Record of Investigation Into Death (Without Inquest)
Corners Act 1995
Coroners Rules 2006
I, Melaine Bartlett, Coroner, having investigated a death of Glen Michael Lindsey
(a) Glen Michael Lindsey (Mr Lindsey) died on the 29th April 2011 at 189 Mary Street, Westbury;
(b) Mr Lindsey was born on the 30th December 1946 and was aged 64 years at the time of his death;
(c) Mr Lindsey died as a result of being thrown from his sulky whilst training a pacing horse;
(d) The cause of Mr Lindsey’s death was a traumatic brain injury with subarachnoid haemorrhage with cerebral contusions; and
(e) No other person contributed to the cause of Mr Lindsey’s death.
Circumstances Surrounding the Death:
1. Mr Lindsey was a divorced man with two adult daughters. He was employed as a dental prosthetist, and had lived in the Westbury area for about 40 years. He was also involved in training pacing horses, and had been training them in the company of his long term friend, David Charles Mace on a daily basis for approximately 5 years prior to his death.
2. I am satisfied from the evidence contained in the affidavit of Mr Mace that Mr Lindsey’s daily schedule was to attend at the property of Mr Mace at Moore Street, Westbury at 6:30 am. He would feed horses at that property and train a show horse before he and Mr Mace then started track work with horses and sulkies. Mr Lindsey had a practice of wearing appropriate safety helmet and goggles, which were always properly secured. I am satisfied that he was wearing these on 29th April 2011.
3. The horses were trained in three day cycles by Mr Lindsey and Mr Mace, and the training consisted of one day of jogging, a second day increasing in tempo, and the third day ending with a three lap session, with the final lap being a sprint to get the horses to race each other.
4. On the 29th April 2011 Mr Lindsey and Mr Mace were conducting training as usual, and it was the third day of the training cycle, so they were engaged in fast track work.
5. Mr Mace was training a horse owned by Mr Lindsey called Return to Sender. This horse had a history of problem behaviour, which had previously resulted in it being barred from racing 3 times. The horse had previously put Mr Mace’s son-in-law and Mr Lindsey into the fence during training sessions. On this day the horse was wearing special gear on his legs to try to keep him in pace and prevent him breaking into a gallop. In addition, Mr Mace had fitted the horse with a wider than usual mouthpiece in an attempt to keep the horse under better control. Mr Robert Collis was training a horse at the same time on the inside track and travelling in the opposite direction to Mr Mace and Mr Lindsey.
6. As Return to Sender came around the southern end of the track he began to cut a corner and headed towards the ditch and Mr Mace was forced to pull hard on the reins. The horse pulled himself out of the ditch and began to gallop. In Mr Mace’s words he “went into a mad gallop”. As a consequence the horse started to drift to the right whilst they were still in the corner and heading for the straight. He continued to drift to the right towards the horse being driven by Mr Lindsey. Mr Lindsey had come up on the outside of Mr Mace and Mr Mace says he recognised they were running out of room on the track and his sulky had become unstable due to his horse being in a gallop. He called out to Mr Lindsey to “back off” when Mr Lindsey was beside him.
7. At this point, Mr Lindsey’s horse’s feet were under the wheel of Mr Mace’s sulky and Mr Mace was still pulling hard on the reins to try to get his horse to straighten up. I am satisfied that at that point the wheels of the sulkies have come into contact with each other. This is evident from the photographs taken of both the sulkies after this incident and referred to later in this finding. Mr Mace turned to his right and said he could see that Mr Lindsey was going to come out of his sulky. After Mr Mace’s horse straightened up he continued along the track and was then passed by the horse which Mr Lindsey had been driving. Mr Mace followed that horse back to the stable area and asked his daughter, Ms Toni Laugher to take Mr Lindsey’s car and go and check that he was all right. Ms Laugher observed the horse had come back without Mr Lindsey in the sulky and with the sulky on its side. The horse went in to the rear of the property towards the stables and as it went round a corner the sulky righted itself on to both wheels.
8. Mr Lindsey was located lying face down on the track by Ms Laugher, and she observed that his head was facing to the right and his helmet had come off his head and was about 2 metres to his rear on the left. His goggles were located nearby. Ms Laugher observed that Mr Lindsey had turned a purple colour. Emergency services were contacted by Ms Laugher and Mr Robert Collis commenced CPR on Mr Lindsey. During the CPR Mr Lindsey vomited and Ms Laugher and Mr Collis turned Mr Lindsey over to clear his mouth and then recommenced CPR. Ms Laugher stated that Mr Lindsey’s colour began to improve. Mr Lindsey vomited a number of times and on each occasion Ms Laugher and Mr Collis would roll him over, clear his mouth and then recommence CPR. This continued until Tasmania Fire Service volunteers arrived at approximately 9.05am. They then hooked up the portable defibrillator to his chest and inserted an airway tube, although this was difficult as Mr Lindsey had vomited which had blocked his airway. This CPR was continued until an ambulance arrived approximately 10 to 15 minutes later. Ambulance personnel took over the CPR and patient care. Treatment was unsuccessful and was ceased at 9:23 am. Ambulance personnel observed that when they arrived Mr Lindsey was lying on his back, and that he was centrally cyanosed, unresponsive, with no respiration or pulse and with palpated pupils fixed and dilated. He also had blood on his forehead and into his hairline, on his face and in his left ear.
9. A post mortem was conducted by Dr Ruchira Fernando, and it was concluded by her that Mr Lindsey died as a result of a traumatic brain injury with subarachnoid haemorrhage with cerebral contusions following the fall from the sulky. Toxicology reports showed the presence of caffeine, but were negative for alcohol and carboxyhaemoglobin. A drug screen was also negative.
10. Photographs of both the sulkies being used by Mr Lindsey and Mr Mace that morning were taken by Constable Marcus Williams at the track. He also took photographs which show the wheel marks on the track in the area immediately before the position in which Mr Lindsey was located. Those wheel marks show that the 2 sulkies were travelling close to each other and indicate that Mr Lindsey’s sulky was angling in a slightly inwards sideways manner and there is a sharper inwards angle approximately 15 metres from where Mr Lindsey body was located. The photographs of the sulkies show that Mr Lindsey’s sulky had a break in the metal undercarriage support bar at the rear under the seat. There is also blue string tied around all 3 of the metal bars running underneath the seat at both the lefthand side and the righthand side. These three bars include the bar which is part of the seat itself, the bar which extends across to each side of the sulky and is attached to the bars on the frame above the wheels, and the bar which is curved and attaches to the frame near the inside hub of each wheel. In addition there are photographs depicting fresh scrape marks and white paint on the sulky being driven by Mr Lindsey. These marks are consistent with similar marks and loss of white paint from the right side frame of Mr Mace’s sulky and I am satisfied that they indicate the impact which occurred between the two sulkies as they travelled along the training track.
11. Harness Racing Australia (HRA) was notified of this incident. HRA has a Sulky Wheel Approval Policy which commenced on 1st February 2009 and which was introduced to implement a national risk prevention program. However, as the name implies this policy relates only to approval for wheel designs to ensure “adequate durability and reduce premature in-race failures”.
12. HRA also has a Standard for Safety and Performance of Sulkies known as The Sulky Standard which was implemented on 14th June 1992 and has been amended at various times since that date. This aim of the Sulky Standard is “to regulate the design and manufacture of the harness racing sulky” so that it will conform to a number of principles “when used in competitive racing conditions”. The Standard states at paragraph 1.1.1 “The sulky shall be inherently sound and safe for its driver and horse when used in races”. In relation to the design of sulkies Paragraph 3 details what components a sulky shall contain and provides in 3.3 that “All components of the sulky shall be attached to one another in such a way that they remain attached during normal use and testing”. And under paragraph 9 which is headed “Fabrication” the Standard provides:
9.1 Tube shapes shall not be distorted in such a way as may result in loss of strength or loosening of rivets or other fixing means.
9.2 If welding is used, the particular instructions of the material manufacturer (or recognised material reference handbook) regarding stress relieving of welds, choice of electrodes, specific welding wire/rod and gas-shield welding must be obeyed. Appropriate welding techniques must be identified and used so that the resulting welds are free of defects. Welds must be along the whole circumference of a tube. Specific inspection procedures may be required in some instances.
13. Workplace Standards was also notified of the incident. A transport inspection was conducted of both the sulkies. That Inspection Report determined that the sulky used by Mr Mace appeared almost new and had been designed and manufactured to a standard that complied with the Sulky Standard and that at the time of inspection it would still meet that standard.
14. The Report concluded that the sulky being driven by Mr Lindsey was poorly maintained and not maintained to the level required in the Sulky Standard. There was no manufacturer logo or branding and by virtue of its overall width dimensions and appearance it was found by Workplace Standards to have been most likely manufactured before changes to the Sulky Standard which commenced on 1 September 1995. The findings on inspection by Workplace Standards were that the off-side front seat mounting bracket of this sulky had broken from the transverse undercarriage support pipe. It was found that the break began in the heat affected zone of the weld joining the inner axle support. The pipe displayed evidence of cracking over a prolonged period before finally breaking when there was insufficient strength left to maintain integrity. The final break in the pipe was found to be fresh. The break showed evidence of a previous attempt to re-weld it but the repair weld quality was of a poor standard and displayed slag inclusions and cold lap in the weld. There was a small square piece of 20mm conveyor rubber between the transverse undercarriage support pipe and the off-side seat frame which was held in place by leather belting and baling twine. The near-side front seat bracket mounting pin was missing. There was also a piece of 19mm copper tube tied between the transverse undercarriage support pipe and the seat frame near the near-side mounting bracket which was tied there with an inner tube and bailing twine. These methods of attachment were described in the Report as “using substandard materials and practices”.
15. The sulky was found to have significant positive camber of the wheels which will cause the centre of gravity to be raised proportionately due to the narrower wheel track. In addition it displayed significant toe-out of the wheels which will cause a proportionate lack of handling stability. As a consequence, if the weight distribution between the wheels was even, the wheels would have had a tendency to fight each other, whereas if the weight distribution was uneven, the vehicle would have had a tendency to move in the direction that the wheel with the most weight was pointing. This would have resulted in it being “unstable in its handling characteristics due to the significant toe-out and the significant positive camber of the wheels”.
16. I am satisfied from the evidence of Mr Mace and the photographic evidence of the track and the sulkies, that the sides of the two sulkies came into contact with each other when the sulky Mr Mace was driving was pulled over towards the sulky being driven by Mr Lindsey due to the temperament of the horse Mr Mace was training. The nature of Return to Sender was known to both men. I am satisfied that Mr Mace did all he could to deal with the horse’s decision to run towards the ditch. He was able to get it back on to the training track and was attempting to get it to straighten up, but by then Mr Lindsey’s horse and sulky were right up next to Mr Mace. As a consequence the sulkies came into contact with each other. Mr Mace indicated that both men had fallen from their sulkies during training on a number of previous occasions, so as a result he was not unduly concerned about Mr Lindsey falling out of the sulky, but he did request his daughter, Ms Laugher, to go and check on Mr Lindsey.
17. As a result of that contact the compromised sulky being driven by Mr Lindsey became unstable and Mr Lindsey came out of it and landed on the track. During that fall he suffered the injuries to his head. There is evidence that the sulky turned over on its side. Ms Laugher described it as being on its side when the horse came into rear of the yard still pulling the sulky and the sulky only righted itself as the horse turned a corner into the yard. As a consequence of the injuries Mr Lindsey suffered a traumatic brain injury with subarachnoid haemorrhage with cerebral contusions and this was the cause of his death.
Comments and Recommendations:
18. I have decided not to hold an inquest into Mr Lindsey’s death. The investigation has elicited all possible information surrounding his death and sufficiently disclosed the identity of the deceased person, the time and place of his death, the relevant circumstances concerning his death and the particulars needed to register his death under the Births, Deaths and Marriages Act 1999. I do not consider that an inquest is likely to elicit any further information concerning the issues that I am required to determine. I am satisfied that no other person contributed to Mr Lindsey’s death.
19. The HRA Sulky Standard relates only to sulkies being used in competitive racing conditions and the Standard is therefore not applicable to use of sulkies during training. However, the Sulky Standard provides an overall standard of safety levels in relation to the construction and maintenance of sulkies, and whilst it is accepted that it would not be feasible to have the Sulky Standard apply to all sulkies wherever they are being used, including during training on private tracks, I would recommend that HRA give consideration to an increased level of education to all trainers to recommend that they only use sulkies that are in a condition which meets the criteria set out in the Sulky Standard to ensure a high level of safety applies at all times for themselves and for any others training with them.
20. I take this opportunity of extending my sincere condolences to Mr Lindsey’s family and those close to him.
DATED : 16 July 2013 at Devonport in the State of Tasmania