Coroner Brandt Shortland says the safety gear Samantha wore is likely to have contributed to her death.
Specifically, he says the 15-year-old was wearing a mandatory adult helmet and neck brace, but he believed she experienced severe whiplash and the weight of the helmet most likely contributed to her death.
He made 11 recommendations - including a review of compulsory support devices for youth, including appropriate youth helmet and neck brace, and design changes to new tracks so walls follow the shape of the racing surface.
Mr Shortland also called for mandatory standards for medical coverage, equipment and personnel on race days.
It was with some disbelief when I read that there was panic and no clear leadership at the time of Samantha's crash because St John were not present due to a booking mix-up.
Races should never go ahead without trained medical staff present.
Mr Shortland can only make recommendations and it is my view that coroners should be given greater powers to compel people and organisations to make changes when it comes to safety.
In this case, it is heartening to see a Speedway New Zealand chief say he fully supports the coroner's recommendations.
It is vital this organisation and all others involved in speedway work together to ensure participants and spectators are as safe as possible. Safety standards need to be met or exceeded in every aspect.