Dominic Chapman
PFD Report
All Responded
Ref: 2024-0309
All 3 responses received
· Deadline: 1 Aug 2024
Coroner's Concerns (AI summary)
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at charity white-collar boxing events.
View full coroner's concerns
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, ( director and sole proprietor of Ultra Events Ltd. ) 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; and (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) In his evidence to the inquest, ( sole director of Ultra 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, , told the inquest: “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.”
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.
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) In his evidence to the inquest, ( sole director of Ultra 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, , told the inquest: “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.”
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.
Responses
Action Planned
This document (Exhibit JL1) is a training workbook for Ultra Events boxing coaches, including sections on responsibilities, weight matching, learning expectations, and a scoring method. (AI summary)
This document (Exhibit JL1) is a training workbook for Ultra Events boxing coaches, including sections on responsibilities, weight matching, learning expectations, and a scoring method. (AI summary)
View full response
30/07/2024, 14:16 servlets getlmg (1500*8876) PROTECTED: TRAINING WORKBOOK Gym Namo Gym Address ' Lino Lino 2 Post Coda City Unitod Kingdom Country Gym Email Coachos Name(s) Coachos Email Coachas' rosponsibilities: Iconfirm that I will follow tho training guidolinos within this document !understand that participants must complcte an absoluto baro minimum of 50% of all training sossions to bo ablo to takc part in tho ovent and thoy should bo actively oncouraged to comploto all sossions For tho avoidanco of doubt this minimum Is 8 out of 10 sossions sproad across tho 8 wooka Iagrco t0 uso tho rocommondod mothod and will koop rocords of matchos including final matching scoros ahead of tho ovont thoso scoros will bo given to tho arca rop who will rocord thom on tho ovont fight ordor. Roplsub-rep responsibilitios Iconfirm that all PARQs will be checkod and roviowed and that participants will bo allowod to start training until thcir PARQ is complotod and chockod and all participants must comploto an absoluto bare minimum of 50X of all training sossions to bo ablo to take part in tho ovont Whoro participant has disclosod prior oxporionco confirm that this has becn discussod with tho coach/coachos and tho gym and agrooment has boon givon for tho participant to tako part Participants bo woighod on wcok !, wook 4 andat tho match up night thoso figuros will bo accuratoly rocorded on tho register and (ight ordor Training Session Plenning Tho pooplo that take part in UWCB events arc boginners total boginnors that havo nover thrown . punchin most cascs will allhavo wido varioty of fitnoss lovols All UWCB coachos will havo a minimum of yoars' oxperionce in combat sports and will bc introducod via porsonal rocommondation Whon sparring starts boxors should always spar similar woights Loarning oxpoctations for tho 8 wook training programmo At tho ond of tho 8 wcoks training programmo. all participants should bo ablo to; Havo high onough fitnoss lovol for 3 X [5 minuto rounds Undorstand how to movo thoir foot corroctly footwork is koy: Understand how to block andlor pary 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: https:Ilcoronersworcestershire icasework com/servletlservlets appPopup?auth-40&db-R4wf8TOlcUorXBqIDFXQrNNVLsb4Koye&st-CASES&r. 1/5 acoring ' (not ! Ml They'
30/07/2024, 14:16 servlets getlmg (1500*8876) End with a 20-minute-high intensity fitness session (suggestions are below) 20 MIN HIIT At the 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 will learn: Tell them what to do in their spare time (this can be practice technique,attend classes, come to HOMEWORK TASK 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 minute burpee minute press up SESSION minute sit Up 30 second rest Repeat 6 times (21 minutes) 30 second squat thrust 30 second press Up 30 second sit Up SESSION 2 30 second twist sit up Rest 30 second Repeat 8 times (20 minutes) 40 seconds burpees SESSION 3 20 seconds sit ups Repeat 20 times with no rest Homework tasks Recovery runs 30 minute jog Attend extra sessions at gym (fitness, sparring etc) Practice lines 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 ajab 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 Dronroce from Wool https:Ilcoronersworcestershire icasework comlservletlservlets. LappPopup?auth-4OO&db-R4wf8TOlcUorXBqIDFxQrNNVLsb4Koye&st-CASES&r 2/5 end they
30/07/2024, 14:16 servlets getlmg (1500*8876) WEEK 3 In lines facing each other practice jab & 1-2 punching to gloves Introduce movement left & right Progress from week 3 Show how to parry & block WEEK 4 Gradually introducing more intensity Here they are learning to block or parry or slip shots they know are coming; so jabs or 1-2s Progress from week Still in straight lines but now they don"t know what shots are coming (must be straight) WEEK 5 Practise countering (reply within 3 seconds with any 3 punch combo for example) Here have effectively started sparring (Headguards MUST be worn) Body Sparring This should be light & technical WEEK 6 Participants don"t have conditioned torsos so will easily hurt ribs so this must be built up intensity wise_ (Headguards MUST be worn) Progress from week 6 Lead hand to head, anything to body sparring WEEK 7 Progress t0 open sparring (Headguards MUST be worn) Session 1 open sparring Session 2 run through what they have learnt and get them mentally ready for what they are about to do. WEEK 8 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 to our events. Imagine if your child was boxing; would you be 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; Matching Following this assessment; these processes must be used by all UWCB gyms/trainers when matching bouts: Fighters ideally matched within 3 kilos: kilos is the target maximum weight difference; however: It is important to remember this is a guide and in white collar boxing there can regularly be bigger weight differences than 7kg and the https Ilcoronersworcestershire icasework comlservletlservlets appPopup?auth-4o&db-R4wf8TQlcUorXBq1DFxQrNNVLsb4Koye&st-CASES&r. 3/5 they ' key happy
30/07/2024, 14.16 servlets-getlmg (1500*8876) bout still be fair. If matches fall outside a 7kg weight difference must be referred to HQ for approval and explained on the fight order: Its better to have a fair match with 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: 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 ad 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 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 good Close to amateur standard 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. 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 a ability discrepancy (this happen if the boxer 'freezes' as its their first bout and the stand-in is more comfortable ) We should let the participant know there will be a stand in as soon as possible. Declaration that will follow tho training and matching procoss throughout thc training period confirm that all participants taking part in thc final avent will completo lagreo tho minimum 507 of training scssions Whero prior oxperioncc is disclosod this has boon takon into account and participants worc matched fairly in with tho rccommondcd scoring method and woight considerations Iconfirm will kocp records of matches and that final participant scores will bc given to tho arca rop ahead of the ovent to bc included on thc fight order alongsido wcights: AIl PARQs wore rocoivod and roviowcd prior to cach participant starting thoir training Coach/Trainor Namo Signature Clcar Date 10/08/2024 https Ilcoronersworcestershire icasework com/servletlservlets.appPopup?auth-40O&db-R4w8TOlcUorXBqIDFxQrNNVLsb4Koye&st-CASES&r: 4/5 they The Very ' could Iino final
30/07/2024, 14.16 servlets getlmg (1500*8876) SUBMII PREVIOUS https Ilcoronersworcestershire icasework com/servletlservlets appPopup?auth-40&db-Rwf8TOlcUorXBq1DFxQrNNVLsb4Koye&st-CASES&r. 5/5
30/07/2024, 14:16 servlets getlmg (1500*8876) End with a 20-minute-high intensity fitness session (suggestions are below) 20 MIN HIIT At the 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 will learn: Tell them what to do in their spare time (this can be practice technique,attend classes, come to HOMEWORK TASK 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 minute burpee minute press up SESSION minute sit Up 30 second rest Repeat 6 times (21 minutes) 30 second squat thrust 30 second press Up 30 second sit Up SESSION 2 30 second twist sit up Rest 30 second Repeat 8 times (20 minutes) 40 seconds burpees SESSION 3 20 seconds sit ups Repeat 20 times with no rest Homework tasks Recovery runs 30 minute jog Attend extra sessions at gym (fitness, sparring etc) Practice lines 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 ajab 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 Dronroce from Wool https:Ilcoronersworcestershire icasework comlservletlservlets. LappPopup?auth-4OO&db-R4wf8TOlcUorXBqIDFxQrNNVLsb4Koye&st-CASES&r 2/5 end they
30/07/2024, 14:16 servlets getlmg (1500*8876) WEEK 3 In lines facing each other practice jab & 1-2 punching to gloves Introduce movement left & right Progress from week 3 Show how to parry & block WEEK 4 Gradually introducing more intensity Here they are learning to block or parry or slip shots they know are coming; so jabs or 1-2s Progress from week Still in straight lines but now they don"t know what shots are coming (must be straight) WEEK 5 Practise countering (reply within 3 seconds with any 3 punch combo for example) Here have effectively started sparring (Headguards MUST be worn) Body Sparring This should be light & technical WEEK 6 Participants don"t have conditioned torsos so will easily hurt ribs so this must be built up intensity wise_ (Headguards MUST be worn) Progress from week 6 Lead hand to head, anything to body sparring WEEK 7 Progress t0 open sparring (Headguards MUST be worn) Session 1 open sparring Session 2 run through what they have learnt and get them mentally ready for what they are about to do. WEEK 8 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 to our events. Imagine if your child was boxing; would you be 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; Matching Following this assessment; these processes must be used by all UWCB gyms/trainers when matching bouts: Fighters ideally matched within 3 kilos: kilos is the target maximum weight difference; however: It is important to remember this is a guide and in white collar boxing there can regularly be bigger weight differences than 7kg and the https Ilcoronersworcestershire icasework comlservletlservlets appPopup?auth-4o&db-R4wf8TQlcUorXBq1DFxQrNNVLsb4Koye&st-CASES&r. 3/5 they ' key happy
30/07/2024, 14.16 servlets-getlmg (1500*8876) bout still be fair. If matches fall outside a 7kg weight difference must be referred to HQ for approval and explained on the fight order: Its better to have a fair match with 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: 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 ad 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 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 good Close to amateur standard 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. 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 a ability discrepancy (this happen if the boxer 'freezes' as its their first bout and the stand-in is more comfortable ) We should let the participant know there will be a stand in as soon as possible. Declaration that will follow tho training and matching procoss throughout thc training period confirm that all participants taking part in thc final avent will completo lagreo tho minimum 507 of training scssions Whero prior oxperioncc is disclosod this has boon takon into account and participants worc matched fairly in with tho rccommondcd scoring method and woight considerations Iconfirm will kocp records of matches and that final participant scores will bc given to tho arca rop ahead of the ovent to bc included on thc fight order alongsido wcights: AIl PARQs wore rocoivod and roviowcd prior to cach participant starting thoir training Coach/Trainor Namo Signature Clcar Date 10/08/2024 https Ilcoronersworcestershire icasework com/servletlservlets.appPopup?auth-40O&db-R4w8TOlcUorXBqIDFxQrNNVLsb4Koye&st-CASES&r: 4/5 they The Very ' could Iino final
30/07/2024, 14.16 servlets getlmg (1500*8876) SUBMII PREVIOUS https Ilcoronersworcestershire icasework com/servletlservlets appPopup?auth-40&db-Rwf8TOlcUorXBq1DFxQrNNVLsb4Koye&st-CASES&r. 5/5
Action Planned
DCMS officials are preparing a targeted consultation of key stakeholders regarding possible amendments to the statutory guidance within the next six months to reduce the risks around white collar boxing. (AI summary)
DCMS officials are preparing a targeted consultation of key stakeholders regarding possible amendments to the statutory guidance within the next six months to reduce the risks around white collar boxing. (AI summary)
View full response
Dear Mr Reid,
Thank you for your correspondence of 7 June, to the former Secretary of State for Culture, Media and Sport, , enclosing a copy of the Reg. 28 Prevention of Future Deaths Report, following the inquest of Dominic Mark Chapman. I am responding as the Minister for Sport, Media, Civil Society and Youth.
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.
Thank you for your correspondence of 7 June, to the former Secretary of State for Culture, Media and Sport, , enclosing a copy of the Reg. 28 Prevention of Future Deaths Report, following the inquest of Dominic Mark Chapman. I am responding as the Minister for Sport, Media, Civil Society and Youth.
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.
Action Taken
Ultra Events now requires medical providers to supply an event-specific risk assessment and Medical Plan. They also reference other changes implemented since April 2022 such as shorter round durations, more stringent standing 8 counts, and clearer wording in event instructions. (AI summary)
Ultra Events now requires medical providers to supply an event-specific risk assessment and Medical Plan. They also reference other changes implemented since April 2022 such as shorter round durations, more stringent standing 8 counts, and clearer wording in event instructions. (AI summary)
View full response
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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 Training Workbook requiring signature from all coaches confirming that they will follow this planning, will be introduced and how will be disseminated and enforced so that are followed to the letter. Ultra Events Ltd. does not carry 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 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 proposed action or an explanation when no action is proposed they they out any
MATCHING CRITERIA Following this incident; we introduced 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 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 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 "JLI" The wording requires all weight discrepancies of more than 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 of the inquest 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 have signed and returned copies for us to retain on file. As such, all gyms have already signed their agreement t0 coach within the requirements of the workbook day 7kg 7kgs day they
9. Our Area Representatives attend training regularly to check that participants are progressing, to record weights, and to assist with matching: As such, can see first-hand whether the training is incorporating all the workbook requirements_
10. We also operate an exit survey in which all participants are asked t0 provide feedback on the event: Any training concerns are discussed with the coach/training provider to ensure standards are being maintained,
11. This level of hands-on attendance exceeds the systems used by England Boxing and the British Boxing Board of Control, neither of which have physical presence at training sessions conducted by member gyms. Risk Assessments
12. 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
13. 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 s0 we can formulate a new risk assessment and, if applicable, a plan; they
14. Medical providers are best placed to carry out risk assessments, as 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 .
15. However; we now ask our medical providers to supply us with their event- specific risk assessment and Medical Plan: email explains that 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 are capable of dealing with any medical event, emergency or otherwise, which may occur, 16 . If that requires them t0 conduct a site visit, analyse plans, or carry out any further enquiries, then they are required to do s0.
17. The risk assessment must then be sent to us to be logged with other event specific paperwork: General 18 . In the statement that filed with the Coroner on the final of the inquest, Iset 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
19. have not dealt with those in this statement as do not appear as a cause for concern in the Coroner's Regulation 28 report: they Our they they fully day they
20, Ican, howevar,confirm that thone chenpas will continue to be operated Ind telined in the fuar 21, Ihat Ihts statenent heips t78 Icamod Coroner In Lndertanding reievani chanpa8 mada since April 2022 Sualemont of Tnrh bolleva (Nat Inu Iucla slutad bn nls winess statamenl art Inje; undorsland Inai proceedings ior contempl ol coun may ba broughi agalnst unyone wha Iukes, or ceubes (0 be Made, 2 falen Italamani 6 0 docunent verifed by * elatement ol 6Urn wllhoul an ticnesl belel In Its buth, Signed: Full Name; Capacky; bILxc1ur Dalcd; 214124 hope
1, Interaeled Purt} 1 Utra Evonts L 1 Fin "JLT" 8
2107.24 IN THEWORCESTER CORONER $ cOuRT Inquest touchiO oN The death OF Mr doMiniC CKAPMAN Interested perBON: ULTRA EVENTS LIMITED DxhiDM "JLI" Tnis I> the exhibll "JLI" relerted la In the lnabe btatenient oll Sigred: Full Nenie" Capacity: MLLiie Daled; 24/15
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 Training Workbook requiring signature from all coaches confirming that they will follow this planning, will be introduced and how will be disseminated and enforced so that are followed to the letter. Ultra Events Ltd. does not carry 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 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 proposed action or an explanation when no action is proposed they they out any
MATCHING CRITERIA Following this incident; we introduced 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 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 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 "JLI" The wording requires all weight discrepancies of more than 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 of the inquest 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 have signed and returned copies for us to retain on file. As such, all gyms have already signed their agreement t0 coach within the requirements of the workbook day 7kg 7kgs day they
9. Our Area Representatives attend training regularly to check that participants are progressing, to record weights, and to assist with matching: As such, can see first-hand whether the training is incorporating all the workbook requirements_
10. We also operate an exit survey in which all participants are asked t0 provide feedback on the event: Any training concerns are discussed with the coach/training provider to ensure standards are being maintained,
11. This level of hands-on attendance exceeds the systems used by England Boxing and the British Boxing Board of Control, neither of which have physical presence at training sessions conducted by member gyms. Risk Assessments
12. 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
13. 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 s0 we can formulate a new risk assessment and, if applicable, a plan; they
14. Medical providers are best placed to carry out risk assessments, as 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 .
15. However; we now ask our medical providers to supply us with their event- specific risk assessment and Medical Plan: email explains that 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 are capable of dealing with any medical event, emergency or otherwise, which may occur, 16 . If that requires them t0 conduct a site visit, analyse plans, or carry out any further enquiries, then they are required to do s0.
17. The risk assessment must then be sent to us to be logged with other event specific paperwork: General 18 . In the statement that filed with the Coroner on the final of the inquest, Iset 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
19. have not dealt with those in this statement as do not appear as a cause for concern in the Coroner's Regulation 28 report: they Our they they fully day they
20, Ican, howevar,confirm that thone chenpas will continue to be operated Ind telined in the fuar 21, Ihat Ihts statenent heips t78 Icamod Coroner In Lndertanding reievani chanpa8 mada since April 2022 Sualemont of Tnrh bolleva (Nat Inu Iucla slutad bn nls winess statamenl art Inje; undorsland Inai proceedings ior contempl ol coun may ba broughi agalnst unyone wha Iukes, or ceubes (0 be Made, 2 falen Italamani 6 0 docunent verifed by * elatement ol 6Urn wllhoul an ticnesl belel In Its buth, Signed: Full Name; Capacky; bILxc1ur Dalcd; 214124 hope
1, Interaeled Purt} 1 Utra Evonts L 1 Fin "JLT" 8
2107.24 IN THEWORCESTER CORONER $ cOuRT Inquest touchiO oN The death OF Mr doMiniC CKAPMAN Interested perBON: ULTRA EVENTS LIMITED DxhiDM "JLI" Tnis I> the exhibll "JLI" relerted la In the lnabe btatenient oll Sigred: Full Nenie" Capacity: MLLiie Daled; 24/15
Sent To
- Department for Digital Culture, Media and Sport
Response Status
Linked responses
3 of 2
56-Day Deadline
1 Aug 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.”
The conclusion of the inquest was that Mr. Chapman “died as the result of an accident.”
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.”
“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.”
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.