No official doctor at equestrian event where teen rider died: Inquest

The Sydney Swans team doctor has slammed the “inadequate” medical care provided by organisers of a NSW equestrian event where a teenage horse rider fell to her death, an inquest heard.

The Sydney Swans team doctor has slammed the “inadequate” medical care provided by organisers of a NSW equestrian event where a teenage horse rider fell to her death, an inquest heard.

There was no official doctor onsite when Olivia Inglis was crushed by her horse Coriolanus as the duo tumbled over a jump at the Scone Horse Trials in March 2016.

“The duty of care was not delivered,” AFL Swans Head Doctor Thomas Cross told the NSW Coroners Court today.

“I would hope this would never happen again. It was inadequate.”

Olivia Inglis aboard Coriolanus.

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The inquest heard an on duty medic engaged to provide general first aid didn’t have the equipment necessary to relieve life-threatening pressure on Olivia’s internal organs.

“We live in Australia. We should be aiming for the doctor/paramedic combination (which) is easily accessible within 100km of major regional centres in Australia,” Dr Cross said.

“We owe it to the families to try and mandate the ideal.”

Dr Cross said there would have been a three-minute window for an intensive care paramedic to administer a cannula ensuring Olivia’s severe chest injuries didn’t cut off airflow to her brain, however there was no appropriate medical kit available.

Sydney Swans team doctor Thomas Cross attended the inquest today. Picture: Tim Hunter.

“You can get a hypoxic brain injury after three minutes,” he said.

Dr Cross, who has worked with the Wallabies and Waratahs rugby union teams as well as the Queensland State of Origin side and several NRL clubs, said the level of care Olivia got was unacceptable.

“I can understand how these regional equestrian events are very difficult to run with limited finances… (but) if you’re going to hold an event you need the best medical care,” he said.

“(You’ve got a) 600kg horse running at speed and the rider unfortunately falling from a height… I appreciate the injuries are rare but they do occur.”

Caitlyn Fischer died just weeks later in April, 2016.

The official doctor had told organisers he wouldn’t be attending the event on the day Olivia died.

The international sports medicine expert said equipment should be sorted weeks in advance and double checked 90 minutes before any event, while the three-minute rapid response goal could be reached by using 4WD cars and guard bikes on large courses with difficult terrain.

Earlier Doctor Lyndel Taylor told the inquest she’d been competing that day and arrived at the scene 20 minutes after the crash, only once she’d alerted a race official when she heard a helicopter circling overhead and realised someone was hurt.

Although the doctor had not been asked to be the medical supervisor she was prepared to assist in emergencies, however that information had not filtered down to race officials, the court heard.

And at no stage had Dr Taylor been asked to attend a safety briefing prior to the event.

The court heard the Scone Committee thought her husband, emergency physician Dr Philip Jansen, was the doctor on duty but she told an official he was at home babysitting their kids.

“I said “he’s not here, he’s not coming and he’s never planned on being here”,” Dr Taylor said.

Olivia was instead left in the hands of medic David Keys, who struggled to use defective suction equipment to clear the girl’s airways in a situation Dr Taylor described as “extremely stressful”.

“He told me straight away that she had a tension pneumothorax and there was no kit,” she said.

“He had correctly identified very time sensitive and time critical injuries. His basic equipment was malfunctioning on him which meant he had very limited options to deliver effective care.”

The parents of Olivia Inglis, Charlotte and Arthur Inglis with the parents of Caitlyn Fischer, Ailsa Carr and Mark Fischer outside Lidcombe Coroner's Court Picture: Peter Rae

Dr Taylor said she and her husband had previously been worried about the limited medical equipment provided at events, with Dr Jansen opting to bring his own gear.

“We personally were concerned that there was not adequate equipment,” she said.

“The stock carried within the ambulances was less than we would have carried ourselves.”

Olivia’s death came just weeks before 19-year-old Caitlyn Fischer was also killed from a blunt force head injury when her horse fell and landed on her at the Sydney International Horse Trials in April 2016.

Deputy state coroner Derek Lee is examining the suitability of medical care provided at both events where the tragedies occurred in a two-week inquest at Lidcombe.

The probe is also investigating the communication between organising committees and doctors who are asked to provide medical services.

An incident investigation revealed the jump at which Olivia died did not meet at least three Federation Equestre Internationale cross country course guidelines.

Equestrian Australia has since changed its rules to require a paramedic with the capacity to provide advanced life support to be present at events.

“The rules are a big step forward,” Dr Taylor said.

“The focus needs to be more about prevention of falls rather than management of falls.”

Dr Taylor called for a higher standard of medical care at riding events, adding the limitations of smaller regional events come back to finances.

“I think the national events should fall under the same guidelines as international,” she said.

“We ride over the same jumps… and I don’t really understand what the difference is between national and international events in terms of rider safety.”

Originally published as No official doctor at equestrian event where teen rider died: Inquest