The horse did not have its lunch and had already been taken out earlier in the day.
One ride later in the afternoon ended in tragedy when the horse reared twice during a dismount, causing its elderly woman rider to fall off.
Madam Lim Ah Boey, 73, was pinned under when the horse fell on her. She died of her injuries in Changi General Hospital that evening.
Yesterday's coroner's inquiry into Madam Lim's death heard that on Nov 14 last year, she had gone to Punggol Ranch with her family as part of her grandson's birthday celebrations.
Earlier that day, the horse, a nine-year-old male called Goku, was supposed to have its lunch from around 12.30pm to 2pm, but was taken out of the stables by a volunteer for an unknown period of time.
At around 3pm, Goku was led out of the stables by a handler to give rides to other patrons.
Madam Lim, wearing a hard-hat and helmet, mounted the horse at around 5.30pm.
A little later, Madam Lim fell off the horse and was pinned down by the 450kg animal. A horse handler, who had taken Goku back to the stable after the accident, found that the horse's lunch had been left untouched.
State Coroner Marvin Bay asked police investigation officer (IO) Tan Soon Kwang if there was anything unusual about the horse not having its lunch, and if it indicated that the horse was unwell or temperamental.
The IO said investigations showed that Goku would normally have lunch before the afternoon rides.
A witness, an events manager at Punggol Ranch, Ms Wan Jasma Zuraini Wan Jalani, told the inquiry that Goku had been scheduled to work from 4pm to 6pm that day.
Ms Wan Jasma, who has been working for Gallop Stable for five years, had obtained a certificate in horse care and management from the British Horse Society on Nov 13 - a day before the incident.
She said horses usually work for two hours, and that if they do "hard work", they will get to rest after an hour or so.
"If they work more than two hours, (I will) not say it's dangerous, but it depends on the kind of work," she added.
Ms Wan Jasma also said the ride was considered "light exercise".
But when lawyer Sunil Sudheesan, who is representing Madam Lim's family, asked Ms Wan Jasma if she would recommend Goku to take patrons for rides at 5pm when it had not had lunch, she said she would not.
A vet who examined Goku the day after the incident found that the horse had multiple lacerations and abrasions on its body from the incident, but showed no signs of rest deprivation or abnormal mental state.
In the investigation report, the vet also concluded there was nothing in Goku's medical history that suggested the horse was difficult to handle.
But the doctor highlighted a few reasons why the horse might have reared - it could have been frightened by sudden movement, it could have been forced into an enclosed space, or if it was attacked by people or other animals.
The inquiry has been adjourned to May 23.
There were four tries to get her off horse
They were celebrating her grandson's 21st birthday, so Madam Lim Ah Boey, 73, and her family of 10 went to the Gallop Stable chalets for a staycation.
But the celebration ended in tragedy when Madam Lim fell from the horse she was riding after five minutes at Punggol Ranch.
The horse then fell on her.
Madam Lim lost consciousness and was rushed to Changi General Hospital, where she died of her injuries.
Police investigation officer (IO) Tan Soon Kwang told the inquiry yesterday that Madam Lim's autopsy report showed that the multiple injuries she sustained were in pattern with one who had fallen off a horse and was then crushed by it.
Madam Lim was pinned under the horse for about 10 minutes before employees of the ranch managed to get the horse up. It walked off by itself.
The IO said no foul play was suspected in her death.
The inquiry also heard that the horse handler made four unsuccessful attempts to get Madam Lim to dismount, as a family member had said that the horse was too far away from the mounting platform for her to get off.
Following protocol, staff members then attempted to get Madam Lim to dismount using a portable mounting platform.
The horse reared twice. The second time it did so, Madam Lim fell off the horse into an open drain beside the mounting platform.
The horse then fell on its back on top of her with its legs in the air.
The IO also told the inquiry that Madam Lim was still alive.
One of Madam Lim's relatives started performing cardiopulmonary resuscitation (CPR) before the Singapore Civil Defence Force arrived and took her to hospital.
During the inquiry, at least eight of the Madam Lim's family members were present.
Four videos documenting what happened after she was pinned under the horse were shown and her family members seemed visibly affected.
Madam Lim's granddaughter also questioned witness Wan Jasma Zuraini Wan Jalani, an events manager at Punggol Ranch, on why her 73-year-old grandmother was allowed to take the ride although there is an age limit of 55 years in the written protocol .
Ms Wan Jasma said that the age limit was only introduced after the accident, to which Coroner Marvin Bay instructed the IO to retrieve the original copy of the protocol used at the time of the incident.
Speaking to The New Paper after the hearing, Madam Lim's granddaughter Low Qin Qing, 29, an administration executive, said: "We're still very much affected after watching the incident (on the videos). But if it helps the case, we'll watch it again."
6 areas to look into
During yesterday's inquiry, Coroner Marvin Bay told police investigation officer (IO) Tan Soon Kwang to look into six areas before next month's closed chamber hearing:
1. If a change in direction when Madam Lim Ah Boey was trying to dismount could have confused the horse?
2. To find the mobile mounting platform and the checklist used by the employees before each ride.
The IO was also told to retrieve the original written protocol Punggol Ranch used during the time of the incident and to retrieve the indemnity forms regarding the case.
3. To find the regulatory body that ensures proper horse care and maintenance and oversees such facilities.
4. To find out if the design of the mounting platform is "usual" across other riding facilities and if it is considered safe.
Also, if the horse has sufficient "wriggle room" in such a mounting platform to break free after falling, without injuring the rider.
5. To investigate if there is an abnormality when a horse fails to have lunch and if the horse's temperament could be affected as a result.
6. To get the pathologist to isolate the different injuries that resulted from Madam Lim's falling off the horse and the horse falling on her.
This article was first published on April 26, 2016.
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