No illegal medications were found in any of 23 horses who died at Santa Anita between Dec. 30, 2018, and March 31, 2019, but 21 had “pre-existing pathology at the site of their fatal injury,” 11 had received injections of corticosteroids to the joints – two within 14 days of injury – and nine of the racing fatalities occurred on sloppy or sealed tracks, according to a long-awaited report released Tuesday by the California Horse Racing Board. The report was issued one day after 27 persons – including East Coast-based trainers Jorge Navarro and Jason Servis – were indicted by the U.S.  Attorney for the Southern District of New York for allegedly administering, distributing, and misbranding illegal drugs. Rick Baedeker, the executive director of the CHRB, on a conference call Tuesday afternoon said the CHRB has begun an investigation related to that development and its potential involvement reaching California. Click here to read the full report Although Baedeker said the board would not comment on that investigation, he advised that the CHRB “retains post-race samples for two years, and can and will test retroactively.” The report issued Tuesday said four other fatalities during that three-month period – three from colic, two of which were to ponies – and one incident of laminitis were not included. Seven additional fatalities from March 31, 2019 through the end of the meet on June 23, 2019, were not included in the report because most were “pathologically distinct,” the report said. According to the report, 13 of the fatalities were the result of injuries in races, 10 in workouts. Seventeen were on dirt, six on turf. Nineteen of the 23 fatalities were the result of injuries to the fetlock, most commonly sesamoid bones. All were examined via necropsies through the CHRB/University of California at Davis post-mortem program. The 77-page document had been delayed for more than two months from when it was originally announced it would be released owing to its scope. “It was too complex” to be rushed, Baedeker said. Among its many findings and recommendations, it said Santa Anita should consider replacing its dirt track with a synthetic surface, and that having track veterinarians and examining veterinarians being supervised by the racing association’s racing office “poses an inherent conflict of interest.” Other recommendations included “real-time adjustment” regarding track maintenance, standardized protocols for moving turf racing to dirt, continuing education for trainers, restructuring claiming rules, transitioning to digital vet records, requiring medical records follow a horse who has been claimed or sold, and video surveillance “at all CHRB facilities.” In addition, the report recommended hiring additional veterinarians owing to the overall increase in official vet exams, and empowering regulatory vets to order diagnostic tests as “a condition of continued racing or training.” Many of the proposals have been approved but are still in the regulatory adoption process, or are to be heard at the monthly CHRB meeting next week. “We’re trying to identify weaknesses and work to eliminate them,” Baedeker said. :: To stay up to date, follow us on: Facebook | Instagram | Twitter Although no illegal medications were found, there were four instances of horses receiving controversial shock-wave therapy as allowed by CHRB regulations, and one horse was twice treated legally with a bisphosphonate, a medication that has come under increasing scrutiny and has been outlawed by many sales companies. Pre-existing conditions, confirmed in necropsies, are difficult to detect for trainers, private vets, and regulatory vets because “many of the pre-existing lesions are clinically silent, by which is meant they do not have recognizable clinical sign,” and “many of the pre-existing lesions were not amenable to current and available diagnostic imaging techniques,” the report said. Dr. Rick Arthur, the board’s equine medical director, said on the conference call that he was “disappointed” with how few trainers of the horses who were fatally injured read the necropsy report on their horse. He added that many trainers “had a basic lack of understanding of the distal extremity of the leg.” The CHRB report said seven complaints will be filed related to violations of turning in daily veterinarian reports, and three complaints will be filed against trainers for training without a proper license, i.e., an unlicensed person or someone with inadequate workers’ compensation insurance hiring someone to be a program trainer for him or her. “In several cases it is suspected that program training was taking place,” the report said. The report said that several trainers told investigators they felt pressure to run, but only one gave a specific example. All investigative reports, vet reports, and necropsies are considered confidential by California statutes and courts, so the names of all horses, trainers, owners, jockeys, and veterinarians were withheld from publication, the report said. All documents were shared with the Los Angeles District Attorney’s office, which announced late last year that no criminal conduct was uncovered after its own investigation. The report chronicles the turnover in the racing office preceding and during the meet, including the termination of longtime racing secretary Rick Hammerle prior to the meet. It says Tim Ritvo, at the time the head of The Stronach Group – he left the position earlier this month -- arrived at Santa Anita in 2017 expressing a desire to increase field size and trainer participation. “Some trainers who were interviewed expressed that the need to run more races with more starters may have contributed to a feeling on the part of the trainers that if they didn’t run their horses, they could lose their allocation of stalls,” the report said, adding that only one specific example was cited. “This perception that horsemen were compelled to enter horses or hustled into races is a safety concern because: (1) horses are not necessarily ready for said races; (2) horses may be entered on quick turnarounds; (3) horses may not be placed competitively, so may overexert or struggle in the race, exposing them to fatigue injury; and (4) a horse may have a significant veterinary history,” the report said, adding “a better knowledge of available horse inventories and writing race conditions accordingly would help alleviate this concern.” During the first two months of the 2018-19 winter-spring meeting, 19 more races were run than the previous year. The 2018-19 meeting had the highest rainfall totals since 2008, the report said. During much of that time, the main track was repeatedly sealed and reopened to promote quick drainage. The report said, “Some of the injuries in this cluster occurred when the racing surface was conducive to horses running faster than what might be considered normal for a particular field of horses.” It said that Mick Petersen, a noted surface expert, was brought in by Santa Anita and told investigators the track “was not consistent due to the complex maintenance decisions made by track management during the time period when Santa Anita had an unusually high amount of rain.” The report said 11 fatalities occurred between opening day Dec. 26, 2018 and the end of January 2019, compared to five for the same period the previous year and just two for the same period two years prior. It said Alex Solis, a CHRB commissioner and retired Hall of Fame jockey, described the track at the time as “wavy” and “inconsistent” when he rode during morning training hours. After the 21st breakdown on March 5, Dennis Moore – who had left as track superintendent prior to the meet – returned as a track consultant. According to the report, Moore said he was never “turned down by Ritvo or anyone at Santa Anita for any track maintenance that he requested, adding ‘I wish every track was as free with their money when it comes to track maintenance costs as Santa Anita is.’” Racing was canceled during much of March. There were no fatalities from March 29 through May 15. “But beginning on May 16, it rained on eight of the next 12 days, and six fatalities occurred over a three-week period,” the report said. “The study indicates a correlation between fatalities and surfaces that have been affected both by heavy rains and the extraordinary procedures needed to maintain them for racing and training,” the report said, adding, “given the apparent correlation between wet weather, sealed tracks and fatalities, Santa Anita management should continue to consider replacing the dirt track with a synthetic surface, which does not need to be sealed.” The report said “data on track maintenance submitted for the investigation and summary was cumbersome, disorganized, and often incoherent,” and recommended improved transparency regarding track maintenance to “allow horsemen to adjust their training schedules in real-time to better protect horses.” It said trainers believed there was excessive wear to the main track near the quarter pole “due to tractor routes,” an uneven base owing to how the track was harrowed, and a surface that dried inconsistently. “Such concerns or suspicions must be closely examined to determine their validity,” the report said. Thoroughness of trainers and attending vets were addressed. In one case, a “horse was being treated by two veterinarians without communication or even an awareness that the other was similarly treating the horse,” the report said. “In one case two veterinarians injected the same joint within five days of each other. In that case, it was the major weight-bearing bone in the joint that ultimately failed in the race.” The report recommends the CHRB consider specific regulations requiring diagnostic imaging before any joint injections. “We’re moving to reform racing over the next year to 18 months,” Dr. Greg Ferraro, the chairman of the CHRB, said on the conference call.