Cuckson Report // Pippa Cuckson
Coroner’s 31 Recommendations to Make Australian Eventing Safer
Sydney, Australia’s deputy state coroner presented his findings into the deaths of Olivia Inglis and Caitlyn Fischer, who both died at events in 2016.
Coroner Offers 31 Recommendations to Make Australian Eventing Safer
A coroner has delivered 31 extensive recommendations about the future organisation of eventing in Australia, requiring a wholesale change in mind-set about safety, review processes and peer-group input into course approval.
Today in Sydney, deputy state coroner Derek Lee presented his findings into the deaths of Olivia Inglis, 17, and Caitlyn Fischer, 19, both at spring 2016 events in New South Wales. If applied, Mr Lee’s suggestions would make Equestrian Australia’s (EA) eventing rulebook the most comprehensive in the world.
They include organised course-walks with officials for all competitors and a rider-representative system at all levels of competition; at-event demotion of riders to a lower level if they do not appear competent; inspection of courses by a second designer, on the top of the existing supervision of the technical delegate; and a central database enabling everyone to check which fences have caused problems at any event.
Recommendations about medical provision includes a maximum three minutes response time, and that ALL riding phases be suspended during a serious incident until medics clear the competition to continue.
Olivia was crushed when her horse fell in the CNC** at Scone on March 6, 2016. She was still alive when assistance reach her, but died from her chest injuries. On April 30, Caitlyn died instantly from “blunt force head injury” in the CCI* at Sydney International. Mr Lee determined the manner of death for both girls was misadventure.
Mr Lee’s inquiry this summer was extended from two to three weeks due to the volume of evidence. He described it as one of the most moving experiences of his career. He covered nine issues, including whether safety procedures were adequate and whether course design contributed to the deaths.
He presented 107 pages of findings in Olivia’s case, and 80 pages for Caitlyn, with both documents containing 31 “consolidated recommendations” to EA, for improving safety and its own transparency.
Regarding the causes of death, Mr Lee accepted witness accounts that Caitlyn’s horse Ralphie was distracted on the approach to fence 2, a sloping table-style portable, and put in an extra stride; what distracted him may never be known.
Mr Lee’s findings were more extensive in Olivia’s case because of the considerable debate over fence 8a and b’s compliance with FEI and EA guidelines. Olivia’s horse Togha fell at the second element. Others including her mother Charlotte had expressed prior concern about its presentation, construction and distances. Mr Lee has expressly banned any publication of imagery of this fence.
Mr Lee stopped short of mandating the future use of frangible technology, which has already increased substantially in Australia follow these tragedies. But he felt frangibles should have been employed at 8a and b. He also offered extensive opinion about the delicate relationship between “guidelines” and designer discretion.
It was “unacceptable” for 8a and b to breach FEI-EA Guidelines, as a vertical with a downhill approach. Mr Lee was also concerned about its bright white colour: “The rails ….were deliberately painted white as a risk mitigation feature to distinguish the fence in shade and to keep the focus of a horse on the top rail. Notwithstanding, it would have been possible to enhance this risk mitigation even further by painting the rails in different shades of white.”
The slim 175mm diameter of some rails was acceptable – “reflective of a worldwide trend at the time that resulted in fence rails with a narrower diameter than had been built previously. It appears that this trend was a product of the advent of frangible technology.
“Whilst the use of a groundline appears, from a course design perspective, to be a matter of personal style and design philosophy, the evidence establishes that it is also an appropriate risk mitigation strategy. If this is the case, then risk mitigation should clearly take precedence over matters of personal course design style. Whilst the evidence establishes that fence 8b/8b could be regarded as a safe fence without a groundline, it also establishes that it could have been made safer with one.
“It is to be remembered that the FEI Guidelines specifically provide that ‘the aim of the [course designer] is to provide a suitable test for the level of competition without exposing horses and athletes to a higher risk than what is strictly necessary to produce the right test for that level’. To give effect to this principle, it can be accepted that fences should be designed with all risk mitigation methods available. In the case of 8a/8b, this did not occur.
“The fact that frangible technology was not considered, and the other risk mitigation methods were not used meant that fence 8a/8b exposed riders to a higher risk than was strictly necessary.”
Mr Lee’s other main emphasis is enhanced risk mitigation and medical cover.
Few participants knew that the official New South Wales ambulance service had “priced itself out of the market” years earlier, and that events were instead hiring a private provider which has since gone out of business.
David Keys, who assisted Olivia, was a qualified physician’s assistant but not an advanced paramedic. He did not possess the equipment necessary to relieve her life-threatening injuries, which Mr Lee found “most troubling.”
There was no official doctor at Scone, contradicting evidence that Lyndel Taylor – who was riding herself – was formally appointed when her husband Dr Philip Jansen was unable to attend. Mr Lee said “attempts were still being made to locate Dr Jansen to have him attend fence 8a/8b…. it was only by chance that Dr Taylor heard a radio broadcast, advised that Dr Jansen was not present, but that she was available to assist.”
Margot White, a registered nurse, also ran forward to help. At the inquest, Mr Keys agreed it would have been impossible on his own to manage Olivia’s airway whilst providing CPR.
In the light of Scone, Sydney arranged for two doctors, and asked the private ambulance service to supply their “most experienced people,” which did not include registered paramedics.
Caitlyn’s mother Ailsa Carr, herself a nurse, was the first to reach her daughter and realised she was dead. Two event volunteers nonetheless tried to revive her, to Mrs Carr’s distress, before the official medics arrived “at least” eight minutes after the fall.
Mr Lee also advised EA on its future handling of the aftermath of serious incidents, after hearing lengthy evidence about the EA’s disconnected review, alleged censorship and the Inglis and Fischer families’ dismay about their low level of involvement.
He also considered that equestrianism is “heavily reliant upon volunteers to perform important functions,” that despite “willingness it is often difficult to recruit sufficient numbers of volunteers to perform important functions” and that there are “certain financial constraints in circumstances where there is significant reliance on public funding which is in turn directed towards high performance programs.”
Caitlyn’s father Mark said of the findings: “The onus is now squarely on Equestrian Australia to take each of the recommendations, as their platform in which to improve safety standards and risk mitigation. There are so many riders in Australia, young men and women, who have parents just like us and we don’t want them to have to go through what we have been through. It’s been a journey but just nothing but pain.”
EA said “Equestrian Australia (EA) acknowledges that the NSW Coroner’s Final Report is constructive and endorses the work we have underway to strengthen safety and risk mitigation in our sport.
“EA will now commence a period of consultation with key stakeholders across the country. The Coroner has made some detailed recommendations, and we want to ensure that we consider the viability and practicality of the recommendations.
“The Board and staff of Equestrian Australia again offer our condolences to the families. We acknowledge the strength and courage both families have shown throughout this difficult process.
The full findings can be downloaded from the NSW coroner’s website here.
The 31 recommendations:
For the purposes of these recommendations: Event means all international (Concours Complet International) and national (CCN/CNC) eventing competitions held in accordance with the Fédération Equestre Internationale (FEI) Eventing Rules and Equestrian Australia (EA) National Eventing Rules.
The following recommendations are made to the President of Eventing New South Wales:
1. That the NSW Eventing Organisers Handbook (the Handbook) be immediately updated to remove reference to Health Services International (HSI) as the preferred New South Wales ambulance service for eventing competitions, and that the Handbook be amended to nominate the current preferred service provider (if any).
2. That a National Safety Manager (NSM) be appointed on a full-time basis.
3. That the position of Event Safety Officer (or equivalent) be created and that: (a) the necessary skills and qualifications for the position, together with the duties and responsibilities of the position, be identified in a position description; and (b) an Event Safety Officer be appointed for every Event.
4. That: (a) the position description of Technical Delegate (TD) be amended to include advising Event Organising Committees in relation to all aspects of an Event, with particular focus on the Cross Country Test, and applicable amendments to the FEI Eventing Rules and EA National Eventing Rules; (b) education be provide to TDs on the role change by way of training seminars; and (c) consideration be given to a national standard providing a reimbursement fee for TDs.
5. That for the purpose of Event official accreditation, EA: (a) Develop a professional development program for ongoing education and training; (b) Review and update the current process for accreditation and re-accreditation; (c) Develop a program for the monitoring and review of the performance of Event Officials on an ongoing and regular basis.
6. That the current version of the EA National Eventing Rules be amended to clarify whether: (a) the EA Guide for Cross Country Course Designers and Officials is to be read in conjunction with the EA Rules; and (b) whether non-conformity with the FEI Eventing Cross Country Course Design Guidelines and the EA Guide for Cross Country Course Designers and Officials amounts to a breach of the EA Rules.
7. That the current version of the EA Guide for Cross Country Course Designers and Officials be amended to: (a) provide a clear and unambiguous meaning of the term “true distance”; (b) eliminate any reference to the term “true vertical” and provide a clear and unambiguous meaning of what constitutes a “vertical” fence; (c) provide a clear and unambiguous meaning of what constitutes an “uphill approach” and “downhill approach”; and (d) provide a clear and unambiguous explanation of the circumstances in which it is acceptable and not acceptable for a vertical fence to be used.
8. That: (a) a comprehensive review of the EA Guide for Cross Country Course Designers and Officials be conducted with a view to determining if aspects of cross country course design should be incorporated as mandatory rules, as opposed to discretionary guidelines; (b) at least an annual review of the EA Guide for Cross Country Course Designers and Officials be conducted to ensure that it appropriately reflects international and national developments and improvements relating to competitor safety.
9. That a mechanism be developed by which a Cross Country Test designed by a Course Designer is subject to peer review and inspection by another Course Designer of equivalent or higher category of accreditation, to certify that the Cross Country Test is appropriate for competition, prior to the commencement of an Event.
10. That Section 5220.127.116.11 of the current National Eventing Rules be amended to provide that: (a) the Course Designer of a Cross Country Test is to be present (and not competing) during the Test in order to critically review the performance of combinations during the Test as it relates to aspects of course design; (b) where the Course Designer of a Cross Country Test is unable to be present during the Test, that this fact be reported to the Event Organising Committee with arrangements made for a replacement Course Designer of equivalent or higher category of accreditation to be present during the Test to perform the requirement set out in (a) above.
11. That a robust and comprehensive process be developed for the review of serious incidents requiring a medical response at an Event. In this regard “serious incident” means: (i) a fatality; or (ii) a head or spinal injury which requires an overnight admission to hospital. Such a review process should include, but is not limited to, the following: (a) the creation of a panel consisting of equestrian experts (with experience in, for example, competing and course design) and non-equestrian experts (with experience in, for example, risk management) available to be selected as members of a Review Panel, none of whom are office holders with EA or any state branch of EA; (b) formation of a Review Panel comprised of at least two equestrian experts; (c) input sought from the competitor, or family of a competitor, involved in a serious incident requiring a medical response, as to the composition of the Review Panel; (d) eyewitnesses and persons directly involved in a serious incident requiring a medical response being formally interviewed and requested to provide written statements in a timely manner following the serious incident; (e) the issuing of preliminary findings and/or a safety warning/advisory to EA members and Event Organising Committees if the Review Panel determines that it has identified any issues which may potentially adversely affect the safety and welfare of competitors at Events immediately following a serious incident; (f) the publication to all EA members of any recommendations made by a Review Panel, with a process implemented for feedback to be provided by EA members and reviewed by EA; and (g) the publication to all EA members of updates regarding the progress of implementation of any recommendations made by a Review Panel.
12. That prior to the commencement of an Event: (a) all competitors in the Event be notified of the availability to participate in a formal course walk, with the TD, Course Designer, Athlete Representatives, Event Safety Officer and a member of the Event Organising Committee to be present; (b) arrange for a formal course walk to be conducted prior to the commencement of the Cross Country Test.
13. That at Events where the Jumping Test precedes the Cross Country Test: (a) the TD and Ground Jury (if present) be required to collect and review data to determine whether the number of penalties incurred by a combination in the Jumping Test is potentially adversely indicative of the capacity of the combination to compete safely in the Cross Country Test; and (b) in circumstances where such a determination is made, require that the TD and Ground Jury give consideration to whether the combination should be eliminated from competing in the Cross Country Test, or downgraded to a lower category of competition.
14. That a reporting system be implemented by which a competitor at an Event is able to confidentially (and with the offer of anonymity): (a) communicate any safety-related concerns during an Event; and (b) provide feedback about safety-related concerns following an Event; for consideration and review by the Event TD, Event Safety Officer, and NSM.
15. That any implemented reporting system should include, but is not limited to, the following: (a) completion of confidential post-event reports by the Athlete Representative, TD, Chief Steward (if present) and Ground Jury (if present) at the conclusion of each Event; (b) review of completed confidential post-event reports by the NSM; (c) reports to be sent directly to the NSM by each official, or collected and sent via the Event TD; (d) a formal feedback system in which the NSM is able to provide written feedback (including statistical data on rider falls) and education to organising committees, Course Designers and TDs; and (e) consideration of the use of available powers of sanction against an organising committee.
16. That Annex F of the current version of the National Eventing Rules be amended to provide that: (a) Athlete Representatives for each competition class are required to be appointed for all Events; (b) the name and contact details of the Athlete Representatives are to be communicated to all competitors, and published in the Event draw, at least seven days prior to the Event; (c) the Athlete Representatives are to be introduced in person at the Athlete briefing (if one is held) preceding the Event; (d) the Athlete Representatives are to be present at the competition venue whilst riders are competing and for the entire duration of the competition; (e) following the formal course walk at an Event, and following each day of competition, the Athlete Representatives are to meet with the TD and Course Designer to discuss any safety related issues concerning the Cross Country Test that have been either identified by the Athlete Representatives, or communicated to the Athlete Representatives by a competitor.
17. That the following be developed: (a) a position description setting out the role and responsibilities of an Athlete Representative; and (b) a formal evaluation document which is to be completed by Athlete Representatives following the formal course walk, following each day of competition, and at the conclusion of the competition to record any safety-related issues identified by the Athlete Representative, or communicated to the Athlete Representative by a competitor, for review by the TD, Event Safety Officer and NSM.
Personal Protective Equipment 18. That: (a) research be undertaken to determine which range of personal protective equipment (PPE) garments meet national and international standards and are most likely to mitigate the risk of injury or reduce the seriousness of injury to riders; and (b) provide on a regular basis to its members the most currently available information regarding such research and standards.
19. That a standardised data collection system be developed for all Events which: (a) Provides a clear and unambiguous definition as to what constitutes a “near miss” at a fence/obstacle; (b) Provides training to fence judges to allow for the accurate recording of instances of a near miss or fall at a fence/obstacle, with such information to be included in the TD Report prepared at the conclusion of an Event; (c) Incorporates the video recording (where available, and whether conducted by EA or obtained from third party recording services) of each fence/obstacle in a Cross Country Test during competition; (d) Creates a panel of suitable experts (consisting of, for example, TDs, Course Designers and experienced riders) to review data collected in accordance with (b) and (c), above to identify any trends which may adversely impact the safety of competitors at Events; (e) Allows for collected data to be input into a database; and (f) Makes such a database available to EA members to be able to readily identify the particular fence/obstacle, the particular Cross Country Test, and the particular Course Designer of the Cross Country Test, where a near-miss or fall has occurred.
20. That the current version of the National Eventing Rules be amended to mandate that at each Event: (a) there must be at least one Medical Response Team consisting of a minimum of two medical providers, one of whom has the minimum skills and experience to: (i) secure an airway, at a minimum with a laryngeal mask airway and ideally with the skill to intubate or perform surgical airway; (ii) decompress a chest with either a purpose-made long decompression cannula or thoracostomy/chest tube; (iii) apply quality pelvic binder (SAM splint or T-pod) and C-collar; (iv) insert IV and give crystalloid and analgesia; and (v) apply suitable splints to fractures; (b) where reasonably possible, subject to geographic limitations, a medical practitioner (the Event Doctor) is to be one of the members of the Medical Response team; (c) there must be two Medical Response Teams at Events when the show jumping test and cross country test are held concurrently; (d) the Event Doctor (if available), or the Medical Response Team, in consultation with the event organising committee and Event Safety Officer is to determine the number of Medical Response Teams that are required to achieve a response time of three minutes or less to the location of a serious incident requiring medical assistance.
21. That the current version of the National Eventing Rules be amended to mandate that a pelvic splint and cricothyrotomy kit are to be included in the medical equipment available at an Event, with: (a) the list of medical equipment to be provided to the Event Doctor or Medical Response Team before the Event for review; and (b) the medical equipment to be checked by the Event Doctor or Medical Response Team to be functional and in good order at least 90 minutes before the commencement of an Event.
22. That the current version of the National Eventing Rules be amended to mandate that each Event is to have one vehicle with four wheel drive capability and rotating beacon lights, for each Medical Response Team, that can be used to provide a medical response in the case of serious incident.
23. That the current version of the National Eventing Rules be amended to mandate that a Medical Response Team must deploy to the location of a serious incident requiring a medical response (a) during a Jumping Test, in three minutes or less; and (b) during a Cross Country Test, in three minutes or less, where possible.
24. That the current version of the National Eventing Rules be amended to mandate that before the commencement of an Event, the Event Doctor or Medical Response Team is to (a) be consulted in relation to the Eventing Serious Incident Management Plan and requested to provide feedback as to the adequacy of medical coverage and response; and (b) attend any pre-Event briefing where the Eventing Serious Incident Management Plan is discussed.
25. That the current version of the National Eventing Rules be amended to mandate that all riding phases at an Event be ceased in the case of a serious incident requiring the attendance of a Medical Response Team and no riding re-commence until all Medical Response Teams have returned to their base location and provided clearance for the Event to continue.
26. That the current version of the National Eventing Rules be amended to mandate that an Event Organising Committee is to advise all competitors registered to compete at an Event of the nature and level of medical services available at the Event, at least seven days before the commencement of the Event.
27. That the National Medical Consultative Group (NMCG) is to be required to: (a) conduct an annual review of the Medical Guidelines; and (b) conduct periodic reviews of the Medical Guidelines to identify developing trends and specific issues relevant to the safety of Event competitors.
28. That the current version of the National Eventing Rules be amended to mandate that an Eventing Serious Incident Management Plan (ESIMP): (a) is to be developed for every Event by an Event Organising Committee, prior to the commencement of the Event; (b) is to be provided to the Event Doctor or Medical Response Team for an Event, prior to the commencement of the Event; (c) is to ensure that an Event Organising Committee is to arrange for the Event Doctor or Medical Response Team to conduct a venue inspection, prior to the commencement of the Event, to ensure that any medical response can be provided in a timely manner, including transportation to off-site medical services; (d) is to ensure that all Event staff (including volunteer staff) are provided with all necessary contact phone numbers for Event Officials, the Event Doctor, and Medical Response Team, and any other medical services providers in the case of a serious incident requiring a medical response; (e) is to ensure that all Event staff (including volunteer staff) are provided with necessary information (including via a mobile phone app) to enable external medical services providers (such as NSW Ambulance) to be directed to the location of a serious incident requiring a medical response in a timely manner; (f) is to ensure that in the case of a serious incident requiring a medical response, Event staff (including volunteer staff) at the location of the serious incident be advised that the arrival of a medical response has been arranged and is imminent; and (g) is to ensure that the TD has possession of the GPS coordinates for the location of each fence judge, so that such information can be provided to enable external medical services providers (such as NSW Ambulance) to be directed to the location of a serious incident requiring a medical response in a timely manner.
29. That the current version of the National Eventing Rules be amended to mandate that the Eventing NSW Cross Country Critical Incident Training video is to be viewed by all fence judges prior to an Event.
30. That the current version of the National Eventing Rules be amended to mandate a minimum age requirement for fence judges at all Events.
31. That all fence judges be informed prior to an Event of the availability of voluntary first aid training, and that EA make arrangements for such training to be provided to any fence judges who volunteer, prior to the fence judge performing any duties, at an Event.