Dr. Berman Statement,

The following is the text of a statement issued by Jefferson County Schools Superintendent Sheldon Berman, summarizing the findings of the system's internal investigation of the death of football player Max Gilpin last August. This was published in the Courier-Journal on July 2, 2009.

Today brings to a close the district's administrative investigation of the PRP coaching staff and head coach Jason Stinson and whether there was any violation of Kentucky High School Athletic Association or JCPS rules and regulations in the events of Aug. 20, 2008, when student athlete Max Gilpin collapsed and later died.

Max's death was truly tragic for his family, the PRP community and for all of us at JCPS. We all want the same thing— to see athletics have a positive influence on the lives of our children. Max's tragic death has affected high school athletics nationwide.

The investigative report was delivered to me last week. A meeting was held as required by our employee practices with Mr. Stinson on Monday, June 29, after he returned from out of town. And so, today I am able to release the final report.

Some have continued to ask why this investigation has taken so long. Let me be very clear — this report and findings represent the most extensive investigation ever undertaken by the Jefferson County Public Schools.

Our investigation initially began in partnership with Louisville Metro Police, but we were soon asked to wait until their interviews were completed.

In early March, JCPS received more than 2,000 pages of documents from the LMPD investigation. It was several weeks after that when we received medical records.

The JCPS investigation involved interviews with over 125 witnesses, players and coaches; a review of the LMPD evidence; a review of our own athletics program; a review of medical files, and consultation with an independent medical expert. Investigators then compiled all the evidence into the final report which consists of more than 270 pages of findings and supporting evidence.

I want to thank our investigative unit for their diligence in pursuing the evidence in this case and in compiling and analyzing the findings. It has been a long, arduous and, heartrending task. I am confident that we have considered and addressed this situation with the utmost concern and integrity.

After careful review of the investigators' and the medical expert's findings, I am satisfied with and support the conclusions drawn in this report.

I determined the need for an investigation on Monday, Aug. 25, prior to learning of any allegations against the coaching staff.

We learned later that there were some adults attending a girl's soccer game at an adjacent field, who alleged that the PRP football coaching staff denied players water during the Aug. 20 practice. Based on the evidence, this was not the case.

The evidence shows that on Aug. 20, Coach Stinson and the PRP football coaches complied with the KHSAA rules and regulations for heat play.

Although it was a hot day, the football practice that afternoon was a typical practice with sufficient water breaks and adequate supervision on the part of all the coaching staff. The football team was well conditioned and had been training for several months prior to Aug. 20.

The Aug. 20 practice was a shorter than usual practice. Water was available on the practice field and the team received 4-5 water breaks during the practice. Some players received additional water breaks during individual drills. Ice packs were available on the field and were in fact used to treat Max Gilpin.

The coaches monitored the players and pulled some players from the conditioning when they showed signs of stress.

The last water break on Aug. 20 began around 5:20 p.m. with practice resuming at around 5:30 p.m. and 30-35 minutes of conditioning involving running, started soon after. Because the team was split to run in two groups, each player individually ran for 15-17 minutes resting in between each gasser during that time frame. Each group ran a total of approximately 1.5 to 1.9 miles.

In comparison to the football team's conditioning activities on Aug. 20, it is important to note that because the heat index was below the 95 degree benchmark, the girl's soccer game at the adjacent field played out as a normal game with two 40-minute halves. Soccer officials determined that water breaks at 30-minute intervals were not required.

While the football team was running the gassers, a player experienced breathing problems and shortly thereafter near the end of the conditioning period and between 6:05 and 6:12 p.m., Max collapsed.

Multiple people responded to assist Max. His father also went out to the field. Max was placed on a Gator and transported to the running water. Ice packs also were applied in addition to the running water as per heat-related response protocol.

The evidence shows that 911 was called at 6:17 p.m., approximately 5-12 minutes after Max collapsed.

At the end of practice, Coach Stinson instructed players to go under a shade tree for a brief team meeting as was their normal protocol. A few players began walking to the water fountains and the coach instructed them to go to the meeting first.

Max was not one of those players. The players were then dismissed to get water or leave. Again, the investigation did not find any violation of KHSAA or JCPS rules.

It is clear from the evidence that the allegations by a few witnesses at the soccer game, were based on their accounts of only a few minutes of the practice that day.

As a result of allegations that the players were denied water, the JCPS investigation included a review of Max Gilpin's medical records.

After reviewing the medical records, an independent physician, Dr. Daniel Rusyniak, a specialist at Indiana University in emergency medicine and medical toxicology, confirmed that the results of tests performed during Max's hospitalization are not consistent with dehydration.

A University of Louisville emergency medicine physician, Dr. William Smock, who has no connection to the case, previously reviewed records for The Courier-Journal and also concluded that Max's heat stroke was not caused by lack of water.

The conclusions of the investigators clearly indicate that Max Gilpin did not die as a result of any restriction in water breaks, or denial of water, or any violation of KHSAA or JCPS rules.

Dr. Rusyniak concluded that the evidence suggests that Max was ill prior to football practice on Aug. 20. The key findings are cited in the summary as well as in Dr. Rusyniak's findings in the full report.

According to Dr. Rusyniak, a history and physical form completed at the hospital based on information supplied by Max's parents, indicated that Max was suffering from fever, congestion and difficulty breathing prior to practice that day.

Dr. Rusyniak concluded that the cause of Max's death — sepsis secondary to a bacterial infection — could have resulted from a pre-existing illness and that the absence of an autopsy makes the cause of Max's sepsis more difficult to confirm.

He concluded that a viral or bacterial illness would have made Max more susceptible to the heat.

Dr. Rusyniak concluded that a combination of many factors may have made Max more susceptible to the heat on Aug. 20, but again that the results of Max's hospital tests are not consistent with dehydration.

While the evidence did not reveal any violation of KHSAA or JCPS rules, I am extremely troubled — actually I am outraged — by the statement made that day by head coach Jason Stinson—that the running would end when someone quit the team.

While this kind of negative motivation may be used in some amateur and even professional sports, that kind of culture has absolutely no place in JCPS' athletic programs.

Coach Stinson's statement is not an appropriate means to motivate student athletes, but the statement is not a violation of any KHSAA or JCPS rule; therefore, I am unable to initiate disciplinary consequences to Mr. Stinson for his remark.

However, I am taking action to ensure that this kind of culture is not tolerated in JCPS. I want to deliver an unambiguous message to Mr. Stinson and to all JCPS employees that such motivational techniques are not acceptable.

Sports venues provide opportunities for positive motivation. At the same time we encourage students to stretch their limits and work hard to achieve their athletic goals, we need to teach them that the competitive spirit is compatible with respect for others. Even as we expand our CARE for Kids initiative, which strives to create caring and respectful communities in our classrooms and schools for both students and adults, we must demand the same approach on our athletic fields.

I have instructed our district Director of Activities/Athletics to immediately develop and present training for all members of our coaching staff on workout strategies that are rigorous, yet incorporate positive motivation and language.

These will begin prior to the start of the school year.

Nothing will bring Max back. It deeply saddens all of us that one of our students passed away after collapsing on the practice field. This tragic event has heightened our awareness — as parents, teachers, coaches, athletic directors and administrators — of the need to constantly seek ways to improve safety for our student athletes.

In April 2009, I forwarded a set of recommendations to KHSAA for their consideration in reviewing the state's athletic rules including heat protocol.

Additionally, JCPS committed to implementing some of those recommendations immediately for the coming school year. They include:

• Expediting the new KHSAA rule requiring assistant coaches to join head coaches in attending approved sports safety courses;
• Requiring that each athlete and a parent attend a seminar on healthy habits, nutritional recommendations, injury prevention and treatment, medication and supplement use, and heat- related guidelines; and
• Requiring that every JCPS athlete list all non-prescription medications and supplements he or she is taking; this list is to be reviewed by the physician who conducts the student's physical examination prior to athletic activity.

As a community, we must all continue to work together to keep the safety of our young people in and out of the classroom as a top priority.

A copy of this final report is being delivered to the civil attorneys representing Max Gilpin's parents, to the Commonwealth Attorney's Office, to KHSAA, and to the Kentucky Education Professional Standards Board. Our attorney also will inform the court that the investigation is complete.

The head coaching position at PRP has been advertised and interviews are pending. When the coach is hired, it will be at the coach's discretion as is normal protocol, to recommend the coaching staff. The assistant coaches involved in this investigation may be eligible to be hired for those positions.

Mr. Stinson meanwhile must remain reassigned to a non-instructional position pending the outcome of the criminal trial scheduled in August.

Max Gilpin's family and friends have suffered a great loss. I hope that the findings of our investigation provide a clearer understanding of what actually happened on the practice field on Aug. 20.

It is my hope that the release of this report will bring some measure of solace and healing to all who have been affected by the loss of this fine young man.