Abstract: At approximately 10:30 a.m. on June 1, 1993, employees discovered Employee #1, a dressage instructor working for False Bay Farms outside of Friday Harbor, Washington, lying unconscious on a hard gravel roadway between two horse barns. It is presumed that she either fell from or with the horse that was found saddled and riderless nearby. As a result, she suffered a closed head trauma and died 8 days later from brain stem herniation due to diffuse cerebral edema. Employee #1 was estimated to be 5 months pregnant at the time of the accident. The baby died of premature delivery at the time of the mother's death. Though the farm had ASTM approved horse riding helmets available, Employee #1 was not wearing one at the time of the accident.