When teenage horse rider Olivia Inglis suffered a deadly fall at a NSW equestrian event, officials didn't know there was a doctor nearby and she was instead left in the hands of a "struggling" medic, an inquest has heard.
Charlotte Inglis told the NSW Coroners Court on Thursday she arrived at the scene minutes after her 17-year-old daughter and Olivia's horse, Coriolanus, tumbled over a jump at the Scone Horse Trials in March 2016.
"When I walked towards her I asked (medic) David Keys if she was dead because she had her eyes wide open," Ms Inglis said.
"He said 'No she has a faint pulse. Mr Keys was struggling to work his equipment. I sat beside them and held her hand."
Ms Inglis said Mr Keys was "fiddling" with a breathing machine, pulling it in and out.
The event's technical delegate, Mathew Bates, told the inquest the fact Dr Lyndel Taylor was on hand to assist in emergencies had not filtered down to race officials on the day.
Counsel assisting Peggy Dwyer said Dr Taylor's statement revealed she'd made herself known to a race official after hearing a helicopter circling overhead and realising someone was hurt.
"She asked if that person needed a doctor ... (they) answered an emphatic 'yes'," Ms Dwyer said.
Dr Taylor was escorted to Olivia and arrived 20 minutes after her fall. The 17-year-old died at the scene.
Her death came just weeks before 19-year-old Caitlyn Fischer was similarly killed during an April 2016 eventing competition in Sydney.
Deputy state coroner Derek Lee is examining the circumstances surrounding both tragedies in a two-week inquest at Lidcombe.
Ms Inglis on Thursday said at the time of her daughter's fall, she and her husband - both Equestrian Australia members - were unaware licensed paramedics were no longer present at events.
"We had no idea we had a paramedic that was unable to use his equipment," she said.
"We had always been under the impression that we had the NSW Ambulance service. (David Keys) was not a trained ambulance officer. He was faced with a dire situation."
Equestrian Australia has since changed its rules to require a paramedic with the capacity to provide advanced life support to be present at events.
The inquest heard Ms Inglis, a highly respected rider in her own right, had raised concerns over five jumps on the course - including the jump where her daughter died - before the fall.
She was worried about the jumps' slim rails, deceptive appearance and the absence of a ground line and discussed her concerns with Olympian Shane Rose.
She said the jump appeared more like a show jump which collapsed on impact and Olivia's horse had struggled with it the day before.
"(Olivia) and I discussed that if he didn't jump the first few (jumps) well she'd pull up and walk home," Ms Inglis said.
An incident investigation report shown to the inquest showed that the jump did not meet at least three Federation Equestre Internationale cross country course guidelines.
Australian Associated Press