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Crowd related medical incidents

Introduction

This guidance has been developed to address some of the issues arising from responses to recent high-profile crowd related medical incidents. It has been published as part of a joint effort between the footballing bodies, including the FA, Premier League, EFL and the Sports Grounds Safety Authority (SGSA), and event medical specialists, in particular the National Events Medicine Advisory Group (NEMAG).

This guidance is intended to assist Safety Officers to prepare for these types of incidents and help them to clarify with event day partners the roles and responsibilities of various medical staff present at events. It reiterates the contents of a briefing note produced by NEMAG in March 2022 regarding this issue, which was supported by the footballing bodies.

In particular, the guidance seeks to assist with two recent trends:

  1. Incidents within the stadium bowl where the crowd, and subsequently players, alert match officials to a crowd related medical incident that they believe requires an urgent response. This has, on occasions, resulted in play being suspended whilst the incident is dealt with.
  2. Incidents whereby the match officials or spectators call directly upon the team/club medical staff, located in the dug-out areas, to deploy into the crowd and deal with an ongoing medical incident.

The guidance highlights some of the advice and best practice that may allow all those delivering the event to ensure the most appropriate and safest incident response, whilst at the same time avoiding unnecessary disruption to the event and to those spectating. It does not seek to direct Safety Officers on the decisions that should be made in such circumstances. Instead, it offers indicative questions for the Safety Officer to consider. At the same time, the guidance recognises that there will always be occasions when the team/club medical staff’s immediacy to an incident necessitates a “Good Samaritan” intervention, and this should remain a viable option.

Complementary guidance for club senior management teams, medical staff, spectators, match officials, broadcasters, teams and coaches is being prepared by the Football Authorities in conjunction with their medical advisors.

Each of the footballing bodies are sharing the key messages contained within the NEMAG briefing note to their respective stakeholders, including clubs, match officials and supporters, to ensure consistent messaging. As part of this joint communications plan the SGSA has agreed to develop this particular guidance note for Safety Officers and to continue briefing Safety Advisory Groups and match safety teams on similar or emerging issues.

Basic principles of medical arrangements at a regulated football match

There are two distinct matchday medical teams:

1. Crowd safety medical team. This team is dedicated to the care and treatment of ill and injured spectators. They work directly with the venue’s Safety Officer. The team typically consists of Crowd Doctors, Paramedics, Nurses and First Responders. These groups are trained and experienced in pre-hospital care and are equipped to deal with life-threatening emergencies.

2. Team/club medical team. This separate medical team is dedicated to the care and treatment of players and officials: for each first team fixture, as a minimum there will be a doctor and paramedic with each club’s physiotherapist usually in attendance. During a match they are responsible for managing illness and injury in the field of play i.e., for players, coaching staff and match officials.

Advice and guidance for Safety Officers

This following set of indicative questions is intended for use by stadium safety teams. The questions reflect the outcomes of recent discussions between the Premier League, FA, EFL, SGSA and event medical specialists. They are also informed by areas of good practice witnessed recently at some football stadiums. It is intended that the answers will help to inform and update local Medical Plans, contingency plans, briefings and wider stakeholder communications.

Pre-match information sharing

Has awareness of the two distinct matchday medical teams been raised sufficiently, including their roles, responsibilities and capabilities?

On a matchday, does the Safety Officer or their representative brief the match officials on the need to ensure the following?

  1. Officials are aware of the scale and capabilities of the crowd safety medical team and how they will be deployed and respond to incidents.
  2. Officials are aware of the benefits of swift and accurate communications via the Fourth Official for all off pitch incidents including spectator related medical issues.
  3. The crowd safety medical team, Tunnel Manager/Steward and the Fourth Official are introduced in person and made aware of the support they can offer one another during an incident.
  4. Referees are able to reassure both Club Captains that appropriate crowd related medical resources and responses are in place to deal with spectator emergencies.

Does the Safety Officer send any of the above information to the match officials in their pre-match briefing sheet?

Does the crowd medical lead attend the crowd safety medical team briefing so all agencies are aware of the breadth of skills, resources, joint capabilities and the communications links to be used in an emergency?

Does the Safety Officer brief the team/club medical team on the appropriate response to medical emergencies in the crowd and the issues that may occur if not followed? For example, a sudden and unplanned suspension of play may have negative implications, such as:

a. Stairwells, vomitories and concourses have the potential to become busier than expected.

b. Catering outlets and bars may be unprepared for unexpected demand or even closed.

c. Additional consideration may be required for wheelchair users and their movements at such times, who may look to access facilities during normally quiet times.

d. Access to a second/simultaneous emergency may be hindered by unusual crowd flows.

e. A prolonged suspension may have significant implications for crowds and staff leaving the stadium and looking for public transport, taxis, etc. This is particularly problematic for evening kick offs.

Do the two Team/Club Doctors and the Crowd Doctor meet before the match and clarify/reinforce their separate roles and responsibilities and response protocols?

Has consideration been given to ensuring that first aiders are deployed in highly visible locations within the spectator viewing areas so they can:

a. Reassure the crowd that there is a first aid presence in the stadium?

b. Be seen to respond quickly to any spectator related medical incidents within the stadium bowl?

Medical support reporting

Are all those at the match aware of the best way to take the FIRST STEP in securing the most appropriate medical support to a crowd related incident?

For example:

Spectators Inform the nearest steward, other staff member, crowd-based medic or police officer. For larger stadiums, is there a facility to report quickly and accurately via the Club’s text service?

Players: Inform the referee.

Referee:  Inform the Fourth Official.

Fourth Official: Inform the Club’s Tunnel Manager/Steward.

Coaching staff/Team Doctor: Inform the Fourth Official or Club’s Tunnel Manager/Steward.

Tunnel Manager/Steward: Inform the Control Room via radio or phone.

Are there sufficient communication links to ensure quick and accurate reporting?

Does the Crowd Doctor have a radio that links to the Control Room and the crowd safety medical teams?

Does the Tunnel Manager/Steward have a radio and access to a nearby phone that links to the Control Room?

Has consideration been given to locating the Crowd Doctor or crowd paramedics close to the dug outs to negate the need for the Team Doctor to leave their post if alerted to concerns in the crowd by spectators, players, coaches or match officials?

Is there a policy to ensure that when a suspected medical incident occurs the Stand Manager or Steward Supervisor (with a radio) attends the incident in person as soon as possible to ensure an appropriate stewarding and medical response is activated and the Control Room is updated?

Medical incidents during play

What are the safety management team expectations if match officials are CONSIDERING a suspension in play?

Is the expectation that:

The Referee should communicate with the Fourth Official the location and specific concerns.

The Fourth Official then liaises with Tunnel Manager/Steward who immediately informs the Control Room and seeks advice/situation report from the Safety Officer.

The Fourth Official should be advised that a dedicated crowd safety medical team will be deployed.

All information should be communicated back to the Referee from the Fourth Official so he/she is aware and can update the Club Captains as appropriate.

If there continues to be obvious signs of concern within the crowd, consideration be given to relaying reassuring messages to spectators via the public announcement system (or in person to those local to the incident) regarding the appropriate deployment of medical resources.

What are the safety management team’s expectations if, WITHOUT NOTICE, the match officials have decided to unilaterally suspend play (which may well be the correct decision)?

Is the expectation that:

The Referee should communicate with the Fourth Official the reason for suspending play and provide information on location and specific concerns of the incident.

The Fourth Official will then liaise with Tunnel Manager/Steward who immediately informs the Control Room and seeks advice/situation report from the Safety Officer.

The Fourth Official will be informed that the Control Room will deploy resources from the crowd safety medical team, seek to determine the severity of the incident and remain in constant contact with the Fourth Official via the Tunnel Manager/Steward.

If the Safety Officer considers there is no legitimate reason to delay the match further, they should ensure Fourth Official is informed of what the response has been, what the next steps are and why a delay is, in their professional opinion, no longer required.

Once reassured, match officials will then communicate that update to Club Captains and review the practicalities of restarting the match.

What actions might be required following agreement between the Safety Officer and the match officials to suspend the match for a crowd related medical treatment?

Is there an agreed process to ensure the Safety Officer and Fourth Official can remain in constant dialogue in relation to the length of delay and potential need for players to return to dressing rooms?

Does the ground have a robust process for keeping broadcast media up to date with any developments so they can ensure supportive messaging, noting that the privacy of patients will need to be protected?

Has the safety team developed pre-prepared public announcements that provide sufficiently detailed updates whilst at the same time not alarming the crowd or unnecessarily undermining the privacy of the patient?

Are there good communication links to the whole safety team to ensure they are kept informed of delays, any messages to give to the public and the need to remain on posts?

Have key staff been made aware that if play is suspended unexpectedly then mobile phones or the 4G network may be lost due to exceptional demand, as spectators reconnect with networks to seek information or contact others outside the ground?

What steps and considerations could take place before restarting a match that was unexpectedly suspended for a long period of time? Who should be involved in the decision making?

Does the safety team have a clear understanding of when the Referee might seek to remove the players from the pitch if there is an unexpected suspension to play?

Does the safety team understand how long player warm ups will take before a match recommences?

Is the safety team confident that matchday stakeholders understand a lengthy delay could ultimately lead to a potential match abandonment? This might occur if the match cannot be restarted in time to ensure the safety of spectators who, at the end of the match, may experience a challenging/rushed egress due to potential Zone Ex and transport issues.

Has the club/venue developed a protocol that ensures that match officials, safety team, emergency service partners and the competition owner’s representative (EFL, FA, Premier League) are all involved in decisions arising from unforeseen and extensive delays?

Other considerations

Has the club/venue considered how to respond from a welfare perspective if it became public knowledge that someone (staff or public) has died at the ground on matchday? Does the plan include roles and responsibilities regarding patient privacy and dignity, informing next of kin, supporting friends/family still at the ground, future family liaison, social media monitoring/fake news responses etc?

Does the club/venue’s Medical Plan or protocol include handover procedures for occasions where the team/club medical team became actively involved in providing care to a spectator before the crowd safety medical team had arrived?

Does the Medical Plan recognise that it is possible for medical professionals to spend significant time (40 minutes and over) stabilising a patient in the stands before any extraction and onward transfer? Is there an ability to deploy privacy screens to the location rather than relying on ad hoc arrangements? Does the Safety Officer have a feedback process with the competition owner for those rare occasions when the safety team and the match officials disagree on the need for a joined-up approach for medical related match suspensions?

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