Queensland Northern Coroner Nerida Wilson delivered her findings in a report today and states that the care provided to Holly at the Laura Rodeo and Races weekend in 2015 was “inadequate”.
The 17-year-old was attending the annual event with her family when she had a cardiac arrest and died.
In a disturbing series of events, the Coroner found that an ambulance did not arrive at the scene, about 300km north of Cairns, for almost two hours after Holly went into cardiac arrest on June 27.
Despite the annual event being attended by about 2000 people there were no ambulances on site for the first two days when camp draft events were taking place. The only medical assistance available was a first-aid nurse and the only equipment she had access to was a basic first-aid kit.
Holly went into cardiac arrest about 9.10am after complaining of a sore back and chest pain. Her father Warren Brown found her unresponsive in her swag about 8.30am and started CPR.
but the first Triple 0 call was not made until about half an hour later because there was confusion about whether an ambulance was already on site.
During the inquest, the coroner heard evidence of “pandemonium and chaos” with campers shouting for help and reports of people setting off on horseback to seek out medical assistance.
Two nurses from the local Laura Primary Health Clinic (LPHC) arrived at the scene about 45 minutes after Holly went into cardiac arrest, after working for the previous 24 hours straight.
This meant basic resources such as an automated external defibrillator (AED) and adrenaline were not available for at least 45-50 minutes.
“Holly’s chances of survival were almost nil without immediate access to advanced emergency care and treatment and resources,” the report stated. “CPR of itself was not enough.”
A recording of one of the Triple-0 calls includes the first-aid nurse describing the scene: “We’ve got a lot of panicking people here … I haven’t got the equipment I need …”.
Paramedics from the Queensland Ambulance Service did not arrive until about 1 hour and 20 minutes later, almost two hours after Holly went into cardiac arrest. A Careflight helicopter arrived about 15 minutes after the ambulance and Holly was pronounced dead at the scene.
In their written submissions, Holly’s parents said: “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”.
In her findings, Wilson agreed with these comments, adding: “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”.
While there was no guarantee Holly would have survived even if better treatment was available, Wilson said she did not receive an adequate medical response.
“The emergency medical response provided to Holly was inadequate,” she said.
The Coroner identified a number of factors that also contributed to Holly’s death including that there was no consistent local council requirement in Queensland for event organisers to get a permit to hold public events that will impact on health services.
She also noted the lack of policy and direction within the Department of Health related to public or special events, which meant no emergency preparedness plan was done for the event.
Wilson has recommended an interagency executive group be formed to consider reforms for mass gathering events in Queensland, to be named “Holly’s Law”. They should also develop plans for emergencies at the Laura Rodeo and Race event.