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• 
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 NSWAmbulance
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.