Fan who collapsed during Championship match died of natural causes, coroner says

The family of a football fan who died after he collapsed with a cardiac arrest during a Championship match have said they were hoping for stronger recommendations from a coroner who concluded he died from natural causes.

Mark Townsend, 57, died after he collapsed among fellow West Bromwich Albion supporters at Sheffield Wednesday’s Hillsborough Stadium on September 28, 2024, a two-week long inquest has heard.

On Friday, 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.

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 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.”

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.

Mr Townsend said he still had questions about the skills of the Lambda staff in the stadium, and the time it took for medics to respond.

“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”.