The sports coach to young Samuel Akwasi, who collapsed and died on The Forest Recreation Ground, has blasted Nottingham City Council for "not doing enough". Samuel's coach Everton Richards and chairperson of FC Cavaliers, spoke after an inquest into the 13-year-old's death concluded.
He died from natural causes after he suffered a sudden cardiac death with a morphologically normal heart. Despite her medical finding, the coroner, Dr Elizabeth Didcock, flagged other areas of concern surrounding that terrible day.
On Friday (March 24) she recommended sweeping changes to the locations of defibrillators, accessibility, and signs to find them. She concluded Samuel's death was a tragedy - but she did not think different actions could have led to a different outcome for him.
Questions remain for Mr Richards, who has welcomed the recommended changes, such as the time it took to locate defibrillators and his insistance the pavilion door was closed - where one could have been.
Read more: Concerns over vital moments leading to death of boy on Nottingham football field
He says one member of council staff was on duty, who they never saw, he claims, and a second defibrillator was further away in the Forest Sports Zone. Mr Richards told Nottinghamshire Live: "That time is too great - there needed to be a defibrillator closer.
"One thing that puzzles me is the so-called member of staff was supposed to be on duty. Why didn't they show themselves? Where is this person?
"After the incident, we were still there. We maintain the pavilion was locked. Look at the size of The Forest Recreation Ground - and they had one member of staff on duty.
"On that day, they let the footballers down. There was no one to advise on a major incident like that at all". Mr Richards had hired the space for the match - but said he had to use his own nets that he keeps in the back of the car - despite maintaining he had paid for the space.
Dr Didcock found two defibrillators arrived almost simutaneously - one from a cafe at the pavilion and one from The Forest Sports Zone. She declared there was no significant delay in shocks being delivered to Samuel once cardiac arrest had happened or a significant delay in the emergency response. He died at the Queen's Medical Centre that day, May 7, 2022.
The coroner referred to the "confusion" as to the location of the defibrillators at the Ground - which had two on site - and she expressed her concern there was no signage provided by Nottingham City Council, as would be expected on the pavilion.
She said the device was inside the pavilion cafe, which had a separate entrance, but the FC Cavaliers thought it was inside the pavilion, and separate to the cafe. "Mr Edwards said the door was closed, likely locked," said Dr Didcock. " I can't be completely sure".
She has recommended Automated External Defibrillators (AEDs) be in place in all Nottingham City Council grounds, accessible 24 hours a day, and located outside buildings and registered with The Circuit - the national defibrillator network links a network of defibrillators to every ambulance service in the UK.
EMAS would then be aware of their location, with an access code available on a 999 emergency call, so the box could be opened. Dr Didcock, Nottinghamshire's assistant coroner, understands this is planned for the Forest Recreation Ground and The Embankment, West Bridgford, but she expressed her frustation this has not been done more quickly after Sam's death.
She has asked the council to attend urgently to signage at The Forest Recreation Ground, and she has recommended access to AEDs at all parks and recreation grounds. And she wants their locations known to all clubs and teams using facilities, including on booking forms, and she has asked all council executives to use a large orange flag system showing the location of an AEDs.
Nottingham City Council’s Portfolio Holder for Highways, Transport and Parks, Councillor Audra Wynter, said: “I would like to offer my deepest condolences to the family and friends of Samuel - to lose a loved one so young is truly devastating.
“We have listened very carefully to the inquest and will need to receive the coroner’s report to fully understand the detail of her recommendations, but we are already in the process of taking action on the points she has raised. A new defibrillator is due to be installed outside the Pavilion in the coming weeks, with more due to be rolled out at Victoria Embankment and other parks, which will be subject to weekly inspections.
"Signs have been installed to direct people to the locations of all defibrillators at The Forest and the standard defibrillator signage the coroner asked for will be installed next week. We are also working with EMAS to improve access for ambulances onto the site, as many access points are locked to prevent other vehicles entering the park.”
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