Inquest into the death of Olivia INGLIS

Contributing factors

• inadequate medical equipment at the event (non-functional suction apparatus, no chest decompression kit, no laryngeal mask airway, no endotracheal tube)
• single paramedic working alone without adequate senior medical backup
• absence of confirmed event doctor despite expectation of one's presence
• course design features: vertical fence with downhill approach, no ground line, ambiguous stride distance between elements, use of narrow-diameter rails, white colouring without differentiation, inadequate height difference between rail elements, lack of frangible technology
• insufficient or unclear pre-event briefing and communication among event officials and medical staff
• poor coordination of helicopter retrieval response initially landing at wrong GPS coordinates
• absence of formal incident review processes
• lack of governance clarity on medical staffing requirements

Coroner's recommendations

1. Remove HSI as preferred ambulance service from NSW Eventing Organisers Handbook and nominate current preferred provider
2. Appoint a National Safety Manager on full-time basis
3. Create the position of Event Safety Officer with specified qualifications and duties
4. Expand Technical Delegate position description to include comprehensive event oversight and provide training on expanded role
5. Develop professional development and ongoing education program for Event officials with review and re-accreditation processes
6. Clarify whether EA Guide for Course Designers is mandatory and whether non-conformity constitutes breach of rules
7. Amend EA Guide to provide clear definitions of 'true distance', 'vertical fence', 'uphill' and 'downhill' approaches
8. Conduct comprehensive review of EA Guide and conduct annual reviews to reflect international developments
9. Develop peer review mechanism for cross country courses by equivalent or higher category course designer
10. Amend Rules to require course designer present during cross country test; if unable, replace with equivalent designer
11. Develop robust incident review process for serious incidents (fatalities, head/spinal injuries requiring overnight hospitalisation) with independent experts, formal interviews, preliminary safety warnings, public recommendations, and implementation tracking
12. Mandate formal course walk prior to cross country test with technical delegate, course designer, athlete representatives, event safety officer, and organising committee
13. Require technical delegates and ground jury to collect and review show jumping performance data and consider elimination or downgrading from cross country
14. Implement confidential reporting system (with anonymity option) for safety concerns during and after events
15. Develop formal post-event reports from athlete representatives, technical delegates, chief stewards, and ground juries reviewed by National Safety Manager with feedback to organisers and course designers
16. Amend athlete representative rules requiring appointment for all events, communication of contact details 7 days before event, in-person introduction at briefing, presence throughout competition, and formal evaluation documents
17. Research and regularly provide information to members on PPE standards most likely to mitigate injury risk
18. Develop standardised data collection system defining 'near miss', training fence judges, incorporating video recording, creating expert review panel, and providing database of fence incidents accessible to members
19. Mandate at each event a minimum of one Medical Response Team (two providers minimum) with one provider having skills in: airway management (minimum LMA, ideally intubation/surgical airway), chest decompression, pelvic binder and C-collar application, IV insertion and analgesia, fracture splinting
20. Mandate Event Doctor (emergency medicine practitioner) where geographically possible as member of Medical Response Team
21. Mandate two Medical Response Teams when show jumping and cross country occur concurrently
22. Require Event Doctor or Medical Response Team to determine number of teams needed to achieve 3-minute response time
23. Mandate pelvic splint and cricothyrotomy kit in medical equipment available at event with pre-event review and 90-minute functionality check
24. Mandate one 4WD vehicle with rotating beacon lights per Medical Response Team
25. Mandate 3-minute response time for Medical Response Teams to reach serious incidents where possible
26. Require Event Doctor or Medical Response Team to be consulted on Eventing Serious Incident Management Plan prior to event and attend pre-event briefing
27. Mandate cessation of all riding phases when serious incident occurs requiring Medical Response Team attendance with clearance required before competition resumes
28. Require Event Organising Committees to advise all competitors of medical services available at event at least 7 days before commencement
29. Require National Medical Consultative Group to conduct annual review of Medical Guidelines and periodic reviews for emerging trends
30. Mandate Eventing Serious Incident Management Plan for every event including venue inspection by medical team, contact information for all staff, GPS coordinates for fence judges and incident location information, notification of imminent medical response arrival
31. Mandate viewing of Eventing NSW Cross Country Critical Incident Training video by all fence judges prior to event
32. Mandate minimum age requirement for fence judges
33. Inform fence judges of voluntary first aid training availability and arrange training for volunteers prior to their first duties at an event