In the winter of 2012, horse racing was in panic mode. For the first (but not the last) time, mainstream media had begun making note of a string of equine fatalities, in this case at Aqueduct's winter meet. A total of 21 horses suffered fatal injuries in 15 weeks of racing from November 2011 to March 2012, prompting outcry from the public and animal rights organizations. Then-Gov. Andrew Cuomo demanded that a task force of independent experts be assembled to analyze underlying causes for the fatalities and “recommend any necessary action” to halt them.
A panel was comprised of Drs. Scott Palmer (then a surgeon and former president of the American Association of Equine Practitioners) and Mary Scollay (then equine medical director for the Kentucky Horse Racing Commission), along with retired Hall of Fame jockey Jerry Bailey, and attorney Alan Foreman, chairman and CEO of the Thoroughbred Horsemen's Association.
Their report was issued in September 2012. The panel had reviewed a range of exercise and veterinary records from the horses who had died, along with general information that ranged from condition books, site inspections, and meteorological data. The panel conducted more than 75 interviews, including NYRA employees, owners, trainers, assistants, jockeys, and racing officials.
One of the difficulties the committee ran into was that 20 of 21 dead horses did not have complete necropsies performed that would give reviewers perspective on whether the horse had preexisting damage in the area of injury.
The list of suggested policy changes submitted by the task force in its 209-page report was lengthy. One section focused on those missing necropsies. The state should require necropsies to take place at appropriate diagnostic laboratories, the panel suggested, and then NYRA should establish a mortality review board to review any and all training and racing fatalities. The panel suggested the board should include NYRA executives, the chief examining veterinarian, and the trainer, assistant trainer, and the attending veterinarian.
A decade later, the Paulick Report has learned, necropsies are performed on horses and records related to those horses are reviewed – but the findings of those investigations have not been consistently reviewed with horsemen.
Four trainers who have had horses suffer fatal racing or training injuries in New York since the task force's report confirmed to the Paulick Report they've never been invited to review results of mortality investigations with officials there.
“I haven't had a breakdown in a long time, but when I did have one back before I left and came back and all that, the horse would break down, they'd cart it off for a necropsy and you'd never hear from them again,” said trainer Gary Contessa. “Never.”
Trainers told the Paulick Report they are often contacted by an investigator working for the state racing commission after the horse's death to ask questions about the horse, but they don't hear back from the investigator or anyone else about the results of their findings.
In other states, the mortality review process involves the trainer as a matter of routine, and has for some time. In 2017, this publication described the standard process in Kentucky, which begins with a necropsy performed by a board-certified veterinary pathologist. The pathologist is tasked with examining the horse's body internally and externally and describing any abnormalities, as well as reporting on any toxicology findings or other types of testing that could be relevant to the horse's case.
The resulting report is not designed to provide an explanation for the horse's fatal injury, only to describe what the pathologist sees. This is an opportunity for the examiner to discover whether there is any preexisting damage present in bones or joints, any infection or inflammation of organs that may be relevant, or any strain to soft tissues that could have factored into the injury.
In Kentucky, the necropsy report is reviewed by commission staff alongside the horse's training and racing history, and any submitted medical records for the horse. The equine medical director sits down with the trainer and reviews those findings, often asking them questions about their own observations of the horse. The goal isn't disciplinary action, but a collective continuing education opportunity through the lens of one horse's circumstances.
“It is a community problem when a horse dies,” said Dr. Mary Scollay, then the equine medical director in Kentucky, told us in 2017. “A mortality review is not about pointing fingers but is about saying, 'What could we, as a group, have done to prevent this? What can we do going forward?' I think the people with the affected horse are grateful that there's interest in what we can do altogether.”
California and Minnesota also mandate trainer participation in fatality reviews. At the time of our 2017 feature, racetracks in Pennsylvania were conducting similar reviews as part of house rules.
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If you appreciate our work, you can support us by subscribing to our Patreon stream. Learn more.At one point, New York's process did involve a conversation with horsemen about the findings. A peer-reviewed research article published in June 2017 in the Journal of Veterinary Diagnostic Investigation described the process used for fatal breakdowns between January 2013 and December 2015. At that time, the process included review of 60 days of veterinary records, exercise history, video review, drug testing, weather conditions, and importantly, interviews with trainers, jockeys, and attending veterinarians.
“Subsequent to reaching a consensus on the findings of the investigation, the chair of the ESRB [NYRA Equine Safety Review Board] discussed the findings with the trainer and made recommendations, where appropriate, to help avoid future injuries,” the study read. “These meetings are intended to serve as a teaching opportunity to help trainers, veterinarians, and other stakeholders prevent equine fatalities in the future. No punitive action was taken, except in cases that involved discovery of a violation of NYSGC regulations, NYRA house rules, or a significant animal welfare concern.”
At the time of that study, New York's fatality rate had come down significantly from its 2.24 per 1,000 starts recorded in 2012, and the rate for 2015 was 1.21. This was probably attributable to multiple regulatory changes made all at once in the wake of the task force report, according to study authors, led by Dr. Scott Palmer. (After sitting on the panel that suggested New York needed a state equine medical director, Palmer was soon after hired for the role.)
“Because a number of the recommendations of the New York Task Force on Racehorse Health and Safety were put in place in conjunction with the NYSGC-CU [New York State Gaming Commission-Cornell University] postmortem examination program and the mortality review process, it is not possible to attribute total success to any one intervention,” the study read. “Nevertheless, integration of the postmortem examination findings into a multi-disciplinary mortality review process, used in conjunction with innovative regulations by the NYSGC, a continuing education program for horse trainers, and related research efforts, has contributed to the overall sustained reduction of racing fatalities between 2013 and 2015 at NYRA racetracks.”
Despite the success of the multi-disciplinary review process, a statement from the New York State Gaming Commission to the Paulick Report indicated that “the purpose of the NYRA Mortality Review Board was to serve as one tool to identify risk factors in fatally injured horses, with a goal of developing a risk factor assessment to assist in identifying horses of interest. Such horses then are subject to appropriate risk management, increased scrutiny, strategically timed examinations, and possible intervention.
“We have surpassed the goals of these recommendations,” the NYSGC statement read.
According to the commission, one of Palmer's first acts related to the review process was to reduce the number of people on the panel's imagined review board.
“Individual meetings with trainers (not attending veterinarians) have continued unabated,” read the statement. “However, it became apparent over the first few years of implementation that relating to each trainer in a one-at-a-time setting was unworkable and inefficient. Instead, the Mortality Review Board pivoted to a broader process, using factors from each review to create continuing education opportunities for owners, trainers and assistant trainers. With specific events and occurrences, members of the Mortality Review Board or Dr. Palmer continue to meet with specific trainers, but that is more an exception than a rule in recent years, in part due to the disruption in protocols associated with the COVID pandemic in 2020.”
Contessa's last exercise-related fatalities both came in 2019, prior to the pandemic, at which time he wasn't contacted with the results of the review board's findings.
Earlier this year, Palmer told this publication that “multiple veterinarians review reports and communicate significant findings with the responsible trainer.”
Horseracing Integrity and Safety Authority regulations now require that in order to be accredited under HISA's system, tracks form a racetrack safety and welfare committee that not only reviews a horse's records and interviews its connections after a fatality, but also that these findings are shared with the trainer, regulatory veterinarian, attending veterinarian and, where applicable, the jockey. That still leaves many years – and many fatalities – that didn't turn into one-on-one learning experiences for trainers in New York.
With limited exception (including one case at Saratoga this year which was found to be the result of a ruptured thoracic aorta), commission spokesman Brad Maione said the information Palmer gleans from his own reviews is distilled into generalized data that's presented in continuing education modules for trainers.
“The findings from reviews of equine fatalities have been expressed in various formats,” Maione said. “For instance, in 2016 New York required a continuing education program for horse trainers. At the program onset, there were no training modules available that were targeted specifically for Thoroughbred trainers. That same year, Dr. Palmer oversaw a module for all New York trainers and assistant trainers that included a summary analysis of equine fatalities that occurred during the 2016 Saratoga meet.”
Contessa agreed that trainers are required to take continuing education classes, but is doubtful attendees take away much practicable information.
“We are required to take continuing education, but they don't speak our language, if you know what I mean,” he said. “They're speaking gibberish and we don't really get the gist of what they're saying half the time. Half the trainers don't want to be there. It would be so much better if we had a one-on-one to talk about, 'Listen, this is what we found out about this horse.'”
Contessa said he believes that the benefit of hindsight in many (though not all) cases could reveal missed opportunities for intervention, especially if reviewers take a look at veterinary medical records. Per HISA regulation, 60 days' worth of veterinary records are supposed to be transferred when a horse is claimed, but Contessa thinks reviews should look farther back than that. For trainers of deceased claimed horses, that may be the first time they'd learn if a horse had a longer-running problem in a joint..
“One thing I can tell you with experience — when you get a problem you have to fix by injecting it, the injections start every three months,” he said. “Then they happen every two months. Then you have to inject them every month. And you may not realize how often you're doing this. But if you can see it in black and white I think it could bring a lot of knowledge to preventing fatalities.
“I think a lot of it is because there's a wall up. There's a wall up between management and the horsemen, there's a wall up between horsemen and the veterinarians, and there's a wall up between veterinarians and the necropsy people. I just think if everyone shared information in this business, we'd get some pretty stark reminders of how close we are to the edge sometimes.”
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