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INVESTIGATION REPORT REDACTED VERSION TEXAS WOMAN S
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TABLE OF CONTENTS,INTRODUCTION AND OVERVIEW 1,I PURPOSE OF THE REPORT 1. II INSTITUTIONAL AND ATHLETICS BACKGROUND 1,III CASE CHRONOLOGY 2. IV IDENTITIES OF INVOLVED PARTIES 3, A Administrators and Staff in alphabetical order 3. B Student Athletes in random order 4,OVERVIEW OF THE INVESTIGATION 5. I METHODOLOGY AND SCOPE OF THE INVESTIGATION 5,II SUMMARY OF THE ALLEGATIONS AND FINDINGS 5.
A Allegation 5,B Source of Allegation 6,C Finding 6. III SUMMARY OF EVIDENCE COLLECTION ACTIVITIES 6,A Documents 6. B Interviews 6,C Expert Analysis 7,IV EVIDENTIARY STANDARD OF PROOF 7. FINDINGS 8,I CAUSE OF THE RHABDOMYOLYSIS OUTBREAK 8. A Allegation 8,B Source of Allegation 8,C Finding 8.
D Summary of Evidence 8,CONCLUSION 29,INVESTIGATION REPORT. TEXAS WOMAN S UNIVERSITY,WOMEN S VOLLEYBALL PROGRAM. IN RE RHABDOMYOLYSIS ALLEGATIONS,INTRODUCTION AND OVERVIEW. I PURPOSE OF THE REPORT, This report the Report summarizes the findings of the external investigation conducted. by the Michael L Buckner Law Firm P A Buckner involving the institution s. intercollegiate sports program and specifically the women s volleyball sports team at. Texas Woman s University TWU The external investigation which was launched to. obtain objective information to identify the cause of the August 2016 hospitalization of. women s volleyball student athletes with rhabdomyolysis Rhabdomyolysis is a syndrome. which is caused by direct or indirect muscle injury resulting from the death of muscle. fibers and release of their contents into the bloodstream 1 The findings contained in the. Report generally involve the coaching methods and management practices of the TWU. women s volleyball program The evidence summary contained in the Report is based on. information collected and analyzed by Buckner as of March 20 2017 Accordingly the. evidence summary issues and allegations may be impacted by subsequent interviews or. the receipt of additional information by Buckner or TWU. II INSTITUTIONAL AND ATHLETICS BACKGROUND, An act of the 27th Texas Legislature in 1901 founded the Girls Industrial College as a.
public institution that would become TWU in 1957 The school had then and has now a. dual mission to provide a liberal education and to prepare young women for the practical. industries of the age with a specialized education Men have been admitted to TWU since. 1972 TWU continues today as a public university that offers a comprehensive catalog of. academic studies including baccalaureate master s and doctoral degrees Now in its tenth. decade the University has grown from a small college to a major university TWU is the. Rhabdomyolysis U S National Library of Medicine available at. https medlineplus gov ency article 000473 htm Rhabdomyolysis WebMD available at. http www webmd com a to z guides rhabdomyolysis symptoms causes treatments Rhabdomyolysis Medscape. available at http emedicine medscape com article 1007814 overview. Texas Woman s University,Investigation Report Redacted Version. March 20 2017, largest university primarily for women in the United States with the main campus in. Denton and health science centers in Dallas and Houston. TWU possesses an enrollment of approximately 15 000 students Dr Carine M Feyten is. the institution s chancellor and president The chair of the TWU board of regents is Mary. Pincoffs Wilson With respect to intercollegiate athletics TWU is an National Collegiate. Athletic Association NCAA Division II institution and a member of the Lone Star. Conference and the Midwest Independent Conference women s gymnastics The. institution sponsors five women s sports teams Chalese Connors is the director of athletics. Charolette Hunt is the assistant director of athletics compliance and academic services Dr. Don Edwards is the faculty athletics representative. III CASE CHRONOLOGY, This case began on August 20 2016 when a women s volleyball student athlete was. admitted to a hospital Further on August 21 2016 seven more women s volleyball. student athletes were admitted to hospitals The treating medical professionals determined. the student athletes were suffering from rhabdomyolysis which is a disorder that causes a. breakdown of muscle tissue which releases cells into the bloodstream and can lead to. kidney failure TWU which could not ascertain whether the outbreak was caused by. exercises workout conditions dehydration or other causes launched an internal. investigation into the cause of the outbreak, On August 22 2016 the Denton County Texas Public Health Department contacted the. institution regarding its investigation into an unusual cluster of a rare condition as reported. to us by a local hospital 2 The department subsequently concluded the student athletes had. exertional rhabdomyolysis, On August 30 2016 the institution retained Buckner to conduct an external investigation.
Michael Buckner M Buckner Buckner president and attorney was assigned to lead. the external investigation, On September 10 2016 M Buckner submitted a request for information to the institution. The institution produced documents in response to the September 10 request for. information on September 1 7 13 16 19 20 and 23 2016. On September 26 28 2016 M Buckner conducted campus interviews of student athletes. students institutional employees and the team physician. Texas Woman s University,Investigation Report Redacted Version. March 20 2017, On October 3 5 2016 M Buckner conducted campus interviews of student athletes and. institutional employees, In November and December 2016 the institution conducted numerous formal and informal. discussions with the hospitalized women s volleyball student athletes and the student. athletes parents regarding the outbreak During this time the institution also began. negotiations with the student athletes to secure relevant medical files. On January 12 14 18 20 and 30 2017 and February 2 2017 the hospitalized women s. volleyball student athletes produced or permitted the institution to supply medical. records and other documents to the Buckner medical and sports medicine experts for. In January and February 2017 Buckner conducted a comprehensive review of the. evidence For example M Buckner evaluated the interview transcripts and documents. produced by the institution Further the Buckner medical and sports medicine experts. analyzed medical files produced by the hospitalized women s volleyball student athletes. On March 20 2017 Buckner submitted the Report to TWU. IV IDENTITIES OF INVOLVED PARTIES, Based on the collection of evidence during the investigation Buckner is able to identify.
the following individuals who were interviewed during the investigation or referenced in. the Report,A Administrators and Staff in alphabetical order. Michael Auvenshine Dr team physician, Shelly Barberee former head women s volleyball coach. Jessica Beener former interim head women s volleyball coach and former assistant. women s volleyball coach,Chalese Connors director of athletics. Brett Crossland sports and conditioning coach,Taylor High assistant women s basketball coach. Charolette Hunt assistant director of athletics compliance and academic services. Texas Woman s University,Investigation Report Redacted Version.
March 20 2017,Nicole Jackson assistant athletics trainer. Beth Jillson head women s basketball coach, Kris Ring assistant director of athletics for sports medicine. Hillary Shaffer former graduate assistant women s volleyball coach. Valerie Stevenson assistant athletic trainer,B Student Athletes in random order. Student Athlete No 1 women s volleyball student athlete. Student Athlete No 2 women s volleyball student athlete. Student Athlete No 3 women s volleyball student athlete. Student Athlete No 4 women s volleyball student athlete. Student Athlete No 5 women s volleyball student athlete. Student Athlete No 6 women s volleyball student athlete. Student Athlete No 7 women s volleyball student athlete. Student Athlete No 8 women s volleyball student athlete. Student Athlete No 9 women s volleyball student athlete. Student Athlete No 10 women s volleyball student athlete. Student Athlete No 11 women s volleyball student athlete. Student Athlete No 12 women s volleyball student athlete. Student Athlete No 13 women s volleyball student athlete. Student Athlete No 14 women s volleyball student athlete. Student Athlete No 15 women s volleyball student athlete. Student Athlete No 16 women s volleyball student athlete. Student Athlete No 17 women s volleyball student athlete. Texas Woman s University,Investigation Report Redacted Version. March 20 2017, Student Athlete No 18 women s volleyball student athlete.
OVERVIEW OF THE INVESTIGATION,I METHODOLOGY AND SCOPE OF THE INVESTIGATION. This case began on August 20 2016 when a women s volleyball student athlete was. admitted to a hospital Further on August 21 2016 seven more women s volleyball. student athlete were admitted to hospitals The medical professionals subsequently. determined the student athletes were suffering from rhabdomyolysis which is a disorder. that causes a breakdown of muscle tissue which releases cells into the bloodstream and can. lead to kidney failure The Denton County Texas Public Health Department concluded. the student athletes had exertional rhabdomyolysis TWU which could not ascertain. whether the outbreak was caused by exercises workout conditions dehydration or other. causes launched an investigation into the cause of the outbreak On August 30 2016 TWU. commissioned an outside firm Buckner to conduct an independent external investigation. From August 30 2016 through March 20 2017 Buckner conducted its investigation. The scope of Buckner s investigation focused on the identification of the cause of the. August 2016 hospitalization of women s volleyball student athletes with rhabdomyolysis. Buckner utilized an investigative methodology and strategy designed to gather information. to substantiate and refute all the possible cause or causes of the outbreak Accordingly. Buckner used recorded investigation interviews document review background research. expert analyses and other investigative techniques to obtain the relevant information. Between September 26 2016 through October 5 2016 Buckner conducted 26 interviews. of 23 individuals The individuals interviewed included student athletes coaches athletics. administrators and institutional employees The interviews were conducted on the TWU. campus Buckner also requested inspected gathered and evaluated approximately 500. pages of potentially relevant documents,II SUMMARY OF THE ALLEGATIONS AND FINDINGS. A Allegation, During the August 2016 pre season period eight women s volleyball student. athletes were admitted to hospitals for rhabdomyolysis which is a disorder that. causes a breakdown of muscle tissue which releases cells into the bloodstream and. can lead to kidney failure The Denton County Texas Public Health Department. concluded the student athletes had exertional rhabdomyolysis which is the. exercise induced breakdown of muscle from extreme physical exertion. Texas Woman s University,Investigation Report Redacted Version. March 20 2017,B Source of Allegation, The institution was provided notice of the outbreak on August 20 and 21 2016.
when eight women s volleyball student athletes were admitted to hospitals Later. the Denton County Texas Public Health Department opined the student athletes. had exertional rhabdomyolysis, During the August 2016 pre season period the rhabdomyolysis outbreak involving. eight women s volleyball student athletes was caused by 1 the student athletes. involvement in an August 18 2016 fitness test which included 75 triceps push. ups conducted by the women s volleyball coaching staff and 2 at least one of the. following two factors a dehydration and b low level of fitness of the triceps. III SUMMARY OF EVIDENCE COLLECTION ACTIVITIES,A Documents. Buckner evaluated approximately 500 documents produced by the institution and. collected through the firm s research The documents were uploaded and stored on. the firm s Box platform The Appendix to the Report includes the most pertinent. documents obtained during the investigation,B Interviews. Buckner conducted interviews with numerous persons A list of the interview. subjects is provided below,INTERVIEW SUBJECTS DATE OF INTERVIEW. Michael Auvenshine September 26 2016,Student Athlete No 1 September 26 2016.
Jessica Beener October 3 2016,Student Athlete No 2 September 26 2016. Student Athlete No 3 September 26 2016,Student Athlete No 4 September 28 2016. October 5 2016,Chalese Connors October 3 2016,Brett Crossland September 26 2016. Student Athlete No 5 September 26 2016,Texas Woman s University. Investigation Report Redacted Version,March 20 2017.
INTERVIEW SUBJECTS DATE OF INTERVIEW,Student Athlete No 6 September 26 2016. Student Athlete No 7 September 28 2016,October 4 2016. Charolette Hunt September 26 2016,Nicole Jackson September 26 2016. Student Athlete No 8 October 5 2016,Student Athlete No 9 September 26 2016. Student Athlete No 10 October 4 2016,Student Athlete No 11 October 5 2016.
Student Athlete No 12 October 4 2016,Student Athlete No 13 October 3 2016. Student Athlete No 14 September 26 2016,October 3 2016. Hillary Shaffer October 3 2016,Valerie Stevenson September 26 2016. Student Athlete No 15 October 4 2016,C Expert Analysis. Buckner retained the following experts to provide subject matter analyses on. medical evidence collected during the investigation. EXPERT REPORT SUBMISSION SUBJECT MATTER,DATE EXPERTISE.
Timothy Neal MS ATC February 10 2017 Sports medicine. Robert H Weiss MD February 3 2017 Medicine,IV EVIDENTIARY STANDARD OF PROOF. Buckner utilized the clear and convincing standard of proof in analyzing the evidence. collected during the external investigation This standard requires proof which results in. reasonable certainty of the truth of the ultimate fact in controversy is highly probable. and requires more than a preponderance of the evidence but less than proof beyond a. reasonable doubt,Texas Woman s University,Investigation Report Redacted Version. March 20 2017,I CAUSE OF THE RHABDOMYOLYSIS OUTBREAK. A Allegation, During the August 2016 pre season period eight women s volleyball student. athletes were admitted to hospitals for rhabdomyolysis which is a disorder that. causes a breakdown of muscle tissue which releases cells into the bloodstream and. can lead to kidney failure The Denton County Texas Public Health Department. concluded the student athletes had exertional rhabdomyolysis which is the. exercise induced breakdown of muscle from extreme physical exertion. B Source of Allegation, The institution was provided notice of the outbreak on August 20 and 21 2016.
when eight women s volleyball student athlete was admitted to hospitals Later the. Denton County Texas Public Health Department opined the student athletes had. exertional rhabdomyolysis, During the August 2016 pre season period the rhabdomyolysis outbreak involving. eight women s volleyball student athletes was caused by 1 the student athletes. involvement in an August 18 2016 fitness test which included 75 triceps push. ups conducted by the women s volleyball coaching staff and 2 at least one of the. following two factors a dehydration and b low level of fitness of the triceps. D Summary of Evidence 3,Summer 2016 Workouts 4, On May 9 2016 the women s volleyball coaching staff received post season. analyses of changes in body fat and lean body mass from the institution s. Most interview testimony were generally consistent with the information contained in the physical evidence collected. during the institution s internal investigation and Buckner s external investigation Thus unless it is necessary to. highlight a quotation from an interview transcript citations in the Report will be to the documents included in the. NCAA Division II legislation permits institutions to conduct summer athletically related activities involving strength. and conditioning training for student athletes Further NCAA legislation permits student athletes to request summer. training workouts from athletics staff,Texas Woman s University. Investigation Report Redacted Version,March 20 2017. performance clinic 5 Note Buckner s review of the analyses did not raise any red. flags or concerns relating to the August 2016 rhabdomyolysis outbreak. On May 10 2016 the athletics compliance office informed the coaching staff that. June 1 2016 is the first day to begin summer workouts for fall championship. On May 12 2016 then assistant volleyball coach Jessica Beener emailed student. athletes inviting the student athletes to participate in strength and conditioning. coach Brett Crossland supervised campus summer workouts 7 Later Crossland. submitted summer training programs to student athletes as well as notifications to. TWU coaches regarding campus workouts 8 The women s volleyball coaching staff. subsequently continued communications with the student athletes regarding. summer workouts Later in the month the institution emailed the student athletes. with additional information concerning summer workouts and pre season. practices 9, On May 19 2016 then head women s volleyball coach Shelly Barberee forwarded.
to the incoming student athletes the summer training program 10 The summer. workouts focused on three aspects jumping low back and posterior chain. strength and conditioning 11 The workouts included exercises that used or. impacted the triceps muscles including but not limited to push ups and dip sets 12. In mid May 2016 Crossland and the women s volleyball coaching staff discussed. summer workouts 13, In June and July 2016 Crossland organized and conducted athletically related. activities for several sports teams including women s volleyball Crossland. designed the 2016 summer training program to address specific strength and. conditioning needs for women s volleyball student athletes Crossland conducted. summer workouts on campus three days a week The workouts included a variety. of exercises including weight lifting cardiovascular exercises and other activities. Crossland also instructed the student athletes on how to complete a triceps push. up which is modified push up that works the triceps muscle by positioning the. arms closer to the upper torso Crossland permitted the student athletes to complete. App 98 102,App 106 107,App 108 110,See e g App 217 223 253. App 274 290,See e g App 277 283,App 103 105,Texas Woman s University. Investigation Report Redacted Version,Page No 10,March 20 2017. triceps push ups either on the athlete s knees or toes or using a wall as resistance. Crossland described the summer sessions as follows. Summer strength and conditioning sessions were held starting June. 12 and lasted through August 17 Sessions were held from 10 30 am. to 12 00 pm CT each Monday Wednesday and Friday during that. time A total of 31 sessions were conducted throughout this time. frame I have attached a copy of the specific workouts that each. athlete completed Due to the workouts being voluntary I was not. allowed to collect data for the number of sessions each athlete. participated in Below is my best estimation of the number of. sessions that each athlete attended during that time any athletes not. listed below did not participate in any summer strength and. conditioning sessions 14, According to Crossland s recollection the majority of the women s volleyball team.
participated in at least one workout during the summer 2016 period However the. testimony of Crossland and women s volleyball student athletes noted the. frequency and quality of the workouts for each student athlete varied For example. Crossland described Student Athlete No 14 and Student Athlete No 7 s summer. workouts as very good but noted other student athletes fitness may have been. impacted by the lack of frequent workouts whether the student athlete worked out. on campus or on their own,STUDENT ATHLETES CROSSLAND ESTIMATE OF. SUMMER PARTICIPATION,Student Athlete No 1 15 occasions. completed sporadically,throughout the summer,Student Athlete No 2 20 occasions. routinely participated in,modified workouts due to. back injury but was,consistent throughout the,Student Athlete No 3 1 2 occasions.
Student Athlete No 4 12 occasions,Student Athlete No 7 26 occasions. Student Athlete No 16 10 occasions,Student Athlete No 17 4 occasions. Student Athlete No 18 4 occasions,Texas Woman s University. Investigation Report Redacted Version,Page No 11,March 20 2017. STUDENT ATHLETES CROSSLAND ESTIMATE OF,SUMMER PARTICIPATION.
completed during the,month of August,Student Athlete No 8 2 occasions. Student Athlete No 10 10 occasions,completed after mid July. Student Athlete No 11 8 occasions,Student Athlete No 14 26 occasions. Student Athlete No 15 4 occasions, Student Athlete No 11 for example acknowledged receiving Crossland s written. summer workout in June but did not use it Instead she only worked out two to. three times in June when she conducted a 10 to 15 minute treadmill running. workout Later Student Athlete No 11 stated she worked out with Crossland on. campus twice a week for one and one half hours Monday and Wednesday starting. with the second week in July to end of the month Student Athlete No 11 did not. recall working out in August prior to the beginning of the pre season period. Conversely Student Athlete No 8 recalled work ing out every day on her own. for one to two hours with running and strength and conditioning exercises from. May to August Monday through Friday and some Saturdays and Sundays. depending on what we were doing Student Athlete No 8 also participated in. Crossland s campus workouts on a few occasions Student Athlete No 4 reported. working out on her own every day during June and July and included weightlifting. push ups running triceps extensions with dumbbells and other exercises Student. Athlete No 4 stated she worked out with Crossland on one to two occasions per. week toward the end of summer second half of July Student Athlete No 4. recalled Crossland included push ups in the summer workouts. Student Athlete No 18 worked out with a personal trainer during the summer and. incorporated cardiovascular arm and leg exercises weights burpees 15 push ups. arm raises in the workouts, A burpee or squat thrust is an exercise performed in several steps 1 standing position 2 squat position with.
hands on the ground 3 low position so the chest and lower body touch the ground 4 return to the squat position. and 5 jump from the squat position to the standing position See Burpee Exercise How to do Perfect Burpees. https www youtube com watch v Pf7wZvraWV0,Texas Woman s University. Investigation Report Redacted Version,Page No 12,March 20 2017. Reporting to Campus, On Thursday August 11 2016 currently enrolled returning student athletes. reported to campus to undergo medical evaluations media training and other. meetings 16, On Friday August 12 2016 17 freshmen and transfer student athletes reported to. campus to undergo medical evaluations and other meetings 18 The institution. catered lunch from Cowboy Chicken 19 Later on August 12 all student athletes. attended an athletics training meeting 20 According to the testimony of some. student athletes the athletics training staff provided the student athletes with. education on proper hydration prior to the start of pre season The athletics training. staff explained the urine hydration levels and noting student athletes urine should. be clear in color The athletics training staff also informed student athletes to. inform the trainers if the athletes have any pain or you know unusual pains or. things like 21 After the meeting the student athletes participated in a team bonding. activity at a student athlete s apartment 22, On Saturday August 13 2016 the institution catered breakfast from Fuzzy Tacos.
for the student athletes 23 Later the student athletes were transported via. institutional bus to Main Event in Lewisville Texas for a team building activity 24. During the outing at Main Event the student athletes bowled played laser tag. mini golf and billiards 25 The team ate lunch at the McAlister s Deli in Denton. Texas 26 Around 4 00 pm CT the student athletes participated in a one hour team. scavenger hunt at Denton Square 27 The team ate dinner at Mellow Mushroom in. App 224 311 The institution also compiled the student athletes medical histories App 301 310. On August 12 2016 then head women s volleyball coach Shelly Barberee began family leave On August 24. 2016 Barberee resigned her position at the institution Barberee s resignation was not connected linked or caused by. the rhabdomyolysis outbreak Barberee declined to be interviewed by M Buckner during the external investigation. Instead Barberee s legal counsel offered to respond to written questions In order to maintain the integrity of the. investigation M Buckner declined the offer,App 224 311. App 292 344, The August 2015 version of the Student Athlete Handbook also required student athletes to report injuries to the. athletics training staff See App 39 40 43,App 292 344. App 292 344,App 292 344,App 293 344,App 292 344,Texas Woman s University. Investigation Report Redacted Version,Page No 13,March 20 2017.
On Sunday August 14 2016 the institution provided breakfast on campus 29. Thereafter the student athletes were transported via institutional bus to Topgolf in. The Colony Texas for a two hour team building activity 30 The team ate lunch at. Pot Belly in The Colony 31 The student athletes participated in a photo session. from 4 00 pm to 6 00 pm CT 32 The team ate a pasta dinner at Beener s house 33. Pre Season Activities 34,Monday August 15 2016, The institution catered breakfast in an on campus facility for the student athletes. prior to the first athletically related activity 35. Between approximately 8 30 am to 9 00 am CT the women s volleyball coaching. staff specifically led by Jessica Beener then assistant women s volleyball coach. conducted an athletically related activity during which the student athletes. completed the first fitness test 36 The session started with student athletes. stretching performing various drills and jogging 37 The first fitness test consisted. of three rounds of ten box jumps a crab walk from the basketball end line to half. court a burpee from half court to the end line and two laps around the basketball. court 38 The student athletes were required to complete each round under eight. minutes 39 All student athletes passed the first fitness test The coaching staff. awarded the student athletes with practice gear after the first fitness test 40 The first. fitness test was developed by Crossland 41,App 292 344. App 292 344,App 292 344, The campus athletically related activities occurred in Pioneer Hall Beener s practice notes and plans for the week. are included in the Appendix App 324 332 381 384 The pre season testing and practice drill result charts are also. included in the Appendix App 373 380 Further the written schedule which may not reflect the actual timetable of. events for the first week of pre season practice is included in the Appendix App 333 336. App 293 344, The fitness tests that occurred during the 2015 pre season were different than the 2016 pre season tests In 2015. according to Beener the fitness tests were completed on the first Monday in the morning session and included 1. two 300 yard sprints 2 one minute burpee test 3 one minute sit up test and 4 one minute push up test App. 292 Beener noted if the student athletes did not achieve an average time of 74 on their two 300 yard sprints they. had to keep doing their sprints until they average 74 App 292.


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