Vicki Williams - the grieving mother of jockey Reece Potter who was tragically killed in a race fall at Tottenham three years ago - has never set out to blame anyone for her son's death.
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Instead, she has successfully campaigned for changes to emergency air services so no-one ever has to suffer the agony experienced by her family.
At its conclusion, Deputy State Coroner Hugh Dillon levelled no blame and made no recommendations in relation to the death.
A total of nine witnesses gave evidence. They included Detective Andrew McGrath (Parkes LAC), Rodney Robb (of Nyngan, trainer of the horse), Todd Smith (Chairman of Stewards, Central Districts and Western Racing Association), Troy Vassallo (Deputy Chairman Stewards, Southern Districts), jockeys in the race Ben Duggan and Stuart Brown, Harry Williams (Reece Potter's grandfather), Brett Cavanough (who had previously owned and trained Half Handy the horse involved in the accident), and Dr Ronald Manning (Director, Statewide Services Division Ambulance Service NSW).
The Coroner's official finding was: "Reece Potter died at the Royal Prince Alfred Hospital, Camperdown, on March 14, 2011, as a result of blunt force head injuries sustained when he was thrown from his horse during a race at the Tottenham Picnic Races on March 12, 2011.
"Potter, 23, received fatal head injuries when his horse Half Handy fell whilst leading the last race on the program at the Tottenham Picnic Races of March 12, 2011.
"Veterinarian Dr Charles Tilley later diagnosed the horse as having suffered a fractured pelvis and possible spinal damage which resulted in the animal being euthanized.
"At the time of the accident, the emergency helicopter service out of Orange was not available due to the fact the service then operated only between the hours of 8am and 6pm.
"As a result of campaigning led by Vicki Williams and shire councils throughout the region in which more than 32,000 people signed petitions presented to the state government, the service now operates 24 hours."
After delivering his findings, His Honour congratulated the family in the way they had conducted themselves throughout the inquest.
"I have great respect for the way you have led this campaign for changes to the air services in country New South Wales," he said.
"One of the distressing aspects of Reece's death is that there are questions they have been waiting for three years to be investigated at an inquest. I apologise it has taken so long," he said.
His Honour said a number of specific factual issues had to be investigated before an answer to the question of how Reece's death had come about.
They included the reason why Half Handy had fallen, the condition of the Tottenham track at the time, did white poly pipes inside the running rails contribute to the horse falling, and if so, has the use of the poly pipes altered or been rectified since the race.
Also, why the emergency helicopter generally available to transport critically ill patients was not used at the time of the accident.
On the day in question, the course was found to be in good condition.
The rail was positioned the length of the home straight and to keep the horses off the steel piping, PVC marker posts were positioned several metres inside the running rail.
The hearing heard the posts were hollow and made from plastic, stood 180 centimetres tall, and positioned 20 centimetres into the ground and 20 to 30 metres apart. There was no evidence to rumours the posts were held in position by steel star posts.
The required standard rail now consisted of flat Colorbond material that is designed to flex and buckle when collided with.
It was between the 1200 and 1100 metre marks that Half Handy fell whilst leading the race.
In his summary, His Honour said he had benefited from repeated viewings of the race in slow motion and expert evidence from Reece's grandfather Harry Williams, and stewards Todd Smith and Troy Vassalo who had watched the film of the race from a number of angles.
During the inquest, an emotional Mr Williams said that after watching the video over and over in slow motion, he had come to the conclusion it had been nothing more than a freak accident.
The Coroner said he had been persuaded by evidence from trainer Rodney Robb that Half Handy had been a very sound horse leading up to the fatal accident.
Mr Robb purchased the horse from Mr Brett Cavanough who had raced Half Handy possibly 11 times for one win and a couple of placings.
"They were certainly serious injuries and it is difficult to say that if the helicopter had been available it would have improved the condition of the victim," the Coroner said.
His Honour said that since Reece's fatal accident, a number of changes had been instituted to emergency air retrieval services in western and north-western NSW.
"A 24-hour helicopter service now operates from Orange and a 24 hour service will commence in Tamworth from January 2015."
In his summary, His Honour said it was clear that although he died very young, Reece had already made his mark on his fellow jockeys and others in the racing world he loved so much.