Taiki Yanagida Coronial report

[bono]

How long has this taken fgs..must be due out soon?

Will the report be damning of RIB's lack of action wrt 'competitive riding'?

Aka "steering horses into other horses"

Highly dangerous to both jockey/horse I would've thought

Does the industry need to have a serious discussion about this practice?

[bono]

So the report is now out and it appears the RIB have taken some remedial measures ( aka satisfying the Coroner's office it looks as if they're doing something but not really)

For example why didn't the RIB charge Jasmine Fawcett with RECKLESS riding last week for trying to force a gap for almost 100 metres?

Where they said " we allow competitive riding but not for that long"

Or Pinn for FOUL riding when clearly elbowing Fawcett...instead of "you're lucky we didn't charge you"

Did the RIB inform the Coroner that "NZ national days" also means 6 days for a Sth Island jockey could in fact be just 2 in reality?

Bet they didn't

Here's the RIB 10 point plan

"Rider penalties – Concern that penalties issued to riders are an insufficient deterrent for 
reoffending (especially when considering Weatherley’s previous charges up to and including 
the day of the incident). It was recommended that a review of penalties and their 
effectiveness takes place, with consideration as to whether stricter stand down periods and 
fines would be appropriate.
Other considerations included could the incident have been avoided if Weatherley’s 
suspension in Race 4 was effective immediately, therefore not enabling him to ride in Race Cor10 CSU-2022-HAM-000352
4
CS0010
Mandatory post-incident drug and alcohol testing – Supported by other jockeys for safety 
reasons, but noting the logistics of mandatory drug testing is not straight-forward with 
accredited personnel not immediately available to attend every race-day meeting. Further 
consideration to identify how a mandatory post-incident drug and alcohol testing regime 
could be structured.

Racing Integrity Unit steward’s induction manual – This requires a full revision to include 
improvements that meet “best practice”, including the provisions about serious injury 
response planning being a priority, an incident checklist to aid an efficient and timely 
response, and improving and maintaining radio communications until after the completion 
of the last race. Development to include testing to ensure best practice and deliver a training 
package for existing stewards and new employees.

Next of kin register – To be readily available, with key contact information in order to 
maintain communications with a jockey’s immediate family members post-incident.
Club Health and Safety Procedures – Currently no oversight of club procedures and NZTR
to explore options for affiliated clubs’ health and safety policy and practice documents.
Preservation of evidence – RIB to develop guidelines for track personnel in relation to 
maintaining the security and chain of evidence for equipment / exhibits following a serious
incident that will likely be the subject of an investigation.

Personal Protective Equipment (PPE) checks – Introduction of clear standards of what PPE 
is required, ensure jockeys have clear guidelines and minimum standards, supported by an 
audit register of all PPE checks.

Clearance from rider falls – Work being undertaken by NZTR regarding concussion reviews, 
whether to extend to track work riding, and the need for medical clearance to return to riding.

Significant Event Response – A Racing Incident Significant Event Response checklist has 
been drafted and under review for use by RIB. The intention of this document is to assist 
the Chair of Stewards with a framework for assessing, coordinating, leading and managing 
a serious incident response in conjunction with the racing club and race track personnel. 
However, this is not designed to mitigate or assume responsibility over other entities’ 
relevant HSWA obligations and/or responses to an incident.

Collaboration of Industry Stakeholders – Noting the importance of industry collaboration to 
understand any lessons and learnings following serious incidents, make meaningful safety 
improvements to protect those working in the racing industry, and review of the existing 
Health Safety and Wellbeing Committee to be fit for purpose with regular meetings to review 
serious incidents and implementation of proposed safety actions."

[bono]

One alarming aspect was a communication the RIB had with a helmet manufacturer

Ffs, just ban them from supplying the industry...simply outrageous behaviour

"All agencies were bound to exercise a degree of caution in relation to ARRO Helmets on the 
basis of that entity not being truly independent and being a NZ-based market competitor. 
One particular engagement from ARRO to RIB was termed unhelpful and bordering on 
offensive."

[bono]

NOTIFICATION THAT CORONER’S INQUIRY WILL NOT BE RESUMED

Sections 70(1)(b) and 70(2) Coroners Act 2006
IN THE MATTER of Taiki YANAGIDA
The Secretary, Ministry of Justice, Wellington
I notify you pursuant to section 70(2) of the Coroners Act 2006 that an inquiry will not be 
resumed in respect of:
Deceased: Taiki YANAGIDA
Late of: 182 Station Road
Matamata
Date of birth: 02 November 1993
Date of death: 09 August 2022
Place of death: Waikato Hospital
Pembroke Street
Hamilton
New Zealand
Age: 28
Occupation: Jockey
Sex: Male
Cause of death:
1a. Direct cause Non-survivable traumatic brain injury
1b. Antecedent causes Spinal fractures at several levels
Haematoma in paraspinal tissue and 
mediastinum
1c. Underlying condition/s
Chest injuries to lungs and fractured ribs
2. Other significant conditions 
contributing to death, but not related to 
disease or condition causing it
Sustained in fall and trampling by horses in 
a competitive horse race
Circumstances of Death:
Taiki Yanagida was 28 years, of Japanese descent, a jockey, single and resided in Matamata. 
Taiki was physically and medically fit with no underlying health conditions and no 
medications. Jockeys require regular medical certification in order to train and competitively 
ride. 
Taiki was first licenced to ride in New Zealand as an apprentice jockey in the 2017/2018 
season. He progressed to a senior rider having completed his apprenticeship with Wexford Cor10 CSU-2022-HAM-000352
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On 3 August 2022, Taiki was participating in a race meeting at the Cambridge Jockey Club. 
He had ridden in four previous rides during the race day. There had been no issues with the 
race track or weather conditions.
Incident
During the running of Race 9 at 16:48 (the Martin Collins New Zealand Maiden 2000m), 
the incident occurred as the field of 12 horses had exited a bend and straightened into the 
home straight, at approximately 250m from the finish line.

Taiki was riding “Te Atatu Pash” when another jockey (Sam Weatherley) riding “Jack 
Hammer”, directed his mount with insufficient clearance of another horse “Goodo Jo” 
making heavy contact with its hind quarters and unbalancing its jockey. That horse then 
shifted outwards into the direct line of Te Atatu Pash, who was immediately brought down 
with Taiki dislodged to the ground. Taiki fell over the front of his horse and was trampled 
by both his horse and the following horse. In addition, another horse “Nantucket” was badly 
hampered by the fallen horse and its jockey was also dislodged but was not injured.

Paramedics examined Taiki on the race track, ascertaining that he had suffered severe and 
multiple injuries. He was transported to Waikato Hospital where he was cared for in the 
Intensive Care Unit (ICU) for almost seven days. He underwent spinal surgery and had chest 
drains inserted. Two days following surgery, medical personnel attempted to wake Taiki, 
but he was unresponsive.

A brain CT scan revealed a traumatic brain injury that would not 
be survivable, or if it were then there would be significant loss in the quality of Taiki’s life.
Doctors consulted with Taiki’s family, and a collective decision was made to withdraw 
intensive care. Taiki was verified deceased by a hospital doctor at 20:14 on 9 August 2022.
A coronial inquiry was opened on 12 August 2022 and was adjourned pending an 
investigation by the Racing Integrity Board into the incident that had led to Taiki’s death.
WorkSafe NZ / Haumaru Mahi Aotearoa

Due to the Cambridge Jockey Club racecourse being a “workplace”, Taiki’s death was 
notified to WorkSafe NZ the day after the incident. 
A member of their Critical Response, Specialist Intervention team advised the Coroners 
Court by email dated 11 August 2022 that WorkSafe had assessed the information from the 
notification, and a decision was made not to intervene. 
This outcome and reasons were communicated by WorkSafe NZ directly to Taiki’s family 
by letters dated 18 November 2022, 20 December 2022 and 18 April 2023.
Post-Mortem and Toxicology Results

A lesser post-mortem examination (confined to an external examination, scans and review 
of Waikato Hospital’s treatment records) was completed. Pathologist, Dr Michael Dray 
provided an autopsy report dated 23 September 2022 confirming that the direct cause of 
Taiki’s death was a non-survivable traumatic brain injury. 

The post-mortem report confirmed brain and spinal injuries from hospital CT and MRI 
scans. Principally, a subdural haemorrhage, subarachnoid haemorrhage and haemorrhage 
within the cerebral parenchyma, and features of diffuse axonal injury. There were also small 
fractures at the occipital region of the skull. Spinal fractures at C1, C6 - T2, T5, T6 - T7 
with instability and displacement, T7 - T9. These spinal fractures resulted in a haematoma 
in the paraspinal tissues and mediastinum. There were additional chest injuries to the lungs 
and fractured ribs. 
3
CS0010
Dr Dray also reported a healing abrasion on the left side of Taiki’s forehead (105mm) 
presumed to be from his riding helmet, and another healing abrasion on the left side of his 
face (70mm) presumed to be from the helmet’s chin strap.

Forensic Toxicologist, Michelle Christensen provided a toxicology report dated 16 
September 2022 with results of the analysis of Taiki’s ante-mortem blood and plasma 
samples. No alcohol was detected in Taiki’s blood, Ketamine (an anaesthetic mediation
administered by medical personnel during treatment) was confirmed. Apart from this, no 
other drugs or substances were detected.

Racing Integrity Board Investigation, Report and Recommendations
The Racing Integrity Board (RIB) conducted an investigation into whether the incident had 
involved a breach of the RIB’s Health and Safety Policy (2021), the Health and Safety at 
Work Act 2015 (HSWA), and New Zealand Thoroughbred Racing Incorporated (NZTR) 
Rules of Racing authorised under section 37 of the Racing Industry Act 2020.
On 27 September 2022, an Adjudicator Conducted Hearing on the charge of reckless riding 
was held in relation to the jockey, Sam Weatherley. That charge was found to be proven, 
Weatherly was found to be in breach of riding Rule 638(1)(d), and a penalty of a nine-week 
suspension from race-day riding was imposed.

In closing statements, the Adjudicator Committee noted that Weatherley had a poor record 
for breaches of the Rules. Prior to the current incident, he had had 11 offences for careless 
riding since November 2019, five of which had occurred in the previous 12 months. A 
number of these involved Weatherley directing his mounts out in the home straight to force 
runs, some in Group races where suspensions of up to 10 riding days, and fines of up to 
$1,000 and $2,000 were imposed. He also had four other careless riding suspensions while 
riding in Australia.

Given the deliberate and sustained nature of Weatherley’s actions in the subject incident 
(Race 9) in directing his mount outwards where there was no run available for him and the 
level of contact made with “Goodo Jo” (with the onflow consequences to other jockeys and 
horses, in particular Taiki), it was found that Weatherley had been “reckless” in his riding.

Furthermore, following Race 4 at the same race meeting on 3 August 2022, Weatherley 
admitted a charge of careless riding after directing his mount outwards when not sufficiently 
clear and crowding other horses. After considering submissions, the Adjudicator Committee 
suspended Weatherley’s licence to ride from the conclusion of racing for the period of 6 to 
20 August 2022 (i.e., a deferred suspension under Rule 1106(2) of a total of seven national 
riding days).

This earlier incident led the Adjudicator Committee to observe that Weatherley’s 
inappropriate riding “… was becoming an unfortunate habit…”.
Ten Recommendations made by the RIB

Rider penalties – Concern that penalties issued to riders are an insufficient deterrent for 
reoffending (especially when considering Weatherley’s previous charges up to and including 
the day of the incident). It was recommended that a review of penalties and their 
effectiveness takes place, with consideration as to whether stricter standdown periods and 
fines would be appropriate.

Other considerations included could the incident have been avoided if Weatherley’s 
suspension in Race 4 was effective immediately, therefore not enabling him to ride in Race 
9; and would a stronger penalty act as a more effective deterrent for reckless riding. Cor10 CSU-2022-HAM-000352
4
CS0010
Mandatory post-incident drug and alcohol testing – Supported by other jockeys for safety 
reasons, but noting the logistics of mandatory drug testing is not straight-forward with 
accredited personnel not immediately available to attend every race-day meeting. Further 
consideration to identify how a mandatory post-incident drug and alcohol testing regime 
could be structured.

Racing Integrity Unit steward’s induction manual – This requires a full revision to include 
improvements that meet “best practice”, including the provisions about serious injury 
response planning being a priority, an incident checklist to aid an efficient and timely 
response, and improving and maintaining radio communications until after the completion 
of the last race. Development to include testing to ensure best practice and deliver a training 
package for existing stewards and new employees.

Next of kin register – To be readily available, with key contact information in order to 
maintain communications with a jockey’s immediate family members post-incident.
Club Health and Safety Procedures – Currently no oversight of club procedures and NZTR
to explore options for affiliated clubs’ health and safety policy and practice documents.
Preservation of evidence – RIB to develop guidelines for track personnel in relation to 
maintaining the security and chain of evidence for equipment / exhibits following a serious
incident that will likely be the subject of an investigation.

Personal Protective Equipment (PPE) checks – Introduction of clear standards of what PPE 
is required, ensure jockeys have clear guidelines and minimum standards, supported by an 
audit register of all PPE checks.

Clearance from rider falls – Work being undertaken by NZTR regarding concussion reviews, 
whether to extend to track work riding, and the need for medical clearance to return to riding.
Significant Event Response – A Racing Incident Significant Event Response checklist has 
been drafted and under review for use by RIB. The intention of this document is to assist 
the Chair of Stewards with a framework for assessing, coordinating, leading and managing 
a serious incident response in conjunction with the racing club and race track personnel. 
However, this is not designed to mitigate or assume responsibility over other entities’ 
relevant HSWA obligations and/or responses to an incident.

Collaboration of Industry Stakeholders – Noting the importance of industry collaboration to 
understand any lessons and learnings following serious incidents, make meaningful safety 
improvements to protect those working in the racing industry, and review of the existing 
Health Safety and Wellbeing Committee to be fit for purpose with regular meetings to review 
serious incidents and implementation of proposed safety actions.
Other Considerations
Taiki’s Racing Helmet
Taiki was wearing a UoF racing helmet (skull cap) made in Italy. This particular helmet 
meets racing industry standards (VG101.040) and NZTR’s specified list of approved skull 
caps. 
Taiki’s helmet became dislodged from his head during the act of falling from his horse (albeit 
the chinstrap clip remained fixed). During the course of RIB’s investigation, direct enquiries 
of UoF were made as to performance expectations of this helmet (i.e., whether or not to 
expect that the helmet should have stayed on). No responses were forthcoming. 

Following the incident, it was confirmed that the chin strap of Taiki’s helmet was still 
fastened. Having reviewed video footage, it was considered that Taiki’s helmet appeared to 
have slid forward and dislodged leaving the chin strap fastened. Flowing from this, is the 
critical question as to whether Taiki’s injuries would have been less severe or survivable had 
his racing helmet remained in place.

A representative of ARRO Helmets engaged by various emails directly with WorkSafe NZ, 
the RIB and the Coroners Court offering their expert assistance and seeking to physically 
examine or have photographs of Taiki’s racing helmet to understand why it might have 
failed. Such communications were purportedly for the sake of enhancing future safety 
measures. ARRO asserted that it was universally agreed that helmets are not meant to detach 
from the wearer during such incidents. This contrasts with evidence of a senior jockey also 
involved in the incident who expressed a rider’s view that all safety equipment has its 
limitations and only provides a certain level of protection for the wearer.

All agencies were bound to exercise a degree of caution in relation to ARRO Helmets on the 
basis of that entity not being truly independent and being a NZ-based market competitor. 
One particular engagement from ARRO to RIB was termed unhelpful and bordering on 
offensive.

RIB also received a letter (Thames Medical Centre Limited dated 20 September 2022) 
produced on behalf of the offending jockey Sam Weatherly, that expressed a view that the 
injuries sustained by Taiki would not have been as severe had his helmet not come off.
Whilst it is acknowledged that Taiki’s primary injury was a traumatic brain injury following 
the fall (with trampling by his own horse and a following horse), it is clear that his other 
severe injuries were secondary and contributory to his subsequent death. Thereby, assertions 
that Taiki would have survived had his racing helmet stayed in place are speculative.

Public Interest Submission
By way of email dated 4 May 2023, I received a submission on behalf of an interested 
member of public concerning Taiki’s incident and a prior contribution to the Coroners Court 
in relation to the death of jockey Megan Taylor (December 2022). 
The submitter (with 15 years’ experience in the thoroughbred breeding side of the racing 
industry) was seeking to challenge RIB’s adjudication processes, the Rules of Racing and 
paucity of penalties in the case of deaths and serious incidents. In short, the submission 
asserted and challenged the protocol of “competitive riding” and “aggressive riding” that 
gets “rubber stamped” by the RIB. Another concern was that the practice of allowing horses 
to be steered into others, is and remains a highly dangerous manoeuvre to both jockeys and 
horses’ welfare.

It is outside my coronial jurisdiction to make any formal comments or recommendations in 
relation to these submissions. However, it is noted that a number of RIB’s recommendations, 
including review of rider penalties, speak directly to the issues raised by the submitter. In 
the absence of other interventions, then continued advocacy within the racing industry itself 
is more likely to bring about changes to rules and behaviours.

Disclosure and Key Family Concerns
By way of letter to Taiki’s family dated 25 November 2025, I noted that the Adjudicative 
Committee’s decision had been disclosed directly to them. With no objection from the RIB, 
I disclosed RIB’s final Incident Investigation Report to the family (with minor redactions on 
the grounds of protecting personal privacy and/or maintenance of the law). Earlier on 13 
March 2023, I had also disclosed WorkSafe NZ’s Enquiries Report (no further action or 
Coroners report) to Taiki’s family. Cor10 CSU-2022-HAM-000352
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My letter acknowledged several of the RIB’s recommendations, notably progressing a 
review of penalties and effectiveness, and to consider whether stricter stand-down periods 
and fines towards an offending jockey would be proper. I also noted other positive 
recommendations for racing industry checks, improving policy and procedures, greater 
collaboration and safety improvements following RIB’s investigation of the incident. The 
RIB has since advised the Coroners Court that all recommendations are either completed, 
underway or ongoing.

My letter also invited any comments or feedback from the family about the cause or 
circumstances of Taiki’s death to inform my decision not to resume my coronial inquiry.
Despite strong and earlier criticisms of the RIB investigation process and lack of
communications, Taiki’s family appreciated RIB’s report which they found to be very 
thorough. However, they maintained a concern that the report did not reach a definitive 
conclusion about who was at fault. 

Taiki’s family considered that Sam Weatherley had a history and reputation for aggressive 
riding, taking risks and reckless or careless riding. Evidence was clear (including video 
footage of the incident) that no gap existed for Weatherley to push his horse through, he had 
clearly showed no regard for the other jockeys in the race, Taiki was not in a position to take 
evasive action due to having no visibility of the horses and jockeys behind him, and that the 
poor judgment and careless action of Weatherly had caused fatal injuries to their son, causing 
the subsequent loss of his life whilst still in his prime age and racing career. In this regard, 
the family advocated that a criminal charge of manslaughter was justified.

For the avoidance of doubt, I have no powers under the Coroners Act 2006 to assign blame 
or fault in relation to any death, and no jurisdiction to inquire into or determine any civil, 
criminal, or disciplinary liability or penalty.

I referred Taiki’s family’s request for a criminal charge of manslaughter to the NZ Police 
for comment, and was advised in May 2023 and again on 10 December 2025 as follows:
“NZ Police have reviewed the Racing Integrity Board (RIB) investigation file and 
the related race day footage. There is nothing untoward leading up to the race nor
any information that exists outside of the events of the incident in question and 
contained within the RIB file that warrant Police to conduct any further enquiries 
or seek an opinion from another jurisdiction … The jockey who caused the chain of 
events leading to the death of Taiki YANAGIDA was found guilty of Reckless Riding 
at a subsequent RIB hearing and as a result was suspended from riding for nine 
weeks.

The tier of offending that the RIB deal with from most serious to least is Foul
(deliberate), Reckless, Improper, Careless and Incompetent. His riding was 
deemed reckless (not deliberate) by the authorities that have the expertise and
legislative powersto assess and lay the appropriate charges. Under NZ law a horse 
is not a motor vehicle or conveyance and reckless use of a horse causing death are
not criminal offences under the Crimes Act 1961 or the Land Transport Act 1998.
The racing industry is regulated under the Racing Industry Act 2020 and by the 
RIB's promotion and enforcement of racing rules that govern the conduct and 
control of race meetings, including managing risk to health and safety of
participants. The NZ Police have no powers or authority to either influence or
[criminally] charge the jockey outside of the decisions made by the RIB regulatory
regime.” Cor10 CSU-2022-HAM-000352
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The other key concern of Taiki’s family was that Sam Weatherley had not been alcohol or 
drug tested immediately following the incident on 3 August 2022. Rather, at his evidential 
interview on 26 August 2022, it was confirmed that he was not tested on the day but was 
asked whether he had consumed any substances that day, he stated he had not. It was also 
stated that he did not use recreational drugs. 

Weatherley was asked to provide a one-inch hair sample for the purposes of drug testing and 
following legal advice, on 29 August 2022 a sample of urine and hair were provided for 
forensic examination. Both results were negative.

Not unexpectedly, those testing results are of little comfort to Taiki’s family as not reflecting 
the situation on the actual day of the incident. However, it is encouraging that one of RIB’s 
report recommendations included further consideration to identify how a mandatory post-
incident drug and alcohol testing regime could be structured.

In response to family concerns around penalties condoning inappropriate riding and how 
was Sam Weatherley to be monitored to change his risky riding style, the RIB informed the 
Coroners Court that it does not condone careless or reckless riding in any fashion. The RIB 
works hard to hold jockeys accountable for their actions and this can be seen with the number 
of charges of careless riding taken against jockeys each year and published on their website. 
Of note, Weatherley was charged with and admitted careless riding on 4 February 2023, 
wherein he was suspended from riding for a further six days.

Concluding Remarks
My evaluation of the cause and circumstances surrounding Taiki’s tragic death, is that it was 
an avoidable incident had the other offending jockey not ridden recklessly. Taiki’s passing 
has likely been challenging for his family to reconcile given the breadth of his racing career, 
skill and experiences within the horse racing industry. 

Having regard to the specific incident and circumstances that resulted in Taiki’s death, 
clearly there is merit in my observation that undoubtedly this incident could have been 
avoided had Weatherley’s earlier suspension in Race 4 been effective immediately, thereby 
not enabling him to ride in Race 9. That said, it is acknowledged there may be other 
considerations, such as a jockey’s race day contractual commitments and race horse owners 
who could also be prejudicially affected by such an approach.

By its very nature, it must be recognised that competitive horse racing is a high-risk activity 
with high impact and consequences when thing go wrong. However, all jockeys should be 
entitled to the professionalism of their industry and riding colleagues for collective well-
being and safety through observation and enforcement of the Rules of Racing.
I give my sincere condolences to Taiki’s family, friends and his racing industry colleagues 
who grieve as a result of his death.

My reasons for the decision not to resume an inquiry:
1. By way of written statement dated 3 October 2022, Constable L Herewini (Coronial 
Services Officer, Waikato) confirmed that in the absence of further information 
indicating otherwise, Police were satisfied that there were no suspicious or untoward 
circumstances surrounding Taiki’s death; and that no person was criminally liable for 
his death;
2. I am satisfied that the reckless riding incident that resulted in this death has been 
considered by the racing industry’s Adjudicator Conducted Hearing and the Racing 
Integrity Board’s investigation, with associated and reasonable recommendations;
3. I accept the Pathologist’s opinion as to the causes of death described above; Cor10 CSU-2022-HAM-000352
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4. I am satisfied that Taiki Yanagida died as a result of traumatic head and spinal injuries 
following a fall and trampling by horses in a competitive horse race;
5. Based on the available information, I am satisfied that all matters required to be 
established under section 57(2) of the Coroners Act 2006 (the Act) have been 
established;
6. Having regard to sections 57 and 63 of the Act, I am also satisfied that there are no 
further circumstances relating to this death that make a coronial inquiry necessary or 
desirable; and
7. Accordingly, I have decided not to resume my inquiry opened on 12 August 2022.
Prohibition on Publication
Under section 74 of the Coroners Act 2006, I am satisfied it is in the interests of decency 
and personal privacy to prohibit the making public of photographs of Taiki Yanagida taken 
during the investigation of his death. I am satisfied such interests outweigh the public 
interest (if any) in the publication of that evidence, and an infringement on the principles of 
freedom of expression is justified.1
Signed at Rotorua on 9 February 2026.
Coroner D Llewell

[Murray Fish]

a sober read.. 

RIP Taiki Yanagida