Inquest into the death of David BROWNE

Contributing factors

• Failure of ringside doctor to examine boxer after signs of concussion at end of round 11
• Failure of referee to apply mandatory 8-count after knockdown at end of round 11
• Boxer suffering concussion with impaired ability to defend himself entering round 12
• Failure of combat sports inspectors to intervene despite duty to do so
• Lack of mandatory training for ringside doctor in concussion recognition
• Lack of clear rules and communication regarding boxer fitness assessment
• Inadequate medical equipment and lack of evacuation plan
• Confusion about which rules applied to the contest

Coroner's recommendations

1. Provide transcript of inquest to next review of Combat Sports legislative scheme
2. Amend Combat Sports Act 2013 to provide comprehensive rules governing all boxing contests in NSW
3. Amend s.63 of Combat Sports Act 2013 to clarify ringside doctor's duty to stop contests when there is serious impairment of ability to defend or likelihood of serious injury
4. Develop mandatory annual training for industry participants, medical practitioners and promoters on rules, roles, medical examination triggers, head injury recognition, and concussion identification
5. Implement accreditation process requiring annual training completion
6. Amend Combat Sports Rules to establish clear pre-determined signal method for medical examination requests during contest
7. Require referee and attending medical practitioner to confer at contest start on communication methods
8. Establish mandatory 'trigger' events requiring medical examination including knockdown, suspected concussion, or inspector/referee direction
9. Require medical assessment for concussion using pocket concussion guide or equivalent tool
10. Allow medical examination at any stage including during rounds and between rounds
11. Require rounds to stop to enable medical examination and extend time between rounds if necessary
12. Require referee to confer with medical practitioner after rounds with significant head blows or concussion signs
13. Define knockdown clearly in rules
14. Require attending medical practitioners to position themselves with effective communication and unobstructed view of combatants
15. Ensure medical equipment available ringside including airway support, oxy-viva mask, and oxygen
16. Require promoter to submit Evacuation Plan to Combat Sports Authority before contest, including venue street address, paramedic access route, designated emergency caller, patient information to convey, and nearest neurosurgical hospital location
17. Require inspection of evacuation plan route by medical practitioner, promoter, and all industry participants before contest commencement
18. Investigate whether paramedic attendance should be required in addition to attending medical practitioner
19. Introduce automatic timing systems for all boxing contests