What coroners keep telling festival medical and welfare teams

Operational Tactical Strategic By Kris Dailly, OTAS Insights. Published 20 October 2026. Correct as of 20 October 2026.

Published by OTAS Live Ltd · United Kingdom (coroners' reports: England and Wales)

What a Prevention of Future Deaths report is

In England and Wales, when an inquest reveals a risk that other deaths could happen, the senior coroner must report it to whoever may have the power to act. The recipient must respond in writing within 56 days, setting out the action taken or explaining why none is proposed [9][10]. The reports and responses are published. We report what the coroners wrote, in general terms, and do not name the people who died or the events.

The reports we looked at

• 2023-0303 (West Yorkshire Eastern, 21 August 2023): a 16-year-old at a large three-day festival in 2022 [1].
• 2025-0372 (North East Kent, 19 May 2025): a 17-year-old at a music festival in 2024 [3].
• 2025-0395 (Hampshire, Portsmouth and Southampton, 1 August 2025): a man at a multi-day festival in 2024 [5].

All three deaths followed MDMA use [1][3][5].

Spotting people in trouble

In 2023-0303 the coroner recorded that the young person walked around the site for about 90 minutes while showing signs of an adverse reaction, and passed at least one checkpoint staffed by stewards or security, but no staff or volunteers intervened [1]. The coroner said further instruction or training was needed so staff and volunteers are proactive [1]. The Home Office reply notes that stewards and unpaid volunteers do not need SIA licences, so any extra training is for the organiser and employers to set [2].

Medical cover that fits the risk

In 2025-0372 the coroner was concerned that the private ambulance staff had minimal training and little experience of managing patients who had taken drugs, at a music event where the risk of drug taking was deemed to be high [3]. The report records that the patient was hot and had a fast heart rate, and that no attempts to reduce her temperature were made while she was with the private ambulance crew [3]. The provider's published response describes enhanced training, a dedicated event team, pre-event briefings, a medical operational plan for each event and a readiness checklist [4].

Who warns the hospital

The same coroner found it unclear who was responsible for making a pre-alert call to the hospital, and none was made [3]. The vehicle had less equipment than an NHS ambulance, and the coroner said it was little more than transport and "may have given a false sense of reassurance" [3]. The provider now says crews can pre-alert on their own if in doubt [4].

Drug supply and entry policy

In 2025-0395 the coroner heard evidence that dealers walked through the campsites as often as every twenty minutes, and that witnesses saw nothing done to disrupt the trade. The coroner was also concerned that people found with drugs who are not considered dealers have them confiscated and are still admitted, which gives rise to demand on site [5]. The police response says drug supply management is the organiser's responsibility under national guidance, with the police working through the Safety Advisory Group [6].

Data and age

In 2023-0303 neither the organiser nor the licensing authority had accurate numbers of under-18s attending. The coroner also heard that four to five people die each year from drug-related causes at British festivals, with no central record [1].

Drug checking

The 2023-0303 coroner asked the Home Office for authoritative guidance on front-of-house drug testing [1]. The Home Office replied that it recognises the potential harm reduction benefits of back-of-house testing of surrendered or confiscated drugs, used for public alerts, but expects no individual results to be given back, which would be front-of-house testing [2]. In England, Scotland and Wales, any service needs a Home Office controlled drugs licence [2][7][8]. Northern Ireland has its own licensing: anyone who wants to possess or supply controlled drugs there needs a licence from the Department of Health [14]. The Home Office says to allow up to 16 weeks to be contacted for a compliance visit, so apply early [8].

What changes next

In England, healthcare and treatment at events is being brought into CQC registration. Applications opened on 7 September 2026 and the rules take full effect on 6 December 2027 [11]. First aid alone is not regulated [12]. UKHSA has published a scoping review to inform a new Event Healthcare Standard [13].

What to do

Operational: stewards, security, welfare and medical crews

• Treat anyone pale, sweating heavily, agitated or unable to walk straight as a medical concern and get help [1].
• Know how to call medical help from your post.
• If you are a crew member and in doubt, pre-alert the hospital [4].

Tactical: welfare, medical and stewarding managers

• Brief every steward and volunteer to be proactive about welfare [1][2].
• Agree in writing who makes the hospital pre-alert [3][4].
• Check the medical plan covers drug-affected patients, set by clinicians [3][4].

Strategic: organisers, licence holders and directors

• Match medical and transport capability to the risk profile, not just the headcount [3].
• Know your audience, including the number of under-18s [1].
• Review supply disruption and entry policy with the Safety Advisory Group [5][6].
• If you want drug checking, plan early for a licence: from the Home Office in England, Scotland and Wales, or the Department of Health in Northern Ireland [7][8][14].
• Check whether your medical provider must register with CQC [11].

Action box

Frequently asked questions

What is a Prevention of Future Deaths report?

A report a coroner in England and Wales must send when an inquest reveals a risk of other deaths. The recipient must respond within 56 days [9][10].

What do coroners keep raising about festivals?

Staff not intervening with visibly unwell people, medical crews not trained or equipped for drug-affected patients, unclear hospital pre-alerts and easy access to drugs on site [1][3][5].

Is drug checking at festivals legal in the UK?

In England, Scotland and Wales, back-of-house testing of surrendered or confiscated drugs can run under a Home Office controlled drugs licence. Northern Ireland has its own licensing, through the Department of Health. The Home Office does not support giving individuals their results [2][7][14].

Do event medical providers need to register with CQC?

In England, many will. Registration opened in September 2026 and the rules take full effect on 6 December 2027 [11].

Who is responsible for drug supply on a festival site?

The police response to one report says it is the organiser's responsibility under national guidance, with the police working through the Safety Advisory Group [6].

What we don't know yet

How many festival drug deaths happen each year, because no central record exists, and when the Event Healthcare Standard will be published. The full report sets these out.

Interest: OTAS Live Ltd, which publishes EPGN, sells event operations services.

Corrections: if you spot an error, tell us using the contact details on the OTAS Insights page and we will correct it and update the 'Correct as of' date. To ask for this brief in another format, use the same contact details.

OTAS Insights: otas.live/insights/

Full report (PDF): https://otas.live/insights/coroners-lessons-festival-medical-welfare/coroners-lessons-festival-medical-welfare-full-report.pdf

Related OTAS Insights: event medical providers and CQC registration, https://otas.live/insights/event-medical-providers-cqc-registration/

Last updated: 20 October 2026. Published by OTAS Insights.

References

All web sources were opened and checked on 20 October 2026.

1. Courts and Tribunals Judiciary, Prevention of Future Deaths report 2023-0303 (Senior Coroner, West Yorkshire (Eastern), dated 21 August 2023), with the published responses. https://www.judiciary.uk/prevention-of-future-death-reports/david-celino-prevention-of-future-deaths-report/
2. Home Office, response to Prevention of Future Deaths report 2023-0303 (Minister of State for Crime, Policing and Fire). https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0303-Response-from-Home-Office.pdf
3. Courts and Tribunals Judiciary, Prevention of Future Deaths report 2025-0372 (North East Kent Coroner's Service, dated 19 May 2025). https://www.judiciary.uk/prevention-of-future-death-reports/emily-stokes-prevention-of-future-deaths-report/
4. Response to Prevention of Future Deaths report 2025-0372 from the private ambulance provider (dated 7 July 2025). https://www.judiciary.uk/wp-content/uploads/2025/07/2025-0372-Response-from-Kent-Central-Ambulance-Service.pdf
5. Courts and Tribunals Judiciary, Prevention of Future Deaths report 2025-0395 (Hampshire, Portsmouth and Southampton, dated 1 August 2025). https://www.judiciary.uk/prevention-of-future-death-reports/benjamin-buckfield-prevention-of-future-deaths-report/
6. Response to Prevention of Future Deaths report 2025-0395 from the police force. https://www.judiciary.uk/wp-content/uploads/2025/08/2025-0395-Hampshire-and-IOW-Constabulary.pdf
7. Home Office, 'Licensed drug testing continues at music festivals this summer' (news story, 24 May 2024). https://www.gov.uk/government/news/licensed-drug-testing-continues-at-music-festivals-this-summer
8. Home Office, 'Controlled drugs: domestic licences' (guidance). https://www.gov.uk/guidance/controlled-drugs-domestic-licences
9. Coroners and Justice Act 2009, Schedule 5, paragraph 7, action to prevent other deaths (England and Wales). https://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
10. The Coroners (Investigations) Regulations 2013 (SI 2013/1629), regulation 29, response to a report on action to prevent other deaths. https://www.legislation.gov.uk/uksi/2013/1629/regulation/29
11. Care Quality Commission (CQC), 'Registration applications now open for event healthcare providers' (published 24 September 2026). https://www.cqc.org.uk/news/registration-applications-now-open-event-healthcare-providers
12. CQC, 'Supporting registration guidance for delivering treatment of disease, disorder or injury at events: relevant exceptions to registering'. https://www.cqc.org.uk/guidance-regulation/providers/registration/supporting-registration-guidance-delivering-tddi/exceptions
13. UK Health Security Agency (UKHSA), 'Healthcare provision at events: a rapid scoping review' (published 19 February 2026). https://www.gov.uk/government/publications/healthcare-provision-at-events-a-rapid-scoping-review
14. Department of Health (Northern Ireland), 'Controlled drugs' (controlled drug licensing in Northern Ireland, under the Misuse of Drugs Regulations (Northern Ireland) 2002). https://www.health-ni.gov.uk/articles/controlled-drugs

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