But it focused particularly on the eight fatalities resulting from musculoskeletal injuries that occurred between March 5 and April 20. That troubling spate included back-and-forth disagreements between the horsemen and the track and prompted the Maryland Racing Commission to shut down racing at the track until onetime Maryland track superintendent John Passero gave the all-clear sign.

HISA’s review included meetings with key stakeholders, reviews of the horses’ race records and necropsies, interviews with track maintenance personnel, and analysis of other records.

Not surprisingly, though, the investigators could find no single cause. That’s typical when spates of fatalities occur, as they also have at Churchill Downs and Saratoga this year.

During the crisis itself, much debate centered on the condition of the Laurel racing strip. Indeed, the state’s horsemen and breeders groups, the Maryland Thoroughbred Horsemen’s Association (MTHA) and Maryland Horse Breeders Association (MHBA), sent a letter to the state Racing Commission saying the state’s racing industry was facing a “catastrophic emergency.”

“The condition of the dirt track is a serious threat to the life and safety of both riders and horses and must be immediately addressed,” the groups wrote.

Nonsense, retorted the Maryland Jockey Club in its own letter to the Commission. “[O]ur track experts have advised that there are no issues with the track and that it is safe to race and train,” the company wrote.

At the Commission’s direction, Passero was retained to review the track and make recommendations. While he found no issues with the base of the track, he believed the maintenance practices the track followed didn’t mesh well with the materials in the cushion.

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“A good cushion serves one purpose: that’s to slow down horses’ hooves before they hit the base,” Passero told The Racing Biz at the time. “This cushion, when it gets a lot of water, especially when it’s a nice day and you’re pouring water on it, it starts to lose some of its body or conditioning. When I walked the racetrack when it was fast, it felt very soft to me, not able to hold up a horse like it should.”

Passero made a series of maintenance-related recommendations, and horsemen said they had made an immediate difference.

“It is notable that following the track maintenance procedures that were implemented after Mr. [Dennis] Moore’s and Mr. Passero’s visits, there were no further fatalities during the spring meet,” the HISA report said. “Therefore, it would be reasonable to assume that those changes contributed to a safer surface going forward.”

At the same time, the report did note some risk factors among the horses themselves. Eight of the 10 horses that died of musculoskeletal injuries during the period had not raced as two-year-olds; older age at first start has been identified as a risk factor for subsequent injury.

In addition, five had recently changed trainers – another risk factor – and one was on the vets’ list at the time. Moreover, the injured horses had “more high-speed furlongs” than a control group leading up to their deaths, another risk factor.

“In summary… there are horse level risk factors that likely contributed to risk for injury,” the report says.

At the same time, the analysis did contain some unusual findings. Perhaps most notable was the unusually high incidence of pastern injuries. Five of the horses suffered comminuted pastern fractures – fractures in at least two places – which the Maryland Racing Commission’s equine medical director described as “very unusual,” according to the report.

“Existing literature supports the idea that P1 [pastern] fractures were over-represented at Laurel Park during the period of this review,” the report notes.

The report also found several mostly minor violations of HISA rules, none of which directly contributed to the spate of fatalities. Among those, two of the horses had been permitted to race while not registered with HISA, which requires all horses to be registered.