A Coroner's recommendations will spark sweeping changes in the equestrian world.
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The findings from the inquest into the death of Olivia Inglis were released by the Coroner's Court of New South Wales in Lidcombe this month.
The findings were handed down by Deputy State Coroner Magistrate Derek Lee.
The Bowral teenager died in March 2016 at an eventing competition in Gundy NSW.
About two minutes after she began the competition Olivia and her horse Togha reached a section of the cross country course which contained an obstacle know as fence 8A/8B, containing two separate fences.
Olivia and Togha successfully jumped the first fence without incident.
However, in the process of jumping the second fence Olivia and Togha fell, causing fatal injuries to Olivia.
The Coroner ruled the manner of the death was a misadventure.
Olivia sustained chest injuries after suffering an accidental fall while competing in the cross country phase of the event.
In the report, the Coroner made delivered 31 recommendations related to safety officers, course design, review processes, event management, athlete representatives, personal protective equipment and data collection.
The recommendations also related to medical coverage, event organisation and fence judges.
The Coroner has recommended Equestrian Australia appoints a national safety manager on a full-time basis and an event safety officer be appointed for every event.
The report also stated recommended there must be at least one medical response team consisting of a minimum of two medical providers at events.
In the case of a show jumping test and a cross country test held concurrently, there must be two medical response teams at events.
The Coroner also recommended the development a standardised data collection system for all equestrian events.
The system would provide a "clear and unambiguous" definition as to what constitutes a "near miss" at a fence/obstacle.
There would also be training to fence judges to allow for the accurate recording of instances of a near miss or fall at a fence or obstacle.
Olivia's death was not the only equestrian-related death which occurred in NSW in 2016.
Almost seven weeks after Olivia's death, 19-year-old rider Caitlyn Fischer, suffered a fatal fall while competing in an eventing competition in Sydney.
As Caitlyn's death raised similar broader safety issues related to the sport of eventing, a coronial investigation was also conducted.
Eventually concurrent inquests into the deaths of both Olivia and Caitlyn were held. The inquests were divided into two phases.
During the first phase of the inquests, evidence was taken regarding certain factual matters particular to Olivia's and Caitlyn's incidents.
During the second phase of the inquests, evidence was taken regarding broader systemic issues related to the deaths.
The Coroner's report found both the NSW Eventing Organisers Handbook and the 2016 EA Rules mandated that a paramedic (or ambulance equivalent) be present during the cross country test.
The report revealed there was no such mandatory provision regarding the presence of a doctor.
"I recommend to the Chief Executive Officer of Equestrian Australia that the NSW Eventing Organisers Handbook be immediately updated to remove reference to Health Services International as the preferred NSW ambulance service for eventing competitions, and that the Handbook be amended to nominate the current preferred service provider (if any)," the Coroner said in the report.
When the news of Olivia's passing broke, there was an outpouring of support from the Southern Highlands community and from the equestrian community around the world.
The hashtag #RideforOlivia received millions of shares on social media.
