Horse racing's federally created oversight panel found no single cause of death among 12 horses at Churchill Downs this spring, but recommends further action and analysis to mitigate risk at the home of the Kentucky Derby, according to a report released Tuesday.
The Horseracing Integrity and Safety Authority (HISA) report also suggested improved veterinary screening and the creation of a blue-ribbon committee to study synthetic surface options throughout the sport.
The report comes two days before the start of Churchill Downs' fall September meet and follows the June 7 suspension of racing to conduct an internal safety review. The spring meet was shifted to Ellis Park in western Kentucky.
That move came in the aftermath of seven horse deaths in the days leading up to the 149th Derby on May 6 — including two on the undercard — and five more in the weeks afterward. HISA immediately convened an emergency summit and recommended pausing the meet after consulting industry experts, veterinarians and trainers.
Though Tuesday's report determined there was no single factor in any of the areas, HISA CEO Lisa Lazarus said on a subsequent Zoom call the investigation revealed a multitude of factors.
"Because of that, we need a multifaceted and a multipronged response," said Lazarus, adding that "horses dying is not okay."
"We have a really significant and real opportunity to tackle all of those factors and make real progress. If you look historically and kind of where we've been and where we are now. We have been making progress repeatedly over the years, but we just need to do better and make more progress faster."
Among the findings in HISA's report:
— An independent review by track surface expert Dennis Moore found no correlation between Churchill Downs' racetrack surface and the fatal injuries some horse sustained. Moore's analysis determined no "major issue" in its makeup, condition or maintenance and said the metrics were consistent with previous years. Moore recommended screening the existing cushion and any new material using a slot desk screen of less than a quarter inch to filter items such as rocks. Churchill Downs has asked HISA to conduct a compliance review after its 2023 fall meet.
— There were no discernible patterns in the locations where horses died or were injured. The injuries occurred at several locations on Churchill Downs' dirt and turf surfaces.
— Necropsies revealed no single cause or identifiable pattern of the horses, and none tested positive for banned substances.
— HISA has not consistently received fatality notices, necropsy reports or timely injuries from many jurisdictions including Kentucky, as required by organization rules. It urged improvement and inclusion of reviews of training injuries.
HISA's investigation revealed an assortment of injuries among the deceased horses but found that four fractures occurred while racing on the dirt track and two others on the turf. There were two cases each of exercise-related sudden death and soft-tissue injuries while racing on dirt.
Veterinarian Susan Stover's analysis of high-speed exercise acknowledged increased injury risk from repetitive overuse injuries and high-intensity exercise without proper rest.
Asked if horses are being run too hard, Stover said, "I don't think that we know that at the moment, but certainly the data from the Churchill Review indicate that that needs to be examined further."
The historic track announced in July that industry experts found no issues with the racing surfaces but it implemented its own improvements, including new track surface maintenance equipment and additional monitoring and equine care. A release added that additional resources would go to track veterinarians for specialized horse care to assist in pre-race inspections and entry screening.
Churchill Downs Inc. CEO Bill Carstanjen said in July that racing would resume this fall with no changes and called the deaths "a series of unfortunate circumstances" in an earnings call with CDI investors.
