IN THE CHESTERFIELD CORONER'S COURT INQUEST TOUCHING UPON THE DEATH OF EDWARD LEWIS BILBEY Date: 14 - 20 December 2020 Interested Party: England Boxing RESPONSE TO REGULATION 28 REPORT To PREVENT FUTURE DEATHS Coroner: Dr Robert Hunter; Senior Coroner Area: Derby/Derbyshire Reg 28 Report Date: 10 March 2021 Response Date: 2021 Coroner's Concerns The Regulation 28 Report identified the following concerns: England Boxing did not have in place adequate and enforceable child protection and safeguarding measures; England Boxing did not have in place any policy or procedure for checking and enforcing compliance with its safeguarding or child protection procedures_ The following points were noted during the Inquest as relevant evidence in support of the concerns raised above: The club's registered Welfare Officer had left the club three years prior, but his name remained registered on "The Vault" system held and maintained by England Boxing; May

2. There was nothing to demonstrate that the name or contact details of the registered Welfare Officer were displayed prominently at the club; 3_ There was a level 2 coach registered on The Vault but the witness's testimony stated that he was not involved in training activities at the club England Boxing's Response HM Coroner will be aware that the tragic event which gave rise to the Inquest and the Coroner' subsequent concerns occurred on 24 March 2017. Between that date and the Inquest; England Boxing, as organising body for amateurIOlympic boxing in England, identified and implemented remedial action which it was believed would increase safety and awareness in sport carried out within EB's remit. Work required in order to carry out other actions identified was dependent upon information revealed the Inquest itself and, as such, have been completed since_ ACTIONS COMPLETED PRIOR TO INQUEST Rule Book At the time of this incident; the rules and regulations governing amateurIOlympic boxing in England were located in various publications available from different sources, which made identifying and applying specific rules unnecessarily cumbersome. were also, to some extent; based upon regulations imposed by other international bodies, meaning that clubs had to sift through information which did not apply on locallregional level in order to find information relevant to them: Since 2018 we have collated all the information on rules and regulations regarding competitive boxing and codified them into one publication. The resultant England Rule Book can be found on our website and is available for open-access viewing Website Since 2018, the England website has been overhauled in order to provide greater clarity on regulation and policy: The structure is now much easier to follow and relevant publications are easily accessible. All guidance available on the website has been scrutinised and updated where appropriate_ Policies have drafted the following policy documents, which were missing at the time of this incident: Emergency Action Plan For a medical Emergency involving boxer. Emergency Action plan for medical emergency involving an official or spectator that requires the ring side doctor_ during They Boxing Boxing We

The policies codify who has responsibility for each aspect of the emergency procedure to ensure that specialist medical attention is available as quickly as possible. They also Iink to the new Rule Book; which provides greater clarification on the roles and responsibilities at a bout or competition: Permit Regulations: Bouts have never been allowed to go ahead without a permit issued by the relevant England Boxing region: However; the regulations regarding the issuing of permits were comprehensively updated in 2019. The new regulations set out in detail the accountability of bout organisers, ensures the suitability of the venue (with reference to the new Emergency Plans) and requires that appropriate safety , security and medical provisions are in place Permits will not be issued unless all of those requirements have been met. Coach Official Training: Since 2017 we have comprehensively restructured our coaching courses We have now introduced refresher course for level one coaches which must be undertaken three years to ensure that coaches up to date. Coaches who do not attend refresher training are decertified. Coaches may only progress to a level 2 status by holding a level certification for a minimum of 12 months and registering up to date safeguarding, first aid and DBS certifications on The Vault, so that we can ensure policies have been adhered to. Training for those officiating at bouts has also been expanded and developed, including training courses for Supervisors, which sets out their responsibilities for implementing the Emergency Plans in the event of an emergency event Campaigns: Following this incident, we initially raised awareness within our Member community of the benefits of ensuring that Automatic Emergency Defibrillators are available within Member clubs, with how funding can be secured in order to do so. That allowed a transitional period for clubs to put in place any initiatives they may have required. Following that initial period, England Boxing took the step of making the installation of AEDs a mandatory requirement by June 2021_ This date may be delayed slightly due to the pandemic, but a deadline will remain in place. Safeguarding: Whilst required before this, since May 2018 all prospective coaches have to attend an approved safeguarding course prior to issue of their coaching licence_ Without it the licence will not be issued. This is in addition to enhanced DBS checks. More recently, we have engaged the services of a prominent QC to review our safeguarding procedures and policies and amend them where necessary. As a result; Regional and Club Welfare Officers are also now required to attend every stay along

regular safeguarding update courses and training: Regional Welfare officers also need to undertake the enhanced "Time to Listen Course" Club membership requires the presence of a registered level and level 2 Coach, a committee and designated Welfare Officer. Clubs must also adopt England Boxing's Safeguarding Policy_ Details of above information must be registered on The Vault" . applications are supplied to England Boxing centrally , with the relevant Region dealing with renewals Regional representative will then conduct a visit to the club in order to carry out physical checks on facilities, whilst the Registrar will check the relevant paperwork and membership requirements before approving the club for the season. Vault: At the time of this incident The Vault" system was in its infancy and its benefits and capabilities were not utilised to the full; Since then, system has expanded in use and registrations are actively tracked, ensuring accountability_ Prior to the introduction of The Vault club membership was administered regionally and, upon centralisation of the process, training and instruction was provided to Registrars in each region. were responsible for confirming the necessary qualifications were in place for the coaches and club before approving the application, but it has become apparent that there was some variation in some of the club facility requirements between regions (but not coaching qualifications). In November 2106, the Coach education system was also centralised. new Coach registering with England Boxing is input into The Vault database by staff based in Sheffield, who check and cross-reference the training, safeguarding, first-aid, and DBS certification to ensure validity. also introduced a new policy for dealing with concerns regarding any items on database. When the Coach renews membership, the England Boxing region in which they are based checks the updated certifications The new club and individual membership criteria are displayed on the England Boxing website to provide access to clear advice regarding membership, which is now consistent nationwide and unaffected by regional variances_ ACTIONS TO BE TAKEN Independent Inquiry: Immediately following this incident;, England Boxing identified a number of issues which required analysis and action_ As set out above, many of those were implemented to the Inquest. However; although the Court will note that post-incident meeting minutes the New the the They Any We any the prior

identified the need for an independent organisational inquiry, the decision was made to postpone that process until the Inquest had taken place That would ensure that there was no risk of interference with investigations being conducted by the Police in the course of the Coroners Inquest and would allow the independent inquiry's remit to be dictated or molded by the Inquest findings Following completion of the Inquest; England Boxing is now in the process of setting up an independent inquiry, the chair of which will be appointed by "Sports Resolutions" , body separate distinct to England Boxing The terms of reference are still being finalised, but the overarching aim will be to investigate the points raised in the Inquest; in particular the two points of concern which appear in the Regulation 28 Report: The inquiry will identify the respective responsibilities of the Regions and England Boxing centrally to oversee adherence to regulations and policies both at the time of this incident and subsequent to it will determine whether those responsibilities were and are met: Some of the regulations and policies which will be investigated relate to the process used in the registration of clubs to "The Vault", along with how that information is cross- referenced and checked regionally. The inquiry's findings will then inform what changes will be required to ensure that policies and procedures are not only in place, but actively adhered to by member clubs_ It is anticipated that the report will be completed by the end of 2021 with any learning notes or recommendations being implemented throughout 2022 would like to thank the Coroner on behalf of England Boxing for conducting thorough investigation into this important matter; which has allowed us to make wholesale improvements to our organisation of Olympic Boxing in England_ That will; in turn, ensure safety measures are implemented and observed throughout each Region; keeping boxers and those who attend bouts as safe as possible_ Signed: Full Name: Capacity: CEO, England Boxing Dated: 4 nla72o2/ and being

Rt Hon Oliver Dowden CBE MP Secretary of State for Digital, Culture , Media and Sport 4th Floor Department for 100 Parliament Street Digital, Culture London SWIA 2BQ Media & Sport WWW gOV ukldcng enqulres@dcms gok uk Dr Robert Hunter HM Senior Coroner Town Hall Rose Hill Chesterfield S40 1LP May 2021 0_ KX Mh am writing to you in response to the regulation 28 report dated 10 March 2021, following the inquest into the death of Edward Lewis Bilbey. am sorry to hear about the tragic circumstances of this case_ There will always be risks associated with participating in sport, but it is vital that robust measures are in place to reduce the risks of major or catastrophic injuries and that procedures are in place to protect athletes' health. Sports must put the safety of their participants first_ The government is wholly committed to doing all it can to ensure children and young people can participate in sport in safe and secure environments. My department is currently engaging across sports to address the issues of concussion and dementia have held a number of meetings with current and former athletes, as well as sport national governing bodies, to understand how government intervention could bring about positive change for athletes' safety My department works closely with Sport England and the NSPCC's Child Protection in Sport Unit to review and strengthen safeguarding provision wherever necessary. The Child Protection in Sport Unit (CPSU) is the lead body for advice and standards on safeguarding in sport in England. It works with sports to build capacity around safeguarding children and young people. All organisations in receipt of public funding from Sport England and UK Sport have been required to meet the standards set out in the Code for Sports Governance since April 2017 . The Code contains specific obligations around safeguarding,

including a requirement for national governing bodies to adhere to the Standards for Safeguarding and Protecting Children in Sport; which are issued by the CPSU. The CPSU undertakes an annual review of NGBs funded by Sport England to assess their safeguarding policies and procedures. The results of these reviews are used internally within sports to strengthen practice. Given these existing measures, we do not currently intend to bring forward any further sport-specific legislation. However; we will continue to work closely with our safeguarding partners to ensure that provision is reviewed and strengthened wherever necessary_ My department will work with Sport England and England Boxing to review and address the specific concerns raised in these reports. With regard to wider safeguarding concerns, the government welcomed the launch of the Whyte Review which is looking into allegations of mistreatment within the sport of gymnastics My department will follow the Whyte Review and its findings closely. w Rt Hon Oliver Dowden CBE MP Secretary of State for Digital, Culture, Media and Sport