The grieving parents of a teenager who watched their daughter "die in the dirt" at a country race meet are pleased a coroner has recommended the introduction of 'Holly's law', in hopes of changing how public events are planned.

Holly Winta Brown, 17, died from a previously undiagnosed condition at the Laura Rodeo and Campdraft in Queensland's Cape York in June 2015.

Ms Brown, a talented horsewoman from the small community of Julatten, was camping with her family at the event when she complained to her father of chest pain after waking up in the morning.

Within hours she was dead. There were no ambulances on site, despite a crowd of 2,000, and it took a rescue helicopter and ambulance more than 1.5 hours to arrive.

Holly's parents spoke outside court, saying their daughter was vibrant and caring. ( ABC News: Kristy Sexton-McGrath )

"We watched our beautiful Holly die in the dirt, " her father, Warren Brown, told a coronial inquest held in Cairns.

"The terror that Holly felt we witnessed.

"Waiting for advanced life support to come, waiting for forgotten equipment, watching Holly with her airway compromised, negates the cost of an ambulance."

'Absolutely chaotic' response to dying teen

Queensland coroner Nerida Wilson handed down her findings in Cairns on Wednesday, recommending statewide reform for "mass gatherings and public events", dubbed 'Holly's law'.

Holly's parents have long campaigned for reforms to be called 'Holly's law' and the coroner agreed that any changes should bear her name.

Holly's parents were joined by friend Jessica Eagle-Rowe, pleased at the recommendation of a new 'Holly's law'. ( ABC News: Kristy Sexton-McGrath )

Ms Wilson described the emergency response at the campgrounds as "absolutely chaotic".

"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," Ms Wilson said.

Ms Wilson wanted an interagency executive group to be formed within six months, to establish standardised protocol for a medevac response to the annual Laura Rodeo.

In her written recommendation, Ms Wilson confined her recommendation specifically to the emergency medical response at the Laura Rodeo and Races, but said: "I am optimistic that such a recommendation will trigger statewide reform for mass gathering public events".

"Without mandated event planning framework in place, mistakes will be made."

Nurses unequipped, working 36 hours straight

The inquest heard three nurses at the Laura Primary Health Care Centre were inexperienced in remote placement work.

Two had worked for 36 hours straight in the lead-up to Holly going into cardiac arrest.

Both had their phones switched off, and when they did arrive at the campground site to attend to Holly their equipment bag had not been restocked.

The coroner described the circumstances in which Ms Brown died as "inhumane". ( Facebook )

There was no ambulance at the event when Holly died, with the nearest one an hour and 40 minutes away.

Ms Wilson was scathing in her assessment of the emergency response to the teenager's death.

"Holly may not have survived, even with advance life support, in or out of hospital," she said.

"However, in this case no-one, not the event organisers, not the Torres and Cape York Health and Hospital Service, nor anyone who witnessed or assisted in 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."



Holly's dream to become a vet cut short

Ms Wilson said she did not blame the nurses, and nor did Ms Brown's family.

"Nurses were not personally accountable for what went wrong on that day," she said.

"They did not arrive until 50 minutes after Holly's cardiac arrest.

"They should have been supported by good internal decision-making by the Torres and Cape Hospital and Health Service."

Holly's parents, Warren and Elle Brown, said the medical response was "grossly inadequate".

They had been pushing for the introduction of 'Holly's law', standardised laws for the emergency planning and risk assessment for country events.

Outside court, Holly's mother Elle Brown welcomed the coroner's findings.

"Holly was a vibrant, caring and determined young woman with aspirations to study veterinary science at university," she said.

"While her dreams were cut short, it is our hope that the implementation of 'Holly's law' will prevent another tragedy from ever happening again."