Sunday, April 19, 2020

Do Something Eventing, Part 6, Caitlyn Fischer's Inquest Report

Now we're going to talk about Caitlyn Fischer's report, here it is for reference:

Caitlyn Fischer was an extremely educated rider.  She was competing at the one star level in Australia and was living/working on the property of her trainer, international event rider Christine Bates (short listed for the Olympics, reserve for WEG, etc...).  Christine's website, with her accomplishments listed, is here for anyone interested.  The trainer stated that she constantly coached Caitlyn and her horse, Ralphie, at the two star level and felt they were extremely proficient and well schooled at the one star level.  Caitlyn had completed a couple one stars prior to 30 April 2016, where she was competing in the CCI one star at the Sydney International Horse Trials.

Caitlyn had walked the cross country course several times and had a plan.  Her trainer told her to stick her plan and ride the first fence like she was expecting Ralphie to spook due to her trainer feeling like the first fence wasn't far enough from the start box for Ralphie to establish a strong canter.

Oddly enough, while Caitlyn was in the warm-up, a rider that was two in front of her had a rotational fall at a combination known as the "Lego Boxes" on course and that the course was being held to take care of the horse and rider, as well as remove that combination from the course.  The extent of injury to that rider was not clear.

Caitlyn's coach told her about the fall and that her start time had been moved back by about five minutes, as well as the news that the "Lego Boxes" were being removed from the course.  Caitlyn's coach said she wasn't affected by news of the fall and continued to warm up Ralphie until it was their turn.

Caitlyn had no issues and met the first fence perfectly, however, the second fence, a sloping table, is where the accident took place.  From all accounts (experienced riders spectating, fence judge, etc...) it sounds like Ralphie either got distracted as he was leaving the ground in front of the second fence or simply second guessed himself and missed.  They had a rotational fall where Ralphie landed on Caitlyn.

As far as that article, can we please acknowledge how ridiculous it is that the organizers gave the standard "it was a freak accident" response?  Are you serious?  The police are responding to your event, there is going to be an inquest, can you not say something like "we're not entirely sure what happened, but we're going to do our absolute best to try and figure it out."

Another issue, Eventing Australia formed their review panel months after the incident, like Olivia's.  MONTHS.  No.  Again, this needs to happen immediately.  You know what happens in a Safety Investigation Board and Accident Investigation Board?  Once the death notifications go up to the appropriate headquarters, phone calls are made IMMEDIATELY to appoint the board members for both.  Maybe this isn't practicable for them, but surely they can cut the time down from months.

I said this in the previous post concerning Olivia, but I'm going to repeat it here.  One thing I do think they should have done, is kept these two cases separate.  The mentioning of both Caitlyn and Olivia in both reports will only cause confusion.  These two girls deserve their own completely separate inquest and report with no mention of the other.  Only the evidence from each specific event should be considered and presented.  There should be no mention of both girls in either report, yet, there is.

13.48 In her notebook statement to the police, Ms. Retallack referred to making only one radio call for assistance. In evidence during the inquest, she referred to making a total of three calls. On her account, the third call was prompted by a lack of movement from the ambulance. Ms Retallack said that she did not receive a response to any of her three calls. Other witnesses state that they heard Ms Retallack’s first call. Dr Golowenko said that he broadcast a response to it which was heard by other witnesses. Only Dr Roche said that he heard a second radio call.

Due to the police response immediately that day after the incident happened, statements were taken.  Ms. Retallack's statement specifically is mentioned.  Normally, in a hearing like this, you would present the witness with their prior written statement while they're on the stand and let them read it, then proceed with questions and confront them on any discrepancies.  It doesn't appear that happened, but we also don't have the transcript, and that would give us that answer.

16.4(e).  Mr. Nicholson wasn't aware he was being interviewed for a review panel. 

That's a massive issue.  Every single interview, with every single witness, should start out with telling the witness who every person in the room is that is listening to the phone call, and that it is being recorded.  It should be standard procedure that every witness interview is recorded, then transcribed, and depending on the content either a summarized or verbatim transcription completed.  Once the transcription is complete it should be sent to every witness to review their interview transcript.  If they have edits they need to discuss them with the interviewers, if not, or when they reach a satisfactory transcription, the witness signs it.  The LAST thing you want is to have the witness' transcript inaccurate in any way, shape or form, as far as the information they are conveying in their interview.

16.4(f) Mr. Kane considered there to be a distinction between a review and an investigation and considered that the panel had been formed to conduct the former. Mr. Kane was asked in evidence about page 4 of the SIEC report. He explained: “Had we been doing an investigation…we would probably have gone through a kind of a cross-examination process, a more robust examination of every witness in potentially a, I suppose a, what’s the right word, a combative way rather than just an understanding of they’re saying way."

This is embarrassing.  Why is there any ambiguity to this process?  This is blatantly unacceptable.  Not only that, this "review" concerned the loss of a life.  It should be taken equally as serious no matter if it is a review or an investigation.  This is how much your organizing officials care about you.

16.(l) There appeared to be a lack of meaningful engagement with the parents of Caitlyn and Olivia. Ms Carr explained: “[Mr, Enzinger] and [Mr. Kane] came and met us in our home and spoke to us. They spent approximately two hours with us, but that during that time they made no notes. They took no documentation and when they left Mark and I turned to each other and said we felt that that had been a complete and utter waste of time. They advised us that they weren’t taking formal statements and I think what made us feel, I guess, alarmed was when we received the first draft of the first report into Caitlyn’s - review into Caitlyn’s death, there were so many errors of fact in relation to some simple things, like the day she arrived, which should have been very clearly documented and I suppose for me, given the experiences I’ve had with other health investigations, that - it made me alarmed that they couldn’t get things as - what I felt should have been as straightforward as that correct."

More embarrassment.  The "review panel" couldn't even get the day that Caitlyn arrived at the event right.  That's a basic fact.  A very simple, easily collected fact.  Again, these are the people whose hands you are putting your life and your horse's life into.  This is how much they don't care.  And there were no notes taken, and no interviews recorded?  Additionally, it sounds like they spoke with them while both were present together.  No.  They need to be separated, and interviewed separately.  You have an EYEWITNESS and essentially and outcry witness and you didn't separate them, or record their interviews in any fashion?  Completely unacceptable.

16.5. "I think we need to become more like the airline industry and more transparent. I think it's a, it's a role we have to take on and I think we have tended to hide these things too much, and if there's anything to learn we should learn it as soon as possible. And if that's the next week's event, let's learn it. So, yeah, I'd certainly encourage transparency."  

This paragraph was also in Olivia's report, and I will say the same thing again about it. Novel idea, sir.

18.4 Mr. Backhouse explained that the scoresheet from a horse and rider combination’s performance in the show jumping could be reviewed by the technical delegate (and the course designer and show jumping judge).  However, Mr. Backhouse acknowledged that opinion within the equestrian community was divided on this issue and that a number of considerations needed to be taken into account: (a) that some horses are “lazy” showjumpers but competent cross country jumpers; (b) different skills are required in each discipline; (c) disqualifications will impact High Performance riders seeking to qualify for Olympic and World Championship level events; and (d) show jumping does not always occur prior to cross country and so this would produce inconsistent disqualifications.

So some horses excel in one area and aren't so great in others?  Ok, so having some additional minimum requirements would weed out the ones that aren't an all around horse.  How is that bad?  Shouldn't you WANT an all around horse?  Disqualifications will impact those seeking to qualify for things like the Olympics and World Championships?  Well, thank you for pointing out the obvious.  We shouldn't be actively trying to limit disqualifications.  If they are warranted, they are warranted, that's part of the sport, should be.  Also, we all have been to events where the order is different as far as cross country and show jumping.  They could just require show jumping to take place before cross country.

18.6. Mr. Etherington-Smith thinks that showjumping IS a predictor and that if a horse has a poor showjumping round it is more at risk to have an issue on cross country.  As he puts it "a good jumper is both careful and both brave and that - a horse that is likely to jump regularly jump too low over showjumps doesn’t suddenly stop jumping too low when it’s presented with a cross-country jump. If it’s likely to hit showjumps it’s likely to hit cross-country jumps."

This guys gets it.  They put this in both reports.

18.8.  A policy involving poor showjumping performance had already been in place since 2017 at a HT and the riders received it well, acknowledging that it is a safety tool.  "Mr. Richardson confirmed that this practice was adopted at Scone in 2017. If a rider had a significant number of rails down (five or six) in the show jumping they were disqualified from the cross country but permitted to rider at the grade below. He explained that this did not cause any problems and that riders accepted it once it was explained that it was a safety measure."

Another point repeated in this report as well.

22.8 Dr Davis raised his views with Dr Roche informally, usually at a debrief following an event which he had volunteered at. Dr Davis raised the issue that the paramedics should be supported by a medical officer and that the minimum level of paramedic required was one that was capable of using a laryngeal mask or capable of using an endotracheal tube and laryngoscope. Dr Davis recalled that Dr Roche agreed with him although no concrete steps were taken to implement this prior to 2016.

Dr. Davis went on to explain: “Again, at the end of most of the Sydney events I expressed my view about the level of paramedic cover, which at Sydney I think is appropriate when there’s medical backup, but it always concerned me that there were plenty of events going on that that may not be at a level that could be appropriate to manage the injuries that you could receive”.

This entire statement is alarming.

22.9 Dr. Davis was not alone in his views. Dr. Taylor said that prior to 2016 she had discussed the level of medical coverage with her husband, Dr. Janson. 

She explained: “…we personally were concerned that there was not adequate equipment, that when, when my husband does the event doctor, he brings his own gear as I think most doctors do. And we knew that there was the, the stock carried within the ambulances was less than we would have carried ourselves”.

Important information to be aware of, appalled by, and should make you want to speak up to your event coordinators/organizers.

22.11 Dr. Taylor also said that, like Dr. Davis, the concerns that she and Dr. Janson held were mentioned informally. Prior to 2016 it appears that the views held by Dr. Davis, Dr. Taylor, and Dr. Janson were never raised in a more formal forum by EA or any organising committee. However, following the tragic events of 2016 there was increased discussion amongst medical practitioners who had experience in volunteering their services at events. This culminated in a teleconference on 20 December 2016 involving members of what was described as the NSW Eventing Medical Safety Group. Dr. Davis, Dr. Taylor, Dr. Janson and Dr. Roche were among the participants. 

Dr. Roche explained the genesis of the teleconference in this way: “Look, it, it actually started very informally where a bunch of us just started emailing to one another, as I said, we, we had a heightened awareness that we could do better, both in terms of preparation, response, planning, et cetera. And it, it, it started quite organically as an email from one person to another and they would copy somebody else in, and the thing sort of gathered momentum. I don't think at any stage it was really sort of formally appointed as a subcommittee, but we, we felt that we were the appropriate people to try and give that knowledge to most of the GPs - sorry, most of the doctors who were providing medical response at New South Wales events, were taking part in that. And that it was appropriate that we advise Eventing New South Wales, who had no other doctors, you know, what we felt was, was the best thing”.

22.12 It appears that this teleconference ultimately resulted in the formation of National Medical Consultative Group (NMCG) in June 2017. One of the primary roles of the NMCG was to prepare and implement Medical Guidelines which are intended to formalise the initiatives that State branches and organising committees are actioning, or have actioned, regarding provision of medical care. The Medical Guidelines were published in May 2018. 

I think the above two paragraphs, 22.11 and 22.12, are very important.  It shows what a group of people that care can do.  They can make positive action happen.  You just have to care.

22.41 Both Dr. Cross and Professor Brown agreed that a response time of less than three minutes would be ideal, and that having a time benchmark would also assist in determining where medical teams are located and what vehicles are required to reach the furthest away fence on a cross country course. Professor Brown explained: “I agree that the three minutes is really the, the benchmark for the paramedic doctor crew”.

Important because while Caitlyn Fischer may have had no chance of survival based on a basal skull fracture being one of her injuries, there are various inconsistencies in the medical response time concerning this incident that have been brought to light.

Consolidated Recommendations start on page 73.  Take a look at them.

1 comment:

  1. This is such a difficult issue. Clearly things need to change to reduce the probability of injury.