AOC Swimming Investigation Findings
23 August 2013
SWIMMING: The AOC has now received the report by Senior Counsel, Mr Bret Walker, into the conduct of the swimming section of the Australian Olympic Team at the London Games.
The investigation went beyond the conduct of the members of the 4 x 100m Men’s Freestyle Relay Team and extended into the conduct of various team officials and others.
Attached to this media release is a Chronology of Events, extracted from Mr Walker’s report, by way of background.
The AOC implemented a ban on Stilnox before the London Games because of serious concerns about the welfare of athletes and their health from its continued use. We were supported in that ban by the Team Medical Director and the Australian Medical Association.
Not everyone agreed with the ban arguing, for example, that the change from Stilnox to lighter sleep medication such as Temazepam would be detrimental to athletes who needed to be weaned off Stilnox. We were assured by the Team Deputy Medical Director that no swimmers had been prescribed Stilnox at the Olympic Games since Athens.
Shortly after the London Games there were rumours that the Men’s Relay Team had taken Stilnox during a bonding session in the swimming team staging camp in Manchester immediately prior to the Games.
The AOC ban was clearly in place at that time and there had been significant media attention due to the publicity about Grant Hackett becoming dependent upon Stilnox during his Olympic career.
The rumours suggested that the Relay Team had used the drug for recreational purposes. Whether the AOC ban was in place or not, this use would be simply unacceptable and disreputable behaviour, if true.
Bluestone Edge conducted a review, at the request of Swimming Australia, into the swimming team at the London Olympics. Following delivery of that report which was very critical of the swim team, the swimmers in the Relay Team held a media conference on 22 February 2013 to admit that they had used Stilnox in a bonding session in Manchester and that they were sorry for their misconduct.
The AOC was disappointed by these admissions, as were many members of the public. While it was a responsible step forward for the swimmers to admit their mistake in this very public way, this was 7 months after the incident. Given the publicity over the announcement of the ban, the AOC could not understand how the Relay Team members could have risked their membership of the Team or how they came to have Stilnox in their possession at the time, and why the AOC was never told of the incident during the Games.
It was also particularly shameful in view of the fundamental term of selection to the Australian Olympic Team by which athletes acknowledge that it is an honour and a privilege to represent Australia at an Olympic Games.
The investigation which was carried out into these issues was thorough and rigorous. Mr Walker’s report examines the circumstances in great detail and is over 60 pages in length. Unfortunately, it was delayed due to athletes and officials being involved in the National Swimming Championships and World Swimming Championships over the past few months.
The investigation was carried out confidentially and the report is necessarily confidential because it concerns patient/doctor confidentiality, confidentiality of other bodies such as Swimming Australia and the investigation carried out by the Integrity Panel of Swimming Australia, and also concerns information given to Mr Walker confidentially by persons who requested protection from any possible consequences for their full and honest disclosures. We appreciate the assistance of all those who co-operated and provided information in the course of the investigation.
Mr Walker found that the Relay Team Members knew the AOC ban would be in place when they entered the Games Village in London, but honestly believed that the ban did not take effect until then. Had they known the ban was in place in Manchester, their conduct would have been very serious and deserving of even more condemnation.
He found that their conduct in the bonding session was disreputable and against the best interests of the Australian Olympic Team. He found the later conduct which involved behaviour towards some female swimmers in the Team was ‘boorish’, selfish, obnoxious and disrespectful. He said it is too simplistic to describe it, as the Relay Team did, as ‘prankish’ or schoolboy behaviour. It was much more than that and it was conduct which they knew if it became public, as it now has, would bring them and the Team into disrepute and attract censure. It upset the female swimmers concerned and while it did not have an effect on the Relay Team’s performance or the performance of those female swimmers at the Games, it certainly affected morale at the time. The failure of team management to address it affected morale deeply in the swimming team and more generally in the Australian Olympic Team as others became aware of the conduct.
The use of Stilnox did not affect the Relay Team swimmers’ performance at the Games for no other reason than it is a sleep inducing drug not a performance enhancing drug. It is not a drug banned by WADA. It was taken 9 days before their event and presumably was well out of their system by then.
The conduct of those who entered the room of the female swimmers was suspected of being at the level of harassment or bullying. Had that been the case, the conduct would have been very serious in breach of the AOC Ethical Behaviour By-law. The female swimmers confirmed that they found the conduct obnoxious and disruptive but not at the more serious level and they did not pursue any such complaint under the Ethical Behaviour By-Law.
The conduct of the Relay Team swimmers in Manchester in fact came to the attention of a number of coaches the very next day. At that stage they were aware of the door knocking, prank phone calls and disturbance of the female swimmers in their room. Some coaches raised the incident with the Head Coach, Leigh Nugent, who dismissed it and did not investigate it. This inflamed the situation amongst the athletes and coaches and was left to fester. The coaches concerned believed the incident was one for the Head Coach to investigate and they were reluctant to take it further at that time because of the imminence of the Games and the possibility of retribution towards their swimmers.
The Head Coach did not report the door knocking and intrusion on the female swimmers to the Section Manager until Day 6 of the Games after the matter was raised with him by the Team Media Services Director, Mike Tancred, who had heard rumours of an incident in Manchester involving the Relay Team. At that time, the Head Coach spoke to the Section Manager who had the clear responsibility of reporting incidents or issues to the Team Executive. They regarded the intrusive conduct as a minor incident not worthy of report. This in hindsight was a mistake. Reasonable minds may differ about whether the Section Manager failed in his duties, with his limited knowledge at the time, to investigate further and report the incident to the Team Executive. Mr Walker made no adverse finding against him.
However, the Head Coach had a discussion with the coaches at the time who reported to him the rumours of Stilnox use by the Relay Team swimmers. The Head Coach’s reaction was to take the view that there was no evidence to show that the Relay Team swimmers had taken Stilnox. However, he says that he then reported the matter to Swimming Australia. Leigh Nugent says he was told not to investigate it further and as a result he did not report the Stilnox allegation to the Section Manager and the incident was therefore not reported to the Team Executive during the Games.
Following the Games, Swimming Australia instituted its own review of the conduct leading to reports chaired by the Honourable Warwick Smith and the Bluestone Edge Review. After receipt of those reports, Swimming Australia announced another inquiry by a newly formed Integrity Panel. That Panel proceeded to make certain findings and imposed sanctions against the swimmers as set out in a confidential report which the AOC has seen in an abridged form. There are certain aspects of that confidential report that the AOC has requested Swimming Australia to investigate further on Mr Walker’s recommendation as he could not, on the evidence available to him, form conclusions in relation to certain matters.
On a separate matter, following the announcement of the Integrity Panel’s findings and sanctions, it was reported in the media that there was video footage showing a Relay Team swimmer handing a Stilnox tablet to another on the return flight from London to Sydney. Mr Walker obtained video footage of one of the swimmers on that flight, but it does not show that he or anyone else gave a Stilnox tablet to another person and does not show that he or anyone else consumed Stilnox on the flight. If there is other video evidence in existence or further evidence becomes available, the AOC will resume the investigation to come to a conclusion on that matter and may impose additional sanctions on any persons concerned. The AOC received credible confidential evidence however that one of the Relay Swimmers had Stilnox in his possession on the plane. The Relay Team swimmer concerned denied that that was true. However, if it were true, in view of all the other circumstances, the AOC would regard such conduct very seriously.
The AOC has accepted Mr Walker’s findings and recommendations as follows:
(i) The Relay Team Swimmers
(1) The AOC finds that the Relay Team swimmers were in breach of the Team Membership Agreement.
(2) The AOC considers that the financial sanction imposed by Swimming Australia is proportionate and sufficient in respect of each of those swimmers.
(3) The AOC imposes as its remedy for breach, or sanction for that conduct, the following for each of the Relay Team swimmers:
(a) Any further conduct which brings them or their sport into disrepute or which is inconsistent with, or prejudicial to, the best interests, image or values of the AOC, is likely to render them ineligible for selection to the 2016 Australian Olympic Team;
(b) Each is jointly and severally liable for the substantial loss sustained by the AOC incurring the costs of this investigation and Report which the AOC would be entitled to recover from them by reason of the breach, but the AOC will not seek to claim such loss from them provided that their conduct does not make them ineligible for the 2016 Games and that none of the findings is disturbed by fresh evidence adverse to the swimmers in question (particularly in relation to the flight home which might make the AOC revisit the matter in a manner adverse to the swimmer in question).
(ii) The Head Coach
The AOC finds that the Head Coach, Leigh Nugent, was in breach of his Team Membership Agreement obligations for failing to investigate the circumstances of the incident when raised with him on 21 July 2012 and again on or about 3 August 2012 but, given that he has stood down from his position and that reasonable minds could differ on the question of his culpability given the information then available and the mistaken overriding direction to him from Swimming Australia, no further sanction should be made against him.
(iii) The Section Manager
The AOC will review the education of athletes and officials as to the lines of communication required within the Australian Olympic Team during the Games Period in view of the failure to communicate the incident that occurred in this instance. It is clear that the initial report or complaint or disclosure is required to be made to the Section Manager. He or she is required to report the incident/issue to the AOC Team Executive via the Issues Management System and daily reporting.
(iv) Swimming Australia
The AOC will make clear to Swimming Australia and any other National Federation that the AOC’s contractual obligations with athletes and officials have priority over any others during the Games Period and request that Swimming Australia ensure that this be strictly complied with in the future.
CHRONOLOGY OF EVENTS
1. This is a chronology of events setting out matters of public knowledge or matters of record within the operations of the AOC up until the commencement of this investigation.
2. On or about 26 March 2012, each of the swimmers in the Relay Team signed the 2012 Australian Olympic Team Membership Agreement for Athletes – Eamon Sullivan, Matt Targett, James Magnussen, James Roberts, Tommaso D’Orsogna and Cameron McEvoy.
3. Clause 1 of the Team Membership Agreement provided an acknowledgement from each of the swimmers that membership of the 2012 Australian Olympic Team was an ‘honour and a privilege’ and that membership was subject to their compliance with the terms of the Agreement.
4. On 1 July 2012, the Sunday Telegraph published a front page article ‘My Battle with Pills’. It reported that former Olympian Grant Hackett had become heavily dependent upon the sleeping medication Stilnox during his swimming career. It said that he had been given Stilnox by swimming team officials and he had overused them, although he said he had only used them under the supervision of a Team Doctor or a general practitioner.
5. The article noted that Stilnox was not a banned substance by the World Anti- Doping Authority (WADA). It is not a medication that enhances performance. When used under medical supervision, it is effective in initiating sleep.
6. The article noted however that Stilnox was widely known to cause strange behaviour, hallucinations, delusions and impaired judgment and reasoning.
7. The President of the AOC, John Coates, was quoted in the Sunday Telegraph article saying ‘Olympic Team Doctors do not prescribe Stilnox and did not in Beijing in 2008. However, we cannot prevent athletes getting access to Stilnox via other doctors or means.’
8. The previous day, before speaking to the journalist from the Sunday Telegraph, John Coates spoke to Dr Susan White, the 2012 Deputy Team Medical Director about the use of Stilnox by Olympic athletes. She was the swimming Team Doctor in 2008 at the Beijing Games. She advised him that a ‘sleep hygiene protocol’ including best practice relaxation techniques had been developed for the 2012 Olympic athletes. She also said that she was ‘unequivocal’ in her opposition to the use of Stilnox and that it had not been prescribed for Olympic athletes by Team Doctors since Athens in 2004.
9. In a separate article in the Sunday Telegraph on 1 July 2012, Dr Brian Sando, a board member of the Australian Sports Anti-Doping Authority and Chair of the AOC Medical Commission, warned against using Stilnox because it was highly addictive.
10. In its Editorial, The Sunday Telegraph expressed concerns that sporting officials in Australia had a lot to answer for, for ‘freely handing’ prescription drugs to athletes ‘who would then go on them and use them recreationally or become dependent upon them’. The Editorial said that the drugs were given to Grant Hackett, as they were given to most members of the elite swimming team, by team officials and doctors who were more concerned with athletes ‘getting a good night’s sleep during competition’ so they could perform at their best, than with the long term welfare of young athletes.
11. The Editorial called upon the AOC to do something about this culture and called on the President of the AOC, on the eve of the London Olympics, to lead the way with regards to the abuse of prescription drugs by officials, Team Doctors and athletes.
12. On 2 July 2012, Grant Hackett phoned John Coates and told him that he was first introduced to Stilnox in 2003 at the World Swimming Championships. He said that its use was normal practice endorsed and prescribed by the Swimming and Olympic Team Doctors at the Athens Games and its use was still widespread even at the Beijing Games.
13. On 3 July 2012, The Australian published an article reporting John Coates’ conversation with Grant Hackett and expressing the opinion of Grant Hackett’s former coach, Denis Cotterell, that Stilnox had cost Grant Hackett the 2008 Beijing Games 1500 metres Freestyle Gold Medal.
14. On 3 July 2012, John Coates announced that, after consulting the 2012 Team Medical Director, Dr Peter Baquie, the AOC would ban Stilnox from use by athletes at the 2012 Games. He said ‘We think it is clear enough with all of the evidence now about the dangers of the drug (Stilnox) in terms of addiction and hallucinations and dependence that justify the stand we have taken.’ This announcement was widely reported in the media. He said that the use of the short acting sleep medication Temazepam would be allowed for a maximum of 3 days subject to approval by the Team Medical Director. It was also reported that the Australian Medical Association welcomed the AOC announcement.
15. On 3 July 2012, the Secretary General of the AOC, Craig Phillips, sent an email to National Federations, Section Managers and Team Doctors informing them of the AOC’s decision to prohibit the use of hypnotic medications and to make revisions to the Team Medical Manual. Relevantly, the email stated that the AOC, with the agreement of Dr Peter Baquie, the Team Medical Director, had determined that certain drugs including Stilnox would be totally prohibited for Members of the Team at the London Games. Any short acting drug (such as Temazepam) could be prescribed for short term use under strict medical supervision by the attending Team Doctor after the approval of the Team Medical Director or Deputy Medical Director.
16. Mr Phillips specifically noted that the prohibitions imposed would be in force for the Games Period as defined in the Team Membership Agreement ie from 16 July to 15 August 2012.
17. He noted that the AOC had appointed Dr Baquie as the Team Medical Director, supported by his two Deputy Medical Directors, Dr Susan White and Dr Donald Kuah, to lead the Team’s medical services at the Games and that they had responsibility for the implementation of any AOC policies and procedures with respect to medical matters. He noted that all doctors appointed by the AOC to the Team were required to comply with any directions given to them from time to time by Dr Baquie or Drs White and Kuah on his behalf.
18. He noted that all Team Members were required to attend a briefing on arrival into the Olympic Games Village and during that briefing, Dr Baquie, a Deputy or other Team Doctor would reinforce a number of medical matters with Team Members including the obligations to disclose medical information, the prohibition of the use of any medications without the supervision of a medical practitioner and the approval of Dr Baquie, the search and seizure provisions in the Team Membership Agreement and that athletes would be required to complete a medication declaration form in which they must disclose the use of any prescribed or over the counter medicines or supplements. Separately he noted that the AOC would brief each Section Manager on arrival and instruct them to be diligent in their monitoring of athlete behaviour and to be alert to any circumstances which would suggest an athlete may not be complying with their obligations with respect to the possession or use of any medications. He noted that the decisions had not been taken lightly and were in line with the AOC’s primary responsibility – the health and well being of athletes.
19. Mr Phillips noted that the 2012 Team Membership Agreement provided that athletes must not use or possess a ‘drug of addiction’, ‘poison’ or ‘restricted substance’ as defined under the Poisons & Therapeutic Goods Act 1966, New South Wales (including the Poisons List). Relevantly, the drug Zolpiden (brand name Stilnox) was included on the Poisons List as a ‘restricted substance’.
20. On 10 July 2012, Dr Baquie sent an email to the Deputy Medical Directors and Team Doctors in which he noted ‘only Zolpiden and Nitrazepam and Flunitrazepam are prohibited in addition to usual clinical and IOC antidoping restrictions on Games clinical practice. A Team Member who has own supply of Temazepam/similar scripts supply with them – confirmation for custom purposes from prescriber, athlete will hand supply to Team Doctor and use reviewed each 3 days and communicated to PB, SW or DK (ie Team Medical Director or Deputy Medical Directors); support person/official use own supply but must not pass on to athletes.’ He then described the process to be used by Team Doctors which Dr Baquie said needed to be made in writing by email if a request for short term non-prohibited sleep medication was made.
21. On 8 July 2012, the Chef de Mission for the London Games, Nick Green, sent an email to Section Managers and Assistant Section Managers advising that as outlined in the Team Managers Guide, each Section was required to log a daily report on any issues/incidents they had encountered. A nightly summary would be provided to the Team Executive for their review. Any general issues would be discussed at the daily Team Management Meetings, however, sport/discipline specific issues would be communicated/responded directly.
22. He noted that it was compulsory for all Sections to lodge a daily report and if there were no issues/incidents to report, they would need to submit a ‘nothing to report’ log. For the first time, the daily reporting would be an online process custom designed for the Australian Olympic Team known as the Issues Management System (‘IMS’). He noted that the IMS reporting would commence from 16 July 2012. The Team Management Guide provided that ‘All Team Members should, without exception, report any problems and issues in the first instance to their Section Manager.’
23. In general, athletes left Australia for the London Games in mid July 2012. Swimming Australia had arranged a ‘staging camp’ for the swimmers in the Australian Olympic Team to meet in Manchester UK on and from 14 July 2012. All Team members for swimming had arrived in Manchester by 17 July 2012.
24. On 16 July 2012, the Games Village opened in London to athletes and National Olympic Committees including the AOC. Nick Green advised the Section Managers that the Village was up and working and that the Issues Management System was live and Section daily reporting had commenced.
25. On 18 July 2012, a general Team Briefing was given to the athletes in the swimming section of the Team in Manchester. Dr Michael Makdissi, the Team Doctor for Swimming, gave swimmers a briefing on medical matters. He said that if anyone had Stilnox with them, they should hand them to him before going to the Games Village in London.
26. On 20 July 2012, the Relay Team had a bonding session which started with a movie and dinner together and later involved the use of Stilnox together in a room at the hotel and resulted in disruptive behaviour towards other Team Members at the hotel.
27. On 22 July 2012, the swim team left the staging camp for London and entered the Games Village.
28. The Opening Ceremony for the Games was on 27 July 2012.
29. The Men’s 4 x 100 metre Freestyle Relay event was held on 29 July 2012. The Australian Relay Team came fourth.
30. On 6 August 2012, Swimming Australia announced that it was conducting an independent review into the swimming team’s performance at the Games.
31. On 12 August 2012, the Games concluded with the Closing Ceremony.
32. On 13 August 2012, most Australian Olympic Team athletes left London and returned to Australia on a chartered Qantas flight to Sydney via Bangkok.
33. In the weeks following the London Games, there were rumours circulating that some swimmers in the Relay Team had taken Stilnox during the bonding session in Manchester.
34. On 2 September 2012, James Roberts denied the rumour in an article in the Courier Mail.
35. On 12 September 2012, The Australian published an article in which Matt Targett and James Magnussen denied taking Stilnox during the Games.
36. On 13 September 2012, Tommaso D’Orsogna gave an interview to Channel 10 in which he did not deny that Stilnox had been taken during the Relay Team’s bonding session in Manchester.
37. On 19 February 2013, two reviews were released publicly, the Independent Swimming Review chaired by the Honourable Warwick Smith which was a wide ranging review into the sport of swimming in Australia. A separate report was released by Bluestone Edge, being a review of culture and leadership in Australian Olympic swimming which contained a number of criticisms of the standards, discipline and accountabilities for the swim team at the London Olympics.
38. On 21 February 2013, Swimming Australia announced that a newly formed Integrity Panel would investigate the circumstances set out in the two reviews and provide a report to its Board.
39. On 22 February 2013, the Relay Team swimmers held a press conference during which they admitted to taking Stilnox in Manchester (with the exception of James Roberts).
40. On the same day, the AOC announced that it would engage an independent Senior Counsel to provide a report on this conduct and any other conduct of concern by Team Members including other athletes and officials during the London Games for report to the AOC.