The death of Phillip Hughes was a tragic accident arising from a "minuscule misjudgement" from the batsman and no players or umpires were at fault, according to the New South Wales coroner Michael Barnes.
Mr Barnes on Friday released his findings from the coronial inquest into the death of Hughes, who was struck on the neck by a bouncer during a Sheffield Shield match at the SCG in November 2014. Although the coroner determined that Hughes had been targeted by bouncers during his innings, he found that no laws of the game had been breached, and Hughes was well-equipped to deal with such bowling.
"Phillip was targeted by short-pitched balls bowled at or over leg stump or middle stump that placed him in greater danger of being struck," Mr Barnes said. "Of the 23 bouncers bowled on that day, 20 were bowled to him.
"However, in view of the evidence of the other players, the presiding umpires, and Mr Taufel [former umpire Simon Taufel], that Phillip was, because of his high level of skill and confidence, comfortably dealing with the short-pitched balls, I conclude that no failure to enforce the laws of the game contributed to his death.
"Such was his skill and experience, he was well able to deal with such bowling, but even the best can't perform perfectly all of the time. He could have avoided the ball by ducking under it, but such was his competitiveness, he sought to make runs from it.
"A minuscule misjudgement, or a slight error of execution, caused him to miss the ball which crashed into his neck with fatal consequences. There is absolutely no suggestion the ball was bowled with malicious intent. Neither the bowler, nor anyone else, was to blame for the tragic outcome."
The coroner also said that while it was hard to believe that no sledging had occurred during the match, the evidence suggested that Hughes' confidence and composure were unaffected by any such sledging. However, while Mr Barnes made no finding as to whether sledging had occurred, he hoped that cricket would use the opportunity to reflect on whether such tactics were appropriate to the game.
"Hopefully the focus on this unsavoury aspect of the incident may cause those who claim to love the game to reflect on whether the practice of sledging is worthy of its participants," he said. "An outsider is left to wonder why such a beautiful game would need such an ugly underside."
The coroner found that independent medical evidence had established conclusively that the injury suffered by Hughes was "unsurvivable", regardless of the efficiency and skill of the emergency response. However, he also noted that there were failings in the emergency response on the day which might have prevented Hughes receiving life-saving treatment, had his injury not been so serious.
"None of those on the field at the time knew how to summon medical assistance onto the field," the coroner said. "Although it was immediately obvious that Phillip was injured, it was not clear whose responsibility it was to call an ambulance. An ambulance was not called for over six minutes after he was hit.
"The person who called the ambulance did not have sufficient information to enable an accurate triage to be made by the ambulance dispatcher. As a result, the ambulance response was given a lower order of urgency than it would have been given had the relevant information about Phillip's condition been conveyed."
Mr Barnes also said that the ambulance service was given inconsistent information regarding how to gain access to Hughes, and that important medical equipment was not immediately at hand at the ground. However, he noted that some changes had already been made to emergency medical response procedures as a result of Hughes' death.
"Not that anyone involved was lackadaisical or cavalier, rather the systems in place to respond to such an incident were inadequate," he said. "Unless addressed, those failings could result in a preventable death occurring... All of those who responded to Phillip's injury did so selflessly and to the best of their ability. They are to be commended."
Mr Barnes also found that, although Hughes had not been wearing the latest model of helmet at the time he was struck, even if he had been wearing the most modern equipment then available, it would not have protected the area of his body where the blow landed. He concluded that Hughes' death was "a tragic accident".
"The family's grief at losing their much-loved son and brother was exacerbated by their belief that unfair play had contributed to his death," he said. "In the course of this inquest they have heard from independent experts, high-ranking cricket officials and some of the players who were on the field with Phillip when he played his last game of cricket.
"Clearly, they do not agree with all that they heard. However, it is hoped that they accept the compelling evidence that the rules were complied with; that Phillip was excelling at the crease as he so often did, and that his death was a tragic accident.
"Nothing can undo the source of their never-ending sorrow but hopefully, in the future, the knowledge that Phillip was loved and admired by so many and that his death has led to changes that will make cricket safer will be of some comfort."
Later in the day, the Hughes family issued a statement saying that they accepted the coroner's findings. They also said they hoped the changes made to the game, in order to make it safer, as a result of their son/brother's death would become part of his legacy.
"[Father] Greg, [mother] Virginia, [siblings] Jason and Megan accept the coroner's findings," the statement said. "They have noted the four recommendations made by the coroner, and Cricket Australia's commitment to implement them. They are deeply hoping that no other family has to go through the pain of losing a loved one on an Australian sporting field.
"As the coroner has noted, Phillip's death has led to changes that will make cricket safer. The Hughes family hopes that this will be part of Phillip's legacy to the game that he loved so dearly. They would like to sincerely thank the many people who have been in contact throughout and since the inquest."
David Warner, one of the witnesses who gave evidence at the inquest, stood by his testimony despite Barnes' conclusion that he found some of the players' versions of events "hard to believe".
"I'm happy with my testimony. The umpires said the same thing, that there was no sledging out there, and I'll stick to my word that there was no sledging out there," Warner said. "And I think we have to respect what they handed down and respect what their thoughts are as well, and us as cricket and Cricket Australia our thoughts and respects are still with the Hughes family."
Warner said he did not think seriously abusive sledging or threats to kill, as alleged at the inquest, were an endemic problem in the sport. "If I go back four or five years, when I used to dish it out a bit, yeah, maybe," he said. "I think at the end of the day we're all adults and when we're on the field we know what line not to cross, and whether you're touching the player or you attack them personally, banter and sledging is about trying to create energy.
"You're talking to your team-mates and no direct threats to any player, that's totally gone. I don't even know if that was in the game. I've never been pointed at and said any words of any malice, for us it's just normal banter. It's not really sledging if you want to say it. I don't think there's any in the game at the moment at all."