The jury in the inquest into the death of professional jump jockey Kieran Kelly has urged the Turf Club to examine the configuration of the racecourse where he was killed.
Returning a verdict of "accidental death" in the fatal fall at Kilbeggan in August 2003, the jury also recommended that the Turf Club carry out a review of safety gear worn by riders.
Mr Kelly (25), died after falling from his mount Balmy Native at the "open ditch" or "regulation fence" - the largest obstacle on a track described as "fast" and "tight" by fellow jockeys in the Dublin City Coroner's Court yesterday.
The Dublin City Coroner, Dr Brian Farrell, said it appeared Mr Kelly suffered a "double fall", having first hit the ground before his horse landed on top of him. Dr Farrell said it was unclear from the evidence which blow proved to be the fatal one.
In a written statement to the court, Prof Michael Farrell, a neuro-pathologist at Beaumont Hospital, said Mr Kelly died of a "severe closed head injury" consistent with "rapid acceleration/deceleration".
Prof Farrell said the case was unusual in that there was no skull fracture, or any other contact phenomena.
Mr Ken Whelan, who was riding another horse in the race, said he had approached the regulation fence behind Mr Kelly's horse, which he said had a reputation for falling. Mr Whelan said the horse seemed to jump the fence, but then he saw Mr Kelly fall eight to 10 feet clear of his mount.
Asked about Kilbeggan, Mr Whelan said it was regarded as a tight track where you had to line up for a turn each time you jumped a fence. "Horses go too fast, but it's part of the game."
A health and safety inspector, Mr P.J. Murphy, told the inquest both horse and rider were extremely experienced. He said Balmy Native, an 11-year-old, had run 63 times but fallen just twice.
Mr Joe Collins, an official with the Turf Club who was standing next to the fence when the fall occurred, recalled seeing the horse lying on top of Mr Kelly.