PaperTexture - Kentucky parents urge schools to prepare, practice emergency plans following son's fatal collapse at soccer practice

Kentucky parents urge schools to prepare, practice emergency plans following son’s fatal collapse at soccer practice

UNION, Kentucky — Take the last proper turn through a winding, manicured neighborhood and it’s easy to spot what is out of place here. Among the glow of sconces and soft white lamps dotting the dark streets, the home with a purple light in the second-story window demands to be noticed. The hue gives off an almost youthful, playful vibe — if it didn’t represent such sadness.

Matthew Mangine Jr’s favorite color was purple.

The beauty of any mess is its proof of life, and Matthew’s room reflected the depth of his. The room, bathed in purple light, is now a time capsule of his 16 years. In one corner stands a single bookshelf, his collection of books and Bibles mingling with statues, stacks of old birthday cards, autographed baseballs and a bank made out of a coconut. A thin layer of dust blankets everything.

On the desk, beneath Matthew’s selection for the 2020 summer reading program — “Of Mice and Men” — is an incomplete driver’s log where he kept track of the supervised miles with his learner’s permit during the six-month waiting period to get his license. The first entry is just three days after Oct. 13, 2019, his 16th birthday.

On the wall above the desk is a framed Vince Lombardi poster, a gift from Matthew’s dad and namesake. For many years, the elder Matthew thought his oldest son would follow him onto the gridiron. But tucked in a corner of the frame is a certificate from St. Henry District High School in Erlanger, Kentucky, signed by coach Steve Hahn, in recognition of Matthew’s participation in soccer, the sport he chose instead. In the opposite corner is a postcard to Matthew from St. Henry faculty, dated April 8, 2020, with handwritten encouragement to a student, like so many, wrestling with the realities of the COVID-19 pandemic: “Matt, we need never be hopeless because we can never be irreparably broken!”

MATTHEW MANGINE JR. was on the edge of independence, an inevitability that made Matthew Sr., an orthopedic consultant, and his mother Kim, a business development manager, nervous but mostly proud. He had started his first real job, sweeping floors and stocking shelves at Kim’s family’s business, Corken Steel Products in Florence, Kentucky. His closest friends say he smiled often and was always ready with a witty one-liner. He told one of his grandmothers that he was “living his best life.”

The Mangines’ roots in this area run deep. The elder Matthew’s family moved to northern Kentucky in the late 70s for his father’s work. Matthew and Kim attended Beechwood High School in Fort Mitchell, where they met, dated and married at 23. Matthew Jr. arrived in 2003 and their youngest son, Joseph, followed in 2009. They moved into their current home in the fall of 2011.

Despite his father’s wishes, Matthew was growing his hair long. Maybe it was a soccer thing. Maybe just a teenage thing. Either way, the pandemic shutdown in March 2020 provided the perfect excuse. A friend from school told him his rebellious look made him resemble a character on “Outer Banks,” so he started wearing his baseball caps backward, too. Thin elastic headbands kept the hair out of his eyes when he played.

On June 16, 2020, after dropping Matthew off at his high school soccer team’s first practice back from the COVID-19 break, Kim swung by the local sporting goods store to purchase more headbands — the receipt from that outing and the unopened accessories now rest on the corner of Matthew’s dusty dresser.

Weather data shows a high of 78 degrees for the start of the 6 p.m. practice. For Matthew and his teammates, even a daunting night of conditioning was a welcome return to normalcy.

Hahn had run the St. Henry soccer program for so long, he had coached Matthew’s uncle, A.J. Mangine, in 2010. Former players say the first workout of every season usually consisted of high-intensity conditioning stations — push-ups and leg lifts, ladders and sprints, with rapid recovery. Sometimes a two-mile run. This particular practice was scheduled to end at 7 p.m. Six minutes after the hour, Kim Mangine, watching from a nearby parking lot, looked at her watch.

“Par for the course, they’re running long again,” she told another parent nearby.

Six minutes later, at 7:12 p.m., she watched Matthew complete the final sprint of practice, his limbs thrashing in deceleration. Then, without warning, his 5-foot-7 frame stiffened and he fell backward to the ground.

“There was just something about the way he collapsed,” Kim says, “that I knew this wasn’t just regular exhaustion.”

According to depositions and sworn statements by those present, there was no athletic trainer at practice that night. When Hahn saw Matthew unresponsive, he directed one of the observing parents, Marc Litzler, to go to the girls’ soccer practice on the opposite side of campus to get athletic trainer Mike Bowling. Surveillance footage from one of the school’s security cameras shows Litzler walking a portion of the 350 yards between the locations. When Bowling reached Matthew more than 10 minutes later, he did not have an automated external defibrillator (AED). In his deposition, he said he had left the device in his car.

At 7:16 p.m., Hahn called 911. After more than a minute on the call, the 911 operator asked to speak to someone else.

911 Operator: Incoming. 9-1-1.

Hahn: Yes, umm, I need assistance at St. Henry District High School.

911 Operator: OK. What’s going on?

Hahn: Umm, I have a young man that is on the ground, umm, having trouble breathing. His eyes are a little bit rolled back, umm…

911 Operator: Where at at St. Henry High School?

Hahn: Umm, we’re at the practice field.

911 Operator: OK, is he responsive?

Hahn: Not…

911 Operator: OK how old is he?

Hahn: He is… [inaudible]

911 Operator: Is he breathing?

Hahn: Umm… [inaudible]

911 Operator: Sir?

Hahn: Yes, I’m here.

911 Operator: OK, is he breathing?

Hahn: Umm… we need immediate assistance. We do have a gentleman here checking his pulse right at this moment.

911 Operator: OK, can I speak to someone else.

The call continued for almost another four minutes. During that time, Kim ran from the parking lot to the practice field. Dr. Steven Noll, an anesthesiologist and parent of another player, saw the commotion and approached to offer help. He tried reviving Matthew. In a report to Emergency Medical Services, Noll says Matthew was not moving or breathing. Noll performed mouth-to-mouth and chest compressions while they waited for EMTs.

Hahn remained on with 911 until EMTs arrived at 7:21 p.m. According to the Point Pleasant Fire Protection official incident report, the EMTs spent nearly 10 minutes at St. Henry. In sheriff’s deputy body camera footage, Kim can be seen pacing with her hands clasped on her head, pleading for updates on her son’s condition.

That same footage shows Matthew was not administered an automated external defibrillator (AED) until 7:24 p.m., after paramedics arrived. Around 7:30 p.m., Matthew was placed in the ambulance and a few minutes later taken to St. Elizabeth Florence Hospital less than two miles away.

Kim, panicked after seeing their son collapse, called her husband. He and their son Joseph immediately drove the 15 minutes from their Union home to the hospital, arriving as the ambulance did. The next 30 minutes are a blur for them, as hospital staff continued trying to revive Matthew. The elder Matthew began to realize what was coming. In the emergency room, shortly after 8 p.m., doctors told him that his son had died.

The chief complaint was cardiac arrest, according to a coroner’s report. The medical examiner eventually ruled the cause of death as “undetermined.” A toxicology report, which tested for 63 substances, came back negative.

Not long after Matthew Robert Mangine Jr. died, his grandfather arrived at St. Elizabeth Florence Hospital. As Bob Mangine hugged his oldest son, he asked a simple question: “Where was the AED?”

BOB MANGINE IS the Senior Associate Athletic Director of Sports Medicine and the head trainer for the men’s basketball team at the University of Cincinnati. His résumé is 30 pages long and he will mark 50 years in the sports medicine field this fall. For many years, he has split his time between two disciplines — a physical therapist by day and an athletic trainer by night. He boasts that the day his son Matthew was born in 1977, he went directly from the hospital to a high school football game to tape ankles and patrol the sidelines. At one point, he was serving 25 high schools in northern Kentucky. In the early 1990s, he and his wife, Marsha, another certified athletic trainer and physical therapist, started their own company, Kentucky Rehabilitation Services, where they employed and mentored a young, up-and-coming athletic trainer named Mike Bowling — who many years later would end up working at St. Henry.

Bob Mangine recalls that it took a long time for automated external defibrillators to be available to athletic trainers. An AED is a medical device designed to analyze the heart’s rhythm and deliver an electric shock to someone experiencing sudden cardiac arrest. The modern device was invented in 1978 but they were heavy and cumbersome. Only emergency crews had access to them initially. Now, they often are stationed in the lobbies of office buildings, in grocery stores and gyms. Today’s versions weigh about three pounds and are relatively easy to use. Although The American Red Cross CPR course didn’t include AED training until 1999, it is now available as a babysitting certification course to anyone over the age of 11.

According to the American Heart Association, nearly 360,000 cardiac arrests occur outside of a hospital setting each year. Of these, less than 10% of victims survive. And according to the American Academy of Pediatrics, sudden cardiac arrest is the leading cause of death in young athletes in the United States — resulting in one death of a high school aged child every three days.

When it comes to cardiac arrest, every second counts. The American Heart Association recommends an AED be used within the first three minutes of a cardiac incident.

IN NOVEMBER 2020, five months after Matthew’s death, his parents filed a wrongful death lawsuit against St. Henry District High School, the Diocese of Covington and St. Elizabeth Healthcare. As a Catholic high school, St. Henry falls under the diocese’s jurisdiction. Bowling was an employee of St. Elizabeth Healthcare.

The civil suit alleges that St. Henry did not properly plan for the first practice after an extended layoff, failed to comply with the school’s Emergency Action Plan (EAP), failed to timely locate an automated external defibrillator (AED), failed to use an AED and failed to comply with applicable standards of care.

There are two relevant governing bodies with laws or statutes applying to St. Henry: Kentucky state law, and the bylaws of the Kentucky High School Athletic Association (KHSAA), which governs state high school sports.

The lawsuit identified two areas of focus: EAPs and AEDs. An Emergency Action Plan is a document detailing how an entity will handle an emergency, like a fire, earthquake or active shooter. Thirty-six states, including Kentucky, have laws requiring sport-specific emergency action plans.

The state laws and the KHSAA rules on EAPs are similar. Both require schools to create a venue-specific EAP, which must be in writing and be posted, distributed, reviewed and rehearsed annually. They are also expected to be updated and amended if there are changes to a facility or locations of the emergency equipment.

St. Henry underwent a reported $6 million renovation, completed in February 2020, that included a new auditorium and fine arts building — the sort of change to a school’s layout and addition of new emergency equipment that is expected to prompt an update to an EAP. State law also says an EAP should include all available emergency equipment, including AEDs.

The KHSAA bylaws also have a specific section on the recommended use of AEDs that says all athletic trainers, coaches, administrators, school nurses and physical education teachers should have access to an AED on school property and at all school sanctioned athletic activities. In addition, it recommends that it take less than three minutes to retrieve an AED at each athletic venue for practices, games and other athletic events.

Kentucky law and the KHSAA require schools to delineate responsibilities prior to an incident. Whomever is submitting the EAP is supposed to specify who is doing what when an emergency occurs. Who is calling 911? Who is directing the ambulance? Who is retrieving emergency equipment?

On June 7, 2020, just a few days before Matthew’s death, Bowling, the athletic trainer, prepared a new 2020 EAP for St. Henry and sent it to acting athletic director Maureen Kaiser. In her deposition, Kaiser says she “glanced” at the document — which did not include two of the newly added AEDs in St. Henry’s new construction — despite her statement in the same deposition that she knew those AEDs were there. She did not forward nor implement the EAP that Bowling sent her in the nine days prior to Matthew’s death.

Bowling wasn’t consistent when filling out the 2020 EAP, either. The question of who will call 911 is asked twice on the EAP form. In the first section, Bowling wrote that goalkeeper coach Keith Kelly would handle those responsibilities. But further down on the page he wrote: “Duties for coaches during an emergency: Steve Hahn and any available coach will stay w/team. Keith Kelly will assist with the injured athlete. Assistant coach John Reding will make 911 call and direct the ambulance and also call AD, Maureen Kaiser.” Of those mentioned in the EAP, only Hahn and Reding were at practice on June 16, 2020.

State law also says the principal of each school has to review the proposed EAP. According to his deposition, David Gish, who was set to become St. Henry’s principal July 1, acknowledged he had never looked at the EAP, even after taking the job. Hahn testified that he had never — in his tenure as head coach at St. Henry — been given a copy of an EAP.

The Mangines’ legal team was prepared to argue that, as soon as the campus layout changed — by adding buildings and new emergency equipment — the administration had to update its EAP before any new activity could take place on school grounds. They point to the inclusion of the phrase “venue-specific” when describing the EAP and believe that once a venue’s logistics change, the existing EAP is no longer “venue-specific” and therefore no longer compliant.

On the 2020 EAP that Bowling drafted and sent to Kaiser prior to June 16, he noted that “an AED is also to be carried by the attending athletic trainer on duty.” Bowling was the only certified athletic trainer on duty the day that Matthew collapsed. And he had left his AED in his car.

On the day of Matthew’s death, St. Henry had five AEDs on campus, including the one in Bowling’s car in the parking lot. The closest AED to the field where the soccer team was practicing was just 50 yards away in the new fine arts building. The Mangines’ legal team timed how long it would have taken to jog from the spot where Matthew collapsed to that location to retrieve the AED and back. It took 47 seconds. Both Bowling and Hahn testified that they did not have keys to the part of the building that housed the AED. Kaiser was also on campus that evening and can be seen in sheriff’s deputies body cam video. She acknowledged in her deposition that she had keys to that building and knew the AED was there.

There are no documented penalties for a school found to be in violation of the AED or EAP rules. The state board or its agency can request records of compliance, but participating schools are left largely to self-report infractions.

Julian Tackett, commissioner and chief executive officer of the KHSAA for almost 40 years, remembers Max Gilpin, a high school football player in Louisville who died after collapsing at practice in August 2008. Gilpin’s death prompted Tackett and Kentucky state Rep. Joni Jenkins to help create a bill that requires practicing an athletic emergency action plan. In Kentucky, the law also requires schools to review their athletic EAP annually and submit written verification of its existence. While there are 288 KHSAA participating schools, Tackett notes there is no penalty for non-compliance.

“The way the membership application reads is that they certify that they have an emergency action plan in place and they have rehearsed it and checked it at all their venues,” Tackett said. “It’s really not an infraction of our [KHSAA] rules. It’s a law in the state. It would be up to a trial court — just like they were going through in northern Kentucky — it would be up to a trial court to try and evaluate if there was a problem.”

That’s why the Mangine family felt they had to file the civil lawsuit. There was no other way to hold St. Henry accountable for what happened June 16, 2020.

According to numerous depositions with representatives from the school and the diocese, neither the Diocese of Covington nor St. Henry District High School conducted an internal investigation. The 2020 EAP that eventually was posted was essentially the same as the 2019 EAP.

Hahn was fired more than a year after Matthew’s death. Bowling retired in May 2022. Kaiser is no longer the athletic director, but is still listed as the school’s health teacher and the girls’ volleyball coach. Gish is now the assistant principal.

IN THE MONTHS following Matthew’s death, the Mangines learned more about sudden cardiac arrest and EAPs and AEDs than they ever imagined. They believe deaths like Matthew’s are preventable. In March 2021, the Mangines filed paperwork to create The Matthew Mangine Jr. “One Shot” Foundation. The goal is to raise awareness and educate parents, coaches and athletes about the number of preventable sudden deaths. Their website emphasizes the importance of properly executing Emergency Action Plans and the expanded use of AEDs and other life-saving measures.

According to the American College of Cardiology, nearly 35 million public elementary and secondary students attend school in states with no legislative requirement for a school AED. Only 24 states currently have requirements for the installation of AEDs on school campuses, and only nine provide some funding for school-based AED programs.

Matthew and Kim have worked with the Department of Emergency Medicine at the University of Cincinnati and with Novacare Rehabilitation, the physical therapy company that employs Bob Mangine, to expand the public’s knowledge about life-saving measures. One way is by organizing Take10 Cincinnati sessions, inspired by a similar program in Austin, Texas. Take10 is not a CPR certification course, but a free 10-minute, hands-on opportunity to prepare anyone to act in an emergency.

The Mangines travel to schools with a big, black duffle bag. Inside are 30 inflatable CPR mannequins and an AED trainer. Athletic trainers lead the sessions, demonstrating how to administer chest compressions and how to follow the AED’s automated prompts. The point is to practice the motions so in the chaos of an actual emergency, muscle memory overrides paralysis.

The Mangines have conducted more than two dozen sessions with schools in their area, but the one they’re most proud of is Taylor High School in Cleves, Ohio, which has trained more than 700 people since June 2021. Every teacher, every coach, every athlete from every sport has participated in at least one Take10 session. That’s the Mangines’ goal for every school they set foot in — to do these sessions three times a year, before every sports season kicks off.

Their foundation also has helped supply AEDs to sports programs. Last winter, the soccer club, Cincy SC, wanted five AEDs for their teams. The soccer club raised all the money while the foundation made recommendations and facilitated the purchases. AEDs can retail for anywhere between $1,100 to $2,500 and the Mangines say cost is often cited as the reason programs often go without them.

As Matthew’s story has gotten more attention, the foundation also has started receiving requests outside of Kentucky and Ohio. Athletic programs and health care systems in Texas, Wyoming and North Dakota have reached out over the past few months. A North Dakota school said that its 12 athletic trainers are forced to share three AEDs. The Mangines know they can’t fulfill every request but want to try to do as many as the foundation’s funds allow.

IN THE MORE than two years since filing the civil suit, the Mangines have dealt with motions and hearings and depositions and decisions. In January 2022, it was a fight for Matthew’s heart. That month, the defense issued a subpoena for the remnants of his heart so they could conduct further testing by a second pathologist. They were trying to determine whether Matthew had a pre-existing condition that would have made him more likely to suffer cardiac arrest. But other than being diagnosed with “activity induced asthma” by the Mangines’ family physician, nothing had ever shown up on any physical. The Mangines were reluctant to comply.

“You’re asking me to give the last remaining piece of my son to you and I don’t know what you want to do with it,” Matthew Sr. says.

Matthew Jr. was not buried with his heart. To the best of his father’s knowledge, whatever remains of his heart sits in a formaldehyde-filled container at Children’s Hospital in Cincinnati, although he says it might be back in the medical examiner’s office in Louisville.

“It’s one of those things you’d like to know for certain,” he says, “but knowing doesn’t really give you any peace. So you move it down on the list and figure you’ll get it eventually.”

Matthew and Kim hear the whispers and see the frowns around town. They know some members of their tight-knit northern Kentucky community disapprove of their decision to take legal action over the death of their son.

“You can just tell by the way people look at you.” Matthew says. “It’s tough to trust anyone … You have your friends, but even people we thought were our friends are different than they were before.”

Says Kim: “If anyone wants to say anything negative or non-supportive about what we’ve done or how we’ve gone about things, all I’ll say is flip the script. I’ll trade spots with them any day.”

Jury selection for the trial in the wrongful death lawsuit was scheduled to begin Jan. 23. The week before, the two sides settled out of court. Terms of the settlement were not disclosed. The Diocese of Covington released a statement that says in part: “Matthew Mangine was a loved and respected student, athlete, and friend at St. Henry District High School. Our school and faith community continues to grieve for him.”

When the reality of Matthew’s absence threatens to unravel her, Kim’s mind flirts with the falsehood that her oldest son is just away at college. Or on a trip with friends. Or at a soccer tournament out of town. The lie feels good for a moment as she imagines him thriving in whatever adventure he’s on. It’s the permanency of death that hurts the most. The “should-have-beens” and the “never-agains.” The wound that cannot be closed that recalibrates the personal spectrum of sadness. Grief lurks just beneath the surface and then, it rages — without warning. A collision between the desperate soul and the neverness.

The spring of 2022 was especially painful as Matthew’s senior class prepared to graduate from St. Henry District High School. His teammates and classmates wanted to recognize their fallen friend with a memorial at the ceremony. They purchased a cap and gown to place on an empty chair and requested a moment of silence for Matthew. With the Mangines’ permission, the students were allowed to adorn an empty chair with a purple bow and a bouquet of purple flowers. They sent pictures to Matthew Sr. and Kim, who chose not to attend.

The recruiting letters from colleges that once filled the mailbox have been replaced with alumni letters from St. Henry, which feels like a cruel glitch in an automated system. Matthew did not graduate. He will not make more memories or take selfies or stack squares of the mundane next to major milestones on a social media feed. About a week after Matthew died, Matthew Sr. and Kim were driving when they got a phone call. It was the local Department of Motor Vehicles, ready to schedule their son’s road test. As they hung up the call, the weight of the exchange leveled the Mangines and they sat and cried for their irreparably broken family.

A SMALL STATUE of a boy holding a soccer ball sits in the garden at St. Paul Catholic School in Florence, where Joseph Mangine is in eighth grade and where Matthew Jr. went to school until 2018. The same statue sits in front of the Mangines’ home where Joseph plays video games on the television that used to be in his brother’s room. He does his best to ignore the silence surrounding him. There are no more impromptu soccer matches in the front yard or spontaneous basketball games on the mini hoop in the basement. Joseph used to make fun of his brother for his “four little beard hairs,” but he also always hoped Matthew might teach him to shave some day.

“There’s no one to be with anymore,” Joseph says, “and that’s pretty hard, not having someone there.”

Over the next six weeks, Joseph and his parents will make a decision about where he will attend high school. St. Henry is no longer an option. Since filing the lawsuit, the Mangines have been back on school property only the few times Joseph’s league basketball games were played there. The nerves they feel watching him compete are somewhat calmed by the presence of the portable AED that goes everywhere with them now. As difficult as those games were for Kim, watching her 13-year-old son navigate the loneliness caused by his brother’s death is worse.

“It’s just a different level of companionship — that sibling dynamic,” she says. “And it just disappeared. I do think that’s why he’s matured so fast. He spends a lot more time with Dad and his golf buddies. That’s how he fills his time now.”

He’s gotten so good at golf that wherever he ends up for high school, he likely will play on the boys’ team. At the Triple Crown Country Club, where he and his dad work on their games, Matthew is never far from their thoughts. Just behind the 18th green, a catalpa tree, known for its heart-shaped leaves and June blossoms, is getting taller every day. The Country Club planted it for Matthew. Some days, depending on the tee placement, when lining up their approach shots, they can aim for Matthew’s tree.

Jen Lada is a reporter and host for ESPN. Video was produced by ESPN’s Simon Baumgart.

Kentucky parents urge schools to prepare, practice emergency plans following son’s fatal collapse at soccer practice
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