Coroner says all football coaches and referees should be trained to spot sudden cardiac arrest

Football coaches and referees should receive mandatory training to spot signs of sudden cardiac arrest, a coroner has said despite opposition from the Football Association (FA).

Assistant coroner Valerie Charbit made the recommendation after an inquest found there was a “missed opportunity” to help teenager Adam Ankers when he suffered a cardiac arrest playing for Wycombe Wanderers’ under-19s side in January 2024.

At an earlier hearing, Ms Charbit ruled a failure to spot the 17-year-old was suffering from cardiac arrest “more than minimally” contributed to his death.

The inquest had heard how a defibrillator was brought onto the pitch but no-one used it to try to save Adam’s life because there was confusion as to whether it was safe to use at the time.

Following that ruling, the coroner – sitting at West London Coroner’s Court – recommended the Football Association require all its accredited members, including grassroots football coaches and referees, to complete a mandatory training course so they can spot signs of sudden cardiac arrest.

According to the FA’s website, members are currently offered a free, online module “designed to help recognise a sudden cardiac arrest and respond appropriately”.

But in her report, Ms Charbit said the training should be mandatory and apply to all members of the Football Association.

In submissions to Ms Charbit, the FA argued against the move.

It said that by making the training mandatory and for all members, children would be excluded from refereeing because it would require them to be “put in the position of having to deliver such basic life support as would be necessary”.

Responding to the FA, the coroner said: “I disagree as to the fact that that shouldn’t be something that children should engage in.

“Children are allowed to train in first aid … I consider it important that the responsibility for first aid lies with all ages within society and outweighs any concern that this would stop them becoming referees.”

She added that the FA raised concerns the recommendation would mean training more than 185,000 coaches, which the assistant coroner said was outweighed by the number of young lives that could be saved if that training was rolled out more widely.

At an earlier hearing, the coroner was told Adam was playing football on January 31 2024 when he collapsed during the second half. He was taken to hospital, where he died on February 4 2024, after it was found he had suffered unsurvivable brain damage.

In their submissions to the inquest, Adam’s family asked Ms Charbit to extend the recommendation to all sports, but the assistant coroner said this would be an “overreach”, adding that this was outside the scope of issues and evidence she had considered.

In her report, Ms Charbit said both ordinary people and ambulance call handlers have “difficulty” recognising the symptoms of cardiac arrest and agonal breathing – sudden, irregular gasps of breath, a symptom experienced by Adam, which should be responded to with immediate CPR.

Explaining her decision to issue a report, Ms Charbit told the inquest that, despite hearing arguments otherwise, she did not believe training provided by bodies such as NHS England and the South Central Ambulance Service, which took the 999 call in Adam’s case, is sufficient.

Although changes made by NHS England since Adam’s death mean a sudden collapse during sport or exercise is now automatically treated as requiring immediate CPR, the assistant coroner said the changes took a “particularly long time” to come into force.

She said: “Although there was training given, and some of those on the pitch were trained, there was still a misidentification of Adam’s agonal breathing by those on the pitch and those receiving the 999 call.”

In her report, Ms Charbit also noted there is a need for better understanding of the use of defibrillators, among those medically and not medically trained, and that cardiac screening for those aged 14 and above, which reduces the risk of sudden cardiac death, is not available to all young people or young football players.

A failure to cascade a family history of arrhythmogenic right ventricular cardiomyopathy (ARVC), an inherited heart condition Adam was identified to have had only after his death, was also noted.

Addressing the virtual hearing, which was attended by Adam’s father, Ms Charbit said: “I remember Adam Ankers. I remember everything I heard about him, and I do hope that this prevention of future deaths report that I have made allows us to prevent a similar death to that which Adam suffered.

“I express my sincere and deepest condolences, at the conclusion of these proceedings, to Adam’s family and friends.”