The death of Mark Townsend at Hillsborough: What we learned from the inquest

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On September 28 last year, West Bromwich Albion fan Mark Townsend died after suffering a cardiac arrest at Sheffield Wednesday’s Hillsborough stadium.

Immediately, concerns were raised about the quality of care he received in the aftermath of the incident. “I want the truth to be out,” Mark’s brother, Steve Townsend, told The Athletic last month, ahead of a two-week inquest into the circumstances surrounding the 57-year-old’s death.

After hearing seven days of evidence, Senior Coroner for South Yorkshire Tanyka Rawden concluded that, though Mark’s cardiac arrest was on the balance of probabilities “unsurvivable”, a lack of ventilation and drugs for over 15 minutes following his collapse was “contributory” to his death.

Rawden was critical of the decision to involve both private contractor Lambda Medical and Yorkshire Ambulance Service (YAS) in providing Mark’s care.

She described “confusion” between the two agencies, while acknowledging that this “did not cause or contribute to Mark’s death”, and called it “disappointing” that Lambda and YAS had only just begun working together on improved communications.

She will produce a Prevention of Future Deaths report over the coming weeks, focused on the positioning of stewards with radios in Hillsborough’s Leppings Lane End — the location of the Hillsborough disaster in 1989, where 97 Liverpool fans were “unlawfully killed” in a crush.

For Steve, though, the feeling of closure is overshadowed by a sense that this all came too late to help.

“They’ve bolted the door after the horse has gone now, saying we’re gonna do this and that,” he told The Athletic after the hearing concluded on Friday. “Lots of little issues have mounted up to one big thing and it’s a kind of blame game.”

The complex interplay between stakeholders — with six separate parties represented in court — offers an insight into how fans’ medical care is provided in modern football. YAS now intends to use Mark’s cardiac arrest as a “case study” for dealing with cardiac arrests in football grounds.

This is how the two weeks unfolded.

Who was Mark Townsend?

Mark was 57 at the time of his death, and had been married to Marion, his wife, since 2019. A factory worker in the automotive industry for over 30 years, the inquest heard he was a huge music fan with a particular love of indie and Northern Soul.

On the day he died, he travelled from his home in Oldbury in the West Midlands to watch West Brom with his nephew, Matt. The pair stopped for a Wetherspoons breakfast before kick-off.

He collapsed in the upper tier of the Leppings Lane Stand just before 1pm, during the first half of the Championship game. He was pronounced dead at Northern General Hospital in Sheffield at 2.38pm. It was later confirmed he had suffered a heart attack.

In a pen portrait read in court, Marion wrote: “Mark loved his life and a day without Mark is like a year without music or sunshine. He was a beautiful soul inside and out.”

Mark Townsend (left) with his brother Steve (Steve Townsend)

Who was in court?

Marion was joined in court on each day of the inquest by Mark’s brother Steve (who is Matt’s father), Steve’s wife and other relatives. They were represented by barrister Peter Wilcock KC, who questioned witnesses on behalf of the family.

Questioning was led by Mrs Rawden, while five other “interested parties” were represented: Sheffield Wednesday, YAS, Lambda Medical, the Sports Grounds Safety Authority (SGSA) and Wednesday’s crowd doctor, Gareth Pritchard.

Lewis Wright, Lambda’s owner and the first on-duty paramedic on the scene of Mark’s collapse, gave evidence but — in an unusual step — also served as his company’s legal representative. It meant Wright frequently cross-examined witnesses who had been critical of both Lambda personnel and his own clinical actions.

What happened when Mark collapsed?

Matt Townsend told the coroner that, shortly before Sheffield Wednesday went 2-0 ahead in the 23rd minute, Mark complained of feeling hot.

When Josh Windass scored, Mark sat down and, shortly afterwards, fell onto Matt’s right leg. Matt and other West Brom supporters raised the alarm to stewards and several expressed concerns about the response.

West Brom supporter Steve Langston, a local authority health and safety manager who tried to help Mark, told the inquest: “There seemed to be a delay between the initial cries for help from the crowd and a steward with a radio being available.”

He added: “At least one steward stated that they couldn’t speak English. They looked like they were rabbits in the headlights.”

Off-duty GP Dr Richard Stones described the response as “a shambles” and estimated a time of around 10 minutes between Mark’s collapse and the arrival of Mr Wright. He said he was “screaming” at stewards for help but they did not respond: “Honestly, they just looked at me.”

Off-duty West Midlands Ambulance Service (WMAS) paramedic Chelsea Jones, who began CPR along with Dr Stones, said: “I asked a steward if they could get a medic up here. They said there were no radios. I said: ‘Use your feet then and go and get someone.’”

Gill Wild, the Upper West Stand manager who first radioed the control room about the emergency, said she had waited for 10 seconds because someone else was using the radio frequency and there was no way to override it.

Hillsborough (Jess Hornby/Getty Images)

Questioning John-Paul Ashton-Kinlin, Sheffield Wednesday’s part-time medical co-ordinator, the coroner asked about a moment on the CCTV footage where a steward looking for help could be seen moving one way across the screen and then back in the opposite direction while a group of supervisors with radios were standing together.

“I am concerned that stewards without radios struggled to find stewards with radios,” she said.

Ashton-Kinlin said it is good practice to position supervisors at intervals across the front of the stand but it is not always possible “in a dynamic situation”. He added: “There are certainly elements we can do to put more fixed stewards in place should they be required.”

He also dismissed suggestions that any of the stewards could not speak English, telling the court he was involved in all their interviews and they would not be employed without a grasp of the language.

Mrs Rawden announced at the end of the inquest that, while she was now satisfied that stewards could use an alternative channel to contact the control room, she would be writing a “prevention of future deaths” report about the positioning of stewards with radios.

She said while the small delay in locating a radio had not “caused or contributed to Mark’s death”, she was concerned about future incidents.

“Stewards have to be clear all the time where radios are, and I do not feel they were on this occasion,” she said. “Every second counts in an emergency situation, and where changes can be made in the hope that lives can be saved in the future, then they should be made.”

Based on CCTV footage, consultant in emergency medicine Dr David Kirby, who was appointed by the coroner to provide expert evidence, said a first defibrillator shock was delivered within six minutes of when Mark appeared to collapse. “In my opinion, that is very quick,” he said.

In her conclusions, Mrs Rawden agreed with Dr Kirby that the initial response and defibrillation were similar in time to what Mark would have received in hospital.

What care did Mark receive in the stand?

Chelsea Jones, the off-duty paramedic in the away end, told the coroner how she was called over by West Brom fans who were aware of her qualifications. In her conclusions, Mrs Rawden said she would write to WMAS to commend Jones’ actions.

She asked supporters to lie Mark on the ground between seats and started CPR immediately. Wright told the inquest he was in the stadium’s control room when the first call came through at 12.58pm. Lambda first-responders were dispatched but Wright also went to the scene himself and was the first to arrive because, he said, he was not carrying any equipment so could move quicker.

He said his first-responders arrived shortly afterwards with a defibrillator, the pads were applied to Mark’s chest and two shocks were delivered.

Stones and Langston both claimed that the battery on the first defibrillator then failed, but Wright denied this, telling the inquest that the defibrillators had been swapped because more qualified paramedics had arrived with a manual defibrillator, which provides the user with more control and information. Mrs Rawden said there was “no evidence” that the machines had been swapped because of a flat battery.

A scoop stretcher was brought by Lambda and fans helped to lift Mark onto it as there was not enough room between the seats to slide it under him in two sections as usual.

Throughout the treatment, West Brom fans were chanting periodically for the game to be stopped.

Langston said: “I remember seeing Kyle Bartley, one of the West Brom players, in conversation with the referee. He was pointing up to the stand. He was gesticulating that there was something going on in the stand.”

But Ashton-Kinlin said: “It’s our belief that once we stopped a game, particularly with it being close to half-time, most people would retreat to kiosks. Stopping the game could inadvertently stop us from being able to take the individual to the concourse and then to the ambulance.”

Mrs Rawden ruled that not stopping the game was a “reasonable” decision.

West Brom’s Kyle Bartley applauds as players commemorate the life and death of Mark Townsend during the Championship game against Middlesbrough on October 1, 2024 (Naomi Baker/Getty Images)

Dr Kirby said he considered the start of defibrillation and CPR to be quick, but he said if it was true that oxygen was not provided for 15 minutes after Mark’s collapse, then that was “a long time” during which deoxygenated blood was being pushed around the body by the CPR.

Dr Kirby did agree with Wright that using a bag-valve mask to oxygenate Mark would have been ineffective while he was being moved.

Mrs Rawden concluded: “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.”

Outside court after the inquest, Wright declined to comment on the findings about ventilation but referred journalists to the Resuscitation Council’s guidance on passive ventilation.

In his evidence, Dr Kirby played down the effectiveness of passive ventilation, where air is forced in and out of the body as a result of chest compressions.

Notably, Mark was also not cannulated in the stands, which would have allowed Lambda paramedics to begin administering drugs — most significantly amiodarone and adrenaline. According to Resuscitation Council guidelines, it is recommended that these be given after the third defibrillator shock.

Wright told the inquest that cannulation was not carried out owing to Mark’s position between the seats, with effective access involving cutting Mark’s trousers off, and Dr Kirby agreed that intravenous access through Mark’s elbow — the preferred method — would not have been possible.

Mrs Rawden concluded that “whilst this contributed to, but did not directly cause, Mark’s death, it was reasonable to make the decision not to cannulate given Mark’s position, the only access point being the least efficient, and the risk of dislodgment on extraction”.

Cannulation presented its own challenges.

The scoop stretcher brought to the scene by Lambda was missing straps to secure Mark, with YAS paramedic Emma Newbould testifying that a Lambda paramedic had told her the straps were “on the other side of the football ground”. Townsend was moved without straps in an effort to bring him to the concourse quickly, in what Newbould described as “a massive health and safety risk”.

In her conclusions, Mrs Rawden did not comment other than to note that the straps had been left in the corner of the stand due to “a mistake”.

Wright said he took the decision to move Mark without straps because he knew it would save time and he believed he had enough staff around the stretcher to ensure Mark’s safety.

What happened on the concourse?

It was on the concourse that the “confusion” referred to by Mrs Rawden became manifest.

On arrival from the stands, the environment, according to several responders, was equally noisy and chaotic. Stewards held up sheets to form a privacy barrier for Mark’s dignity, with hundreds of West Brom fans streaming inside during half-time. Only four metres by four metres, with around a dozen medical personnel inside, paramedics had to shout to make themselves heard and use hand signals.

Mark had been carried down, unstrapped, by Lambda personnel and at least one fan, Langston. They quickly found themselves joined by more paramedics — from YAS, the local NHS general care provider.

Stadium medical contracts are generally split, with one contract concerning the players, and another separate contract looking after the crowd. At Hillsborough, Lambda Medical held the crowd contract, while YAS was responsible for the players.

That arrangement has changed this season, with Lambda now holding both contracts.

According to Wright, backed up by emails later shown to the coroner, YAS stated it would not provide crowd assistance “outside a major incident”. Due to this understanding, several Lambda paramedics were surprised to see YAS staff members attend the scene.

Over the course of the inquest, it became clear that YAS matchday commander Lesley Baker was central to this unorthodox change of plan, which she defended in court by saying “she did it for Mark’s care”.

Baker’s job was to be in Hillsborough’s control box, monitoring the on-pitch players for serious medical issues — a collapse, for example — before dispatching the necessary resources. Her counterpart, Darren Deakin, whose own day job was as an incident commander for YAS, was doing the same job for Lambda that day.

On Mark’s collapse being reported to the command room, Baker testified that there was “hesitation” from Deakin on whether advanced critical care was needed. Claiming to have had no response from Deakin, she reported the cardiac arrest to YAS’ Emergency Operations Centre (EOC). In turn, they dispatched a critical care paramedic, Sam Hewson, and further ambulances to the scene.

Feeling the response was “chaotic and not quick enough”, Baker subsequently decided to leave the control box to command the incident from a logistical standpoint. She described the decision as “difficult”, noting it was the first time she had left the box in 15 years of experience.

Wright, in his testimony, described this decision as “absolutely unheard of”, while Ian Perkins, representing Sheffield Wednesday, accused Baker of “abandoning her role”, with both questioning what would have occurred if there had been a player incident.

Mrs Rawden described Baker’s actions as “an unprecedented but informed decision”.

A lone shirt is draped over the seat of West Bromwich Albion fan Mark Townsend (Adam Fradgley/West Bromwich Albion FC via Getty Images)

After leaving the control box, Baker subsequently showed YAS paramedic Hewson to the concourse. Hewson is a cardiac specialist — he testified he attended an average of 133 out-of-hospital cardiac arrests each year, as opposed to three for an ordinary paramedic.

On arrival, Hewson testified that he encountered two issues: he was unable to decipher Lambda paramedics’ seniority due to a lack of epaulettes, and also struggled to work out who was leading Lambda’s response, a role ostensibly filled by Wright.

Hewson subsequently stood over Mark, ensuring he could be heard by team members, and stated: “My name is Sam, I am taking over this cardiac arrest.” Hewson told the inquest that Lambda personnel did not appear “receptive” to his presence.

Wright described Hewson’s announcement as “intimidating”, adding that, with two more YAS ambulance crews joining the response, there were now “two teams doing one job”.

All parties agree that YAS and Lambda encountered communication issues when working together, painting a picture of a chaotic working environment.

“It just seemed chaotic and people were fighting over particular roles,” said Hewson. “At one point, drugs were administered by the person who was supposed to be doing the airway. In my opinion, (Lambda’s) cardiac arrest response wasn’t drilled fully.”

In his witness testimony, Wright challenged such suggestions and said: “There was a clear plan and clear leadership.”

Having been carried to the concourse unstrapped, Mark’s defibrillator pads had become loose. YAS and Lambda paramedics disagreed over who identified the issue, and who fixed it, but shocks resumed. Simultaneously, after over 15 minutes, Mark’s airway was established for the first time.

As defibrillator usage restarted, Hewson accidentally shocked Lambda paramedic Moira Finlayson, who could be seen on CCTV moving backwards after his warning, but whose knee still appeared to be close to Mark. Hewson acknowledged he should have double-checked that paramedics’ limbs were clear.

After several subsequent shocks, Mark’s pulse faintly restarted, but was lost again after less than a minute.

Another dispute surrounds drug administration. Mark received two drugs: amiodarone, to calm the heart and return its rhythm to normal, and adrenaline, used to increase blood pressure and subsequently aid oxygenation. The amounts, however, were contested.

YAS paramedics claimed to have observed Lambda personnel administering half-vials of adrenaline, less than the recommended dosage, with YAS paramedic Newbould testifying she saw Wright squirting out unused liquid onto the floor from a syringe. This was denied by both Wright and Finlayson.

Mrs Rawden acknowledged the conflicting evidence and said: “It cannot be said whether the correct doses were administered.”

In her evidence, Lambda paramedic Sarah Linakar claimed Hewson should have considered three other drugs — calcium, magnesium, and lidocaine — but Hewson’s decision-making was supported by independent expert Kirby.

By this point, preparations were being made to extract Mark. An automatic CPR machine was in use for his planned transportation, but YAS staff expressed their frustration that the straps for the scoop, needed to take Mark downstairs to the car park, were still not present.

Hewson described how he felt they had “lost the forward momentum”. Eventually, over 25 minutes after the first Lambda paramedic arrived, replacement straps were brought from a waiting YAS ambulance.

En route to the hospital, Mark’s heart restarted once again, with Hewson testifying that he was becoming “cerebrally agitated” — moving his arms but not consciously. However, Mark was still dangerously ill. Shortly after arrival at Sheffield’s Northern General, his heart stopped once more.

Doctors then realised Mark needed surgery to remove an obstruction, but concluded that the operation was not possible. He was pronounced dead at 2.38pm, just over 90 minutes after first collapsing.

Despite the working difficulties, both YAS and Lambda felt Mark received the necessary care on the concourse. Mrs Rawden agreed.

“There are lessons to take from two teams coming together, but Mark did receive a response, oxygenation, and did receive good resuscitation on the concourse,” said Hewson. He still raised concerns about Lambda’s response through the internal system at YAS later that day.

Mrs Rawden agreed with independent expert Kirby, concluding that the delay in assisted ventilation and drugs in the stand were likely to have been “contributory factors”, but stated that the decision not to cannulate to provide drugs was “reasonable”.

She concluded that he “died due to an acute myocardial infarction which, on the balance of probabilities, was unsurvivable”.

What recommendations have been made?

Speaking on Friday, Mrs Rawden expressed her frustration that it was only during the inquest that she received a statement from Wright stating that Lambda and YAS “intend to run joint exercises in the future”.

“It is disappointing that I had to raise these concerns,” she stated in her verbal conclusions. “I expected all interested parties to have considered the issues of risk.”

Several amendments have already been made.

The coroner said she had been told that the YAS matchday commander would ensure they had access to the radio frequency of the private medical providers.

Lambda informed her that it now runs a simulation ahead of every fourth game on patient extraction, while it has also changed its epaulette design so as to better identify senior paramedics. It has now also introduced a policy of keeping “clip straps” attached to the scoop at all times.

Mrs Rawden’s other recommendation, to be further explored in a Prevention of Future Deaths report, which was welcomed by West Bromwich Albion, is for the positioning of supervisors with radios in the Leppings Lane End to be approved, allowing for quicker communication after a collapse.

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.

Full statement. ⬇️

— West Bromwich Albion (@WBA) October 10, 2025

“I don’t think the recommendations go far enough,” Steve told television reporters outside the inquest. “I’d have liked to think there would have been some say on the ground and the state of the ground.”

Sheffield Wednesday’s Leppings Lane End was not cited by the coroner as a contributory factor to Mark’s death. In her conclusion, she referenced evidence from the SGSA that the stadium complies with all of its guidelines.

For Mark’s family, who were praised by the coroner for their conduct during the two-week inquest, it did little to ease their sense of loss, but Steve took a modicum of hope from the assurances that changes have been made by Lambda, to its working relationship with YAS, and by Sheffield Wednesday.

“As long as that gets done, that’s all I can hope for if it prevents another family from going through what we, the Townsends, have been through in these last 12 months,” he said.

This news was originally published on this post .

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