The Queensland Coroner has found that the emergency response to the death of a teenager who died at the Laura Rodeo and Races in 2015 was inadequate.
Teenager Holly Winta Brown, 17, died of a fatal arrhythmia caused by undiagnosed heart muscle scarring while camping at the popular horse sports event.
Vital medical equipment was not available for two hours after she went into cardiac arrest.
In written submissions to the coroner, Holly's parents, Warren and Eleanor Brown said they "watched our beautiful Holly die in the dirt".
"The terror Holly felt we witnessed, waiting for advanced life support to come," the submission read.
"Waiting for the forgotten equipment and watching Holly with her airway compromised, negates the cost of an ambulance."
Northern Coroner, Nerida Wilson found that the Laura clinic was not adequately resourced, staffed or equipped to provide an emergency medical response at a mass event.
At the time, two full-time nurses were assigned to the Laura Primary Health Clinic, with the Torres and Cape Hospital and Health Service engaging one additional contracted agency nurse to provide first aid at the 2015 event, and to backup paramedics.
Ms Wilson found that the TCHHS did not adequately plan for the temporary increase of Laura's normally 80-person population to between 2000-3000 people for the mass event.
Holly woke at her campsite on the morning of June 27, 2015, complaining of a sore back.
After eating breakfast, she vomited before going to rest in her swag, telling her mother she had chest pain.
When her father checked on her about 8.30am, she was not responsive and had shallow breathing. Holly went into cardiac arrest about 9.10am, with an off-duty nurse starting CPR.
The first Triple 0 call was placed at 9.40am, and Queensland Ambulance Service paramedics arrived within 1 hour and 20 minutes of being deployed, almost 2 hours after Holly's cardiac arrest.
In evidence at the inquest, the unfolding scene was described as chaotic, with basic resources such as a defibrillator and adrenaline not available on site for at least 45 minutes.
Other obstacles to the medical response included poor mobile phone reception, with the first Triple 0 call failing, no provisions to back up fatigued nurses who had done double shifts and a lack of equipment once first responders arrived.
"Otherwise hard-working, caring, rural nurses were made to look and feel incompetent," Ms Wilson found.
"Their usual competency and professional capacities should not be measured against the events of that day."
Ms Wilson in her findings said that "the indignity of being attended to in full public view for two hours with no immediate access to anything resembling advanced life support was inhumane".
"Holly may not have survived even with advanced life support in, or out, of hospital," she wrote.
"However, in this case, no one, not the event organisers, the TCHHS, nor anyone who assisted, or witnessed the tragedy, and especially Holly's parents can look back on Holly's death, and know that all that could and should have been done, was."
Ms Wilson delivered written recommendations that an interagency executive group to be convened within six months to consider reform for mass gathering events in Queensland, and specifically to establish a standardised protocol for emergencies at the Laura Rodeo and Race event, which would bear Holly's name.