Finding into death of Friederike Antonia Ruhle

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE Court Reference: COR 2015 3242

FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008 Findings of: Paresa Antoniadis Spanos, Coroner Deceased: Friederike Antonia Ruhle Date of birth: 7 September 1989 Date of death: 1 July 2015 Cause of death: Chest injury in a workplace incident

Place of death: Prahran

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of FRIEDERIKE ANTONIA RUHLE without holding an inquest: find that the identity of the deceased was FRIEDERIKE ANTONIA RUHLE

born on 7 September 1989

and that the death occurred on 1 July 2015

at the Alfred Hospital, 55 Commercial Road, Prahran, Victoria 3181

from:

I(a) CHEST INJURY INA WORKPLACE INCIDENT

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Ms Ruhle, affectionately known as ‘Fred’ or ‘Freddy’, was a 25-year-old stable hand and track rider from Germany who was living with her partner, Shane Sinclair, in Hoppers Crossing at the time of her death. She is remembered as a cheerful, happy person who was

passionate about horses and loved working outdoors. Ms Ruhle had no known health issues.

BACKGROUND

2. Since about the age of seven years, Ms Ruhle had owned her own horse and participated in dressage and show jumping in Germany. Upon arriving in Australia as an adult, she spent a period working as a stable hand for a race horse trainer, Lisa Jayne Smith, before relocating to Melbourne, where she met Mr Sinclair. Around November 2013, Ms Ruhle was offered a job

working as a stable hand with Ellerton and Zahra horse trainers in Flemington.

3. In mid-2014, Ms Ruhle gained employment with Byron Cozamanis working as a stable hand.

She was required to submit her resume, in which she detailed her horse riding experience, and noted that she had not previously raced horses or worked as a track rider. Initially, Ms Ruhle was only doing stable work. However was she was keen to ride the horses, she would volunteer to take on extra duties, and so once she established her riding ability,! Mr

Cozamanis assigned her a horse to ride.

4. Ms Ruhle was slowly given more track work and progressed to more difficult horses as her skills improved. This was a staggered process which was monitored by Mr Cozamanis and assistant trainer Giovanni Spiga. Mr Spiga considered Ms Ruhle to be a good track rider, able to do fast and slow track work, and capable of riding all kinds of horses, including the young

ones that can be harder to control.

1 Ms Ruhle’s riding was supervised by either Mr Cozamanis or Mr Spiga, who determined when she was ready to undertake track riding based on their personal experience. No formal assessment was ever performed.

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Caulfield Racecourse consists of a main course and five training tracks: two grass gallops, two sand tracks and an all-weather Polytrack. The Lead Sand track, which is 1500 metres long

and six metres wide, is used for non-gallop/slow track work.

In 2012, the Melbourne Racing Club [MRC] commenced a project to transition all track railings at Caulfield Racecourse from aluminium and steel railings and legs to plastic railing, which is considered safer for both horses and riders. This was a protracted process, as MRC needed to ensure the continual safe operation of the Racecourse, which is used by an

estimated 550 horses and their riders each day.

On Friday 26 June 2015, work was undertaken to transition aluminium rail to plastic rail on the outside of the Lead Sand track. Work began at the winning post and about 100 metres of track was completed that day. The following Monday, 29 June 2015, .the transition work continued on the Lead Sand track outside rail and work was completed for the day at the 200 metre mark, At the point of completion for the day, the existing aluminium rail and new plastic rail were overlapped and taped together, with a white pad placed over the join to cover any exposed edges. Rail works were then suspended as the current supply of plastic rail had

been exhausted.

CIRCUMSTANCES PROXIMATE TO DEATH

On the morning of 1 July 2015, track training supervisor Shane Hookey conducted a pre-start inspection to ensure that all tracks were secure. As part of this inspection, Mr Hookey checked the point at which the new plastic railing joined the old railing aluminium railing. He

did not identify any safety issues.

At about 4:00am, Ms Ruhle commenced work. She rode two horses around the sand track without incident before starting on her third horse for the day, a two-year-old unnamed grey thoroughbred gelding that was known as Son of Excellent Art. Ms Ruhle completed the first lap of the Lead Sand track, accompanied by Mr Spiga and jockey Stephen Harper on their own mounts. However, as she commenced the second lap, at a location near where railing works had been suspended, her horse was spooked and shyed to the left,? causing Ms Ruhle to fall from the horse to the right. As she fell, she held on to the reins for a number of metres before letting go and falling to the ground on her back. Mr Harper saw the horse step

sideways and onto Ms Ruhle’s upper body before running on down the track. Mr Harper

2 There was some discussion throughout the course of the WorkSafe investigation as to what startled Son of Excellent Art, with the most likely cause being identified as the recent change to the track due to the barrier railing works. The evidence suggested that Son of Excellent Art was a quiet horse that was not easily spooked, and that Ms Ruhle had ridden it on a number of occasions without incident. It is not necessary for present purposes to determine the precise cause, and I proceed on the basis that racehorses are intelligent animals that are highly strung and will be spooked from time to time — a risk that unfortunately cannot be negated.

yelled out to Ms Ruhle, who he saw was not moving, and tried to stop but was unable to as his

horse pursued Son of Excellent Art.

10. Atabout 5:35am, Mr Hookey was working in the Caulfield Racecourse observation box when he saw a horse coming past the winning post on the lead track without a rider. He sounded the warning siren, indicating to other track users that there was a loose horse, and unsuccessfully attempted to catch the horse. He was informed that there was a rider down at the 250 metre mark of the Lead Sand track. Mr Spiga, who saw Son of Excellent Art coming up behind him, jumped off his own mount and caught him. He stabled both horses before returning to the track to check on Ms Ruhle. Mr Hookey radioed David Bodnar, the racecourse ambulance

attendant, who picked him up in the ambulance on the way to render assistance to Ms Ruhle.

11. Mr Hookey and Mr Bodnar found Ms Ruhle on the grassed section beside the Lead Sand track at the 250 metre mark, unconscious and struggling to breathe. She was dressed in normal track work gear with her safety vest and helmet still affixed. Mr Spiga arrived soon after and contacted emergency services, while Mr Bodnar supported Ms Ruhle’s aitways until ambulance paramedics arrived. While in transit to the hospital, Ms Ruhle suffered a bradyasystolic arrest.2 Paramedics commenced cardiopulmonary resuscitation, which was

continued on arrival at the emergency department of the Alfred Hospital (Alfred ED).

12. Emergency clinicians at the Alfred ED performed a bilateral chest thoracostomy,’ draining a large volume right haemothorax.’ This was followed by a resuscitative thoracotomy.° However, despite maximal therapy Ms Ruhle was unable to be revived and was declared

deceased at 7:21am.

MEDICAL CAUSE OF DEATH

13. Senior forensic pathologist, Dr Michael Burke of the Victorian Institute of Forensic Medicine, reviewed the circumstances of the death as reported by police to the coroner, post-mortem computer assisted tomography [PMCT] scans of the whole body and performed an autopsy.

Among Dr Burke’s anatomical findings were multiple fractured ribs, bilateral haemothoraces

and a pulmonary laceration involving a large calibre pulmonary artery branch.

3 Cardiac arrest marked by an extremely slow pulse, usually less than 30 beats/min.

4 This is a small incision of the chest wall, with maintenance of the opening for drainage.

5 This is a collection of blood in the pleural space.

5 The procedure allows immediate direct access to the thoracic cavity, permitting rescuers to control hemorrhage, relieve cardiac tamponade, repair or control major injuries to the heart, lungs or thoracic vasculature, and perform direct cardiac massage or defibrillation.

14, Routine toxicological analysis of post-mortem samples taken from Ms Ruhle’s body did not

detect any alcohol or other commonly encountered drugs or poisons. Dr Burke attributed Ms

Ruhle’s death to chest injury in a workplace incident.

INVESTIGATIONS OF MS RUHLE’S DEATH

Ms Ruhle’s death was reported to the Court by the Alfred Hospital. In the normal course of events, a member of Victoria Police would be appointed to conduct an investigation into the circumstances surrounding Ms Ruhle’s death. However, ase the incident leading to death occurred in the course of Ms Ruhle’s employment, an investigation was initiated by the Victorian WorkCover Authority [WorkSafe]. While the WorkSafe investigation was underway, and in order to avoid unnecessary duplication of inquiries as required by section 7

of the Coroners Act 2008, the coronial investigation of Ms Ruhle’s death was suspended.

WorkSafe Investigation

The WorkSafe investigation of Ms Ruhle’s employer, Byron Cozamanis examined whether he had breached the Occupational Health and Safety Act 2004 or any other Victorian

occupational health and safety law.

In August 2016, I was advised by WorkSafe that following its investigation and legal review, it had decided not to commence a prosecution against any party in relation to Ms Ruhle’s death due to public interest considerations, but WorkSafe did issue a letter of caution to Mr

Cozamanis.

Resumption of the Coronial Investigation

On 8 August 2016, WorkSafe provided a copy of their brief of evidence to the Court. The brief contains statements and other documents obtained in the course of WorkSafe’s investigation of Mr Cozamanis. As the materials are voluminous, I do not purport to summarise all of the evidence, but will refer to it only in such detail as is warranted by its

forensic significance and in the interests of narrative clarity.

Following receipt of the brief, I met with the WorkSafe investigator to discuss the issues that arose during the investigation and to determine whether any opportunities for prevention of

similar deaths could be identified. Concerns had been raised about the adequacy of Ms

Ruhle’s protective gear, the absence of formal qualifications for track riders and the feasibility

or otherwise of providing falls safety training to track riders.

Registration and Formal Qualifications for Track Riders

Currently in Victoria, a person can undertake track riding work at a Racing Victoria licensed venue after completing a minimum of two units from the National Racing Industry Training Package’ and obtaining registration with Racing Victoria as a stablehand. The required units of competency do not include any actual riding elements or assessments. A Certificate III in Racing (Track Rider) is available at some TAFE institutions in Victoria, but this qualification is not a mandatory requirement for employment as a track rider. Racing Victoria previously

provided a two week intensive Track Rider Program, however it was discontinued in 2016.

According to Racing Victoria, a stablehand is a person who is employed by a licensed trainer in a thoroughbred racing stable and whose prime function is to care for horses and to meet their individual needs of feeding, grooming, exercising (including track work riding) and transporting. There is no separate registration for track riding. The decision to allow a stablehand to undertake track riding work is made by the trainer employing them, based on

their own criteria and requirements.

While there is no suggestion that Ms Ruhle was not competent or experienced enough to be undertaking track riding work, the absence of formal qualifications and registration requirements for track riders is concerning given the level of danger inherent in this kind of work. Jockeys, who undertake substantially similar work, undertake a rigorous apprenticeship

including theoretical and practical training, which is strictly assessed.

Fall Safety Training

Currently, track riders and jockeys do not receive any training or instruction on the safest way to fall from a horse. Material provided to me during the course of this investigation supports a finding that there are “safer” ways to fall from a horse and that riders can be trained in how to

fall more safely so as to minimise the risk of injury as far as possible. Moreover such training

is available at a modest fee and safety gains can be made after even a few hours of training.

Had Ms Ruhle been trained in how to fall safely, including by letting go of the reins and rolling clear of the horse, it remains a possibility that her injuries may have been less serious

and her death prevented.

7 Those units, Unit RGRCMN201A — Follow OH&S Procedures & Observe Environmental Work Practices and Unit RGRPSH201A — Handle Horses, form part of Certificate II in Racing (Stablehand).

Adequacy of Ms Ruhle’s Protective Gear

27,

The Australian Rules of Racing® require every rider to wear a certified safety vest as prescribed by the Australian Racing Board? [ARB]. Following the death of jockey Simone Montgomerie on Darwin Cup Racing Day in 2013,!° the ARB conducted an evaluation of the protective capabilities of safety vests worn by jockeys in Australia to ascertain whether current standards were appropriate for these vests. During engineering testing, the Phoenix

Tipperary Ride Lite Vest [Tipperary Vest] failed by a considerable margin.

On 3 September 2013, the ARB issued a Notice to All Licensed Persons, stipulating that they had suspended approval of the Tipperary Vest for use by all track riders and stable hands effective 1 October 2013. This notice was distributed to all key stakeholders. The ARB subsequently deleted the SATRA Safety Vest standard, under which the Tipperary vest purported to be certified, from the prescribed standards under AR.87B as being unreliable and

not used in any other major racing jurisdiction.

On 1 July 2015, Ms Ruhle was wearing a Tipperary Vest which she had been given by a

former track riding colleague, Emma Collins, prior to it being banned.

The WorkSafe investigation revealed inconsistent practices at Cozamanis Racing concerning the checking of safety equipment to ensure it is compliant with regulations. According to Ms Collins, when she commenced working for Mr Cozamanis in 2013, she was required to provide her own riding safety gear. She said nobody from Cozamanis Racing checked her safety gear to ensure that it met the required standards at any time during her employment.

Furthermore, Ms Collins said her safety gear was never inspected by race stewards while she

was performing track work at Caulfield Racecourse.

Mr Spiga said that in his position as assistant trainer, he would normally check an employee’s safety gear to ensure that it was compliant with standards, however he was confident that Mr Cozamanis had already done so for Ms Ruhle. When he had commenced working at Cozamanis Racing, he had provided his own cap and vest, and Mr Cozamanis had personally

inspected them to ensure they were compliant with standards.

Like the earlier death of Ms Montgomerie, evidence suggests that Ms Ruhle would have sustained fatal injuries even if the vest she was wearing had met Australian standards, as no

vest is designed to withstand the full weight of a horse. However, this will not be the case in

8 The Australian Rules of Racing are administered and amended by Racing Australia, the national industry body representing thoroughbred racing in Australia, in adherence to world’s best practice standards of integrity and animal welfare.

9 ‘The Australian Racing Board was subsumed by Racing Australia on 13 April 2015.

10 Inquest into the death of Simone Montgomerie [2014] NIMC 028.

all falls and so it is essential that all rider safety equipment is regularly checked to ensure

compliance.

CONCLUSIONS

31. I find that Ms Ruhle, late of Dona Drive in Hoppers Crossing, died at the Alfred Hospital in Prahran on 1 July 2015 and that the cause of her death was the chest injury that she sustained

in a workplace incident.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected to

the death:

1. Although unlikely to have changed the outcome for Ms Ruhle, the investigation of her death revealed inconsistent positions as to who is responsible for providing personal protective equipment [PPE] to riders in the racing industry and ensuring that it is compliant with

standards.

2. The CEO of Racing Australia, Peter McGauran, maintains that there is no obligation on a trainer under the Australian Rules of Racing to ensure that his or her riders have compliant PPE. Conversely, the WorkSafe publication Horse Stables and Track Riding Safety states that ‘employers must ensure staff are equipped with and use all necessary PPE’ and that “training is provided in the correct selection, inspection for wear or damage, use and care of

PPE such as... helmets, body protectors and other riding gear.’

3. Where employee safety is at stake, clarity in roles and responsibilities is paramount.

4. It seems sensible that the trainer, as the employer, should provide compliant PPE, particularly when dealing with a largely migratory workforce as appears to be the case with track riders. At the very least, trainers or their designees should be inspecting PPE used by their employee riders at the beginning of their employment, and regularly thereafter, to

ensure compliance with current Australian Standards.

5. Lam advised that since being issued with an Improvement Notice by WorkSafe, Cozamanis Racing has instituted a number of measures to improve rider safety and ensure that PPE is compliant, including institution of a policy whereby casual track riders’ equipment is inspected on their first attendance at the stables and at monthly intervals thereafter. This is a

commendable and sensible improvement in their work practices.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations

connected to the death:

1. That Racing Victoria consider the feasibility of compulsory fall safety training for

individuals engaged in track work with racehorses.

I direct that a copy of this finding be provided to the following: Shane Sinclair Ms Ruhle’s family The Alfred Hospital WorkSafe Victoria Melbourne Racing Club Racing Victoria Racing Australia ”

Minister for Racing

Signature:

“Ppawo

PARESA ANTONIADIS SPANOS CORONER Date: 2 February 2018