Coroner's Finding: Sarah Kate Waugh

Contributing factors

• Horse (Dargo) unsuitable for beginner riders - ex-racehorse that had raced only 15 days before delivery to TAFE
• Inadequate pre-implementation risk assessment for new in-house riding program
• Inadequate assessment and vetting of individual horses prior to use
• Inexperienced instructor (Sara Falkiner) without formal riding instruction qualification or independent accreditation
• Inadequate supervision of instructor by Mr. Bastian
• Open paddock gate allowing access to laneway
• Student lost left stirrup and control of horse, which accelerated to gallop due to racing instincts

Coroner's recommendations

1. Review and amend Certificate II in Agriculture unit performance criteria and assess feasibility of teaching beginner riders stock work skills within 40 hours tuition and less than 40 hours actual riding time
2. Review adequacy of relying on staff prior learning and industry experience without independent accreditation of riding skill
3. Review best practice for assessment of horses for use in these units
4. Amend tender documents to require horses educated for use with beginner riders, experienced in lessons with beginner riders, educated for stock work, and experienced in stock work
5. Tender documents must exclude ex-racehorses and horses under 10 years of age
6. Tender documents must require detailed information about each horse including age, breed, height, date of purchase, source of purchase, education level for beginner riders, recent experience with beginner riders, education for stock work, experience in stock work, racing training or racing history, Australian Stud Book Microchip Number, Australian Identification Number, and details of how horses would be kept on non-TAFE days
7. Assessment of tender applications must account for the significance of missing information relative to ownership duration
8. Assessment of tender applications should include cross-checks using Australian Stud Book Microchip Number and Australian Identification Number
9. TAFE NSW undertake independent occupational health and safety audit of Rural Skills Campus including risk assessment of paddocks and properties used for riding exercises to ensure fitness for purpose and use of single-purpose gates
10. Undertake risk assessment of equipment to be used in course instruction
11. Review assessment process for horses, including necessary assessor experience and adequacy of assessment forms and tools; consider independent assessment by two staff riding each horse with measurement of deceleration response from gait to gait within 3-beat stride
12. Strictly enforce guidelines prohibiting use of cameras and phones whilst riding
13. TAFE NSW adopt the Australian Horse Industry Council Horsesafe Code of Practice in the conduct of horse units
14. The Australian Skills Quality Authority, AgriFood Skills Australia and TAFE NSW review the unit guide, its implementation including horse selection, and recognition of staff prior experience in the absence of independent accreditation