1_ When Mr Gonzalez Barron lost consciousness; there was a delay before it was recognised that this was not part of the performance. He was 51 years old and undergoing very vigorous exertion, but there was nobody at the wrestling match tasked specifically with ensuring that he was well and that; for example, he had not lost consciousness_ The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it She did not appreciate that there would be non native English (mostly Spanish) speakers working the event, which might raise language barriers in an emergency: She did not know who the staff were, to identify them or where would be positioned; She did not know the procedure for summoning assistance. May how they

She did not know the protocol for ringing ambulance. She did not know who should do this or how she could ensure that it was done: She did not know that the ambulance should be directed to the rear of the building:
3. In the event;, the instructions given to the London Ambulance Service did not include the direction to drive round to the rear entrance and so valuable minutes were lost as the paramedics made their way from front to rear on foot outside the building: 4_ When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened: She had no understanding of the nature of the emergency: The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going: The first aider did not take the defibrillator with her when she first went to the she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue_ but she did not know where it was, she did not ask for it and nobody brought it.
5. When the first aider arrived at Mr Gonzalez Barron's side, she cut off his face mask: Though she was told immediately by someone she thought to be a doctor that Mr Gonzalez Barron was not breathing and had no pulse, she did not start cardiopulmonary resuscitation (CPR): She did hand over her pocket mask and oropharyngeal ainways, and she did go to retrieve emergency equipment from the first aid room 15-20 seconds away, but she could not remember in court if she fetched the defibrillator on her first or second return to the first aid room_
6. When Mr Gonzalez Barron collapsed, the scene was chaotic: No person took charge: There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance, for example in retrieving her equipment: She was distracted by the noise and comment of those around_
7. The chest compressions in progress when the London Ambulance Service (LAS) arrived were ineffective. 8_ The handover to LAS was confused, with mixed messages as to whether the automated external defibrillator had delivered a shock or not No_person took charge of a competent handover toLAS an ring; :

All of this resulted in the following: Cesar Gonzalez Barron could be seen to begin struggling at around 10.13pm, although this was not recognised at the time He collapsed unconscious at 10.15pm. It is unclear at what time his breathing and heartbeat were first checked and it is not known exactly when he suffered a cardiac arrest He was put in the recovery position at 10.17pm; This was two minutes after he lost consciousness Either he should have been placed in the recovery position as soon as he lost consciousness and had been properly assessed, or if he had already arrested CPR should have been started immediately: Nearly four minutes after he had stopped moving, at 10.19pm, the first aider got into the ring, though the first aid room was Only 15-20 seconds away: She was told that he had no breathing or heartbeat A minute later, at 10.2Opm, Mr Gonzalez Barron was turned onto his back and a 999 call was made to the London Ambulance Service. The call should have been made five minutes earlier;, when he lost consciousness_ Chest compressions were started two minutes after that; at 10.22pm. CPR should have been started as soon as Mr Gonzalez Barron arrested, which was at least two minutes earlier, possibly more_ The London Ambulance Service arrived at his side and confirmed the cardiac arrest at 10.3Opm: ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe that you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 December 2019. 1, 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 wby no action is_proposed