A coroner is recommending that the World Kickboxing Association clarifies it rules on medical support required at events following the death of a Sheffield teenager during a championship bout.
Scott Marsden, aged 14, collapsed in the final seconds of the fifth and final round of a fight in Leeds in March 2017 after a kick to the chest.
The Malin Bridge youngster was immediately treated by a team of four medics supplied by a private organisation for the event at the Leeds Martial Arts Academy, in Morley.
An NHS ambulance arrived 21 minutes after the first 999 call, followed by a specialist cardiac arrest team led by a doctor, an inquest heard.
The Forge Valley School pupil was taken to Leeds General Infirmary but died the following day.
A pathologist told the two-day inquest in Wakefield that the teenager died from commotio cordis, a rare disruption of the heart's rhythm caused by a direct blow at a specific moment in the heart beat cycle.
Delivering a narrative verdict on Tuesday, coroner Jonathan Leach described how he was surprised that the owner of the Leeds Martial Arts Academy, Paul Lynch, had not read the rules of the WKA, under which the event took place.
The coroner said he was also surprised that Mr Lynch did not require the medical services organisation which supplied the medical team, TopCat, to supply him with its staff's qualifications in writing.
The inquest heard how one member of the team, who all worked part-time at events, was trained to the equivalent of an ambulance service emergency medical technician level one and the others were classed as first-aiders. He said there was no doctor at the event in an official capacity.
Mr Leach said the rule book of the WKA specified a doctor with trauma experience should be present.
He said that he had been told that there was an expectation from the WKA that medical teams should include a paramedic with trauma experience and that they should carry a defibrillator and have a vehicle to transport casualties to hospital.
But the coroner said this was not specified in the rules.
He also said the "haphazard" way in which TopCat managed equipment available to its medical teams was "most unsatisfactory."
Mr Leach said he would be writing to the WKA recommending that they "make it clear as to what it required in terms of a medical team."
He said that the association should also require referees, or other officials, to check the qualifications of the medical teams supplied to events.
The coroner also recommended a defibrillator should be installed in Mr Lynch’s gym, although he accepted that the medical evidence in Scott's case was that a defibrillator would not have helped.