances of Mr Riding's death and potentially assist Us in providing a more helpful response to Her Majesty's Coroner: As such; we would be grateful if Her Majesty's Coroner would provide Us with a copy of the review document; once it has been completed. We would be grateful for a short extension of days from the time that we receive a copy of the review document;by which to provide our response: 9 Pation The FA Group Postal Address +41101 802 16; [86} Tin Qtnf-s MaeuSujun Wemlynu: Shi? ~[0} 800 169 1804 WEMBLEY 8 S73RCEs President Wpmbiey POB [967, w [heFArom CONNECTED By "4 Haoevis Lc Fco" SVIIPTE:} Reglstration. 77797 Having = having kindly

The FA takes the matters raised in Her Majesty's Coroner's Report seriously and we look forward to providing a substantive response in due course: We can be of any further assistance, please do not hesitate to contact us. We look forward to hearing you in due course: Yours faithfully; The Football Association Email: Direct Dial from

goals] 5-A-SIDE. THE WAY IT SHOULD BE: Goals Soccer Centres plc Orbital House Peel Park East Kilbride Mr: Joseph Hart Coroners Officer Gerard Majella Courthouse, Boundary Street, Liverpool, 15th January 2019 Dear Mr Hart am writing in response to your Regulation 28 Report of 26th November 2018. Please find attached our comprehensive response to the Coroner' $ concerns as specified in your document: have been CEO of Goals since April 2018and want to stress that Health and Safety is a high priority for our business. We have recently created a Health and Safety sub-committee to the PLC Board which will oversee all of our activities in this area: It will have the same status as other sub-committees such as the Audit or Remuneration Committees. will be Chairing this committee_ also want to stress that; even before joined, Goals has always taken a proactive role in staying ahead of current regulation in this area. This is true in our early adoption of Defibrillators across all of our centres as well as adding training on these units into standard first aid training: Our approach to locating the units is in line with other institutions such as major gyms and the FA's new football hubs and was decided after significant consultation_ However, we are not complacent and understand that there is always room for improvement ad areas where we should Iearn and make things better. We have detailed a number of such areas in our response We are keen to make sure we handle medical emergencies as affectively as possible and would welcome any further suggestions you might have in this regard_ hope you find our response comprehensive and easy to follow. If you have any questions or comments please contact me directly. Furthermore, would welcome the opportunity to discuss our response in person with the Coroner, if appropriate: look forward to hearing from you Yours sincerely Andy Anson CEO GOALSFOOTBALLCD UK

Goals] 5-A-SIDE, THE WAY IT SHOULD BE: Dear Mr Hart RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS_SECTION 5 CORNORNERS CONCERNS Following the Coroner' s Report sent to Goals Soccer Centres PLC ('Goals') on 28th November 2018, please find below the Coroner s concerns with our formal response to each them_ Coroner Concern SS (1) | heard evidence that there was a significant delay in bringing a Defibrillator to the pitch where Jack had collapsed. There was a delay of some minutes before the Defibrillator was deployed; make it clear that this could not be said to be a contributing factor in Mr Riding' s death: have received evidence ofthe systems in place to deploy the Defibrillator from Goals Soccer Centres plc: It remains a concern to me that when matches are being played that the Defibrillator is kept away from the pitch and the deployment ofthe equipment is dependent on which members of staff are present am concerned that any delay in the deployment of this emergency equipment presents a risk of future death. 55 (1) Response In 2014 Goals proactively initiated a rollout of Defibrillators across all our clubs. This decision was based on our commitment to safeguarding all of our customers and esta blishing best practice within our industry: After proactively insta defibrillation units in 2014 across our entire estate, were sited inside the clubhouses The decision to place the units inside was based upon recommendations made during consultation to ensure the units remain in good working order: Before these units were purchased, we met with the Head Community Liaison officer for the Scottish Ambulance Association (SAA) and consulted with the British Heart Foundation (BHF) for guidance and best practice on the type of equipment and to ensure that we are providing the most appropriate product for our environment: The rollout of the Defibrillators was undertaken based on best-practice advised during the consultation with the SAA and BHF and we adopted their expert advice As a result of the advice received, the conscious decision was made by Goals to house the Defibrillators in reception area's which are constantly manned by staff, while the facility is open. In addition, the Defibrillators could also be observed and monitored. We were advised that external unit placements are susceptible to vandalism and damage and were clearly advised not to place units outside: To in full working order outside units would need to be wall mounted and lockable and keys would still be held inside at reception or within the site which would further delay access to the Defibrillator when collecting the and unlocking the equipment for use. After further review and consultation with other new 5-a-side and full-size facility developments, it is clear that the units are still being placed inside including at the FA's new hubs in Liverpool and across the UK, for example at Heron Eccles opening late 2018 in Liverpool. We firmly refute that there was a significant delay to the Defibrillator being accessed or used. CCTV footage sent previously (appendix 10 in our response dated 18th November) showed our response time of less than 1 minute from staff receiving the information that the Defibrillator was required and taking it out onto the pitch: Although we do not have exterior CCTV footage to verify timings to the pitch, Appendix 1 highlights the distances between pitches and the facility clubhouse and reception which is less than 10Om the clubhouse to the pitch; This distance is much shorter than in many other sports-related leisure BOALSFOOTBALL,CD UK Riding alling they keep key rapid from and from

ggoals] 5-4-SIDE: THE WAY IT SHOULD BE, facilities. The Defibrillator unit was with Manager Nicole Johnston on the pitch ready to be deployed when necessary: There were several minutes when the Defibrillator was on the pitch while Nicole was speaking to the 999 call operative taking CPR instructions. When instructed, the unit was o and ready for use and produced a single shock after which the Ambulance Crew took over: All Goals staff members are trained in the use of the Defibrillator so any staff member on duty is able to operate a unit when necessary: Staff training is detailed further in our response to the coroner' $ concern detailed in S5 (3). We do recognise speed is the primary factor in getting the Defibrillator to the point of emergency ad knowledge of Defibrillator location is vital for customers (staff are aware of equipment locations as this is included within their induction): We have therefore undertaken an additional audit of Defibrillator locations and signage across all facilities (Appendix 2) and as a result will make the following adjustments:
1) All Defibrillators will be housed in a location highly visible to the public in our receptions by 1st March
2019. 28 units are already located in a prominent position visible to the public and will remain in place, 18 units will be relocated into more prominent positions for customers with clear Defibrillator signage:
2) All exit doors from our clubhouse/changing facilities to pitches and all individual pitch gates will have additional Defibrillator location signs placed by 1st March 2019. Coroner Concern S5 (2) heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew_ have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the that policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like: am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding's death, any delay of this kind presents a risk of future death: S5 (2) Response In addition to First Aid training, all staff are trained in 'situational awareness' . This training includes medical emergencies. In particular, the training includes directing a member of staff to g0 and wait for an ambulance at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the casualty: In the case of Jack this didn't happen and we acknowledge that this part of the emergency was not handled in line with Goals training: Since the incident, we have immediately circulated the Emergency First Aid Incident Procedure (appendix 13 in our response dated 18th November) to reaffirm the GOALSFOOTBALL,CO,UK Duty Riding

goals] 5-A-SIDE. THE WAY |T SHOULD BE: procedure and to ensure all clubs are compliant in understanding their roles and responsibilities during an emergency incident in the immediate short term_ In addition, the subsequent independent review of Health and Safety (commissioned following the incident) has provided a new draft document (Appendix 3) called "Goals Normal Operating Procedures and Emergency Action Plan 2019" which was created on the back of the updated "Goals First Aid risk assessment" (Appendix
9). The "Goals Normal Operating Procedures and Emergency Action Plan 2019 specifically includes (in section
2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it have been agreed and a timeline for rollout across the business is as follows: Phase Action Completion Date Phase 1: Final review of new documentation and sign off by Head of Corporate 31/01/2019 Operations and PLC Health & Safety Committee Phase 2: Standard documentation sent to clubs for specific club detail input and to be 15/02/2019 returned and reviewed by Head of Corporate Operations Phase 3: "Goals Normal Operating Procedures and Emergency Action Plan 2019" 01/03/2019 Final detailagreed by Goals Senior Management team and implemented across all clubs Phase 4: Regional Manager audits are to be re-reviewed and the new documentation 28/02/2019 and actions implemented into the Regional Manager club audits As part ofthis rollout, situational training emergency First Aid scenario training will be provided and role- played by all clubs and refreshed annually: Details of this can be found in the response to the training concern detailed in S5 (3). Coroner Concern S5 (3) have seen a limited risk assessment to consider what should be done in the case of a medical emergency on the pitch: have seen no clear indication of the extent and subject matter of any First Aid training: have seen evidence that training has taken place: In the absence of any such evidence am concerned that a lack of training may present a risk of future death. S5 (3) Response AIl Goals staff have received Emergency First Aid, Health and Safety and Defibrillator training which broadly consists of 4 tiers of job-specific training in the form of: Induction training, Defibrillator video training, learning and practical training: first phase of training is compulsory and provided during all staff job inductions. The inductions cover site specific locations f First Aid equipment, Defibrillators, First Aid kits and essential site information. Further to induction, all staff undertake video training on using a Defibrillator provided by our Defibrillator provider, Lifepak: This provides training in operational use of the units. The content of the 13-minute video GOALSFOOTBALLCO,UK and The

goals] 5-A-SIDE; THE WAY IT SHOULD BE. training can be found via a link in our company H&S policy (Appendix 5, page 16). The training is refreshed every 6 months (Appendix 4 signed shows latest staff refreshers): In addition to Induction and video training, all staff including Receptionists, Bar staff, Maintenance staff and Car Park Security complete bespoke e-learning in Health and Safety Level 2 and Emergency First Aid via our e-learning provider Flow Hospitality: The course specification can be found in Appendix 6 which in Summary covers with emergency situations, primary & secondary surveys, basic life support (CPR) and the recovery position. The final level of in-depth and practical training is provided for all Managers. In 2015 we proactively implemented steps to improve Defibrillator training levels. Until 2018 the First Aid training syllabus did not cover practical training in the use of Defibrillators, however following consultation with our First Aid provider, we added Defibrillator practical training into our First Aid syllabus. At this time this training was not standard topic within the syllabus of the standard qualification (Level 2 Emergency First Aid at Work QCF) Goals consciously implemented Defibrillator practical training well before this was made mandatory: The qualification was updated in January 2018 to include practical training ad assessment in the use of Defibrillator, which we continue to provide, specifically covering First Aid skills in cardiopulmonary resuscitation (CPR) and use ofan automated external Defibrillator (AED) (Further content ofthe training can be found in Appendix 7). We have held 18 Emergency 'First Aid at Work' qualification courses in the past 24 months ad Appendix 8 shows 172 staff First Aid trained to this level with practical Defibrillator training; valid for 3 years. Since the incident we have committed to significant increases to further enhance the level of training staff receive: By 31st July 2019, All General Managers, Regional Managers and Operations Team members will complete the Level 3 'First Aid at work' (18 hours) (They previously were required to complete the 'Emergency First Aid at Work' course 6 hours). Course specifications Appendix 7 . Bv 31st July 2019 any staff member working 16 hours or more on reception will receive the 'Emergency First Aid at work' course covering practical training and assessment, in addition to video training: Course specification Appendix 7_ By 1st January 2020 all reception staff (regardless of hours worked) with 1 years' service will receive the 'Emergency First Aid at work' course covering practical training and assessment, in addition to video training: Course specification Appendix 7 _ To support the new Emergency Action Plan and Serious First Aid Incident Procedures, we are implementing scenario-based training to deal specifically with emergency First Aid procedures with the following rollout plan: GOALSFOOTBAIL.COLUK dealing Duty 1-day 1-day

goals] 5-A-SIDE. THE WAY IT SHOULD BE: Phase Action Completion Date Phase 1: Create club-based scenario and First Aid incident on the pitch training and 31/03/2019 video roles & responsibilities for the Goals e-learning platform Phase 2: Create scenario-based training to emulate Emergency First Aid procedures 31/03/2019 in each club with all staff members and implement an annual refresher Phase 3: Roll out video & scenario-based training to all staff to complete in the 2nd 31/08/2019 Defibrillator refresher training Phase 4: Regional Manager audit to be re-reviewed and new training to be checked 28/02/2019 as part of new Regional Manager audit procedure The video training course will be accessed via the Goals e-learning platform in time for the second running of the 2019 Defibrillator refresher training; along with on-site situational role-play training which all staff members will be required to undertake: Coroner Concern S5 (4) | note that Goals Soccer Centres Plc recognise a need to review the Health and Safety processes_ They have instructed an Independent Consultant to undertake a review of Health and Safety processes and procedures but with no clear timescale for this review am still of the view that am under a duty to prepare this report: S5 (4) Response The Independent Consultant Health and Safety review is now complete (Appendix 3) and the timescales for the rollout ofthe new documentation training and subsequent actions and procedures are highlighted in the responses to the Coroner concerns in S5 3 & 4, above: Appendices, referenced in document: Number Document Liverpool North Pitch overview Goals Defibrillator Audit Goals NORMAL OPERATING PROCEDURES AND EMERGENCY ACTION PLAN 2019 Defibrillator Refresher Training Goals Health and Safety Policy November 2018 Goals e-learning Training Goals Qualification Overview Goals First Aiders Goals First Aid Risk Assessment December 2018 We hope this response adequately addresses your concerns. We are to discuss this in more detail at your convenience and would welcome the opportunity to meet in-person: