Inquest into the death of Adelene Leong at the Royal Adelaide Show finds there were many opportunities to save her life

There were multiple missed chances to fix a dangerous ride at the Royal Adelaide Show that killed eight-year-old Adelene Leong, the deputy coroner has found – as he called for urgent changes.

The death of an eight-year-old girl who was thrown from a ride at the Royal Adelaide Show was “inexcusable” and the circumstances leading to the horror accident must never be repeated, an inquest has found.

Deputy Coroner Ian White has urged an urgent nationwide reform of the regulation of amusement rides – including the creation of centralised databases which would record safety concerns around particular rides.

He also recommended the Royal Horticultural Society of South Australia, which runs the show, to conduct a review of the configuration of their infrastructure to ensure emergency services can make it to an incident quickly.

Adelene Leong, 8, was flung from the Airmaxx 360 ride on September 12, 2014.

She suffered critical injuries and died at the scene.

Opening the inquest into Adelene’s death last year, counsel assisting the Coroner Sally Giles said the Airmaxx had a “troubling history” of incidents in the month before the accident.

Deputy Coroner Ian White heard that the recommended height limit for the ride was 140cm but the ride was advertised in Adelaide with a 120cm height limit.

Adelene was 138cm tall in boots.

As a result, Ms Giles said the ride had been “plagued with complaints, many of them by young children below the manufacturer’s recommended height limit”.

Adelene Leong was thrown off the Airmaxx 360 ride in 2014 and died at the scene.

On Tuesday, Mr White delivered his 155 page findings into the accident.

“Adelene’s death that day was inexcusable,” he said.

“It could and should have been prevented. The circumstances of her death must never be allowed to be repeated.”

Mr White said that from the moment the Airmaxx ride arrived in Australia it had been beset with problems which would end in the death of the eight-year-old.

“This inquest has revealed the many times opportunities were missed to change Adelene’s fate,” he said.

“The evidence of these missed opportunities is likely to produce understandable reactions of frustration and despair to the public.

“There needs to be a meaningful response to honour Adelene’s short life.”

Screen grabs from footage released by the Coroner's Court of Adelene Leong seconds before she was thrown from a ride at the Royal Adelaide Show and killed.

Evidence photographs tendered to the Industry Court of the Airmaxx 360 ride at the Royal Adelaide Show, in which Adelene Leong was flung to her death. Pictures: SafeWork SA via the Industrial Court.

Among a raft of recommendations, Mr White found there was an “urgent need for reform of the regulation and governance of amusement rides in Australia”.

This includes the creation of national databases for plant equipment which would allow state-based safety bodies to check on alerts about rides across the country.

Franco Camatta, who acted for Adelene’s mother at the inquest, said his client had been devastated by incident.

“It has been a very unfortunate series of events,” he said.

“It hasn’t been an easy time for her at all. She lost her husband a few years before and came to Adelaide for a holiday with her friends and they went to the show for some fun and she took her daughter home in a box.”

While the scope of the inquest was broad, Ms Giles confirmed at an earlier hearing that the decision by SafeWork SA not to prosecute the owners of the ride for breaches of work, health and safety protocols would not be examined.

Following Adelene’s death, the ride was sold to a touring carnival in the UK for $180,000.

At the Hull Fair in England in 2019, a woman suffered a fractured skull when she was thrown from the Airmaxx.

The UK Health and Safety Executive has been investigating the crash but has so far not confirmed whether the ride which killed Adelene was the same ride operating in Hull.

However, Mr White in his findings said he had heard evidence that it was the same ride.

Originally published as Inquest into the death of Adelene Leong at the Royal Adelaide Show finds there were many opportunities to save her life