Crowd medical services in attendance at English league football matches are commonplace, although there is little published data examining the use of these services.
The aim of this study was to provide detailed data by examining the usage of the crowd medical service at Fulham Football Club (FC) in the English Premier League. This data has implications in terms of resources, provision of level of service, and training needs of staff. Establishing detailed, up-to-date data on the use of crowd medical services at a London Premiership football stadium will help justify risk assessments for routine medical provision, with reference to the Department for Culture, Media and Sport's (2007) Guide to Safety at Sports Grounds guidelines regarding levels and standards of staffing.
Craven Cottage remains one of the smallest grounds in the Premier League, with a seated capacity of 25 678. The club has recently seen plans approved for the construction of a new Riverside Stand, which will raise capacity to 30 000 seats (additional 13%) increase. In view of this increased capacity we aimed to complete a retrospective data analysis to assess whether the number of injuries/illnesses requiring medical assistance at each match has any correlation to the crowd numbers in attendance and whether requirements have increased from season to season. Specific aims were to describe the frequency of patients presenting per match, assess the cause of presentations, analyse any patterns of consultation, and assess hospital transfer rates of those requiring treatment. This data will be used to assist us in planning medical support for the increased capacity.
Background of the club and stadium
Craven Cottage is the home stadium to Fulham FC, a Premiership football club situated in south west London, England. The club was started in 1879. In 1896, after two years of development, the club finally took residence in their new home, Craven Cottage (Fulham FC, 2016).
In 1906 the first proper stand was built. The stand, currently called the Johnny Haynes Stand, was accompanied by a pavilion, which is the present-day Cottage. In the following years, the stadium had further improvements, concluding with the construction of the Riverside Stand in 1972. Following promotion to the Premier League in 2001, the stadium was unable to meet Premier League requirements. League guidelines dictated that Craven Cottage had to be an all-seater stadium as opposed to offering standing seats as it had historically done, ahead of the 2001/2002 season (Fulham FC, 2016).
Consequently, the club moved to Loftus Road as refurbishment of Craven Cottage commenced and was completed in the summer of 2004. Craven Cottage remains one of the smallest grounds in Premiership football; however, there is concern that construction of the new riverside stand may have implications for the medical team (The Stadium Guide, 2012).
In order to anticipate these concerns, this study aimed to review nine seasons of medical data for Fulham FC in relation to attendance numbers per game to aid in planning for the future.
Medical care
Medical care within the ground is provided by a team of first aiders, nurses and a crowd doctor. The stadium contains a main treatment room and secondary first aid post, with first responders strategically placed on match days. An event medical company and transfer service cover players and officials. London Ambulance Service NHS Trust are available on site for major incident cover, with St John Ambulance available for crowd transfer.
Background literature
Considering the high volume of the English Premiership League matches, there is a lack of data detailing patterns of crowd medical service use in individual contemporary sports stadiums in the UK.
The Football Licensing Authority is concerned with ensuring spectator safety at International, Premiership, and Football League games in England and Wales. At the end of each season, all clubs submit data on the number of documented spectator first aid or medical consultations at football matches.
Each year the Sports Ground Safety Authority (SGSA) collates and publishes the number of reported injuries for all competitive league and cup games at football grounds in the Premiership and Football League plus Wembley and the Millennium Stadium. Each club is asked to provide the total number of reported injuries, broken down by a number of specific causes.
An injury is classed as a wound, trauma, hurt or harm, usually applied to damage inflicted on a body by an external force. Illnesses are by their nature excluded. Pre-existing injuries are also discounted, as the report focuses on injuries that occurred within the curtilage of the ground on match days (Football Licensing Authority, 2012).
Although the SGSA discounts these for the purposes of reporting, illnesses and pre-existing conditions still make up a large proportion of work for staff on medical cover at football stadiums and as such use vital resources within the ground.
The Football League Association had previously expressed concern over a perceived increase in spectator injuries: 0.42 per 10 000 spectators during the 2007/2008 season compared with 0.26 in 2006/2007. Although from 2007–2012 the total numbers stayed relatively static, there was a 22% decrease in the number of injuries reported in 2012/2013 season (Football Licensing Authority, 2012).
For the 2012/2013 season, the total number of injured spectators reported as having been taken to hospital was 77, compared with 79 in the previous season. The overall new injury ratio was one injury for every 36 947 spectators.
Interestingly, an Australian study of Australian rules football games over a 2-year period found that spectators who supported different football teams generated statistically significant differences in patient presentation rates (F15, 618=1.998, p=0.014) (Zeitz et al, 2013). Historically within the UK some clubs have been known as ‘risk teams’: those whose supporters are well known for violence. The study by Zeitz et al (2013) also demonstrated that there is a positive correlation between the crowd size and patient presentation rates at mass gatherings. This agreed with previous findings.
A 25-year review of data on mass gatherings (sporting events, music festivals) was published by Michael and Barbera in 1997. Their findings suggested that the number of spectators and patients requiring treatment do have a statistically significant relationship (p=0.0001). However, an American study by De Lorenzo et al (1989) of a 50 500 seat indoor stadium, catering to football, basketball, and rock concerts suggested that crowd size alone has only a minor influence on patient volume at any given event.
Another study was undertaken by St John Ambulance Australia and looked at environmental factors (including crowd size, temperature/humidity, and venue type) on the number of patients and the patient problems presenting to first-aid services at large, public events in Australia (Arbon et al, 2001). A patient cohort of 11 956 was evaluated, with patient presentation rate across all event types as 0.992/1 000 attendees, and the transportation-to-hospital rate 0.027/1 000 persons in attendance. Interestingly, the study by Arbon et al found that rates of patient presentations declined slightly as crowd sizes increased. They concluded that prediction of patient load at events is complex and multifactorial (fluctuating with variables such as age, weather, temperature, and type of event). However, they did demonstrate that attention to existing historical data for an event can improve planning and the provision of healthcare services at mass gatherings.
A retrospective review of all emergency medical services records at mass-gathering events held at or near a south-eastern US university between October 24 2009 and August 27 2011, concluded that high volume turnout corresponded to increased need for medical provisions (Locoh-Donou et al, 2013). Locoh-Donou et al also demonstrated that the football category of events had the highest mean number of cases with 37.09 cases/event, for a total of 408 cases on average, demonstrating that certain sports were considered high volume in terms of medical assistance required.
From the literature we can see that crowd data appears to vary from type of event, stadium type, and crowd numbers attending. If UK football follows the same pattern as Australian rules football (something that has not been clearly analysed in the literature yet), it begs the question of whether Fulham attendances for medical assistance compare with national statistics on number of casualties? In order to facilitate a best plan for Fulham, an examination of the club data and comparing it to nationally reported results should allow us to assess patterns in medical provisions for a fixed stadium type in a central London location. We need to know whether crowd size influences number of attendances to medical services as a 15% increase in capacity could potentially overwhelm current services.
The Premier League Football Association published figures from combined statistics for all injuries occurring at Premier League clubs that showed one injury for every 36 948 spectators for the 2012/2013 season (Football Licensing Authority, 2012). Additionally, levels reported for the seasons 2008–2012 ranged from one injury per 24 038 and one injury per 27 940 (Football Licensing Authority, 2012). For Premiership and international matches held at Premiership venues in 2012/2013, there was one injury per 41 061 crowd attendances. Total attendances recorded were 17 738 470. Of these, 29 patients were taken to hospital and 432 spectators were treated for injuries (Football Licensing Authority, 2012).
The only primary data collected, analysed and published by medical staff at Football matches in the UK are from Glasgow Celtic Football Club (Scottish Premier League, playing at Celtic Park) (Crawford et al, 2001), Millwall Football Club over two seasons (English League, non-Premiership, playing at The Den) (Leary et al, 2008) and Aston Villa (English Premier League, playing at Villa Park) (Bhangu et al, 2010). Glasgow Celtic Football Club reported a consultation rate of 1.0/10 000 spectators (for the 1999/2000 season), Millwall 3.1/10 000 spectators (over six seasons), and Aston Villa 1.0/10 000 spectators (for the 2007/2008 season). Unfortunately the published data does not allow comparison over just two seasons. However, as the volume of attandence to medical services are generally low, it is useful to consider these as they are the only full data sets published to date. These values include injuries, trauma and medical presentations, and thus are more representational of workload than Premiership published figures.
Methods
A retrospective analysis was done on data from the existing database held on record at Fulham FC and spanning a period from 2004–2013. This database was designed and used to capture all episodes of care over the length of the football league seasons, allowing a review of all activities from assessment and advice to those requiring hospital admission.
Data collection
For each clinical encounter, data is entered on to standardised patient report forms and stored in a secure facility, as well as onto a computer database in real time. All computer data for Fulham FC season 2004–2013 were analysed. Specific ethical approval was not required as this was retrospective anonymised data, but permission was sought and granted by the operations director and the stadium safety officer at Fulham. Information access included location of injury, nature of presenting complaint, mechanism of injury, home or away fan and discharge mode (hospital, back to game, follow up with GP) and treatment given. The club records allow us to highlight cases where the mechanism of injury was an alleged assault and analyse this data separately in an Excel table.
Results
Nine seasons of crowd medical data from Fulham FC were analysed (2004–2013). During this time there were 830 presentations to medical services, with 512 new injuries/trauma and 318 medical presentations, making up 61.69% and 38.31% of consultations respectively (Figure 1). Overall, 43 patients were transported to hospital (5.18%). During the study period, there was one fatal non-traumatic cardiac arrest. Out of the 512 injuries assessed, a mechanism of assault accounted for just 2.41%.
Out of the 512 new injuries, these are further classified into the type of injury (Figure 2) and the percentage workload (Table 1).
| Number | % | |
|---|---|---|
| Head injury | 18 | 3.50 |
| Back/spinal injury | 10 | 1.95 |
| Fractures/bone injury/dislocation | 20 | 3.91 |
| Soft tissue injury (sprain/strain etc.) | 76 | 14.84 |
| Eye injury | 10 | 1.95 |
| Skin wounds (lacerations/abrasions/nosebleed etc.) | 247 | 28.24 |
| Foreign body | 12 | 2.34 |
| Other | 82 | 16.02 |
| Burns/scalds | 30 | 5.86 |
| Abdominal injury | 4 | 0.78 |
Data from 2007–2014, were analysed in more detail, looking at the location of all new injuries/trauma (Figure 3).
By analysing location for injuries, we found the Hammersmith and Putney stands had slightly higher numbers of injuries; however, when this was calculated as a percentage of the capacity in attendance for each area within the stadium, both individually and over the span of a decade, the numbers for all four stands were comparable, accounting for extremely small numbers (Table 2).
| New injuries total seven seasons | As a percentage of the capacity | |
|---|---|---|
| Johnny Haynes (5 889 capacity home only area) | 20 | |
| Riverside (4 689 capacity home only area) | 44 | 0.34% |
| Putney (7 281 capacity home and neutral official away area) | 57 | 0.94% |
| Hammersmith (7 769 capacity home only area) | 56 | 0.92% |
| Outside ground | 48 | 0.72% |
| Elsewhere | 54 | |
| Not documented | 72 | |
| New injury location total | 361 |
Other locations for injuries occurring included the bars, restaurants, suites, pitch side areas, cottage and turnstiles, with low numbers throughout.
Between 2007–2014 there were 19 documented assaults resulting in a medical consultation at Fulham FC. The injuries sustained can be seen in Table 3).
| Epistaxis | 1 |
| Fracture (nose) | 1 |
| Fracture (clavicle) | 1 |
| Neck injury | 1 |
| Laceration face | 6 |
| Wrist injury | 1 |
| Knee injury | 1 |
| Soft tissue injury face | 3 |
| Abdominal injury | 1 |
| Head injury | 1 |
Discussion
This study has shown that at Fulham FC there have been no significant differences or trends in trauma, medical cases or consultations per 10 000 spectators since 2004 (chi-square tests, 9x2 contingency tables). Statistical analysis was carried out using SPSS v22 (IBM Corp). There is no correlation between injuries of any type and overall attendance at games.
Comparison to other clubs
Over nine seasons there were 4 157 597 crowd attendances at Fulham FC matches, with a consultation rate per 10 000 gate admissions of 1.97. This is comparable to Premiership League teams Celtic (1.0/10 000 over one season, 1999/2000), Aston Villa (1.0/10 000 over one season, 2007/2008) and Milwall (3.1/10 000 over six seasons) (Crawford et al, 2001; Leary et al, 2008; Bhangu et al, 2010).
Comparison to nationally published data from Premiership clubs
Interestingly, looking at the Premiership League's national injuries statistics (data from 2011–2013) our new injuries consultations appear to be higher than the national average, where one injury per 41 061 spectators for 2013 is quoted (Football Licensing Authority, 2012). This may be due to discrepancies in reporting though. Without individually analysing all Premierships teams trauma data, this is impossible to comment further on.
Conclusions
Location
Although the Putney and Hammersmith stands appear to have more injuries occurring than Riverside or Johnny Haynes, by calculating the number of injuries as a percentage of the stand's maximum capacity, the four main stands all have a low number of injuries with no statistical differences.
Assaults
In contrast, however, more assaults occurred in areas where fans mix, irrespective of capacity in those areas. An increased number occurred at the Putney end (where away fans, neutral and home fans can be unsegregated), as well as an increased number occurring just outside the grounds.
Despite being of concern for stadium policy, policing, ground safety, and to the safety of both medical staff and ticket holders in attendance, assaults still thankfully represent only a small proportion of our clients (2%).
There was no statistical difference associated between crowd numbers and either injuries sustained, assaults or transfer to A&E (chi-square test). Fulham FCs plans to increase capacity of the Riverside should not affect match to match provision of medical cover, though will of course be accounted for in major incident planning.
The medical consultation rate at Fulham FC is comparable to reported levels at other clubs, although there is a paucity of published data on medical consultations at football grounds throughout the UK, possibly because mandatory reporting of these is not required by the Football Association. The rate of consultation per 10 000 attendances at Fulham FC has remained around 2/10 000 over the period from 2004–2013 and has not been influenced by the increased crowd capacity or increases in attendance after gaining promotion or entry to the European cup competition. Crowd disturbances resulting in assault have remained at a low level during this period and assaults do not seem to represent a threat to the non-violent fans.
Plans to increase capacity should not affect provision of medical cover, though will be accounted for in major incident planning in the number of medical staff required to attend matches for increased crowd numbers. GP and A&E services should not be stretched by the increased capacity.