Do Something Eventing, Part 7, In Summary

We have looked closer at some of the issues with the incidents here in the U.S. as well as abroad.  It's obvious that eventing as a whole has problems.  It's not a U.S. problem, it's not a Europe problem, it's not an Australia problem, it's an Eventing problem.

Just the other week the GoFundMe for Frangible Fences was up to $87,000 with the Manton Foundation now stepping in to match donations up to $250,000.  Now, there is a call for eventers to donate the amount of an entry to the fund.  Also, still crickets from the billionaire that could single handedly fund every xc fence with frangible technology.  The billionaire that will pay for Bloody Mary's shenanigans, sponsor entire events, and provide tens of thousands in division winning prize money.  But nothing to support the safety of life saving measures?  Actions speak louder than words.

This whole global pandemic thing happened right after the latest aftershock from the last death of a horse and rider at an event this past February.  It has distracted the majority of the eventing community away from it again.  Donations will continue to trickle in, but no actual, human, accountability will be demanded, until the next death.

I would sincerely hope that this down time caused by the pandemic was being used wisely by the powers that be at U.S. Eventing to allow for some positive, noticeable, action to be put in motion in the sport when it comes to deaths.  However, I'm definitely not holding my breath.  Why?

Did any of you know there are actual scholarly papers published on the safety of eventing?

The British Journal of Sports Medicine published an article called "Rider injury rates and emergency medical services at equestrian events" back in 1999.  Here is the abstract:

Abstract Background—Horse riding is a hazardous pastime, with a number of studies documenting high rates of injury and death among horse riders in general. This study focuses on the injury experience of cross country event riders, a high risk subset of horse riders. Method—Injury data were collected at a series of 35 equestrian events in South Australia from 1990 to 1998. Results—Injury rates were found to be especially high among event riders, with frequent falls, injuries, and even deaths. The highest injury rates were among the riders competing at the highest levels. Conclusion—There is a need for skilled emergency medical services at equestrian events.

Here is the link to the full article:  https://bjsm.bmj.com/content/bjsports/33/1/46.full.pdf

1999 people.  20 PLUS years ago.  And here we are still losing horses and riders on a regular basis, more than any other equestrian sport.

In 2003, the Equine Veterinary Journal published article called "A retrospective case-control study of horse falls in the sport of horse trials and three day eventing."  Here is the abstract:

REASONS FOR PERFORMING STUDY:

Serious injuries to horses and riders in horse trials (HT) and three-day events (3DE) are usually associated with falls of horses, which invariably involve falls of the riders. Many potential causes for these falls have been discussed.

OBJECTIVES:

The aim of this case-control study was to investigate the risk factors for horse falls on the cross-country phase of horse trials and three-day events.

METHODS:

Using retrospective data, significant risk factors identified with unvariable analysis (P value <0.2) were entered into a multivariable logistic regression model. Significant risk factors (P value <0.05) were included in the final model.

RESULTS:

It was revealed that a number of course, obstacle and rider variables were significantly and independently associated with the risk of falling. Falling was associated with obstacles sited downhill (Odds ratio [OR] 8.41) and with obstacles with ditches in front (OR = 5.77).

CONCLUSIONS:

The relationship between course variables and the risk of falling was characterised and showed a significantly increased risk with increasing numbers of jumps on the course and for jumping efforts later in the course. In contrast, after allowing for the total number of obstacles on the course, an increase in the total number of jumping efforts appeared to have a protective effect. A later cross-country start time was associated with a decreased risk of a horse fall. Amateur event riders were approximately 20 times more likely to fall than professional riders.

POTENTIAL CLINICAL RELEVANCE:

This study has identified a number of risk factors associated with horse falls and highlights areas that can be altered to improve safety in cross-country competitions.

Link:  https://www.ncbi.nlm.nih.gov/pubmed/12638789

Another published again in the Equine Veterinary Journal in 2006 called "The risk of horse-and-rider partnership falling on the cross country phase of eventing competitions."  Here is the abstract:

REASONS FOR PERFORMING STUDY:

Fatalities resulting from horse falls occurring during the cross-country phase of eventing competitions initiated epidemiological investigation of the risk factors associated with horse falls.

OBJECTIVES:

To identify variables that increased or decreased the risk of a horse fall during the cross-country phase of an eventing competition.

METHODS:

Data were collected from randomly selected British Eventing competitions held in Great Britain during 2001 and 2002. Data were obtained for 173 cases (jumping efforts resulting in a fall of the horse-and-rider partnership) and 503 matched controls (jumping efforts not resulting in a fall). The risk of falling was modelled using conditional logistic regression.

RESULTS:

An increased risk of a horse fall was associated with jumping into or out of water; taking off from good-to-soft, soft or heavy ground; fences with a drop landing; nonangled fences with a spread > or =2 m; and angled fences. Other risk factors included riders who knew that they were in the lead within the competition before the cross-country phase; an inappropriate speed of approach to the fence (too fast or too slow); horse-and-rider partnerships that had not incurred refusals at earlier fences; and riders who received cross-country tuition.

CONCLUSIONS:

This study has identified modifiable course- and fence-level risk factors for horse falls during the cross-country phase of eventing competitions. The risk of horse and rider injury at eventing competitions should be reduced by 3 simple measures; maintaining good to firm take-off surfaces at fences, reducing the base spread of fences to <2 m and reducing the use of fences at which horses are required to jump into or out of water. Risk reduction arising from course and fence modification needs to be confirmed by intervention studies.

POTENTIAL RELEVANCE:

Knowledge of factors that increase or decrease the risk of a horse fall can be used by UK governing bodies of the sport to reduce the risk of horse falls on the cross-country phase of eventing competitions, and reduce the risk of horse and rider injuries and fatalities. As one in 3 horses that fall injure themselves and one in 100 horse falls results in fatality to the horse, we suggest that immediate consideration is given to these recommendations.

Link:  https://www.ncbi.nlm.nih.gov/pubmed/16536386

In 2016 the journal Animals, an international peer-reviewed open access journal devoted entirely to animals, including zoology and veterinary sciences, published monthly.  This article is titled "Look Before You Leap:  What Are the Obstacles to Risk Calculation in the Equestrian Sport of Eventing?"  Here is the abstract:

All horse-riding is risky. In competitive horse sports, eventing is considered the riskiest, and is often characterised as very dangerous. But based on what data? There has been considerable research on the risks and unwanted outcomes of horse-riding in general, and on particular subsets of horse-riding such as eventing. However, there can be problems in accessing accurate, comprehensive and comparable data on such outcomes, and in using different calculation methods which cannot compare like with like. This paper critically examines a number of risk calculation methods used in estimating risk for riders in eventing, including one method which calculates risk based on hours spent in the activity and in one case concludes that eventing is more dangerous than motorcycle racing. This paper argues that the primary locus of risk for both riders and horses is the jump itself, and the action of the horse jumping. The paper proposes that risk calculation in eventing should therefore concentrate primarily on this locus, and suggests that eventing is unlikely to be more dangerous than motorcycle racing. The paper proposes avenues for further research to reduce the likelihood and consequences of rider and horse falls at jumps.

Where are all my "it was a freak accident people at" now?  These "freak" accidents have been going on for so long that the scientific community not only has taken notice of it for over 20 years, but has enough data to statistically analyze it as well?  Again, STOP with the freak accident bs.

You want to see some examples of freak accidents?  Here, have at it:

https://abc7.com/tag/freak-accident/

I will leave you with this before we get back to our regularly scheduled Klein and Super B programming, and until the next death, when we do this all over again.  Complacency kills.  No matter what your part, rider, organizer, trainer, student, fence judge, etc... Complacency kills.  So, you continue just acting like it's a freak accident and blindly participating in the circus, only thinking about yourself and how it would never happen to you, but remember, you can control you.  You cannot control these organizers, you can't control the TDs, the safety officials, the judges, etc...  Remember the absolute shit show that goes on behind the scenes at a lot of these events and ask yourself if you are ok putting you, and your horse's life, in their hands that day.  If so, well, hopefully they're in a good mood that day, got some sleep the night before, and have the proper life saving equipment onsite, should they need it.

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:

http://www.coroners.justice.nsw.gov.au/Documents/FISCHER%20Caitlyn%20-%20Findings%20%20Final%20(2).pdf

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.

https://www.abc.net.au/news/2016-04-30/teenage-equestrian-dies-after-falling-from-horse/7373018

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, or...it 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.

Do Something Eventing, Part 5, Olivia Inglis' Inquest Report

Olivia Inglis' Inquest Report:  

http://www.coroners.justice.nsw.gov.au/Documents/INGLIS%20Olivia%20-%20Findings.pdf

There was some concern about cross country that was a mixture of the type of fence the 8a/8b combination was, as well as Togha's poor showjumping performance the day prior, where he had six rails down.  The concern over that particular combination was shared by other riders as well.  Olivia's mom went and shared her concern with the course designer, in this case someone she knew and was familiar with.  The course designer, Shane Rose, reassured Olivia's mom that the fence was nothing particularly challenging for the level and maintains that to this day.  Other expert riders would testify about that combination in the same manner at the inquest.  That specific combination had been used on the course in years past, and had no issues.  Shane Rose had competed at a HT where it was on his course as well, and he didn't give it a second thought, it rode well for him, and everyone else.

Olivia had no issues through the course up until 8b.  She and Togha jumped 8a perfectly, then Togha hung a knee at 8b.  They fell, and from the jump judge's account Olivia hit the ground first, then Togha fell on top of her.  When Togha managed to get up, Olivia was motionless.

Despite the fact that the ambulance quickly made its way to Olivia, the medic had equipment that was malfunctioning.  He states that he tested the equipment that morning, it was working properly, however when he brought it to Olivia it was not operating properly.  That piece of equipment was an oropharyngeal suction kit.

I have questions that weren't answered in the inquest report.  This is where it would be helpful to read the transcript from the actual proceedings.  He tested the suction kit that morning, that type of kit is battery operated with a rechargeable lead acid battery.  Most of these kits have a battery indicator light on them, did he check it, if it was a model that had one?  Did the company properly maintain the equipment?  Meaning, what was the expiration date on the battery?  Was the suction kit collected into evidence for testing after it failed?  Why not?

Mr. Keys, the medic, also stated that he knew Olivia needed at least one chest tube, but preferably two, in immediately, and that the ambulance was not supplied with the equipment to conduct that procedure.  Another piece of equipment he stated should have been on the ambulance, but was not, was a laryngeal mask airway and/or an endotracheal tube.  Also noted was the fact that he was a Physician's Assistant, so he was more than qualified and capable to properly use any equipment necessary for that particular scenario.  He had all the necessary skills, but was not provided adequate equipment.

More questions, who determines what is on the ambulance?  Is there an inventory, if so is that equipment on it?  If it's not on the ambulance, why not, since it is something a medic would expect to have on hand?

Also, since Mr. Keys was contracted and provided with that ambulance by the company, I would want to see all the requirements of the ambulance from that company.  I would want the inventory reviewed, checklists of equipment (if any existed), information about when the last time the ambulance was in service, and if the previous operators failed to properly restock any of the medical supplies/test the equipment, power it down properly, plug it in to charge, etc...

"11.12. Following the events of March and April 2016, HSI was no longer deemed to be the preferred ambulance or paramedic service for NSW eventing competitions. However, the NSW Eventing Organisers Handbook, which is believed to still be in force, still provides that HSI occupies this status. It is evident, given the events of 2016 and what had transpired since that immediate amendment of the NSW Eventing Organisers Handbook is necessary."

I'm sorry, what?  This fatality happened in March 2016, and as of October 2019 this update had not happened in the Organisers Handbook that is still in use??????

"11.13 RECOMMENDATION: I recommend to the Chief Executive Officer of Equestrian Australia that the NSW Eventing Organisers Handbook be immediately updated to remove reference to Health Services International as the preferred NSW ambulance service for eventing competitions, and that the Handbook be amended to nominate the current preferred service provider (if any)." 

Why does it take an inquest 3 years later to tell this organization to do this????

The organisers (spelled in the Australian version) also had no idea that the doctor they had originally scheduled was unable to be present at the event.  They never contacted him to confirm his presence and there was a folder in the office with his name on it, that he never picked up (no one wondered where he was?).  His wife was there, also a doctor, competing. She was not there in her capacity as a doctor.  However, when Olivia went down, Dr. Taylor (the competitor) overheard the call for a doctor on a radio while she was in the warm-up.  She asked if a doctor was needed, knowing that her husband was not present.  She was informed a doctor WAS needed, so she responded.

She later stated that it was not only entirely inappropriate, but inadequate for the organisers to count her presence as adequate physician coverage, due to the fact she was there to compete.

Think about that.  Sure, she is on the grounds but she is nowhere near in the loop with what is going on at control.  She was in the warm up asking if they needed her ONLY because she happened to overhear a radio call.  Then she has to dismount, find someone to take her horse and find a ride to the accident?!  She also has no clue who else is there, what equipment they have, etc...

Dr. Taylor stated that Mr. Keys had been there quite a bit longer than she had by the time she arrived.  She said he correctly identified all of the issues and injuries but due to the absence of the necessary equipment, neither of them could perform the required effective care.  About the time Dr. Taylor arrived, an air ambulance was inbound.  The trauma team on the air ambulance did have all the necessary equipment and all procedures were performed as soon as they reached Olivia.  By that time, Olivia no longer had a pulse and Dr. Taylor and Mr. Keys had already started CPR.  Another issue that was noted is that if Mr. Keys did not have Dr. Taylor he could not have effectively done CPR and managed Olivia's airway.  There SHOULD have been a dedicated doctor that day, or another medic, as Mr. Keys stated that he did feel uncomfortable not being "two up" in the ambulance, meaning being teamed with another medic that day.

"12.12 Dr. Cross was also asked about his expectations of the organising committee contacting the purported event doctor to ensure that the doctor was aware of their obligations. He explained: “I think the duty, duty of care was not delivered. I would hope this would never happen again so I would - I, I don’t - I think reading of the documents and hearing the evidence I, I think it was inadequate."

So here is where you would call your Subject Matter Expert in an Accident Investigation Board when we conduct them.  In this case, our Subject Matter Expert would be a Emergency Room Physician with no real knowledge of the case and no familiarity with the parties involved.  We would explain what happened, and let the doctor review the evidence.  After this we would ask that doctor after his review, if in his professional opinion as an Emergency Room Physician, if they (Dr. Taylor and Mr. Keys) had the proper medical equipment on site and it was functioning correctly, does he think that Olivia would have likely survived.  Keeping in mind, that's a hard thing to opine about because each case is different, but most times our experts can articulate their opinion extremely well.

"10.4 At the commencement of the inquest Lucy Warhurst, Chief Executive Officer of EA, made the following statement to the court: “We are committed to ensuring that the deaths of Olivia and Caitlyn are honoured by ensuring that all lessons learned will be applied through education and training, the safety of riders, 16 coaches, horses, officials and all participants. Equestrian Australia’s number 1 priority is and will remain the safety of its participants”.  

Really?  And how are you going to do that when you can't even update a handbook?????

"11.4 The President of the organising committee for the 2016 Scone Trials, Blair Richardson, said that he did not turn his mind to what level of medical services was actually going to be provided."

You would HOPE this would be on the top of their priority list, clearly, it's not.  I bet you making sure that every last competitor is paid up for entry is though!

"11.5 Further, Mr Richardson acknowledged that in 2016 he was unaware of the provision in the 2016 EA Rules that a paramedic equivalent or ambulance must be present during the cross country test and a doctor should be present during the cross country test.  He agreed that he did not turn his mind to whether a doctor would be present to assist."

This is the PRESIDENT of the organising committee for that event and he doesn't even know the rules?????

"11.8 After being engaged for the event, Mr Keys collected the ambulance from a location near Bowral. He was told by Mr Taylor that it was fully stocked. Mr Keys said that he briefly looked at the equipment to make sure that the majority of equipment he expected to be available was in fact available."

Key word here, majority.  He made sure the majority of the equipment was there...but not everything he would expect?  Now here, we may have the issue of if Mr. Keys was familiar at all with eventing.  It is extremely possible he had absolutely no actual knowledge of what three day eventing was, meaning he could have thought "ok, people riding horses around" and not realized that people would be jumping solid jumps at speed.  I don't see anywhere that they asked him that question, again a complete transcript would be helpful.

"12.5 Mr Bates explained that at the safety briefing there was an expectation that Dr. Janson would be the event doctor. At the briefing it was indicated that at the last minute Dr. Janson was unavailable but that Dr. Taylor (Dr. Janson's wife) would be present at the event as a competitor. On this basis Dr. Taylor was listed at the event doctor.  Mr Bates said that he did not seek confirmation at the briefing whether Dr. Taylor would in fact be the event doctor. He said that he left that matter for the organising committee to confirm. Mr Bates said that he was “comfortable that there was no requirement under the rules to have a doctor but it was good to know that [Dr Taylor] was at least on the grounds."

Great, here we have miscommunication between the officials as well as an assumption that it would be fine knowing a doctor is present, even though that doctor specifically says in the inquest it would be inappropriate and inadequate for them to assume that by the mere presence of her being there as a competitor, an it is easy to see why.

"13.44(c) Mr. Lochore said that he did not think that a 3% gradient would be considered downhill, and that a 5.5% gradient was not considerable and not something that would be considered inappropriate at the two star level. He acknowledged that, a 5.5% 94 gradient was possibly not in line with the FEI Guidelines. However, he said that he had designed many courses at the two star and three star level that had not adhered to the guidelines in this respect.

(d) Mr. Tapner said that whether the downhill approach could be described as significant or not, the fact remained that the approach was downhill. On this basis he considered that it was inarguable that the FEI Guidelines had been breached.

(e) Both Mr. Johnston and Mr. Etherington-Smith agreed that fence 8A/8B was not consistent with the FEI Guidelines.

(f) Mr. Bates (TD that day) offered this view: “That’s why these are guidelines and not rules because course designers are subject to so many variables and that downhill would be referring to a much a steeper gradient than what that was at 8A/8B”. He explained that the term “vertical” was subject to interpretation and that 8A was not a true vertical because the profile of the fence made it appropriate.

(g) Mr. Rose (course designer for the course that day) did not consider 8A to be a true vertical-faced fence, as it had a sloped profile. He also explained that there was room for interpretation as to what constituted a vertical and what was considered to be downhill with the FEI Guidelines as they are not rules."

And above we have testimony from several course designers to include the one from the day Olivia died, and the TD from that day, arguing about what exactly 8a/8b was and if it was, in fact, considered appropriate.  The sections following that discuss the ground line, the spread, the filler, and frangible technology.  It is great to see this all brought up and discussed on the record.

Another massive issue, Eventing Australia formed their review panel months after the incident.   MONTHS.  No.  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 six months.

Where Safety Investigation Boards (SIBs) and Accident Investigation Boards (AIBs) differentiate from an inquest is they happen MUCH faster.  Evidence is collected immediately for the SIB.  The SIB is meant to be solely to determine the facts and is non-attribution.  The SIB wants to find the cause so that preventative measures (if needed) can be put into place, training can be developed to go out to the field so that lessons are learned and mistakes are hopefully not repeated.  Once the SIB is done, a portion of their report along with the evidence is released to the AIB.  The AIB members (this is the team I am on) will review the evidence, identify their witnesses/victims, locate them and contact them.  They will all be recorded and placed under oath prior to giving their recorded verbal statement.  They will be allowed to review any prior statements made to the SIB and asked if they would like to adopt that statement, then elaborate or add any details they feel are relevant.  If at any point we suspect something incriminating is about to come out of their mouth, we stop them and read them their rights.  At that point the interview is either terminated, if they invoke their rights and request counsel, or it continues once they unequivocally state they decline counsel and wish to continue.

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.

18.4 (c) Some witnesses, including those mentioned above, were only spoken to over the phone and never asked to make and sign formal statements. Mr. Rees (Caitlyn's case) said in evidence that he would have been happy to participate in an interview with a representative of Eventing Australia (EA). 

(d) Statements that were taken from some witnesses contained inaccuracies which it did not appear were ever resolved. 

(e).  Mr. Nicholson (Caitlyn's case) 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.  As I mentioned aboved, not only should it be recorded, every witness should be placed under oath as well.  Every interview should then be transcribed and depending on the content, in either a summarized or verbatim transcription.  Once the transcription is complete it should be sent to every witness to review.  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.

"18.4 (g) In Olivia’s case, no consideration was given to whether an independent course designer should be engaged to review fence 8A/8B.

(h) Mrs. Farrar (safety consultant) was instructed to not pursue certain lines of inquiry, such as attempting to accurately measure the distance between 8A and 8B (because the panel felt that the focus should instead be on rider experience and their striding), and seeking expert opinions from experienced riders such as Mr. Tinney and Mr. Tapner about whether the fence could have been built in a way that posed a lower risk."

Ok, full stop.  If a witness says that she was instructed to not pursue certain lines of inquiry that involved something like accurately measuring the distance between the fences in the combination where a fatal incident took place, you ask who it was that told them to NOT do that.  Then, remember that rights advisement I talked about?  Call up that witness that is the one that instructed the other one not to take the measurement, and prepare to read them their rights.  That, in our world, would be along the lines of an obstruction charge.

"18.4 (j) Some items were removed from Olivia’s final report which appeared to have relevance such as: rider impressions of the ground conditions at Scone, a diagram taken from the Barnett Report showing the risk of horse fall for different fence types, a recommendation that cross country fence profiles be made more forgiving with no vertical faces even on ascending oxers, and details of discussions with Health Services International (HSI).

(l) There appeared to be a lack of meaningful engagement with the parents of Caitlyn and Olivia."

While extremely painful for a witness to have to relive the event by telling it, if you have eyewitnesses, you ask them to make a statement.  Either a signed, sworn written statement or a recorded verbal statement.  In the case of something so traumatic, if the parents stated they had a preference for written or verbal, you let them have their preference.  You NEED this information memorialized.

"18.5. Geoff Sinclair, a Level 3/4 technical delegate, member of the FEI Eventing Committee and chair of the FEI Risk Management Steering Group, was asked at the inquest to provide a view about the matters set out at paragraph (m) above. He said: 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."  

Novel idea, sir.

At paragraph 20.5., Mr. Rose waffles on his opinion about rails down predicting poor cross country performance, though he does agree, further data analysis is necessary.

At paragraph 20.6., 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."

In paragraph 20.8., 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."

"23.8  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."  

So medical doctors had suggested this and it was never implemented.  Airway is one of the most important things to manage in trauma and the powers that be never saw it necessary to require a paramedic on site with those skills?  Thanks for caring.

Consolidated Recommendations start on page 95 of the actual marked pages, page 100 according to the page count if you want to type it in the page box at the top of the document to go straight to that section.

I hope that by breaking this report down a bit and highlighting some of the more alarming things, I have helped some of you see the deep issues this sport is facing around the world.  If you think that U.S. Eventing doesn't have these same problems, you are lying to yourself.  Take responsibility for you and your horse's safety.  Educate yourself.  This is just a fraction of the information that could be provided, yet we don't even get this in the U.S.  Is this really something you still want to be a part of and support right now?

The next post will be Caitlyn Fischer's inquest report with the same break down.

Do Something Eventing, Part 4, Inquest Reports

Let's take a look at the process of Coronial Inquests that takes place in Australia.

Here is the Coroners Act of 2009, it establishes the rules for the inquests:

https://www.legislation.nsw.gov.au/inforce/b864672a-d308-c9d5-ba2a-8ed827ad721c/2009-41.pdf

Two of inquests have taken place recently regarding the deaths of Caitlyn Fischer and Olivia Inglis.  They are two eventers that died within weeks of each other, on cross country, at recognized events in Australia, in 2016.

The links to the entire reports are below, and if you have not read them, READ THEM.  They are mostly written in layman's terms and are easy to follow for a reason, in addition to being available for anyone to read.  The reports list evidence that will remain unpublished beyond the inquest due to sensitive nature.  This includes video of the accident, photos of the scene, etc... so you know what you won't see in them.  Again READ THEM.  Please.

These reports go over the entire incident in detail.  They are not to the standard of an Safety Investigation Board or Accident Investigation Board in the U.S., but they are a damn good start, and a LONG way ahead of anything U.S. Eventing is doing.

Their purpose:  "Inquests have a forward-thinking, preventative focus. At the end of many inquests Coroners often exercise a power, provided for by section 82 of the Act, to make recommendations. These recommendations are made, usually, to government and non-government organisations, in order to seek to address systemic issues that are highlighted and examined during the course of an inquest. Recommendations in relation to any matter connected with a person’s death may be made if a Coroner considers them to be necessary or desirable."

I'm going to discuss them in detail, but before I do that, I really want you guys to read them.  Please.  ESPECIALLY if you are still eventing.  Read what is, and is not, happening at these events.  If you think these shenanigans are just that...keep in mind these were both RECOGNIZED events.

Olivia Inglis Inquest Report:

http://www.coroners.justice.nsw.gov.au/Documents/INGLIS%20Olivia%20-%20Findings.pdf

Caitlyn Fisher Inquest Report:

http://www.coroners.justice.nsw.gov.au/Documents/FISCHER%20Caitlyn%20-%20Findings%20%20Final%20(2).pdf

The next post will discuss them in detail.  On second thought, to keep things more organized, I might actually split them up and discuss them each in detail in their own posts.

Do Something, Eventing, Part 3, Multiple Issues

Initially, I wanted to provide more data than I am going to.  There are a few problems though, schooling horse trials scores can be difficult to find as they are removed from websites after a certain amount of time, if they are even posted at all.  Some of the riders that have died in schooling accidents, the name of the horse they were riding is not always posted or mentioned in articles.  This means, even if you can find show records, there is no way to know if any of the horses listed on the records are the horses in schooling accidents.  This isn't ideal for accuracy.  

In an effort to locate additional information for these fatal incidents I have spent hours reading through forum posts, news articles, and press releases, trying to find the missing pieces I was looking for.  Sometimes I was successful, sometimes not.  That is why it took me so long to get this posted.  So to show what I'm getting at, I narrowed it down to a few accidents.

First, let me put a disclaimer that this is in no way, shape, or form an attempt to smear, criticize, or victim blame.  I would never claim to have even an inkling of education on how to ride an upper level course.  The information below are mostly objective findings.

Philippa Humphreys, Jersey Fresh 2016

The horse she was riding that day was Rich N Famous.  A horse that only had ONE double clear xc run on his record.  Every single other xc at that level had rails in showjumping and/or time on xc.  This makes me wonder immediately if this horse was fit for the level?  It could never make the time on xc.  Was fatigue setting in that day?  This was a pretty big Warmblood.  After the accident, Megan O'Donoghue evented Rich N Famous seven times after Philippa's death, at multiple levels and guess what?  The horse NEVER made the cross country time.  Not at Prelim, not at Intermediate, not at the 2* level, not at the 3* level and not even at Training level the one time she took him Training.  He then went to a different rider that evented him at Novice, and guess what?  He still was getting XC time penalties.  The fact that another upper level rider took this horse out at multiple levels and the horse still wasn't making XC time, EVER should say something loud and clear.

Dr. Melanie Tallent, Schooling Cross Country, 2019

Melanie Tallent, was schooling with her trainer present.  She had two horses and I could not find any information about which horse she was riding the day of her accident, though from what I have found, it appears to be Dunlin, the one in the video and photo links below.  I have found nothing but wonderful things posted about Melanie Tallent.  She sounds like a very kind person, who was very dedicated to her horses.  On a very sad note, there is a post out there on a forum where a family member of hers is looking for answers and having a rough time coming to terms (as anyone would) with what happened.

There is not much in the way of a USEA record for her.  There is a post in the forums saying that she had recently competed at HTs and was 1st and 2nd in her division, it was a schooling horse trials because her last recognized USEA event was at the Horse Park of NJ in June 2019.  So what I was able to pull is very limited in scope as far as information.

In the posts on the forum the family member says they wished there was video of the accident to help understand what happened.  Another poster says if there was a video they hope no one would watch it because it wouldn't change things.  No, it wouldn't, but it could educate.  And I would hope that people WOULD watch it to understand.  You can find HOURS and HOURS of cockpit voice recordings of aircraft accidents as well as video of the impact, in some of those videos you are witnessing HUNDREDS of people die at once and most people have no problem watching those.

Melanie's short record is telling, there are two horses on it.  Despite that fact, there are many photos and some video of Melanie and Dunlin missing distances and hanging a knee here and there.  There is no disputing the fact that this is a recipe for disaster in front of solid fences.  In the video below, they are on a BN course having to trot a lot of the last part of the course, she stops him and turns him around after one jump as well.

Here are two photo galleries from shows:

Radnor recognized HT:  https://akdragoophoto.zenfolio.com/p95654858


Plantation Field jumper show:  https://akdragoophoto.zenfolio.com/p982079085

There are many photos and some video of Melanie and Dunlin missing distances and hanging a knee here and there.  There is no disputing the fact that this is a recipe for disaster in front of solid fences.  In the video above, they are on a BN course having to trot a lot of the last part of the course, she stops him and turns him around after one jump as well.

Two things come to mind with this type of stuff, once I was taking a lesson with a Jeffray Ryding at her farm in Santa Fe, NM.  A friend was there with me with her Trakehner mare.  Jeffray made a comment that the mare needed to seriously fix her habit of let her legs kind of dangle in the air over fences.  The mare just did not have tight knees.  Jeffray recommended gymnastics to help her snap her knees up.  The reason for this, Jeffray said, is that a horse that jumps like that is dangerous because those dangling legs are opening her up for hanging a knee and causing a serious accident.

Another time I was at Doug Payne's barn and he was saying that one of the horses he had in for training didn't seem to really care where his feet went and that he would really like him to be more aware of where his feet where or care more where his feet went.

A family member made a statement that Melanie had won her last horse trial before her death.  I believe it was about two weeks before her death.  It was a schooling horse trial, I don't know which one.  However, her family and friends stated she was an expert rider who was very successful.  This information translates into online posts and articles where they are interviewed.  But, we all know, schooling horse trials are not recognized horse trials.  There are less jumps, there are a significant number of jumps that are not maxed out, slower time requirements, shorter cross country courses, shorter stadium courses, sometimes cross country is completely untimed at schooling horse trials.  Sometimes, the judges don't eliminate people for things they would be instantly eliminated for at a recognized horse trial.  Sometimes there are only a few people in the division, it could only be three and one of them could get eliminated for coming off on cross country, and the other may have had some rails or time.  Someone can easily leave these details out to friends and family.

Again, this is NOT to criticize, this is just an attempt to provide another view, and promote a different line of thinking.

Ashley Stout, Schooling Cross Country, 2019

We do know Ashley was riding Avant Garde when her accident happened.  Both she and her horse were killed.  Ashley has a pretty outstanding record, and we know her horse was trained by Holly Payne-Caravella, so he had a great education.

Both Avant Garde and Ashley had a stellar record.  In 15 recognized horse trials they had one cross country run with a small amount of time penalties (5.20) and no jumping penalties.  Out of those stadium rounds, four had rails.  Three of those rounds had one rail, and one of them had two rails.  This may actually be your freak accident that everyone wants to believe all these accident are.  But not every horse and rider are Ashley Stout and Avant Garde.  I can't find any mention of what type of fence Ashley was schooling when they had the rotational fall.  Was it a table?

Katharine Morel, Rocking Horse Recognized HT, 2020

The video below has caused some uproar as Katherine Morel was the latest eventing fatality at a recognized Rocking Horse HT this past February.  Watch from 1:15 to 1:40.  No penalty of any kind was applied for that.  And yes, I get it, you can have a crappy ride.  Kerry On didn't do this everytime out on cross country.  The point is, a penalty of some kind (some are saying a yellow card should have been issued) would have sent some kind of message.  Now, will the rider always get that message?  No, but it's worth a try.  You can YouTube some of her other rides, and you WILL see a common trend with this horse as well that most likely created some issues.

Jennifer Chapin, GMHA Recognized HT, 2019

13 Stadium rounds on her recognized record with Joinem, the horse she was riding the day of the fatal accident, all with at least a rail, one with as many as 6 rails.  The horse's last three events prior to the fatal accident were at Preliminary.  The fatal accident was at Preliminary as well.  The three events prior were one with 6 rails, the next one with 3 rails, and the next one Jeffie came off on cross country.  The following event was the fatal accident that occurred at a fence in the warm up.

Joinem has since went to a new owner in Pennsylvania.  He has been evented once at a recognized event since the fatal accident, about a month and a half after it happened.  His next event was at Training level, where he had 2 rails.

Out of the incidents I've summarized here, I think we have a few problems present.  The main theme being, just because you can, doesn't mean you should.  Should coaches look harder at the horses their students are on?  Should the riders, be more honest with themselves about their level of comfort and not doing something because their friends are and their coach is telling to stop being such a wuss?  It's a slippery slope for coaches/trainers because in today's participation trophy culture, the minute you're honest with someone you may very well lose their business, which means lost income.  I know for sure there are coaches/trainers out there that are going to keep telling their students they're the greatest thing ever because they need to pay their bills.

One scary trend I see, that I am not a fan of, is people that say they take Xanax or other prescription drugs to be able to calm their nerves while riding whether they are schooling at home or at a show.  It seems to be pretty acceptable now and (insert unpopular opinion here) I think it's completely unacceptable.  If you have to medicate yourself to participate in a voluntary hobby, is it really the hobby for you?  Is it fair to your horse?  Your family?  Yourself?  It almost seems cool to say how you have to medicate yourself, like it's normal.  It shouldn't be normal, it's not normal.  It's not cool.

On that note I am NOT talking about being low level nervous.  I think everyone has some level of nerves, if you don't, that may be a red flag for a different issue.  I'm talking about nerves to the point where you have to medicate yourself prior to riding no matter if it is schooling or showing or trail riding or whatever.  There is a difference, and if you say there isn't, time to be honest with yourself.

What is the problem?  Is it you, is it your particular horse?  Know when to say when.  It's ok to know when maybe you don't have the right horse, for whatever reason.  It could be personality conflict, the horse doesn't seem interested in what you want to do as far as discipline, too much horse, not enough horse, there could be a lot of potential reasons that it's not a good match.

This was not to take a jab at anyone that legitimately needs medication for mental health reasons.  I am talking SPECIFICALLY about people that are so nervous to ride, or afraid of their horse, that they SPECIFICALLY take their medication to be able to get on the horse and go school, show, etc...

The other issues are things I have already covered in previous posts.  I do think frangible technology needs to be employed on a lot more cross country fences.  However, again, these are not freak accidents when they keep occurring.  Death in eventing is a trend that needs to decline.  The powers that be need to do something.  Safety needs to improve at events, think back to the story I told you in a previous post about the footing request being denied.  THOROUGH accident investigations need to take place, and findings need to be publicly presented so that trends can be identified and preventative measures developed from actual investigative facts.

But, can the riders mitigate the risks as well?  Yes, 1,000 times yes, instead of just being like "Well, my chances are higher that I die in a wreck hauling to the event."  Take some personal accountability and while you're at it, get pissed off that your fellow riders are dying.  Everyone says they care, offer empty comments about thoughts and prayers, and then blindly go off like it never happened thinking it could NEVER happen to them.  You are participating in a sport where death is a trend, if that doesn't make you care more, well, good luck to you.

Complacency kills.