A jury in Monterey, California has found the nonprofit Multidisciplinary Association for Psychedelic Studies partially responsible for the death of 20-year-old Baylee Ybarra Gatlin who died after being cared for by members of the MAPS Zendo Project at the 2017 Lightning in a Bottle (LiB) music festival.
The Zendo Project, which is in the process of becoming an independent nonprofit, is a pioneer in harm reduction. It trains volunteers to provide peer support for those having difficult experiences, including challenging encounters with psychedelic substances. The Zendo first began offering services at Burning Man in 2012 and expanded to other festivals over the years.
The verdict in the case, Carla Gatlin, et al. vs Do Lab Inc., stems from a civil lawsuit for wrongful death brought by Gatlin’s family against MAPS, Do Lab, Inc. the producer of LiB, RGX Medical, which provided medical services at LiB, and RGX founder Richard Gottlieb.
After considering evidence from multiple witnesses in three weeks of testimony, the jury found that MAPS employees were negligent and their negligence was found to be a substantial factor in Gatlin’s death. Zendo volunteers involved in Gatlin’s care also were found to be negligent, but the jury did not find that this negligence was a substantial factor in her death.
Jurors awarded $2 million each to Gatlin’s mothers Carla Gatlin and Susan Ybarra-Telias to compensate them for the loss of their daughter’s “love, companionship, comfort, care, assistance, protection, affection, society and moral support.” The jury was also required to establish the percentage of fault for parties in the case.
It determined that MAPS was 25% responsible for Gatlin’s death which requires the organization to pay $1 million in damages.
RGX Medical operated a medic tent at the 2017 LiB where Baylee Gatlin was first brought by her friends before being referred to the Zendo. The jury also found that 55% of the responsibility for Gatlin’s death was held by Richard Gottlieb doing business as RGX Medical, which provided onsite first aid and event medical services for the festival. The Do Lab was found by the jury to be 20% responsible for Gatlin’s death. The jury also found that negligence by the Do Lab and Richard Gottlieb dba RGX Medical was a substantial factor in causing harm to Baylee Gatlin.
The Gatlin family already reached a settlement last year with the Do Lab, RGX Medical, and Gottlieb for $4 million, which was paid by the Do Lab’s insurance company. Because they had already settled with the plaintiffs, Do Lab, RGX and Gottlieb were not represented by attorneys at the trial and had no opportunity to present arguments or submit evidence. James Farinaro, an attorney for Gottlieb and RGX Medical, did not reply to a request for comment on the verdict.
During the trial, the jury was instructed by Judge Thomas W. Wills to not consider the earlier settlement in their decision. Keith Bremer, an attorney for the Do Lab, confirmed that because the Do Lab, RGX Medical and Gottlieb have already settled in the case, they will not be required to pay any share of the $4 million in total new damages awarded by the jury.
Because they were included in the apportioning of fault at the request of MAPS, Gatlin’s parents were found by the jury to have 0% responsibility for the harm caused to Baylee Gatlin.
MAPS noted that they wanted to include Baylee Gatlin to be considered by the jury for a percentage of fault in the harm that led to her death, but that the judge excluded her from this consideration. “The judge explicitly excluded Baylee Gatlin from the list, over defense objections, based on a ruling in Frausto v. Dept. of Cal. Highway Patrol,” said MAPS. “Any responsibility held by Gatlin herself, the person who manufactured or provided substances to her, nor any of the people who witnessed her behavior was not able to be considered by the jury.”
Gatlin’s family initially sought $5 to $10 million in damages from MAPS. Efforts by MAPS and Gatlin’s parents to reach a settlement before the trial were unsuccessful.
A cross-complaint filed by MAPS against the Do Lab, RGX Medical, and Gottlieb was withdrawn at the request of MAPS. Initially named as a defendant in the case, the Zendo Project was later dismissed from the lawsuit. The Zendo Project did not choose to immediately comment on the case.
MAPS says it believes that it has grounds to appeal the verdict and the jury award. In a statement about the verdict, the organization said that “MAPS’ counsel, leadership, and Board of Directors believe there are adequate grounds to appeal the decision. In the coming days, MAPS will file post-verdict motions for judgment notwithstanding the verdict and a new trial for not properly instructing the jury that certain testimony should not have been allowed.”
MAPS says it was not able to comment on possible pending legal actions or what testimony they considered improper. The organization said that details will be provided in publicly available legal motions that will likely be filed in the next few weeks. The organization would also not comment on how much the trial costs, or how MAPS planned to raise funds to pay damages or support a second trial if it is granted one. “MAPS is always careful to ensure that donors’ gifts are carefully stewarded and transparently reported, practices which continue to earn us top ratings from Guidestar and Charity Navigator,” MAPS said in a statement.
MAPS was denied an earlier summary judgment in the case prior to the trial and judgements notwithstanding the verdict are extremely rare. As MAPS is uninsured for the services the Zendo provides, raising money to pay damages or to fund a new trial could impact its ability to fundraise as a nonprofit. It could also potentially affect funding for its wholly owned for-profit, MAPS Public Benefit Corporation, which is moving towards FDA approval of its Phase 3 clinical trials investigating MDMA-assisted therapy for PTSD.
Gatlin Family and MAPS Reflect on the Verdict
During their deliberations, jurors were required by the judge to determine if plaintiffs proved that MAPS failed to act as a “reasonable careful person” in providing Zendo services to Gatlin. Judge Wills instructed the jury to “consider the customs and practices in the community to determine if MAPS acted responsibly” and also “decide if the custom and practice was reasonable.”
In its statement, MAPS says it believes that the verdict in this case could impact the ability of harm reduction groups to provide peer support. “MAPS recognizes that the result of this trial may now engender a chilling effect for the organizations that offer harm reduction services,” reads the MAPS statement.
The verdict returned by the jury could potentially influence the Zendo’s ability to secure insurance or affect services offered by medical providers at festivals. The MAPS statement asserts that because people may use psychedelics and have challenging experiences, “we as a community must acknowledge and mitigate the risks by providing harm reduction services…” Much of the testimony during the trial focused on whether MAPS and the other defendants did this effectively.
According to the Gatlin family’s complaint, Baylee Gatlin began showing signs of distress near an LiB stage area the day before her death on May 28th, 2017. Observing that her legs were shaking and that she was unable to drink water or speak coherently, her friends brought her at 7 pm that evening to a medical station operated by RGX Medical adjacent to the tent that housed the Zendo Project space. Gatlin’s friends told Zendo and RGX volunteers that they believed she had taken LSD.
While Gatlin later tested positive for LSD, the family asserted in their complaint that she died of multi-organ failure due to heatstroke. They contend that their daughter did not receive proper care or fluids despite the fact that Zendo volunteers and her friends saw that she was having convulsions, vomiting and foaming at the mouth. When an ambulance was called six and half hours after Gatlin arrived at the Zendo, the complaint says she had a temperature of 105 degrees, a heart rate of 170 and was in respiratory distress.
Attorneys for Gatlin’s family argued during the trial that it was not harm reduction services themselves that caused Gatlin’s death, but the negligent care that she received from both Zendo and RGX staff. During the six and half hours during which she was at the Zendo, Gatlin’s medical condition significantly deteriorated and she went into cardiac arrest in an ambulance on the way to the hospital. MAPS attorney Charles Custer argued during the trial that the psychoactive substance 25I-NBOMe may have played a role in Gatlin’s death, but it was not detected in her pathology tests.
In its lawsuit and later during the trial, lawyers for Gatlin’s family said that MAPS was negligent in the hiring, training and supervision of Zendo staff and volunteers. They asserted that the Zendo was understaffed and deviated from the protocols outlined in its own training manual. When asked at the courthouse after the verdict what she felt MAPS and the Zendo should do in response to the verdict, Carla Gatlin replied, “Train their volunteers better. I know it’s hard to tell the difference between a bad trip and dehydration because they really mimic each other. But just more training.”
During a talk at the Palenque Norte speaker series at the 2022 Burning Man gathering, Giron, who was serving as Director of Harm Reduction for the Zendo Project in 2017, noted that Zendo services at Burning Man include a medical triage volunteer on each shift who does a brief assessment of each guest as they enter the space. The triage volunteer is available to sitters in the Zendo for additional evaluation of guests, including monitoring of vital signs, and can escalate cases to medical providers if needed.
Attorneys for Gatlin’s family noted that the Zendo did not have their own medical triage person in place during the 2017 LiB. Carla Gatlin said after the verdict that she doesn’t believe that Siri Garfinkle, her daughter’s first sitter in the Zendo who covered her in blankets, evaluated her properly. Garfinkle testified that she did not touch Baylee Gatlin during the first few hours she was in the Zendo. When Garfinkle did touch Gatlin later to roll her on her side and protect her airway as she vomited, she said Gatlin did not feel warm.
Carla Gatlin believes that if someone had evaluated her daughter to see if she was running a fever, that would have alerted them that Gatlin was gravely ill and needed more care. “I don’t think they followed their protocols,” says Gatlin. “I don’t think they trained their volunteers through their protocols such as touching somebody, doing the skin test.” Asked if she felt the Zendo staff had a duty to call an ambulance instead of escalating to RGX Medical as their protocols called for, Gatlin replied, “As a human, yeah.”
Interpretations of Negligence and Responsibility
The first question on the unofficial special verdict form for the Gatlin case, which was read aloud in open court as the jury’s final verdict, asked the jury “Sara Gael Giron, Ryan Beauregard and persons responsible for creating and operating M.A.P.S. Zendo Project and the Zendo Project Training materials were employees of M.A.P.S. (hereinafter “employees”). Was any one of them negligent?” The jury answered “yes” to this question. Giron has worked with the Zendo project since 2013 coordinating harm reduction services and Beauregard is the Zendo Project Manager.
The jury was also asked if a group of people named in the verdict form, people that the plaintiffs claimed were Zendo volunteers or “agents of M.A.P.S.,” were negligent. To this question the jury answered, “yes.” The jury did not find that this negligence was a substantial factor in Gatlin’s death.
The verdict form appears to indicate that the people named in the document contributed to the negligence. But MAPS spokesperson Betty Aldworth says that MAPS believes that the language of the verdict supports the interpretation that no specific individuals were found to be negligent. Aldworth first confirmed that the jury had found MAPS employees, including Giron and Beauregard, negligent. She then said that this had been an error on her part and not the position of MAPS.
According to Aldworth, the specific negligence of Giron and Beauregard is not supported by the jury’s decision because the verdict form “does not ask or specify which employee(s) were negligent.” She says that “MAPS fully supports Sara Gael Giron and Ryan Beauregard, and does not believe they were negligent based on all of the evidence.” Custer, the MAPS attorney, argued during the trial that the Zendo had no medical responsibility for Gatlin’s care. He said this was the responsibility of RGX Medical which assessed Gatlin and cleared her to enter the Zendo. The jurors heard conflicting testimony from Garfinkle and Gatlin’s later Zendo sitter Sasha Friedkin about how many times RGX staff was summoned to check on Gatlin while she was being cared for in the Zendo. Garfinkle and Friedkin testified that an RGX medic checked on Gatlin at least five times throughout the night and into the next morning.
Testimony from RGX volunteer Michelle Pardo, who assessed Gatlin and admitted her to the Zendo, said that another RGX volunteer also assessed Gatlin prior to her evaluation. Pardo, who was a registered nurse but providing first aid services as an RGX volunteer, testified that there was a licensed physician in the medic tent who may have been a chiropractor. According to Pardo, she was not called in to the Zendo to assess Gatlin until nearly 1 am when she pulled back her blankets, realized that the young woman was gravely ill, and alerted a supervisor to call an ambulance.
Commenting after the verdict, Carla Gatlin says she found the conflicting testimony “really weird,” but added that “there are no records so you don’t know. You just have to go by what people say.” Zendo records were introduced as evidence during the trial, but attorneys said that there was no RGX patient form available for Baylee Gatlin. Carla Gatlin says she is skeptical that Pardo or the other medic properly evaluated her daughter before she entered the Zendo.
“She said that she saw her and took her blood pressure and took her to the Zendo, which I find hard to believe,” said Carla Gatlin. “She [Baylee Gatlin] was kinetic. Either way it doesn’t matter, they sent her in and then they didn’t check on her again for six hours. If they had a medical professional in the [Zendo] tent this wouldn’t have happened.”
Long Term Impact of the Verdict
The verdict in the Gatlin case could have a long-term impact on peer support services like those offered by the Zendo. Juror Jeanne Turner said outside the courtroom after the decision that the jury intended for the verdict to send a message. “We are hoping that organizations like MAPS and Do Lab will pay better attention to safety measures,” said Turner.
Turner said that protocols for Zendo guests to be checked out by the RGX medical staff for medical issues appears to have failed when Baylee Gatlin was in their care. “We felt that people in the [Zendo] tent might have been referred to the medical tent,” said Turner. “But there was really no follow through.”
Carla Gatlin did note that Pardo, the RGX medical volunteer, took action when she saw her daughter around 1 a.m. the following morning. “The first nurse that came in, they saw her, they threw ice on her and called an ambulance. That was a trained professional,” said Gatlin.
Gatlin contends, however, that the medic station where her daughter was assessed, which was not the main festival medical unit, did not have adequate staff. She says that with an event as large as LiB, she believes that the county and event producers should provide more infrastructure and resources for medical services.
“Definitely a lot more medical, and not volunteer medical but an actual licensed physician who can make the call to put an IV in somebody. I know dehydration is a big thing in these places so they should just be prepared for that constantly,” said Gatlin. “Keep the people safe. You build a city, but you don’t have the city infrastructure.”
MAPS spokesperson Betty Aldworth says she believes that medical services were inadequate at LiB and asserts that it was the responsibility of RGX to handle all medical issues. “From the testimony I heard, it seemed to be evident that medical was overwhelmed,” says Aldworth. “Do Lab contracted with RGX to handle all medical and the county signed off on a safety plan.”
Carla Gatlin said that she and Baylee’s other mother believe that much of the responsibility for effective harm reduction rests with those organizing and permitting events. She said that a new county ordinance in Ventura County, California where she lives now mandates specific resources required for safety services at festivals. She says that her family refers to this requirement as “Baylee’s law.”
“The biggest thing is I really want these festivals to be safe. I don’t want any more kids dying,” says Gatlin who noted that there have been more deaths recently at large music events. “Kids are going to keep going, they are going to keep doing drugs,” says Gatlin. “And I am afraid they are not going to be safe.”
Aldworth says that MAPS is continuing to improve its harm reduction services to meet evolving needs. “There is a continual improvement process happening at MAPS and that is a culture that is also embedded at the Zendo,” says Aldworth. “It is not just individual incidents that compel that improvement process. We are also learning how to respond to new realities in festival culture, the effects of new drugs that arrive on the scene, and all the factors that go into providing the safest environment possible.”
“The Zendo exists specifically for the purpose of creating safety and mitigating risk. Just because we are mitigating risk doesn’t mean we can always prevent negative outcomes and in this tragic case, unfortunately, the negative outcome was the loss of this young woman’s life.”
Update: This story has been updated to include a link to the unofficial special verdict form that was filled out by the jury to arrive at their final verdict. The text has also been updated to reflect the precise language in that document and an assertion by MAPS that they believe no individuals were identified as negligent in the verdict. The story has been corrected to reflect that Baylee Gatlin herself was not considered by the jury for percentage fault in the harm that led to her death. Gatlin was excluded by the judge for that consideration over the objections of MAPS. Additional comments from MAPS note that it is unable to reply to questions about any pending legal action and asserts that it is a careful steward of donor funds.
Disclosure: Ann Harrison has consulted for the Zendo Project and contracted with RGX Medical for services.