Coroner Alan Macalister has completed the inquest into the death of Luke Zion McCrostie, who died at the Central Motor Speedway in Cromwell on March 17, 2007, aged 18.
His findings and recommendations have just been made public.
Luke was riding a 4WD quadbike as part of a demonstration event, when the vehicle was involved in a crash with two other quadbikes and he hit the concrete perimeter wall.
Despite medical care, he died at the scene as a result of his injuries.
Mr McCrostie and his wife, Gaylene, told the Otago Daily Times they were glad the inquest into their eldest son's death was completed, but it did not change how they felt.
"People talk about moving on, but it's not a fact of moving on because you never really do. I don't want to forget . . . when people ask me how many children I have, I still say four," Mr McCrostie said.
The coroner's findings allowed loose ends to be tied up, as there had been no death certificate issued for Luke, and his bank accounts could not be closed without one.
"It's a bit like a journey we're on where we have to cross over certain bridges, and this is the last bridge. We just didn't expect it to take three years," Mr McCrostie said.
Mr Macalister said the time taken to complete the inquest reflected the "inadequacy" of the investigation, which became apparent at the inquest hearing.
"This arose from the absence of reports from either Speedway New Zealand Inc or a Motorcycle New Zealand Inc report because of the lack of involvement of those organisations," he said.
That meant an independent report had to be commissioned.
Asked to elaborate yesterday on his comment about the inadequacy of the investigation, Mr Macalister said now his decision had been made public, he could not comment further.
In his findings, Mr Macalister said Cromwell speedway officials had failed to get the required permits for the demonstration quadbike event, although that did not have any bearing on Luke's death.
"The track was not expressly licensed by Speedway New Zealand for the purpose of the demonstration . . . nor was any application made or permission granted for the event.
"There should have been a meeting permit applied for and obtained . . . also, a Motorcycle New Zealand official must be present . . . there was no such official present," Mr Macalister said.
A scrutineering form had not been signed by one competitor, and Luke missed out on the drivers' briefing after arriving late.
Mr McCrostie said family members were not particularly happy about Luke being involved in quadbike racing, but accepted it was what he wanted to do.
"I was a little bit frustrated regarding him riding a 4WD motorbike at great speeds with a concrete wall beside him - it's a bit different to being out in the paddock. He knew how I felt but boys will be boys," he said.
Luke had just sold the quadbike and it was to be his last time racing it, Mr McCrostie said.
"That was the frustrating thing, because that last race is what took his life."
Mr Macalister said speedway officials thought the event was compliant as a demonstration.
"There was no evidence to suggest that permits would not have been granted and/or that the event would have been held in a materially different form. Recorded discrepancies have not been shown to have contributed to the crash," he said.
Mr Macalister also found the Squirrel helicopter dispatched from Queenstown to take Luke to Dunedin Hospital was not the best choice and instead a helicopter at Dunedin with advanced life support equipment on board should have been used.
"St John has addressed these issues. The dispatch criteria and assigning of helicopters has been reviewed and updated training and support documentation delivered.
"It must be stressed that even if the decision had been to use the [Dunedin] helicopter, that would not have changed the outcome," he said.
Mrs McCrostie said the family had never blamed speedway organisers, or anyone else, for what happened, although Mr McCrostie still wondered whether a speedway track was the right place for quadbike racing.
"We actually applaud organisations that give opportunities to young ones of all ages to do what they love in a reasonably safe environment, so that was never an issue.
"Yes, there's a couple of things they [speedway officials] didn't do but it never would have changed the outcome.
"If this [Luke's death] has helped change the way things are done for the better, then that's something good to come of it," Mrs McCrostie said.
National and local speedway officials said most of the recommendations by Mr Macalister had already been implemented and the paperwork needed before meetings were run "tightened up".
Speedway New Zealand is the governing body for speedway competition in this country, and its president, Peter Kuriger, of Opunake, said the accident highlighted areas the organisation needed to address.
"Without a doubt, it highlighted some issues and we've tightened up our procedures, and in fact in the past year we've disciplined [the officials at] two [North Island] tracks who didn't have the correct permits to run events," Mr Kuriger said.
Promotional events such as demonstrations which formed part of speedway meetings also required permits.
In this instance, New Zealand Speedway was under the mistaken impression the quadbike event had been held under the auspices of Motorcycle New Zealand.
Mr Kuriger said although the coroner had described the organisation's minimum first aid requirements as "somewhat vague", he believed they were clearly spelled out.
It was already a requirement to have an ambulance and medical staff at speedway events.
"It is a real shame that a young man lost his life in this way and our condolences go to his family," Mr Kuriger said.
Central Motor Speedway promoter Phil Burgess said it was the first and only serious accident at the Cromwell speedway.
He said the speedway committee had yet to read the coroner's report but held its own inquiry following the accident.
"As a result of that, we are more stringent about paperwork and our signing-in procedures for competitors and have improved first aid cover at meetings, " Mr Burgess said.
Quadbike crash
The coroner's findings and recommendations:
- Luke Zion McCrostie died at the Central Motor Speedway at Cromwell on March 17, 2007, as a result of injuries sustained when the quadbike he was riding came into contact with another and crashed into the concrete perimeter wall.
- The speedway event was a race, not a demonstration.
- Approval for the event was not obtained from Speedway New Zealand Inc.
- A permit was not obtained from Motorcycle New Zealand.
- A Motorcycle New Zealand official was not present.
- None of the above discrepancies were influential in relation to the occurrence of the crash.
- Quadbikes are not inherently more dangerous than any other motorcycle speedway class.
- High-standard first aid was provided.
- Speedway New Zealand should remind tracks of their responsibilities.
- Permits should be issued by relevant authorities.
- All competitors should hold correct licences.
-Quadbikes should be controlled by classes in accordance with machine performance and rider ability.
- Competitors new to venues should be given practice time.
- Speedway New Zealand should ensure first aid, including an ambulance, is available at every event.
- Speedway New Zealand's first aid rules should clearly define minimum requirements.
- Demonstration events should not be held under racing conditions.
