Coroner slams child protection 'failures' and 'serious missed opportunities' which led to Derbyshire teenage boxer's death

Edward Bilbey, 17, who had made no secret of his dream to become world champion, collapsed in the ring at the Post Mill Centre, South Normanton, on Friday, March 24, 2017, shortly after the three-round bout.

He later died at King’s Mill Hospital and an inquest heard he had trained ‘excessively’ in the build up to the tournament by boxing in bin liners, taking frequent hot baths and not drinking for 12 hours before the fight.

The cause of death was a cardiac arrest due to the combined effects of an inherited heart condition and metabolic disturbance caused by intense training and rapid weight loss through dehydration.

However, recording a narrative verdict, Derbyshire coroner Dr Robert Hunter said: “His death was in part contributed to by a failure to have adequate safeguarding and child protection measures in place.”

There were several ‘serious missed opportunities’ which could have prevented Edward’s death at such a young age, the inquest heard.

The coroner said investigations showed England Boxing’s regulations and compliance procedures for amateur coaching and training had been ‘wholly unacceptable’.

"The absence of such procedures provides an historical and continuing risk to child protection and safeguarding,” Dr Hunter told Chesterfield coroners’ court.

"It is not acceptable for governing bodies to rely on the trust of individuals to ensure compliance.”

The coroner said, if the staus quo was maintained, ‘more children will suffer harm or die’, and confirmed he will be writing to England Boxing’s chief executive to see what measures it plans to take.

The coroner also described Edward’s step-dad and professional boxing coach Jason Shinfield, of Shinfield’s Gym in Somercotes, as an ‘unreliable witness’ who had been ‘evasive and convoluted’ when confronted with facts which contradicted his evidence.

Although Mr Shinfield denied any involvement in amateur boxing at the gym, the coroner said evidence from Edward’s mum Michelle and brother Henry contradicted this.

Dr Hunter said Mr Shinfield’s failure to weigh Edward ahead of the fight, instead ‘casually’ trusting him to weigh himself at home, was another ‘missed opportunity’.

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He should have realised Edward, from Ripley, could not have made weight without dehydration and would have pulled the fight – something the inquest was told Edward’s mum had requested.

Dr Hunter also criticised the ‘disorganised and chaotic’ response to Edward’s collapse in the ring as he awaited the judges' decision.

The inquest heard there was a 17-minute delay in calling for an ambulance, misuse of an oxygen cylinder and a failure to clear Edward’s airways after he vomited or take his blood sugar earlier.

"There was also a delay in clearing the venue and children were present and observed this frightful tragedy before their very eyes,” Dr Hunter said.

"That in itself was a child protection matter.”

Michelle paid tribute to her 'special angel’ after the incident.

In a statement, she said: “My Eddie boy, my champ. He was more than just a boxer, he was a beautiful, clever, handsome, caring, honest, respectful and truly pure soul with a heart of gold and a kind word and time for everyone."

Boxing was Edward’s ‘passion’ and ‘made him who he was’, his mum said.

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