Cricket : Lessons learned from a tragedy

Phillip Hughes tragic death on 27 November 2014 shocked the cricketing world. One of the sports most talented and likeable stars was lost when he was struck on the neck by a short pitched delivery in a Sheffield Shield match at the Sydney Cricket Ground.
Amongst the grief, questions abounded as to how such a fatal injury could occur, with modern rules and safety equipment. The media quickly latched onto murmurings of unsportsmanlike conduct, ugly sledging and deliberately dangerous bowling, throwing the Hughes family and all involved with the match into the spotlight. Many were quick to suggest blame on a number of fronts.
Thankfully, all of the evidence was gathered and considered impartially, applying principles of natural justice, in a coronial inquest last October. The coronial findings are a welcome voice of balance and clarity on what truly happened on that fateful day and what lessons can be learned from the tragedy.

The Injury
In his finding of 4 November 2016, NSW State Coroner Michael Barnes concluded that Phillip Hughes died as a result of a traumatic basal subarachnoid haemorrhage. The cricket ball found its way through the narrow gap between the shoulder and helmet grill to strike Hughes just under the left ear. The impact fractured the first cervical vertebra and dissected the vertebral artery. Due to the nature of this very rare and incompletely understood injury, Phillip Hughes’ death was essentially inevitable from the moment he was struck.
The following matters were brought to the Coroner’s attention to be considered as part of the inquest:

• Dangerous play;
• Adequacy of safety equipment;
• Emergency planning and response.

Allegations of Sledging
The Hughes family, and other witnesses, were concerned that threats of violence may have been made to Phillip and his batting partner during the course of the days’ play. The inquest had cause to examine the widespread practice of sledging in competitive cricket.
The Coroner noted that throughout its long history, fair play has been paramount in cricket, so much so that in the vernacular “it’s just not cricket” is still used to describe something that is unjust or improper. Until recently, the spirit of the game was so well-regarded that batsmen were expected to give themselves “out” by “walking” even if the umpires failed to detect the dismissal.
With increased commercialisation and very lucrative contracts dependent upon individual performances, it is perhaps inevitable that these honourable qualities would fray. The administrators have demonstrated their desire to preserve them by stipulating adherence to the spirit of the game in the rules. It is against the spirit of the game to direct abusive language towards an opponent.
“Sledging” is a term used to describe humorous, insulting or threatening remarks directed at a batsman or spoken in his hearing with a view to intimidating the batsman or breaking his concentration. It is very common at all levels of the game: indeed, one experienced player said it had occurred in every high level game he had played in, prior to Phillip Hughes’ death.
Philip Hughes’ brother Josh and another witness gave evidence that following the incident, one of the players, Cooper, recounted threatening comments made by a bowler to Phillip Hughes before the injury. Cooper and the bowler denied the allegations. The conflicting evidence was left unresolved because Coroner Barnes found it was irrelevant to the cause of injury. This is because the nature of play, whether dangerous or not, was video recorded for all to see. If the alleged comments were intended to unsettle Hughes, then the video evidence showed they were ineffectual. Hughes was playing well and confidently, showing no signs of intimidation or fear. It was universally considered he had the upper hand against the bowlers immediately prior to injury and in fact on the ball in question he confidently attempted to play an attacking shot
The presiding umpires, Hughes’ batting partner and other players on the field at the relevant time, all gave evidence that Hughes appeared comfortable, relaxed and in control in the session of play after lunch when the threats were allegedly made. That suggested that even if the threats were made, they did not affect Hughes’ composure so as to undermine his capacity to defend himself against short-pitched, high bouncing bowling and so the threats could not be implicated in his death.
On that basis, no finding was made as to whether the sledging alleged actually occurred. However, the Coroner hoped, the focus on this unsavoury aspect of the incident may cause those who claim to love the game to reflect upon whether the practice of sledging is worthy of its participants. An outsider is left to wonder why such a beautiful game would need such an ugly underside.
Dangerous Bowling
The Hughes family were also concerned that Phillip had been subjected to excessive bouncers (short pitched and high bouncing balls) that increased his risk of being hit and were concerned that the umpires had failed to intervene as they should have, to protect the batsman.
The Coroner noted this was not the first death to occur in a cricket match and reinforces that cricket is a potentially dangerous game. It involves a heavy, hard ball being speared at the batsman from a relatively short distance at great speed. It is a testament to the skill and courage of those who play the game at the highest levels that more incidents don’t occur. Still, safeguards are essential if death and injury is to be minimized. The precautions upon which player-safety depend are:

• The rules;
• Their enforcement; and
• Personal protective equipment.

The inquest heard from an independent expert umpire that the umpires on the day applied the laws in relation to short pitched bowling extremely well, none of the relevant laws were breached and no other action was required by the umpires. The rules limit a bowler to 2 bouncers above shoulder height per over. There also possibly existed a more general discretion to intervene in the case of dangerous short bowling not necessarily above shoulder height, although this was far from clearly expressed. The Coroner did consider that the drafting of the rules relating to unfair bowling was ambiguous as to precisely what constitutes a “fast, short pitched ball” and whether there is greater scope for umpires to intervene to protect tail-end batsmen. On that basis he made a recommendation that Cricket Australia review the rules to address this ambiguity and provide more guidance to the umpires about how the laws should be applied.
However this ambiguity had no bearing on the application of the rules to Hughes’ innings on the day. The number and frequency of bouncers bowled to Hughes did not breach the rules and the umpires called balls as short very well on the day and responded as required. Hughes was an in form, top order batsman and there was no suggestion he was struggling to safely play the bowling, nor a prompt to intervene in any way. The Coroner noted that while compliance with the rules makes the game safer, it cannot make it risk free. There was no suggestion the critical ball was bowled maliciously and neither the bowler nor anyone else was to blame for the tragic outcome.

Safety Equipment
Phillip Hughes was not wearing the most up to date safety helmet when he was struck. However, even if he was, it was found that this would not have protected the area of his body struck by the ball. Since Hughes’ death, equipment to protect a batsman’s neck is being developed including a stem guard helmet extension, however the consequent loss of neck movement may be counterproductive to avoiding other types of injuries so the jury is still out on this innovation. One of the Coroners’ recommendations was that Cricket Australia continues its testing and development of devices to identify a neck protector that can be mandated for wearing in at least all first class cricket matches. This is all that sensibly can be done. The findings show safety equipment needs to be viewed from a broad perspective and there are many different considerations to be taken into account. Mandating a specific precaution in response to a specific tragedy should be done with great caution as it can be misguided, ineffectual and potentially harmful. However ensuring that all player equipment is safe and compliant with Australian, or other relevant, standards should be a key concern of all sporting organisations.

Emergency Response
The medical evidence was clear that the injury suffered by Phillip was un-survivable, regardless of the skill and efficiency of any emergency response. However, the incident did expose some serious shortcomings in the emergency response procedures at the Sydney Cricket Ground. These were:

• No one on the field including the umpires knew how to summon medical assistance;

• It was not clear whose responsibility it was to call an ambulance and this did not happen for 6 minutes after Hughes fell to the ground;

• The person calling the ambulance did not have sufficient information as to the urgency of the situation, resulting in the request being given a lower priority than was appropriate for the nature of the injuries;

• The ambulance service was provided with poor instructions in respect of accessing the cricket ground which resulted in further delay. It took 21 minutes from the time of injury for an ambulance to reach Hughes;

• Medical equipment such as a stretcher was not immediately to hand and had to be fetched from another location;

• The only first aid assistance available to assist the team doctor was from the team’s physiotherapist (there happened to be an emergency medical specialist in attendance on the day, as a spectator, who offered his assistance but this was a lucky coincidence).
Since Phillip’s tragic death, a number of improvements have been made including:

• All necessary emergency equipment is now stored on the medicab positioned adjacent to the field;

• A professional paramedic, the team doctor and two team physiotherapists are now present at all first class games;

• The medical room at the SCG has been re-positioned to allow easier access to the field;

• Wall charts provided by the NSW Ambulance Service detailing the information that should be provided to the 000 operators are posted around the ground at key points; and

• a Player and Official Emergency Medical Plan (POEM Plan) was developed to ensure the effective responsibilities of the parties are clear.

The Coroner went further and recommended NSW Cricket implement a policy of a pre-match medical briefing to allocate emergency responsibilities amongst officials and better training of umpires in requesting urgent first aid.

Implications
The coroner’s report provides some comfort that the potentially dangerous game of cricket is being well managed by its custodians in terms of promulgating and enforcing the rules and the use of safety equipment. However no system is perfect and areas for further refinement were identified in clarifying some rules and further exploring the effective use of neck guards. This case study highlights the unavoidably dangerous nature of some sport. It is part of the courage and greatness of top class batsmen that they can handle and dominate terrifyingly fast bowling and this is a quintessential element of this game steeped in history and tradition. The game and its rules have evolved over time with past threats such as the Bodyline Series of the 1930s and must continue to do so when justified. However all hazards can never be removed and a balance must be struck between reasonable precautions and inherent risks.
Sledging continues in the game, some within the bounds of acceptable competitiveness and gamesmanship, some beyond it. A solution is not obvious nor was it necessary for the Coroner to make a finding upon. It will remain the province of the umpires to exercise their discretion to keep this within acceptable limits. The inquest has served to shine more light on the darker side of this practice and might hopefully cause a change of general sentiment and player conduct.
The most telling findings relate to the importance of having an appropriate, efficient and documented emergency response protocol. Whilst even the best emergency response would not have saved Phillip Hughes, the recommendations and the improvements already made highlight the importance of these emergency response procedures for various sporting organisations to ensure that preventable deaths do not occur and serious injuries can be minimised. In particular, ensuring that appropriately trained medical staff are available, that medical equipment is easily accessible and that there are clear procedures for summoning emergency services can mean the difference between a near miss and a tragic outcome. These steps are also important for risk management and protection from legal liability.
Ultimately, the inquest found that Phillip Hughes’ death was a tragic but unavoidable accident. It nonetheless allowed his family to vent their concerns and have these properly answered and thoroughly examine the adequacy of relevant safety measures in the game. Nothing can undo the terrible tragedy and senseless loss of one of the heroes of the game. It is only perhaps a small consolation that, Phillip Hughes’ death has lead to great improvements in emergency response equipment and procedures that may save several lives in the future.

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