CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Olivia Inglis Hearing dates: 13 to 24 May 2019; 22, 23 and 24 July 2019 Date of findings: 4 October 2019 Place of findings: Coroner’s Court of New South Wales, Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – Equestrian Australia, FEI, eventing, cross country test, show jumping test, Scone Horse Trials, Sydney International Horse Trials, course design, riders representative, fence judge, medical response, medical coverage, medical equipment, event management, risk mitigation, data collection, personal protective equipment, incident review system File number: 2016/75934 Representation: Dr P Dwyer, Counsel Assisting, instructed by Ms A McCarthy (Crown Solicitor’s Office) Mr B Hodgkinson AM SC and Ms K Edwards for Equestrian Australia instructed by Ms R Arnold (Hall & Wilcox) Findings: Findings pursuant to section 81(1) of the Coroners Act 2009: Identity The person who died was Olivia Inglis. Date of death Olivia died on 6 March 2016. Place of death Olivia died at Gundy NSW 2337. Cause of death The cause of Olivia’s death was chest injuries. Manner of death The manner of death was misadventure. Olivia sustained the chest injuries after suffering an accidental fall whilst competing in the cross country phase of an eventing competition. Recommendations: Consolidated recommendations pursuant to section 82 of the Coroners Act 2009 are contained in Appendix A. Non-publication orders: Pursuant to s. 65(4) of the Coroners Act 2009, I direct that the following parts of the coronial file and brief of evidence are not to be supplied to any person until such time as any application is made and any contrary direction is made in that regard: 1. The sensitive photographs taken at the scene of the incident involving Olivia Inglis contained in Exhibit 1, Volume 1: Olivia Inglis, Tabs 6 and 13; 2. The sensitive photographs taken at the scene of the incident involving Caitlyn Fischer contained in Exhibit 1, Volume 1: Caitlyn Fischer, Tab 19; 3. The video footage of the incident involving Caitlyn Fischer contained in Exhibit 1, Volume 1: Caitlyn Fischer, Tab 22; and 4. The photograph of the fence 8A/8B combination contained in Exhibit 26. Pursuant to s. 74(1)(b) of the Coroners Act 2009, I direct that the following parts of the coronial file and brief of evidence containing sensitive material are not to be published: 1. The sensitive photographs taken at the scene of the incident involving Olivia Inglis contained in Exhibit 1, Volume 1: Olivia Inglis, Tabs 6 and 13; 2. The sensitive photographs taken at the scene of the incident involving Caitlyn Fischer contained in Exhibit 1, Volume 1: Caitlyn Fischer, Tab 19; 3. The video footage of the incident involving Caitlyn Fischer contained in Exhibit 1, Volume 1: Caitlyn Fischer, Tab 22; and 4. The photograph of the fence 8A/8B combination contained in Exhibit 26. Table of Contents 1. Introduction ............................................................................................................................................... 1 2. Why was an inquest held? ......................................................................................................................... 1 3. Background to the inquest ........................................................................................................................ 1 4. Olivia’s life .................................................................................................................................................. 3 5. The sport of Eventing ................................................................................................................................. 5 6. Governance ................................................................................................................................................ 6 7. Background to the events of 6 March 2016 .............................................................................................. 8 8. What happened on Sunday, 6 March 2016? ........................................................................................... 10 9. What was the cause of Olivia’s death? .................................................................................................... 14 10. What issues did the inquest examine? .................................................................................................... 15 11. What preparations were made for medical coverage at the 2016 Scone Trials? ................................... 17 12. What happened at the 2016 Scone Trials pre-event safety meeting? .................................................... 20 13. Was fence 8A/8B a safe, rule compliant, and appropriate fence for the two star class? ....................... 24 General principles .................................................................................................................................... 24 Background to construction .................................................................................................................... 24 Applicable rules........................................................................................................................................ 25 Course designer’s personal philosophy ................................................................................................... 27 Previous experiences in 2015 and examination in 2016 ......................................................................... 27 Approach to fence 8A/8B ........................................................................................................................ 29 Vertical with downhill approach is unacceptable / true vertical ............................................................. 30 Skinny rails ............................................................................................................................................... 32 Colour of the rails .................................................................................................................................... 33 Ground line .............................................................................................................................................. 34 Number of strides between elements / true distance ............................................................................ 35 Spread as the last element ...................................................................................................................... 41 Spread fill ................................................................................................................................................. 43 Overall riders’ perspective of fence 8A/8B .............................................................................................. 46 Overall course designers’ perspective of fence 8A/8B ............................................................................ 48 14. Aspects of the EA Guide ........................................................................................................................... 51 15. Peer review of course design ................................................................................................................... 53 16. Course designer present at an event ....................................................................................................... 54 17. Broader issues .......................................................................................................................................... 56 18. Incident review system ............................................................................................................................ 57 19. Course walk .............................................................................................................................................. 62 20. Rails down in show jumping .................................................................................................................... 64 21. Riders Representative system ................................................................................................................. 66 Experiences of the families of Caitlyn and Olivia ..................................................................................... 66 Introduction of riders representatives .................................................................................................... 67 Conveying concerns to riders representatives ........................................................................................ 67 21. Personal Protective Equipment ............................................................................................................... 73 22. Data collection ......................................................................................................................................... 76 23. Medical coverage at events ..................................................................................................................... 78 Medical coverage prior to 2007 ............................................................................................................... 78 Applicable provisions of the EA Rules and FEI Rules ............................................................................... 81 Level of medical coverage ....................................................................................................................... 83 Response time