The coroner investigating the death of Nottingham Panthers player Adam Johnson has told the governing body of ice hockey in the UK she is “sufficiently concerned that deaths may occur in the future” if neck guards are not worn.
Sheffield’s senior coroner Tanyka Rawden opened the inquest into the death of Johnson on Friday following the tragic incident at the city’s Utilita Arena on October 28, when he was hit in the neck by the skate of a member of the opposing Sheffield Steelers team.
During the four-minute hearing there was no mention of the coroner issuing a Prevention of Future Deaths (PFD) Report in the wake of the death. But details of the report have now been published.
The report, which is addressed to Ice Hockey UK and the English Ice Hockey Association (EIHA), says: “During the course of the investigation my inquiries revealed matters giving rise to concern.
“In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.”
Mrs Rawden outlined the “matters of concern” as: “The International Ice Hockey Federation (IIHF) recommends that neck guards or protectors are worn, but there is no requirement for ice hockey players over the age of 18 to wear equipment designed to protect the neck.
“In due course the inquest will consider whether the use of a neck guard or protector could have prevented Mr Johnson’s death.
“At this stage in my investigation however, I am sufficiently concerned that deaths may occur in the future if neck guards or protectors are not worn.”
The death of the 29-year-old American has shocked the ice hockey world, especially as the incident happened in front of 8,000 fans, including many children.
The Panthers and the Steelers are members of the Elite Ice Hockey League, a 10-team set-up comprising outfits from across the UK. It is the most senior level of ice hockey in the UK.
According to the PFD report: “During the game Mr Johnson sustained an incised wound to the neck caused by the skate of another player.
“He was taken by ambulance to the Northern General Hospital in Sheffield where he died as a result of his injury.”
The report requires the governing body to respond within 56 days and adds: “Your response must contain details of action taken or proposed to be taken, setting out the timetable for action.
“Otherwise, you must explain why no action is proposed.”
A coroner issuing a PFD report so early in an investigation is a highly unusual move. These reports are normally produced after a full inquest is concluded and Mrs Rawden made it clear on Friday that this hearing will not take place for many months.
South Yorkshire Police are also continuing to investigate the incident.
The Elite Ice Hockey League has said it will not make the use of neck guards mandatory but will “strongly encourage” players and officials to wear them following the tragedy.
Last week, the English Ice Hockey Association (EIHA) said neck guards will become mandatory from 2024, but the Elite League is not under the its control.
On Saturday, ice hockey fans paid tribute to Johnson at Nottingham’s Motorpoint Arena.
Many supporters were in tears as they signed books of condolence.
They walked past a photo of Johnson and a shirt displaying his name and team number, 47, as they came onto the ice – which had been carpeted – to pay their respects to the American.
Last week, Ice Hockey UK issued a statement which said it will extend the existing International Ice Hockey Federation (IIHF) recommendation that all players at all levels across the Great Britain representative teams use an approved neck guard whilst participating in all on ice activities with Great Britain.
It set out medium term actions, to be completed with 12 months, which include conducting a thorough Player Health, Safety and Wellbeing Review.
The governing body also set out the long term actions for Ice Hockey UK to provide its stakeholders with clear guidance on the ongoing and continuous improvement of player welfare.
Ice Hockey UK said: “It is deeply regrettable that any player loses their life playing our sport, and it is incumbent upon us as the national governing body for the sport to do all we can to prevent a repeat of this tragic accident, but also to prevent other foreseeable incidents in the future.
“We have a moral and legal duty to respond in a measured and reasonable way.”