On 4 October 2019, the NSW Deputy Coroner delivered his findings into the deaths of Olivia Inglis (who died on 6 March 2016) and Caitlyn Fischer (who died on 30 April 2016). Although the accidents occurred at separate horse-riding events, they were only seven weeks apart. Because they raised similar issues, concurrent inquests were held. This blog is concerned with what the coroner had to say about the emergency medical planning and response rather than matters to do with the organisation of equestrian events.
Inquest into the death of Olivia Inglis
On 6 March 2016 Ms Inglis was taking part in a cross-country jumping event. At 9.13am she and her horse fell whilst attempting a jump with the horse landing on top of her. It was immediately clear that she had been seriously injured. David Keys was described as a paramedic who was on duty at the event, but as the coroner noted, prior to paramedic registration in 2018, who or what was a paramedic was unclear. On p. 11 (footnote 10) he said:
It will become apparent that the inquest considered certain issues related to the level of medical cover that was available at the event, and whether that cover could be described as paramedic services. For convenience, the terms “paramedic” and “ambulance” have been used in these findings. However, consideration of the precise matters related to these issues will be discussed later.
Mr Keys attempted to treat Ms Inglis but found that his suction equipment malfunctioned. He did not have equipment to intubate or to decompress her tension pneumothorax even though he was trained and experienced in those procedures. Ms Inglis’ mother gave evidence (at [8.16]) that:
“Mr Keys was struggling to work his equipment and so he was sitting beside Olivia and he had a machine that was needed to clear her airways and he was putting it in and out and he was turning it off and on and fiddling with it…He was very, very nervous and he just kept fiddling with his equipment”.
Mr Keys was assisted by Dr Taylor, a medical practitioner who was also a competitor in the event. The presence of Dr Taylor allowed him to try to ventilate Ms Inglis with a bag and mask whilst the Dr Taylor performed chest compressions. A NSW Ambulance helicopter landed near the scene. The ambulance retrieval team took over patient care but were unable to resuscitate her and she was pronounced deceased at the scene at 10.05am.
Preparation
Health Services International (HSI) was the preferred supplier of event health services for Equestrian Australia (EA). HSI was contracted to provide ‘paramedical services’ for the event. At [11.14]:
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. Nor did Mr Richardson turn his mind to the number of paramedics that would be present. Mr Richardson said that he was unaware of any difference in the level of paramedic services. He explained: “I didn’t know they were different levels so I presumed ‘Paramedic’ means someone who, if you have a fall, is equipped, who can help you. I, I didn’t know there was different levels”.
Mr Keys was an experienced army combat medic who worked for HSI on a casual basis. At [11.7]:
Following the booking request … Mr Keys was engaged by HSI to be present at the Scone Horse Trials… Mr Keys sought clarification … as to whether he would be working in a first aid or physician assistant capacity. Mr Keys sought this clarification so that he could understand his scope for the use of medication. According to Mr Keys, Mr Taylor informed him he would be working in a first aid capacity at the 2016 Scone Trials
The Coroner found that the EA rules required that a doctor or paramedic be engaged for these types of events. The NSW Handbook did not however mention the need for a doctor and, as for a paramedic, the coroner found ([11.10]-[11.11]):
It is arguable whether the presence of Mr Keys at the 2016 Scone Trials satisfied the mandatory provisions. This is because the evidence established that he was being employed in a first aid, as opposed to a paramedic (or physician assistant), capacity. This is contrary to the quote provided by HSI which indicated that paramedical services would be provided for the event.
Notwithstanding, it was fortuitous that Mr Keys brought a care skillset to the event that was actually higher than had been requested or contemplated. Conversely, it is most troubling to know that the equipment which was available to him did not match this skillset
It was believed that a Dr Janson would be on site as the event doctor, but this had not been confirmed with him and he was not in fact there. This was discovered only by chance when a member of the organising committee bumped into Dr Taylor, Dr Janson’s wife, that they discovered he was not there. Dr Taylor, agreed to fulfil the role of event doctor even though at an event safety meeting, held on 4 March, she had already been listed as the event doctor. Neither Mr Keys nor Dr Tayler were at the 4 March ‘safety briefing’. At [12.16]-[12.17] the Coroner said:
Dr Taylor said that the committee also knew that she was present as a competitor, and not the event doctor… Dr Taylor explained that although she had previously been asked to be the event doctor at other events she had only performed the role once or twice. This is because she was usually competing at events and thought it inappropriate to provide medical cover at the same time.
After Ms Inglis’ fall calls were being made on the radio for Dr Janson even though he was not there and this had been known at the safety briefing, indicating a lack of communication to those in the field and running the event: ‘Mr Bates [who convened the pre-event safety meeting] agreed that this demonstrated a breakdown in communications’ ([12.10]).
The coroner made the following findings ([12.13]-[12.16]):
As noted above, neither the NSW Eventing Organisers Handbook nor the 2016 EA Rules mandated that a doctor was to be present during the cross country test at the 2016 Scone Trials. The indication that Dr Janson was to be the event doctor seems to have been a product of the regular practice of organising committees to request medical practitioners to volunteer their time and services in this capacity. Whilst the willingness of medical practitioners to assist in a volunteer capacity is to be commended, it appears that the absence of a formal process that attended such arrangements caused some shortcomings, and created ambiguity at the 2016 Scone Trials.
It is unclear exactly how Dr Janson came to be nominated as the event doctor. What is clear, however, is that as late as 4 March 2016 there was an expectation that he would be present. Up until this point there is no evidence to suggest that any confirmation was sought by the organising committee or event officials that he would be present. It was only through a chance encounter with Dr Taylor that it became evident that he would not be present. It is also not entirely clear how Dr Taylor came to be listed as the event doctor. Clearly, this determination was made prior to the pre-event safety meeting, given that Dr Taylor’s name was already included on the checklist used by Mr Bates. It seems that Dr Taylor’s presence at the event as a competitor was seized on as an opportunity to regard her as the replacement event doctor, even though the evidence establishes that this was never confirmed with Dr Taylor herself. Dr Taylor’s evidence suggests that if confirmation had been sought it is likely she would have declined to volunteer as she was competing at the event.
What is troubling is that despite the change of event doctor, it is clear that this was not communicated to all relevant event officials. At the time of Olivia’s fall, attempts were still being made to locate Dr Janson in order to have him attend fence 8A/8B. Again, it was only by chance that Dr Taylor heard a radio broadcast in this regard, advised that Dr Janson was not present, but that she was available to assist.
The absence of both Mr Keys and Dr Taylor (who was believed to be the event doctor) from the pre-event safety meeting seems incongruous if the purpose of the meeting was to ensure that the cross country test was to be conducted as safely as possible. It can be accepted that financial constraints and the dependence on volunteers are limitations. However, it seems that there is scope to improve this process.
Inquest into the death of Caitlyn Fischer
Ms Fischer was also taking part in a jumping event when she and her horse fell. Ms Carr, Ms Fischer’s mother and a registered nurse, was the first person to reach her after the fall. She
… saw that Caitlyn was lying on her left side, facing away from her, and was motionless. Ms Carr ran around the fence and leaned over her daughter. She saw that Caitlyn’s pupils were fixed and dilated and that the left side of her left orbit appeared fractured, with the left side of her head appearing “crushed and bloody” but with no obvious active bleeding. The left side of Caitlyn’s helmet, which she was still wearing, had been crushed into the ground.
Ms Carr felt for a pulse and could not find one. She also saw no signs of respiratory effort. Ms Carr realised that, tragically, Caitlyn was already deceased.
Even so officials attempted CPR until the on site medical team arrived and confirmed that Ms Fischer was deceased and CPR was terminated.
Medical coverage
Moving from the specifics of these deaths to events generally the coroner considered the issue of medical services at events. (The discussion below, and paragraph numbers are taken from the report of the Inquest into the death of Olivia Inglis but the text appears in both reports).
It was noted that prior to 2007 medical coverage was provided by NSW Ambulance but fee changes had meant that NSW Ambulance was priced out of the market and event organisers had turned to the private ambulance market.
FEI is the International Federation for Equestrian Sports. FEI recognises a single national federation for each country. In Australia the national federation is Equestrian Australia (EA).
At [23.5]-[23.6] the coroner said:
Both the FEI Rules and the EA Rules contemplate the provision of paramedical services during the cross country test. Annex D to the FEI Rules refers to “a paramedic with Pre-Hospital Trauma Life Support (PHTLS) or International Trauma Life Support (ITLS) certification” and that “the Cross Country Test will require [sic] Pre-Hospital Trauma Care Specialist”. Similarly, Annex D.1 to the EA Rules provides that “an ambulance (or paramedic equivalent) MUST be present during the cross-country test” (original emphasis).
However, in 2016 there was no national registration or accreditation for the paramedic profession in Australia. Accordingly, at that time registration varied between jurisdictions, employers and practice settings…
And at [23.10]:
The evidence during the inquest established that most of the witnesses, including experienced riders such as Ms Bishop, were unaware of the change in medical service providers after 2007. Mrs Inglis said that until hearing the evidence in the inquest she was unaware of the change in level of paramedic services at events. She said: “As a member of EA, I had never realised that there’d been a point when that happened and we had suddenly different ambulance, different level of care at the events. That quite shocked me”.
Ms Fasher, former chair of the EA board said ([23.13]):
“Yes, look, I think it’s fair to say that as a result of this inquest a lot of us have become acutely aware as to what was the situation. I don’t believe the organising committees understood that, nor did very many of the rest of us. We assumed as laypeople that paramedics were in fact paramedics, with all of the things that you assumed in terms of their skill.”
The coroner said (23.15] and [23.17]):
The evidence suggests that following the change from public to private medical service providers in 2007, no re-evaluation was conducted on a general level by organising committees as to (a) whether the provisions of the NSW Eventing Organisers Handbook and the 2016 EA Rules could be complied with; and (b) whether an appropriate level of medical services could be provided. Certainly it is clear that no specific re-evaluation was conducted prior to 2016 at Scone or at the Sydney International Horse Trials. Rather, it is evident that past practices (probably dating back to 2007/2008) had been adopted regarding this aspect of preparation for the event…
Notwithstanding, in this context it can be accepted that organising committees, and event officials, having been advised of a preferred medical service provider, could assume that such a provider was capable of providing an appropriate level of medical care. Until the tragic deaths of Caitlyn and Olivia in 2016 there was no direct basis to query whether this was the case or not. However, the change in medical service providers in 2007 represented a missed opportunity for EA to demonstrate appropriate governance by ensuring that the same level of medical care that was provided at events prior to 2007 would similarly be provided after 2007.
In essence prior to 2007 EA had contracted with NSW Ambulance, after 2007 they contracted with private ambulance providers and no-one thought to question whether they were receiving the same level of service believing that a paramedic is a paramedic when clearly, before registration in 2018, that was not the case.
The FEI rules also provided that for cross country jumping events a ‘fully equipped Pre-Hospital Trauma Care Specialist with trauma and resuscitation skills must be available on site’ ([23.18]). EA rules provided that for events of less than 150 people this requirement could be satisfied by perhaps one or two on-site paramedics. The coroner said (at [23.27]):
… it is plainly evident that the EA Rules provide no clear and unambiguous rule or guideline as to what level of medical services is to be provided at an event, particularly during the cross country test.
The coroner recommended (at [23.48]):
… to the Chief Executive Officer of Equestrian Australia that the current version of the National Eventing Rules be amended to mandate that at each Event (a) there must be at least one Medical Response Team consisting of a minimum of two medical providers, one of whom has the minimum skills and experience to: (i) secure an airway, at a minimum with a laryngeal mask airway and ideally with the skill to intubate or perform surgical airway; (ii) decompress a chest with either a purpose-made long decompression cannula or thoracostomy/chest tube; (iii) apply quality pelvic binder (SAM splint or T-pod) and C-collar; (iv) insert IV and give crystalloid and analgesia; and (v) apply suitable splints to fractures; (b) where reasonably possible, subject to geographic limitations, a medical practitioner (the Event Doctor) is to be one of the members of the Medical Response Team; (c) there must be two Medical Response Teams at Events when the show jumping test and cross country test are held concurrently; (d) the Event Doctor (if available), or the Medical Response Team, in consultation with the event organising committee and Event Safety Officer is to determine the number of Medical Response Teams that are required to achieve a response time of three minutes or less to the location of a serious incident requiring medical assistance.
He also recommended that each team be provided with a vehicle and aim for a response time to any event of less than 3 minutes ([23.50]-[23.51]).
With respect to event planning he recommended ([23.60]):
… that an Eventing Serious Incident Management Plan (ESIMP): (a) is to be developed for every Event by an Event Organising Committee, prior to the commencement of the Event; (b) is to be provided to the Event Doctor or Medical Response Team for an Event, prior to the commencement of the Event; (c) is to ensure that an Event Organising Committee is to arrange for the Event Doctor or Medical Response Team to conduct a venue inspection, prior to the commencement of the Event, to ensure that any medical response can be provided in a timely manner, including transportation to off-site medical services; (d) is to ensure that all Event staff (including volunteer staff) are provided with all necessary contact phone numbers for Event Officials, the Event Doctor, and Medical Response Team, and any other medical services providers in the case of a serious incident requiring a medical response; (e) is to ensure that all Event staff (including volunteer staff) are provided with necessary information (including via a mobile phone app) to enable external medical services providers (such as NSW Ambulance) to be directed to the location of a serious incident requiring a medical response in a timely manner; (f) is to ensure that in the case of a serious incident requiring a medical response, Event staff (including volunteer staff) at the location of the serious incident be advised that the arrival of a medical response has been arranged and is imminent; and (g) is to ensure that the Technical Delegate has possession of the GPS coordinates for the location of each fence judge, so that such information can be provided to enable external medical services providers (such as NSW Ambulance) to be directed to the location of a serious incident requiring a medical response in a timely manner.
Finally the coroner recommended that fence judges, who sit at every jump, be provided with some basic training in what to do in the event of a fall and injury and be offered formal first aid training should they wish to receive it ([23.69] and [23.71]).
Implications
These findings may have significant implications both for those that organise equestrian events and those that provide event health services. Relying on doctors, paramedics or first aiders who happen to be at the events because they are also involved in equestrian sport is not sufficient.
The findings with respect to the organisation of the Scone event where Ms Inglis’ died demonstrates too the value in protecting the title of paramedic. Lay people did not understand what the term meant and failed to see any difference between NSW Ambulance paramedics and anyone else who arrived in an ambulance. At least with registration now to call oneself a paramedic means something.
Ms Inglis’ death also demonstrates the issue, often discussed here, about discrepancy between skill level of putative employment. Mr Keys was an experienced medic with experience in intubation and releasing a tension pneumothorax but on this day was told he was there as a ‘first aider’. If he had failed to provide care that he knew he could because of that direction I suspect the coroner would have been much more critical. In fact, he did the best he could with his skill set, what stopped him was that he did not have the equipment necessary to perform those tasks. One can infer if he had it, he would have used it as he should have in those circumstances.
Providing medical services at complex events such as cross country jumping, or large music festivals, is not simply a matter of asking someone with a first aid certificate to turn up with a first aid kit and a stretcher (which is a bit what it was like when I first started in the field). Today extensive planning and risk management is required, and teams are not only expected but increasingly required to bring advanced level skills and equipment to the scene. It is up to those providing the event health services to ensure that they have the necessary skills – if laypeople don’t understand that there are levels of skills then they cannot be expected to make the assessment of what teams are required. Ensuring those that provide event health services take responsibility for providing the service that is needed, not just the service the client asks for is, no doubt, part of the reasoning that lies behind Victoria’s plan to regulate the event health sector and also the push that lead to paramedic registration.
Australian Emergency Law 
This blog post mentions the benefits of paramedic registration that came into place after these incidents occured. Michael could you perhaps elaborate how, in the absence of appropriate and working equipment as well as staff levels, Mr Keys being a registered paramedic would have affected the outcome? Does registration not further entrench organisers’ reliance on titles rather than assessing the individual organisations providing services? How would an organiser be able to tell whether they are being provided an experienced operator such as Mr Keys, being trained in intubation and chest decompression, versus a registered paramedic who graduated last month?
Registration would not have made a difference with respect to the care provided and received because, as the coroner noted, Mr Keys was an experienced medic and qualified to intubate and relieve a tension pneumothorax if he had been supplied with the equipment. What registration would have done is helped the organisers to understand that there are different level of skills and that if they engaged ‘a paramedic’ they would be getting a registered health professional. It’s true there are still skill levels within the profession (just as there are with medical and nursing practitioners) but at least the term means something and the paramedic has ethical and professional obligations to both reflect on their scope of practice and whether that is sufficient for the task they are being asked to undertake.
I said ‘Lay people did not understand what the term meant and failed to see any difference between NSW Ambulance paramedics and anyone else who arrived in an ambulance. At least with registration now to call oneself a paramedic means something.’ I think that makes my point.
With registration being in place, how do you envisage that lay people would see the ‘difference between NSW Ambulance paramedics and anyone else who arrived in an ambulance’? Do you believe organisers and patients will be checking 100 points of ID and looking up practitioners on the AHPRA website? Do you envisage that from December 2018 paramedics who were dependent on an income from an ambulance service or private provider will suddenly be in a position to immediatly grasp and prioritise their ‘ethical and professional obligations’ above paying the mortgage and feeding their families?
You stated that now ‘to call oneself a paramedic means something’ and I acknowledge that as an industry we are currently still high fiving ourselves, but I question what it ‘means’ for the public, organisers and would have meant for these patients.
In short, I feel that I need to question the relevance of your comments about registration to these two cases.
With registration being in place, how do you envisage that lay people would see the ‘difference between NSW Ambulance paramedics and anyone else who arrived in an ambulance’?
People will see that if someone turns up with ‘paramedic’ on their uniform they have a minimum level of qualification and that they have had their character and fitness to practice assessed. Someone who turns up in an ambulance but who does not have ‘paramedic’ on their uniform will not bring their guarantee. So people will be able to see the difference between a paramedic and anyone else who turns up in an ambulance.
Do you believe organisers and patients will be checking 100 points of ID and looking up practitioners on the AHPRA website?
No
Do you envisage that from December 2018 paramedics who were dependent on an income from an ambulance service or private provider will suddenly be in a position to immediately grasp and prioritise their ‘ethical and professional obligations’ above paying the mortgage and feeding their families?
Suddenly? No, but I’ve argued before that registration was never going to change paramedicine from 1 December, but it is a step to allow the profession to do so. Now event first aid service companies that are owned and managed by paramedics will have those obligations and over time, as the profession develops will hopefully do that and start bringing pressure onto event organisers to ensure that they contract, and pay for, proper on-site health services. And companies that are not managed by paramedics and other registered health professionals will, I hope, be at a market disadvantage even if they can beat a paramedic service on price.
In the case of Mr Keys however he would not have needed ‘clarification … as to whether he would be working in a first aid or’ paramedic capacity. As a registered paramedic he would know that he was a paramedic regardless of what his employer called him and that he has his own duty to his patient. That would have given him more authority to insist that he be supplied with the equipment and other resources (eg another practitioner) to ensure that he could practice to the standard that would be expected by the profession in all the circumstances. And if he was not given what he needed he would have to consider whether he could undertake the task. In short yes, there will be times when a registered practitioner has to prioritise their ‘ethical and professional obligations’ above paying the mortgage and feeding their families’.
You stated that now ‘to call oneself a paramedic means something’ and I acknowledge that as an industry we are currently still high fiving ourselves, but I question what it ‘means’ for the public, organisers and would have meant for these patients.
What it means for the organisers is the same as calling oneself a doctor or a nurse. They can have some confidence in the quality and competence of the person with ‘paramedic’ on their uniform recognising that within paramedicine (as within medicine and nursing) there will be different skill levels and competence.
It might not have meant anything for these patients as there was not, in fact, any question about the competence of those tasked with providing care though in one case the actual contracting health service company may have been inadequate in not providing enough people or adequate equipment but we don’t know if that would have made a difference to the outcome for Ms Inglis.