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.