Phillip Hughes and the inquest: what the coroner found.

This page draws only on the coroner's published findings. It does not name witnesses or go into the disputed evidence heard at the inquest.

The inquest

The inquest into the death of Phillip Joel Hughes was held in the NSW State Coroner's Court at Glebe from 10 to 14 October 2016. Magistrate Michael Barnes, NSW State Coroner, delivered the findings on 4 November 2016. Some press reports described him as a deputy state coroner; the findings name him as State Coroner.

The formal findings

• Date and place. Hughes died on 27 November 2014 at St Vincent's Hospital, Darlinghurst.
• Cause. The cause of death was a traumatic basal subarachnoid haemorrhage. The medical evidence before the inquest attributed it to an injury to the vertebral artery in the neck, a type of injury it described as rare but known in contact sports.
• Manner. He died of injuries sustained two days earlier, when he was accidentally struck by a ball while batting in a first-class match at the Sydney Cricket Ground.

The coroner found no suggestion that the ball was bowled with malicious intent, and that neither the bowler nor anyone else was to blame. He found that the independent medical evidence conclusively established that the injury could not have been survived, however efficient the emergency response had been. He concluded that the rules had been complied with and that the death was a tragic accident.

What the coroner said about the helmet

The findings deal with the helmet carefully, and they do not support the idea that a helmet could have prevented this injury:

• Hughes was struck on an area of the left side of his neck that his helmet did not protect, and there was no suggestion that the helmet malfunctioned.
• He was not wearing the most up-to-date helmet, and the rules then in force did not require him to. Even the most modern equipment then available would not have protected the place where the ball struck.
• In November 2014 the latest Australian standard for cricket helmets was AS/NZS 4499:1997 and the latest British standard was BS 7928:2013, dated December 2013. The helmet worn likely met the Australian standard but not the 2013 British one.
• It did not appear that a BS 7928:2013 helmet would have given extra protection at the site of the injury, though the coroner called this a safety issue that warranted further consideration.
• Expert evidence summarised in the findings was that better helmet design may play only a limited part in preventing this kind of injury: a helmet reduces the force on the head but is less able to stop the head moving relative to the neck, and restricting that movement might cause other injuries.

The four recommendations

1. Bowling rules. That Cricket Australia review the Sheffield Shield playing conditions on dangerous and unfair bowling (then numbered 42.2.1 and 42.3.1) to remove anomalies, and give umpires more guidance on applying them.
2. Neck protection. That Cricket Australia keep working with equipment developers, players' associations and testers towards a neck protector that could be made mandatory, at least in all first-class matches. The coroner recorded that in 2016 Cricket Australia recommended neck protectors but had not made them mandatory, because there was then not enough evidence that they worked.
3. Medical briefings. That the Sydney Cricket and Sports Ground Trust and Cricket NSW review how the daily pre-play medical briefing is carried out, considering a one-page document each day naming who fills the key emergency roles.
4. Umpire training. That umpire training be reviewed so umpires can make sure medical help is summoned effectively and quickly.

Changes the coroner recorded

The coroner noted that Cricket Australia, Cricket NSW and the Sydney Cricket and Sports Ground Trust had reviewed the death and made changes, which he called commendable. Among the changes recorded in the findings:

• from 15 February 2015, the ICC told member boards that BS 7928:2013 would be the de facto international standard for cricket helmets;
• the 1997 Australian helmet standard was withdrawn from 18 March 2015 and declared obsolete from 18 June 2015, with no plan then for a new one;
• from October 2015, Cricket Australia required players representing it, or a state or territory in its competitions, to wear helmets complying with BS 7928:2013, and the 2016-17 Sheffield Shield playing conditions required a batter facing fast or medium-pace bowling to wear one;
• the Trust began requiring hirers of its venues to complete a Player and Official Emergency Medical Plan, with a daily medical briefing.

Cricket Australia's own independent review of the death, led by David Curtain QC, reported earlier, in May 2016; it is described on the Curtain review. How helmet rules developed afterwards is on helmet rules: the history, and neck protectors as equipment are on neck protectors.