The coronial inquest into the death of jockey Simone Montgomerie has recommended that crossings not be positioned near the finish of a race, reports Racing Network.

Coroner Greg Cavanagh, SM, sitting on Monday in the Darwin Magistrates Court, issued a 22-page report into the death of Montgomerie, who died after falling from Riahgrand on Darwin Cup day last year.

Cavanagh recommended that the Australian Racing Board “articulates and implements a written protocol for the assistance of Principal Racing Authorities (PRAs) in each State and Territory, advising against crossings being positioned in the final stages of a race.”

The coroner also said he was “comfortably satisfied that Montgomerie fell from Riahgrand because it had an extreme and unusual reaction to the pedestrian crossing that was at that time positioned around 200 metres before the finishing line."

“The horse baulked or shied to the left and then appeared to try and stop before lurching forward again, and not even the most gifted of riders, as Montgomerie was, could stay seated.

“Although horses have been known to baulk or shy at crossings, necessitating a range of measures to try and blend them into the rest of the track, this reaction from the horse was very exceptional and unexpected.”

During the coronial inquest, Cavanagh noted the evidence given by the Darwin Turf Club and Thoroughbred Racing Northern Territory.

Cavanagh commended the DTC for making the proactive decision to remove the 200-metre crossing after Montgomerie’s accident since that cautious approach was warranted.

He said given the “bizarre circumstances of this accident” and the measures that had been taken to ensure the crossing was maintained before 2013, "I am not critical that it wasn’t done beforehand."

“I accept without hesitation that Ms Montgomerie’s death has been devastating for the close-knit racing community in the Territory and those who gave evidence before me have approached this inquest in a spirit of co-operation that speaks to their genuine concern for Ms Montgomerie and her family and the desire to learn from this tragedy to ensure there is no repeat.”