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After a months-long study that took up 100 pages and comprised hoards of research, the New York Task Force on Racehorse Health and Safety released the results of its investigation into the 21 on-track equine deaths at Aqueduct Racetrack earlier this year.

"There was no single factor that caused these fatalities, rather, a perfect storm, if you will, of superimposed layers of contributing factors were responsible," said Dr. Scott Palmer, the chairman of the task force. "As an industry, we all have to look in the mirror."

"This will be a major priority for the new board," said Howard Glaser, New York’s Director of State Operations.

All 21 deaths occurred between November 2011 and March of this year, a rate roughly double the New York Racing Association's and nation's average.

The report, requested by Gov. Andrew Cuomo, found that while nothing criminal occurred, a number of factors, including a sharp increase in purses due to revenue from a new casino featuring video slot machines, lead to dangerous and sometimes fatal conditions.

"An unintended consequence of the increase in claiming purses was a relative devaluation of the horse, where purse was of substantially greater value than horse competing for it,” said Alan Foreman, CEO of the Thoroughbred Horsemen’s Association and a member of the task force. “The task force believes this imbalance incentivized poor decisions in the management of some horses."

The report was also critical of the overuse of legal medications, which are believed to help unsound horses reach the starting gate and make it harder for veterinarians to diagnose their ailments.

The task force recommends drastically limiting their use and taking management of on-track vets away from NYRA's racing operations and putting it under the control of the board and CEO.

"A lot of things here are really helpful,” New York State Racing and Wagering Board Chairman John Sabini said. “Personally, I would like to see more examination of all the licensing bodies of veterinarians because people who don't practice on track don't answer to us and I'd like to see that changed as well."

“We understand that among the recommendations in the report are reform of the veterinary structure, stronger drug prohibitions, and new claiming and purse rules," NYRA President and COO Ellen McClain said in a statement released Friday. "While we recognize that some of these protocols are strictly in the purview of the NYSRWB, we look forward to working with the State to create an even safer environment for our horses and jockeys, and strengthen the New York racing industry so that it can continue to provide thousands of jobs and economic support for New York, the leading racing jurisdiction in the nation.”

Moving forward, the greater challenge will likely be convincing longtime trainers and veterinarians to buy in after years of the current practices.

"I can tell you, in four years on this job it's been a difficult struggle all along but I think stuff like this helps us do it," Sabini said.

"I think, that we take away from the panel is that we want to reduce those risks or control those risks for the health of the horse and rider," Glaser said.

Friday's report is expected to be followed in the coming weeks by the findings of the Inspector General's investigation into NYRA's finances and a recent scandal that resulted in the overcharging of bettors by roughly $8 million, after which Gov. Cuomo and state lawmakers are expected to announce NYRA's new board of directors and CEO.