West Bromwich Albion fan, 57, who collapsed during Championship match at Hillsborough died of natural causes
The family of a football fan who died at Sheffield’s Hillsborough Stadium have said they were hoping for stronger recommendations after a coroner concluded he died from natural causes.
Mark Townsend, aged 57, died after he collapsed among fellow West Bromwich Albion supporters at the home of Sheffield Wednesday on September 28, 2024, a two-week long inquest has heard.
The inquest principally concerned health professionals’ decision not to ventilate Mark or cannulate him where he had collapsed on the stand but to move him first.
Today (October 10), Sheffield's senior coroner Tanyka Rawden said she accepted there had been confusion between the paramedics from the private medical team contracted by Sheffield Wednesday, who were the first to get to Mr Townsend, and those who arrived later from Yorkshire Ambulance Service.
But Mrs Rawden said she did not believe this "caused or contributed" to Mr Townsend's death.
Mr Townsend’s family has criticised the stadium as “not fit for purpose” in the event of an emergency, with his brother, Steve Townend, remarking: "I'd like nothing more than to see it in a pile of rubble, to be perfectly honest, and I think that should have been a finding."
No preventing future deaths report
The coroner said the decision not to ventilate Mr Townsend in the Leppings Lane stand, before he was moved to the concourse behind, "is likely to have contributed to, but not directly caused, Mark's death".
And she said the same about a decision not give Mr Townsend drugs through a cannula while he was in the stand, but she thought this was "reasonable" in the circumstances.
Mrs Rawden said in her conclusion: "Mark was not cannulated whilst on the stand.
"As a result, adrenaline and amiodarone were not given after the third (defibrilator) shock, in line with Resuscitation Council guidelines.
"Whilst this contributed to, but did not directly cause, Mark's death, it was reasonable to make the decision not to canulate given Mark's position, the only access point being the least efficient, and the risk of dislodgment on extraction."
She continued: "Mark was not ventilated whilst in the stand.
"Whilst assisted ventilation would not have been possible during the extraction process, it would have been possible to use a bag valve mask whilst Mark was stationary and the absence of this is likely to have contributed to, but not directly caused, Mark's death."
The coroner continued in her conclusions: "The attendance of two medical teams on the concourse, and two cannulation sites, caused confusion between the teams around the drugs being administered to Mark.
"It cannot be said this confusion caused or contributed to Mark's death."
The coroner declined to write a ‘prevention of future deaths’ report about the way the teams from the private ambulance firm Lambda Medical and the public ambulance service work together, after hearing about ongoing co-operation work, including a major exercise simulation at Hillsborough earlier this year.
But she said it was "disappointing" this work was only just getting under way more than a year since Mr Townsend's death.
Mrs Rawden said she had looked in detail at the time it took for Mr Townsend to received medical treatment, based largely on the CCTV footage of the incident.
She said the first defibrillator shock was given five minutes and 51 seconds after a West Bromwich fan first raised the alarm, which she said was "comparable with the level of treatment expected in a hospital setting".
The coroner also said she believed a decision not to stop the match was reasonable, as it would have caused crowd movement which may have hindered the emergency response.
Mrs Rawden said she will be writing a ‘prevention of future deaths’ report to Sheffield Wednesday after voicing concerns about the location of stewards with radios and other stewards knowing how to find them.
The coroner praised the efforts of off-duty West Midlands paramedic Chelsea Jones, who was at the match as an away-fan and was one of the first give Mr Townsend, from Oldbury, West Midlands, CPR in the stand.
She said: "Chelsea's actions that day were a significant factor in giving him the best possible chance."
‘Not fit for purpose’
Speaking outside Sheffield's Medico-Legal Centre on Friday, Mr Townsend's brother, Steve Townsend, said his family was hoping for more recommendations from the coroner.
"I don't think the recommendations go far enough," he said.
Mr Townsend also said he thought the inquest did not focus enough on the difficulties presented to the emergency teams by the confined spaces in the Leppings Lane stand, which is where the Hillsborough tragedy happened in 1989 - leaving 97 Liverpool fans dead.
"Is it fit for purpose in this day and age, in a ground so synonymous with personal tragedy?" he asked.
He said: "I'd like nothing more than to see it in a pile of rubble, to be perfectly honest, and I think that should have been a finding."
Mr Townsend said his brother and "best mate" was "just a genuine beautiful human being who's missed every day".
What have SWFC and WBAFC said?
A spokesperson for SWFC said: “Sheffield Wednesday Football Club have engaged fully with the coroner’s inquest into the sad death of Mark Townsend. We welcome the findings that Sheffield Wednesday comply with relevant safety guidance, that we provide health and safety infrastructure over and above what is strictly required, that the Sports Ground Safety Authority considers communication systems within the club to be sufficient and that there were no failings from Sheffield Wednesday that contributed to, or caused Mark’s death.
“Whilst the coroner’s findings have confirmed that the medical response time on the day was comparable to what might be expected in a hospital setting, we will be carefully considering the coroner’s recommendation to explore whether there may be ways to further improve the speed of communication on matchdays as part of the club’s ongoing commitment to maintaining the highest standards of safety at Hillsborough stadium.
“We recognise the devastating loss to Mark’s family and friends and our thoughts and condolences continue to be with them..”
West Bromwich Albion Football Club also issued a statement at the conclusion of the inquest.
“West Bromwich Albion Football Club notes the findings of an inquest into the tragic death of Mark Townsend, who passed away following a medical emergency at Hillsborough Stadium on September 28, 2024,” it said.
“The club continues to provide the Townsend family with its love and support as they grieve Mark’s loss.
“The club welcomes the coroner’s decision to issue a Prevention of Future Deaths report and urges all associated parties to swiftly act on the concerns raised.”