Inquest into the death of Caitlyn FISCHER

Contributing factors

• horse distraction at fence 2 causing loss of focus
• horse attempted extra canter stride prior to jump
• accidental fall from horse
• delayed medical response (approximately 5 minutes)
• inadequate medical coverage specifications in EA rules
• lack of formal course walk prior to competition
• inadequate guidance on personal protective equipment standards

Coroner's recommendations

1. Update NSW Eventing Organisers Handbook to remove HSI as preferred service provider
2. Appoint full-time National Safety Manager
3. Create position of Event Safety Officer for every event with defined skills and qualifications
4. Amend Technical Delegate position description to include risk management advice and education
5. Develop professional development program for Event Official accreditation
6. Clarify in EA Rules relationship between EA Guide and Rules regarding course design compliance
7. Amend EA Guide to provide clear definitions of 'true distance', 'vertical fence', 'uphill/downhill approach'
8. Comprehensive review of EA Guide to determine what should be mandatory rules vs guidelines
9. Implement peer review system for Cross Country courses prior to competition
10. Require Course Designer presence during Cross Country Test for critical review
11. Develop robust incident review process for serious incidents with specified panel composition and family involvement
12. Mandate formal course walk prior to Cross Country Test with Course Designer, Athlete Representatives, and officials
13. Require collection and review of Jumping Test penalties to assess Cross Country readiness
14. Implement confidential reporting system for safety concerns (including anonymous reporting option)
15. Establish formal reporting and feedback system for Athlete Representatives, Technical Delegates, and officials
16. Amend Athlete Representative requirements for appointment at all events with defined communication timeline and duties
17. Develop position description and evaluation documents for Athlete Representatives
18. Conduct research and provide regular guidance to members on PPE standards meeting current best practice
19. Develop standardized data collection system including near miss definition, fence judge training, video recording, expert review panel, and database accessible to members
20. Mandate Medical Response Team with minimum two providers with specified trauma skills (airway management, chest decompression, pelvic binder, IV access, fracture splinting)
21. Require Event Doctor where reasonably possible subject to geographic limitations
22. Mandate two Medical Response Teams when show jumping and cross country concurrent
23. Mandate three-minute response time for Medical Response Teams
24. Require pelvic splint and cricothyrotomy kit in medical equipment with pre-event checking
25. Mandate four-wheel drive vehicle with rotating beacon lights for each Medical Response Team
26. Require cessation of all riding phases during serious incident response
27. Require event organizers to advise competitors of medical coverage level at least seven days before event
28. Require National Medical Consultative Group to conduct annual and periodic reviews of Medical Guidelines
29. Mandate Eventing Serious Incident Management Plan for every event with specified requirements including venue inspection and GPS coordinates for fence judges
30. Mandate viewing of Eventing NSW Cross Country Critical Incident Training video by all fence judges
31. Establish minimum age requirement for fence judges
32. Inform fence judges of voluntary first aid training availability and provide arrangements for provision