Dear Ms Mutch RE: Richard John Whale Your ref: 8927/CLB On behalf of Manchester United Football Club Limited (the "Club"), write in response to your Regulation 28 Report (the "Report" dated 21 December 2018. note that the Report has also been sent to Trafford Metropolitan Borough Council ("TMBC") and the Department for Digital, Culture, Media & Sport ("DDCMS" ), each of whom understand will also be submitting their own response to the Report. Opening remarks Before turning to the specific matters raised in the Report; let me first reiterate that everyone at Manchester United is deeply saddened by the death of Mr Whale. The club continues to extend its sincere condolences to his family. The health, safety and security of all supporters ad visitors at Old Trafford is of utmost importance to Manchester United and we go to great lengths to ensure our procedures are audited, monitored and adhered to at all times. We work with independent safety inspectors from the local authority (TMBC) , national stadium safety inspectors (the Sports Ground Safety Authority, "SGSA") , and external safety auditors to ensure the correct procedures are administered_ We believe that the club operates its health, safety and security arrangements to an exceptionally high standard and in full compliance with the law; this is reflected in the consistently excellent feedback we have received from the regulators However; we are not complacent in this regard and we constantly seek to learn and to improve our procedures We therefore welcome the observations in the Report on opportunities for further risk reduction. Following the conclusion of the inquest into Mr Whale's death in November 2018,we have implemented the following additional steps in close consultation with TMBC and the SGSA: The match-day slips/trips/falls risk assessment has been further reviewed, updated and enhanced with input and advice from TMBC_ It has also been externally validated by an independent health and safety consultant: This now includes the potential risks arising from 'impediments caused by the presence of spectators, staff and stewards' The risk controls have also been expanded to include the briefings, training and guidance provided to stewards and the 'real time' monitoring and auditing that is taking place as described further MANCHESTER UNITED FOOTBALL CLUB LIMITED Sir Matt Busby Way, Old Trafford;, Manchester M16 ORA Telephane: 0161 868 8000.Facsimile: 0161 868 8804 . WWW manutd com Rcglstercd In England No 95489 VAT No C8 561 0952 51 being

Acha UnITEO below. In addition, the risk assessment also includes reference to steward vigilance, customer engagement and steward positioning on vomitories. Briefings are continually ongoing to all stewards, which cover their duties, roles and responsibilities This information is also included in match briefing notes. Within these briefings, we have increased the focus on the importance of the provisions of the Stewards Code of Conduct: The briefings place particular emphasis on (i) stewards' awareness of their surroundings and prevailing situation, (ii) customer engagement; (iii) ensuring that vomitories remain unimpeded at all times, and (iv) ensuring availability of handrails for supporters at all times. In addition, specific steward positioning guidance has been delivered to all stewards who are responsible for vomitory areas which: provides guidance to ensure that steward positioning allows supporters to use the handrails and to ensure that the stewards facilitate their use; emphasises the need for stewards to be continually alert to people coming to use the vomitory and to move accordingly to allow space to pass; and further emphasises to all stewards that their focus must not be distracted by events taking place on the pitch during the match, in order that they maintain their position and awareness of their surroundings as to carry out their regulated duties. Regular proactive checks have been put in place to ensure that no more than two stewards are present in the vomitory space (save for exceptional circumstances where an additional stewarding presence is required): In periods of footfall; one steward will near the head of the vomitory whilst the other will move down inside so as to maximise accessibility of the handrails: As part of this new monitoring and audit process we have introduced new quality assurance compliance check sheets. Head Stewards Deputies members of our Safety & Security Team conduct audit checks across the stadium, which involves questions to stewards about their knowledge and understanding of their specific duties, codes of conduct and vomitory protocols This also includes quality assurance of supervisors' briefings. Outcomes are recorded on the compliance check sheets, and advice and training is given as required (information on these topics is also contained in Stewards Handbook which is issued to all stewards): The completed sheets are collated and evaluated by senior safety staff and filed post match All of the above was in place prior to the Boxing fixture, and is in addition to our already rigorous and extensive spectator safety measures. As noted above, we continue to strive to improve our spectator safety measures. We are therefore keeping all of the above under continuous review in close consultation with TMBC and SGSA Response to the specifics of the Report The Report (at section 5) lists four specific matters of concern respond to each of these a5 follows: day heawy stay every fully Day We

icx UNITEO
1. The Local Authority had issued a list of recommendations to the club after the death of Mr Whale: There was no mechanism in place for discussion of those recommendations or to ensure that they had been followed or if not followed discussion for reosons. As noted in paragraph 21.3 of our legal counsel'$ closing submissions to the inquest; the letter sent by TMBC to the Club did not ask for a written response, nor was any response subsequently requested by TMBC (with whom we met regularly following receipt of the letter) The Club carefully considered the contents of the letter and carried out such actions as were necessary, whilst continuing to regularly consult and confer with TMBC (including verbal discussions of those recommendations). However, on reflection and having conferred further with TMBC following conclusion of the inquest; we accept that it would have been preferable if there had been a more formal mechanism put in place for discussion of those recommendations and their implementation: In future, should we receive written advice TMBC we will ensure that this is formally responded to in writing: We also understand from TMBC that any future correspondence from them which calls for a reply from the Club will be appropriately time-lined to ensure an auditable response trail (an approach with which we agree)
2. The widths of the staircases ("vomiteries" [sic]) is set in the Green Guide: Those widths take into account the handrails but not the inevitable reduction in width that takes place when stewards are deployed into them. In effect; the vomiteries are significantly narrower at points than the suggested widths. The content of the Green Guide is a matter for the SGSA, whom we anticipate will be working closely with the DDCMS to provide a substantive response to this concern: As noted and accepted during the inquest, the vomitory in question fully complies with the requirements of the Green Guide as applicable at the time of construction.
3. The green guide does not give guidance as to placement of stewards or suggest best practice to avoid stewards blocking access to the handrails It was accepted during the course of the inquest that the role and placement of stewards was vital to ensuring the sofety of the public at football matches: Again, the content of the Green Guide is a matter for the SGSA The positioning of the stewarding at Old Trafford stadium is something that SGSA and TMBC have had (and continue to have) many opportunities to observe and advise upon. Neither organisation has ever indicated to the Club that the positioning of the stewards within the vomitories (which is standard practice across most if not all major football stadia) is a cause for concern: Indeed, understand that at the inquest the evidence from TMBC was that in their opinion stewards need to be located in the position in question for safety reasons; this concurs with our own view and with long-standing practice: However; in view of concern raised in the Report we have carefully reviewed the position: We remain satisfied that the positioning of stewards is appropriate, and as noted above we have issued detailed positioning guidance to all stewards deployed in vomitories in light of the findings at the inquest which explicitly codifies existing good practice:
4. It wos accepted by MUFC that the club stewards were not complying the code of conduct relating to stewards although one was trained and one was undergoing training: A supervisor was from the very with

AchERa UNITED also supervising them: There was no evidence of regular audits of stewards and their compliance with the Code of Conduct: The Club is naturally disappointed that the two stewards in question exhibited lapses in behaviour which were not in compliance with the Code of Conduct: As noted at paragraph 24 of our legal counsel's closing submissions to the inquest (and confirmed by Mr Phil Rainford in his evidence) , the Club's stewarding arrangements are very regularly audited from a health, safety and security perspective. In the 12 month period immediately prior to the inquest; the Club was inspected or audited from a health, safety and security perspective by TMBC on at least five occasions, SGSA on at least four occasions, the Safety Advisory Group on one occasion and external independent safety and security auditors on one occasion (which included viewing two matches): None of these regulators, inspectors or auditors advised the Club of any issue relevant to the inquest relating to stewarding arrangements, including the positioning of stewarding in the vomitories. Nevertheless, we have fully taken on board the concern which has been raised here: Accordingly, as mentioned above in my opening remarks, we have into place an additional match-by-match system of proactively checking both stewards' positioning within vomitories and checking compliance by stewards with the Code of Conduct (including live auditing of both issues throughout each match): trust that the above response addresses the issues raised in the Report Should you have queries regarding the above, please do not hesitate to contact me_

Dear Ms Mutch,

Thank you for your letter of 21 December 2018, enclosing your Regulation 28 Report on the death of Mr Richard Whale on 11 December 2017 following an incident at Old Trafford, the home ground of Manchester United FC (MUFC).

The Sports Grounds Safety Authority (SGSA) is the UK Government’s expert body on sports ground safety. It has a statutory responsibility to regulate local authorities in their oversight of safety at all football grounds in the Premier League and the English Football League, as well as at Wembley and the Principality Stadium. It also issues licences to these stadia to enable them to admit spectators.

The SGSA is aware of the incident leading to the death of Mr Richard Whale in December 2017. Since the incident took place, the relevant SGSA Inspector has been liaising closely with both Trafford Metropolitan Borough Council (MBC) and MUFC, most recently in November 2018. This liaison has focused on ensuring that lessons are learned from the incident and are being applied by the club and the local authority, particularly in relation to the ongoing provision of suitably qualified and trained stewards at Old Trafford. There has been monitoring of stewards’ behaviour in and around vomitories, especially during ingress and egress.

Based on the assurances received from both MUFC and Trafford MBC, the SGSA is satisfied that both organisations have identified the relevant spectator safety issues arising from the incident, and that each has taken appropriate steps to address these issues. The SGSA will continue to monitor and take action as necessary, as part of its ongoing regulatory remit.

I note your report references the SGSA’s Guide to Safety at Sports Grounds (the “Green Guide”). I agree with your finding that it does not include explicit “guidance as to the placement of stewards or suggest best practice to avoid stewards blocking access to the handrails”. The 5th edition of the Green Guide, the current edition at the time of the incident, did include guidance on handrails and stairways at 8.81, 8.92, 9.9a3 and 9.9e4, with paragraph 9.9e emphasising that

1 Guidance  at
 8.8  states,  “Handrails  for  stairways  and  ramps:  As  stated  in  Section
 8.6,  a  handrail  is  provided  for  people  to  grasp,

for  guidance  or  support.  If  the  handrails  are  to  serve  only  as  handrails  for  stairways  or  ramps
 –  that  is  they  are  not  barriers  as

described  in  Section
 8.7b
 -­‐  the  design  should  meet  the  following  requirements:  [including]
 a.  Handrails  of  the  same  height  should

be  provided  on  both  sides  of  stairways,  landings  and  ramps…” 2 Guidance  at
 8.9  states,  “In  order  to  ensure  free  flow  of  people,  and  avoid  crowd  pressures  building  up,  the  head  of  each

stairway  should  be  designed  so  that  flow  onto  the  stairway  is  uniform  across  its  width.” 3 Guidance  at
 9.9a  states,  “If  passage  through  the  vomitory  is  by  steps,  the  design,  dimensions,  barriers  and  handrails  should

meet  the  requirements  for  stairways  (see  Chapter
 8).”

Department for Digital, Culture, Media & Sport

during ingress and egress stewards should position themselves to ensure the unimpeded passage of spectators who wish to leave. However, the 5th edition was not explicit about spectator access to handrails on egress.

The SGSA has since published the latest 6th edition of the Green Guide in October 2018. This latest edition expands upon the guidance in the 5th edition and includes specific guidance on vomitories and the positioning of stewards (section 9.8), vomitory widths (section 9.9) and vomitory control measures (section 9.10). It recognises that the width of a vomitory, and of gangways leading to a vomitory, are key control measures (section 9.9). Furthermore, Chapter 4 highlights that safety at sports grounds relies to a great extent upon the deployment of an appropriate number of well trained and suitably equipped stewards, with section 4.6 outlining stewards’ duties and section 4.10 detailing current stewards training and assessment processes. The new edition of the Green Guide has informed the SGSA’s engagement with Trafford MBC and MUFC.

In light of the concerns you have raised the SGSA is amending the Green Guide so that section
9.8e makes a specific reference to access to handrails in the context of vomitories and the positioning of stewards. The relevant extract is below, with the proposed new wording shown in italics:

“Management should ensure that no spectators or non-essential staff are allowed to stand in vomitories during an event.

Similarly, during ingress and egress, stewards should position themselves to ensure the unimpeded passage of spectators. Stewards should not prevent spectators being able to access any handrails present. This is essential towards the end of an event (or a significant part of an event) in order to prevent overcrowding, to avoid impeding those spectators who wish to leave, and to ensure spectator safety.”

I hope this reassures you that suitable guidance is in place for sports grounds and that necessary remedial action, overseen by the SGSA, is being taken by Trafford MBC and MUFC to avoid a repetition of the incident which resulted in the tragic death of Mr Whale.

Dear Ms Mutch,

Re: Richard John WHALE Thank you for your letter dated 21st December 2019 which contained a Regulation 28 Report to Prevent Future Deaths. Trafford Council are aware that the jury conclusion into the death of Richard John Whale was one of accidental death, with contributed factors relating to impedance and lack of awareness of the stewards, obstruction of access to both handrails by stewards, and lack of awareness by the stewards of their surroundings. In terms of the matters of concern relevant to the Local Authority (Trafford Council) Point 5 (1) namely (italics): The Local Authority had issued a list of recommendations to the club after the death of Mr Whale. There was no mechanism in place for discussion of those recommendations or to ensure that they had been followed or if not followed discussions for reasons. the Council’s response is as follows: The Council has a dual regulatory role in relation to sports grounds safety. Firstly, under The Safety at Sports Ground Act 1975, the Council is responsible for issuing the General Safety Certificate and enforcement of the conditions. In issuing a General Safety Certificate, the Council has to be satisfied that appropriate policies and procedures are in place to ensure the reasonable safety of all people who attend a sports ground. Secondly, the Council is the relevant enforcing authority in relation to the Health and Safety at Work etc. Act 1974, including the investigation of accidents that are reported to the local authority under the Reporting of Injury, Disease and Dangerous Occurrences Regulations 2013. It was within this remit that the Council undertook an investigation into the accident to Richard John Whale. The investigation found that the Club had satisfactory arrangements in place at the time of the accident in relation to maintaining the safety of spectators at the ground, and that there was no evidence available which would warrant any formal action under the Health and Safety at Work etc Act 1974. Following the outcome of the investigation, a letter was sent to the Club outlining three recommendations. This was an informal letter highlighting good practice recommendations to Alison Mutch OBE HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG

Corporate Director, Place Trafford Council Trafford Town Hall, Talbot Road Stretford, Manchester, M32 OTH Email

Telephone 0161 912 4265

Your Ref: 8927/CLB

Date 8 February 2019

the Club, and it did not stipulate any legal contraventions which the Club should action or that any action should be taken within a specified timescale. The responsibility, therefore, was with the Club as to whether or not the recommendations were implemented. However, it is anticipated that these recommendations would have been picked up and highlighted through a number of existing mechanisms which allow for discussions to take place between the Council, the Club and other interested parties. This is primarily done through meetings of the Safety Advisory Group, where issues relating to sports grounds safety are discussed. The Council also have regular engagement with the Club where necessary, such as in response to any match-day incidents, and undertake proactive match-day monitoring audits where issues relating to safety are discussed. Following the conclusion of the inquest, Council Officers and the regional Sports Ground Safety Authority Inspector have met with the Club to discuss the concerns raised during the inquest. During these discussions, the Club explained the actions they have taken to address the recommendations highlighted in the letter from the Council, and they have also explained that they are undertaking additional awareness training for stewards and monitoring of stewards' behaviour whilst carrying out their duties at the stadium. Council officers undertaking future match-day audits at the Club will include observations of the monitoring of stewarding behaviour by the Club. In addition, the Council have now requested that the Club responds to any future recommendations or requests within a specified time frame with a review of all actions where it is considered necessary. This positive approach has been welcomed by the Club and has been implemented with immediate effect. Further, as part of our commitment to safety at sports ground duties, the Council is currently reviewing its policies and procedures and will include an appraisal of the Coroner’s concerns as part of this review.