Coroner Wilson, sitting in Cairns, has handed down her findings from the Inquest into the death of Holly Winta Brown (12 June 2019).

The Laura Rodeo

Laura is approximately 300 kilometres north of Cairns and approximately 140 kilometres west of Cooktown ([42]). According to Google maps, it is approximately 4 hours’ drive north of Cairns.  On 26 June 2015 Ms Brown (aged 17) was in Laura with her parents, her brother and friends to attend the Laura Races and Rodeo.   The weekend was a big event. The prior weekend was the Laura Dance Festival and participants stayed in town until the weekend of the 26-27 June 2015 for a combined rodeo and horse racing weekend ([48]-[50]).  It was accepted (at [52]) ‘that approximately 2000 people attended over the course of the weekend for the 2015 year’.  The normal population of Laura was 80.

For the horse weekend, 26-27 June, there were two event organisers.  The Laura Amateur Turf Club (LATC) organised horse racing events.  The Laura Rodeo and Camp Draft Association (LRCDA) Inc organised the rodeo and camp draft events ([45] and [46]).  The committees arranged medical cover for their events ([156]) without any attempt to coordinate together to provide event medical service for the suite of horse events and with no effort to provide health services for ‘non-event related emergencies’ ([156]-[160]) such as a medical emergency in the camp ground.

Medical services were provided by two nurses from the Laura Primary Health Clinic that was operated by The Torres and Cape Hospital and Health Service (TCHHS).  For the weekend of the 26-27 June (with at least an extra 2000 people in town), ‘one additional contracted agency nurse to provide first aid at the 2015 event, and to backup the QAS’ ([57]).

Ms Brown’s death

On the evening of 26 June 2015 Holly attended a nearby campsite and socialised with her friends. Her parents, Warren and Eleanor Brown collected her at around 2:00am (27 June) and returned to the family campsite. When Holly woke that morning she told her father she was not well and that she had a sore back. Her father rubbed her back, gave her panadol and suggested she lay back down in her swag. Holly ate breakfast, vomited and went back to rest in her swag. Holly told her mother she had chest pain. When Holly’s father checked on her at approximately 8.30am, or soon after, Holly could not be roused, her breathing was shallow, and she was unresponsive.

Warren Brown called for help and commenced cardiopulmonary resuscitation (CPR). Ms Janae Ives, a nearby off-duty nurse attending the weekend event, was alerted to the scene. By coincidence, Ms Ives was an experienced clinical nurse employed as a triage emergency department nurse at the Cairns Hospital…

Ms Ives arrived at the Brown’s campsite, (she will say by 9.00am) she saw that Holly was unresponsive, and she was present when soon after her arrival, Holly went into cardiac arrest (at around 9.10am). Ms Ives took control of the scene and the CPR. She co-ordinated the emergency response and remained with Holly as events unfolded.

A triple zero call was made at 09:40 ([9]).

Efforts to resuscitate Holly continued whilst waiting for the emergency services to arrive. Nurses from the local Laura Primary Health Clinic (LPHC), who were at that time on fatigue leave after working a double shift, arrived in the clinic troop carrier (a recovery vehicle) with a ‘Thomas Pack’ and a modest amount of equipment and supplies (adrenaline; a travel automatic emergency defibrillator-AED and an oxyviva).

Holly achieved a return of spontaneous circulation (ROSC) however it was clear that she was not responding and was in a critical condition. The resuscitation efforts and interventions provided to her at the scene were insufficient to revive her…

The Queensland Ambulance Service arrived on-site at approximately 11.00am and the Careflight emergency helicopter arrived at approximately 11.15am, some two hours after Holly’s cardiac arrest. By then all attempts to revive Holly were futile.…

Holly was pronounced deceased at 11.44am by the Careflight escort doctor, Dr Dunn.

The Coroner continued ([18]-[20]):

It is now known that Holly suffered an arrhythmia as a result of undiagnosed heart scarring, possibly due to (childhood) rheumatic fever. Holly’s condition was rare.

Basic resources such as an automated external defibrillator (AED) and adrenaline were not available on site for at least 45- 50 minutes after Holly’s cardiac arrest. In the circumstances, Holly’s chances of survival were almost nil without immediate access to advanced emergency care and treatment and resources.

The health response

Nurses Harvey and Farrelly were the two nurses who worked for the health clinic. They had done two transfers to Cooktown the night before and needed to take a break. They gave evidence that given there were only two nurses in the clinic it was impossible for them to have days off as they had to respond two-up to any call out.   The Coroner said at [148]:

At the time of Holly’s emergency on Saturday morning Nurses Farrelly and Harvey were resting for the first time in almost 24 hours. They had not slept since Thursday evening.

Nurse Leighton was the agency nurse engaged to provide an extra person for the rodeo weekend.  She understood that she was to provide basic first aid and to support the Queensland Ambulance Service (QAS) on scene.  She understood she could call the Health Clinic for further support if required.   That was her understanding but when she arrived, she discovered that QAS would not be on scene.  The Coroner said ([110]-[114]):

Nurse Katherine Leighton was not properly briefed or prepared as to the nature and extent of the role and expectations required of her on 27 June 2015 or for the event as a whole.

Nurse Katherine Leighton completely exposed as the employed ‘medical person’ at the grounds on 27 June and it is troubling in the extreme that Nurse Leighton was not aware until she attended the grounds on that Saturday morning that she was the only medical person on site and that QAS were not scheduled to attend the morning event.

Further compounding Nurse Leighton’s vulnerability, despite the fact that the nurses then on fatigue leave were ‘second on call’, Nurse Leighton had no adequate onsite backup available to her whatsoever…

Upon her arrival at the scene of Holly’s emergency Nurse Leighton immediately knew that the situation was critical and she knew she had absolutely no equipment or resources to advance the care already being administered by Janae Ives and student paramedics with the assistance of bystanders.

For these reasons I find any characterisation of Nurse Leighton as being professionally inadequate to be without merit. She was not provided with any professional scaffolding whatsoever by the TCHHS such that she could adequately respond to a medical emergency, the magnitude of Holly’s.

(The student paramedics referred to was attending the event as a participant, not part of the medical response team).

The Torres and Cape Hospital and Health Service (TCHHS)

The story of the preparation (or lack of it) by TCHHS and their failure to liaise with Queensland Ambulance to ascertain when QAS would be on site for horse racing, but not for campdraft events, makes very disturbing reading.    I won’t repeat it all but an impression of the chaotic nature of the event health management can be seen in the Coroner’s review of the evidence in paragraphs [253]-[255]:

It is submitted that this confusion occurred in part due to neither Mr Fenton [Director of Nursing (TCHHS)] nor Ms Wardlaw [Executive Director (TCHHS) Nursing and Midwifery] obtaining details of the timing and nature of the events over the Laura Horse Sports Races and Rodeo weekend, or the presence or otherwise of QAS during those events and failing to ensure this was communicated to the nurses. It is submitted that this confusion was exacerbated by a change in the Director of Nursing just prior to the Horse Sports Races and Rodeo weekend and inadequate handover. Specifically, Mr Fenton went on long service leave from his position on 19 June 2015 and Vicky Jackson [Director of Nursing and Midwifery] was responsible for covering the role of DON for the week of 22 to 28 June 2015, prior to the commencement of Julie Ross as Acting DON.

In terms of Mr Fenton’s actual instructions to the nurses, the only firm evidence is the email to Ms Harvey [Nurse – Laura Primary Health Clinic] of 18 June 2015. There is no evidence that he gave clear instructions to the nurses as to the expectations he had and whether they should attend with or without the vehicle.

Ms Jackson came into the role on 22 June 2015 for an interim period of one week between 22 June 2015 and 28 June 2015. Her evidence was that she received an inadequate briefing with regards to the weekend. She stated “I had concerns about planning for the event as I could get no clear direction from the Executives regarding staff placement over the period leading up to the event. Staff seemed to have not been given a clear pathway or expectation for their roles and appeared to have limited knowledge around orientation or indeed what my role would be or for how long I would be assisting them. As the DONM covering for that week I felt that I had been provided with misleading information and an inaccurate handover regarding the upcoming organisation of the event. It appeared to me that decisions were made without full disclosure and stakeholder consultation.”

Earlier, at [209]:

There is no evidence that Ms Wardlaw [Executive Director (TCHHS) Nursing and Midwifery] turned her mind to the nature of events to be held over the weekend or the population increase and the associated risks involved. In her oral evidence Ms Wardlaw acknowledged that she was not aware of the likely population increase associated with the event and her evidence suggests she did not have an understanding of what was involved in the activities being run, admitting she did not know at the time what a camp draft was.

At [213]:

Mr Pressley [Executive General Manager – Southern Cape York] was asked during oral evidence whether he put in place any other steps to make sure the LPHCC was adequately equipped to respond to the weekend, given the influx of people and the high risk nature of the events. He stated, ‘No, not that I can recall.’

Queensland Ambulance Service

At [289]:

The QAS were engaged by event organisers for discrete events which the QAS planned for and attended. The QAS applied appropriate risk assessment tools including the QAS risk assessment calculator. The QAS have demonstrated sufficient skill and interest in refining their risk assessment tools and in my view given that no criticism is directed to the QAS it is outside the ambit of this inquest to suggest any change or modification to those tools.

The coroner’s findings

The Coroner said ([58]-[64], emphasis in original):

… I find that the Torres and Cape Hospital and Health Service had a responsibility to, and did not, adequately plan for the temporary increase in population of between 2000-3000 people during the 2015 rodeo and race event (referred to as a ‘mass event’ as attendance exceeds 1000 people). In the absence of advance assessment and planning, the Laura clinic became the first emergency responder service to a population of 2000-3000 people.

I find that in 2015 the Laura Primary Health Clinic was not sufficiently equipped, resourced or prepared to provide a first emergency responder service for unplanned medical emergencies at a mass gathering event.

I find that the emergency medical response provided to Holly Winta Brown at the 2015 Laura Rodeo and Race weekend was inadequate.

I find that the inadequate response to the medical emergency was a result of an absence of formal direction, guidance and policy establishing appropriate protocols and pathways for all stakeholders in relation to roles and responsibilities for event planning and risk assessment in the context of a mass gathering.

I find that the lack of clear policy and guidelines within the Queensland Health, the Torres and Cape Hospital and Health Service, and / or standardised procedures generally in Queensland, for mass public event planning, mitigated against co-ordinated interagency planning.

With respect to the nurses on scene, the parents of Ms Brown asked, at [304] ‘“Why were the clinic nurses so ill equipped and so ill prepared[?] We witnessed mistake after mistake.’  The Coroner answered that question.  She said ([305]-[311], emphasis in original):

I have earlier noted that the clinic nurses should not ever have been put in the position they were. They were entitled, and needed to, take a full rest break before coming back on duty. A process should have been in place for a backup nursing team to cover Nurses Harvey and Farrelly that day. They were not fit for duty. They should not ever have been expected to make critical, potentially life saving decisions, and administer life saving treatments in their fatigued state.

They were not prepared for the medical emergency when they arrived and it was necessary for return trips to the clinic to obtain equipment. Otherwise hard working, caring, rural nurses were made to look and feel incompetent. Their usual competency and professional capacities should not be measured against the events of that day.

Nurses Harvey, Farrelly and Leighton are not personally accountable for all that went wrong on that day. Nurses Harvey and Farrelly did not arrive until almost fifty minutes after Holly’s cardiac arrest. Notwithstanding their lack of preparedness and lack of equipment fit for the purpose – any response fifty minutes after a cardiac arrest was inevitably ineffectual.

In final oral submissions at Inquest Mr Brown acknowledges:

“… I don’t blame the nurses. They were thrown into a situation there, where I don’t think they could handle, especially in that short a period of time”

I agree with Mr Brown on that point.

Nurse Harvey sent an email to Vikki Jackson on 25 June (the day before the weekend event commenced) as follows:

“Have just spoken to the rodeo people and they have nil equipment for the first aid and have said we bring car and first response bag with us. If that is done we have no emergency gear here at the clinic for call outs. Please inform me what you would like put in place”

It is unacceptable that only 24 hours prior to the event, a clinic nurse was still grappling with the logistics of covering the event, and the needs of the community of Laura. Nurse Harvey should have been supported by good executive decision making within the TCHHS and supplied with additional resources as required. She essentially had to make a call between either servicing the community, or assigning meagre resources available to her (including the clinic troop carrier) to the event grounds.

The Coroner offered her ‘sincerest condolences to Holly’s parents Warren and Eleanor and to Holly’s brother William and her wider family and friends for their tragic loss’ ([337]).  She noted (at [312]-[314]

Mr and Mrs Brown concluded in their written submissions:

“We watched our beautiful Holly die in the dirt. The terror Holly felt we witnessed, waiting for advanced life support to come. Waiting for the forgotten equipment and watching Holly with her airway compromised, negates the cost of an ambulance.”

I agree and would add that the indignity of being attended to in full public view for two hours with no immediate access to anything resembling advanced life support was inhumane.

Holly may not have survived even with advanced life support in, or out, of hospital. However, in this case, no one, not the event organisers, the TCHHS, nor anyone who assisted, or witnessed the tragedy, and especially Holly’s parents can look back on Holly’s death, and know that all that could and should have been done, was.

The coroner’s recommendations

The coroner made a recommendation (at [332]):

That within six (6) months of these findings an interagency executive group be convened to consider reform for mass gathering events in Queensland and specifically to establish a standardised protocol to provide for an out of hospital emergency medical response at the annual Laura Rodeo and Race event.

There were more details but what is of most interest is that, although the first sentence talks about ‘reform for mass gathering events in Queensland’ the recommendations were directed to the Laura event with the proposed group to include representatives from Laura service clubs.  The protocol was to have regard to issues of access to the Laura ground and the impact of the Laura event on the community.  This was not or at least not clearly an all-of-Queensland recommendation.

Commentary

The inquest findings make disturbing reading.  Anyone who has had anything to do with providing first aid or event health services at a public event would be shocked by the lack of planning and failure to undertake any rudimentary risk analysis.

I am disappointed that the coroner focussed on the TCHHS.  A health service does need to plan when there is a population surge in its area of responsibility and recognise that there may be extra-ordinary demands on its services.  But surely responsibility for planning for health services at the event rests with the organisers of the event – in this case the Laura Amateur Turf Club and the Laura Rodeo and Camp Draft Association.

In my view, by focussing on the TCHHS, the coroner let the organising committee’s off very lightly.  Her comments, directed to the committees, were ([162]-[163]):

The event planning for the Laura Rodeo and Race weekend must include a risk assessment of the event as a whole and not just the discrete events run by separate organisations. It should not matter in what capacity people attend the event, all should have access to medical coverage that complies with best practice including access to the Chain of Survival.

I can discern no reason why the responsibility for attendees to access 24 hour medical assistance should not be apportioned equally between the organising committees and in accord with event planning best practice, with reference to the TCHHS and QAS for input. Both committees must play an active role in the formulation of a preparedness plan that demonstrates access to medical coverage in accord with the ‘chain of survival’.

The Turf Club arranged for QAS to attend its events. The Camp Draft Association ‘approached a private medical provider and at the same time via Facebook called for interested ‘medicos’ to cover the weekend campdraft events’ ([159]).  They looked to the Laura Clinic nurses to provide cover as ‘the LRCDA considered the cost of engaging QAS ‘was very expensive for the club …’ ([126]).

As the coroner noted ([327]):

There are a number of valuable tools available to stakeholders including a manual commissioned by the Commonwealth Government “Safe and Healthy Mass Gatherings: A Health, Medical and Safety Planning Manual for Public Events”.  That such tools exist and are easily accessible further demonstrates what appears to be, in my view, a reprehensible lack of foresight by the organising committees.

The coroner did not make any recommendation for any legal action against any person.  Both the Turf Club and the Camp Draft Association were operated by volunteer committees. Under the Work Health and Safety Act 2011 (Qld) a person conducting a business or undertaking (a PCBU) does not include a volunteer organisation (s 5(7)).  It follows that the Act does not apply to either organisation.  If it did, I would suggest that they had failed in performing fundamental duties to ensure health and safety in particular the duty to ensure adequate first aid and emergency services (Work Health and Safety Regulation 2011 (Qld) rr 42 and 43).

Notwithstanding the size, and remote location of Laura, it is hard to believe that no member of either organising committee had been to a public event and seen anyone of the many private event health service operators on duty.  In my view any reasonable person organising such an event would have realised that they needed to arrange on-site health services. They could not or at least should not, reasonably, rely on the local clinic that normally managed the health needs of 80 people.

With respect to the recommendations that the coroner did make, she reported (at [317]) that a root cause analysis commissioned by the TCHHS identified ‘four contributing factors (which I accept all contributed to the inadequate response to Holly’s medical emergency)’.  One of them was:

There is no consistent local Council requirement in Queensland for event organisers to obtain a Council permit system to hold public or special events where that event will impact on local health services. This enabled an event in the Cook Shire being held without coordinated inter-agency notification or emergency planning for the event. Consequently there was no emergency preparedness plan established.

The coroner could, for example, have recommended that the Queensland government develop consistent requirements, across Queensland, ‘for event organisers to obtain a Council permit system to hold public or special events where that event will impact on local health services’ but she did not do so.

In my view the coroner missed the opportunity to make significant recommendations to event organisers generally to take risk assessment seriously and to take on board the organisers’ responsibility to arrange for proper care of those that attend large public events.