Report: Blunt head trauma cause of death for jockey Jorge Herrera by Press Release|01.10.201301.10.2013|9:14pm9:36pm The California Horse Racing Board has released the summary of an investigation into the death of jockey Jorge Herrera, who was killed during a racing accident at the Alameda County Fair meeting at Pleasanton in Northern California on July 5, 2012. Participating in the investigation were CHRB investigators, Alameda County Sheriff deputies, Alameda County Coroner and Cal OSHA. Cause of death was blunt head trauma. The report did not find fault with ambulance or paramedic staffing at the racetrack. Following is the complete text released by the CHRB. To : Kirk E. Breed, Executive Director From : Dan Dailey, Supervising Special Investigator Northern Enforcement Subject : JORGE HERRERA DEATH INVESTIGATION SUMMARY The investigation into the accidental death of Jockey Jorge Herrera has been completed after receipt of the Cal OSHA and Alameda County Coroner's final reports. This summary was delayed as the completed report had been reviewed by Supervising Special Investigator II Coulter who retired 10-31-12 without issuing a summary. The following is directed to your attention based on a joint investigation conducted by CHRB investigators, Alameda County Sheriff deputies, Alameda County Coroner and Cal OSHA. On July 5 2012, Jockey Jorge Herrera rode the #8 horse Morito in the 8th and final race of the day. The race went off at 5:02:55. As the horses approached the ½ pole, Morito “clipped heels” with the #9 horse Tribal Sun causing Herrera to be unseated and fall to the ground 5:03:17. At some point Herrera was kicked or stepped on by a horse causing significant head injuries. The on track ambulance from WestMed, staffed by two (2) EMT 1s was on scene at 5:03:57 as was fitness Veterinarian Sarah Sporer. They immediately began trying to find an airway and begin emergency treatment. Herrera's airway was severely compromised and they were unable to establish a good airway. Alameda County Fire Department Paramedics were on scene at 5:06:35 according to a film review of the incident. The Paramedics were stationed adjacent to the race track at the north side of the grandstand. Note: Immediately after the accident, numerous people were commenting on the slow response of Paramedics to the scene, estimating in some cases 20 or minutes response time. These contentions were refuted by the film review. Paramedics were also unable to establish a good airway and began Advanced Life Support measures in preparation for transport. Track Physician Dr. Wong arrived on scene at 5:11:05. Herrera was loaded into the Paramedic's Plus ambulance for transport at 5:24:17. CPR and other Advanced Life Support procedures were being used to try and save Herrera. Herrera was transported to Eden Medical Center Trauma Unit in Castro Valley where he succumbed to his injuries. CHRB investigators collected all of Herrera's riding and safety equipment and kept them as evidence. They also interviewed all jockeys and racing staff who witnessed the accident. “Morito” was examined by Dr. Sporer at the receiving barn and blood was drawn for analysis. All statements obtained by persons who witnessed the accident and the film review are consistent with the conclusion that “Morito” clipped heels with “Tribal Sun” causing “Morito” to stumble and unseat Herrera. Cal OSHA was contacted by Alameda County regarding this incident. In their final report dated July 16, 2012, Associate Safety Engineer Sean Sasser issued the following conclusion: “Based upon documentary evidence and interviews gathered during the course of the investigation the time of the accident Mr. Herrera was in the middle of a race when the horse he was riding clipped the hoof of a horse in front of them. This caused the horse Mr. Herrera was riding to throw Mr. Herrera over the head of the horse to the ground. Mr. Herrera was then stepped on by the horse he was riding or by following horses resulting in fatal injuries to Mr. Herrera. Due to the independent contractor status of Mr. Herrera Cal/OSHA does not have jurisdiction over the accident.” The Alameda County Coroner's report dated July 6 2012 lists the cause of death as: 1) BLUNT HEAD TRAUMA A) TWO TRANSVERSE BASILAR SKULL FRACTURES WITH ACUTE SUBARACHNOID HEMORRAGE B) SUBCUTANEOUS HEMATOMA, RIGHT TEMPORAL SUBCUTANEOUS TISSUE The final Alameda County Sheriff/Coroner report was completed on August 2nd, 2012. Their investigation supports all of the above information as to the cause and manner of death. OTHER ISSUES IN THIS CASE AMBULANCE STAFFING The investigation concluded that the on track ambulance provided by WestMed Ambulance was staffed with two Emergency Medical Tecnician1 medics. The CARF application for the fair was received by CHRB on 3-19-12 and set for the Board to hear on 4-26-12. The application indicates in Item #14 C that the on track ambulance would be staffed through a contract with WestMed ambulance service. Two Emergency Medical Technicians will staff this ambulance. The ambulance and crew will be on the track during races and training hours and are responsible for initiating basic life support measures, including immediate medical stabilization, care and transport to medical care facilities. Fire Department Paramedic Engine- During the live race meet, a fully equipped Alameda County Fire Department Paramedic Engine is parked roughly 100 feet from the Jockey Clubhouse. The engine is staffed with four County of Alameda Firefighters including at least two licensed Paramedics. The requirements in the submitted application were met. There was however a discussion at a meeting in Santa Anita between Commissioner Derek and Chris Korby regarding Paramedic staffing on the ambulance. Per Mike Martin, Commissioner Derek recalls the conversation; however we are unable to locate a transcript of the meeting as it may have occurred at a Track Safety Committee meeting where a transcript was not prepared. This discussion was not contained in the 4-26-12 Board meeting transcript when the application was approved. RELEASE OF INFORMATION Before the investigation could begin in earnest, statements were being made regarding the response time of the Paramedics and the cause of death. Bloodhorse.com / Horse Racing News quoted Safety Steward Paul Nicolo several times along with Darrell Haire, Jockey's Guild and DVM Sarah Sporer. Comments attributed to the CHRB staff caused confusion and conflicting information to be distributed before the investigation could answer those questions. CHRB staff, including contract employees should be reminded not to make statements regarding incidents unless authorized by the ED or his designee. The other issue that occurred was the convening of a Board of Stewards meeting the next morning where they intended to interview potential witnesses. As the Stewards were also witnesses and may be responsible to conduct a hearing at a later date, this should not have occurred. Present at this meeting were all of the principal agency managers. It quickly devolved into accusations by Mr. Haire regarding the medical response. CHRN investigators were able to convince the Stewards to conclude the meeting and allow the CHRB and Alameda County Sheriff/Coroner's investigation to proceed. This caused Mr. Rick Pickering, Alameda County Fair Manager, to become defensive of his medical response protocol in this meeting and in further communications with CHRB staff.