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MAPS Prepares For Trial in Wrongful Death Lawsuit

At festivals the world over, it has become increasingly common for the organizers to arrange for harm reduction facilities, safe spaces where festival goers having challenging experiences, often due to substances they might have taken, can be cared for in a quieter, supportive environment. 

Among the pioneering efforts to provide harm reduction services is the Zendo Project led by the nonprofit Multidisciplinary Association for Psychedelic Studies. The Zendo Project first began offering services at Burning Man in 2012 and then expanded to other festivals over the years.

These care spaces are not designed to treat medical emergencies. Often staffed by trained volunteers, their mandate is to support those who may be having a challenging psychological or spiritual experience after ingesting a substance. As the group explains on the Zendo website, their purpose is to provide those in need with “a calm meditative presence of acceptance, compassion, and caring. [And to] promote feelings of trust and security.” Some harm reduction providers also seek to reduce other risks by distributing earplugs, electrolytes, safer sex supplies and educational information. 

If someone suffers an injury or is overcome by illness, they are directed to the medical tent. In many cases, the people seen at harm reduction facilities require little more than a calming presence and a place to sit or lie down until the substance passes through their system.

Some people with more extreme symptoms seeking care in a harm reduction space may be experiencing a combination of a drug and a physical ailment. In the case of a misdiagnosis or inappropriate treatment, where does the responsibility lie? This question is at the center of a wrongful death civil lawsuit filed against MAPS that will be considered by a jury at a public trial in Monterey Superior Court beginning on October 31. 

The lawsuit stems from the death of 20-year-old Baylee Ybarra Gatlin in 2017 after she attended the Lightning in a Bottle music festival in Monterey County, California. During the event, Gatlin was a guest at a care space run by the Zendo Project. The trial will determine whether MAPS is negligent in the wrongful death of Gatlin and if they are liable for financial damages. 

The lawsuit was filed in 2018 by Gatlin’s mother Susan Ybarra-Telias and stepmother Carla Gatlin. Other defendants included Do Lab, Inc., the LiB festival producer, and RGX Medical, which provided medic services at LiB, as well as RGX Medical founder Richard Gottlieb, and up to twenty unnamed people connected to these organizations that the Gatlin family contends share some responsibility for liability and damages in their daughter’s death. The Zendo Project was initially named as a defendant, but was dismissed at the request of MAPS. 

The Gatlin family reached a settlement last year with the Do Lab, RGX Medical, and Richard Gottlieb for $4 million, which was paid by the Do Lab’s insurance company. RGX continues to provide medical services to Lightning in a Bottle. 

MAPS was not a party in the settlement. A motion filed in the case on July 12, 2022 by their lawyers noted that MAPS was “uninsured for this case.” As the Zendo Project was part of MAPS in 2017, it was also uninsured for the services it was providing. 

In preparation for this article, Lucid News reached out to MAPS, the Zendo Project, RGX Medical, Gottlieb, attorneys for the Gatlin family and the Do Lab, and Sara Gael Giron, who was serving as Director of Harm Reduction for the Zendo Project in 2017. They declined to comment. Rick Doblin, MAPS founder and executive director, spoke with Lucid News about the case in July. 

The Death of Baylee Gatlin 

Harm reduction is “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use,” according to the National Harm Reduction Coalition

The Gatlin case illustrates the consequences when something goes terribly wrong. The following account is based on the wrongful death lawsuit filed by the Gatlin family. It recounts the difficult events of that day from the family’s perspective and presents details intended to have an impact on the judge and jurors. The complaint includes both established and disputed information and also highly charged language intended to sway a jury. 

According to the Gatlin family’s complaint, Baylee Gatlin began showing signs of physical stress near an LiB stage area the day before her death on May 28th, 2017. She was unable to drink water or speak coherently and her legs shook uncontrollably. Gatlin’s companions took her at 7:00 that evening to a medical station operated by RGX Medical, which was providing onsite first aid and event medical services for LiB. In their briefs in the case, MAPS describes the medical tent as adjacent to the tent that housed the Zendo Project space. 

The complaint alleges that “Her friends, believing she had consumed drugs,” were directed by “personnel” at the medical station to the Zendo for care. The complaint further alleges that, “This occurred without any proper medical assessment by personnel at the medical/first aid station.”

While at the Zendo, Gatlin’s family says that her symptoms worsened. The complaint asserts that Gatlin had convulsions, was incontinent, repeatedly vomited and had a high temperature. “Throughout all of this,” alleges the complaint, “the unqualified personnel in the MAPS’ Zendo tent kept her out of the ‘medical tent,’ failed to contact qualified medical personnel or arranged for medical transport. The unqualified personnel in the MAPS’ Zendo tent responded to her symptoms by placing blankets on her.” 

According to the lawsuit, Gatlin remained at the Zendo for six hours and did not receive medical care until an ambulance was called at 1:07 a.m. the next morning. The complaint claims that Gatlin was not able to advocate for her own care. When the ambulance arrived, the complaint says she had a temperature of 105 degrees, a heart rate of 170 and was in respiratory distress. Gatlin went into cardiac arrest while being transported to the hospital and was pronounced dead at 3:42 a.m.. 

According to local press reports, Gatlin’s death was first mischaracterized as due to an LSD overdose. The complaint asserts that “Baylee Gatlin’s blood tests were positive for Lysergic Acid Diethylamide (LSD) use,” but says that medical records establish that she primarily died from overheating. The complaint notes that “mere LSD ingestion does not cause multi organ failure (hours long) and hyperthermia, and dehydration also ‘hours long’; nor does it cause or contribute to cardiac arrest, cause unspecified; disseminated intravascular coagulation; hemorrhage from sites in respiratory passages, unspecified kidney failure and fever, or hyperkalemia, all which proximately caused and resulted in Baylee Gatlin’s death.” 

Gatlin’s family argue that it was not the harm reduction services that caused Gatlin’s death, but the negligent care that she received, and that the defendants deviated from their official plans and did not provide proper training to their staff and volunteers. 

“Instead of arranging for qualified competent personnel to oversee, control manage, and assess and triage all festival attendees in need, defendants and each of them arranged for so called ‘harm reduction’ entities to provide non-medical care for festival attendees suffering from adverse consequences of dehydration, overexposure, and/or drug use,” the Gatlin family allege in their complaint. They insist that the defendants operated in reckless disregard of “industry standards and common sense.” 

In 2019, Gatlin’s mothers filed an amended complaint for damages, alleging that defendants were also negligent in hiring/supervision/retention of people involved in the incident. It also contends that the defendants engaged in fraud and intentional and negligent misrepresentation in the promotion of the event and their services. 

Varying Accounts and MAPS Legal Arguments

Were the jury to decide that MAPS was obligated to provide medical evaluation and care as part of the Zendo’s services, it could place a significant burden on future harm reduction efforts.

Legal filings by MAPS in the Gatlin case present a very different account of what occured the night of Gatlin’s death and what they believe is their legal responsibilities to guests in the Zendo space. In a brief filed with the court in advance of the trial, MAPS lawyers argue that “no duty existed for MAPS’ unpaid volunteers to assess [Gatlin] medically or provide medical treatment.”

The MAPS brief asserts that the Zendo’s role was limited to providing “volunteers to sit with people,” and that it “provided no medical treatment and merely assisted festival attendees who were having bad experiences after taking substances, providing a safe place to rest.”

The MAPS brief claims that Gatlin was assessed in the medical tent. “She was found to have normal vital signs and directed to the adjacent Zendo Harm Reduction tent. Multiple witnesses will confirm medical personnel came to the adjacent Zendo tend [sic] to check Decedent’s vitals throughout the evening.” 

Speaking with Lucid News in July, MAPS’s Doblin said “There is no evidence that we had any medical responsibility.” 

In a statement made in support of a MAPS motion for summary judgment, Sara Gael Giron, the former Director of Harm Reduction for the Zendo Project, said that she observed Gatlin in the Zendo tent during the evening of May 27 starting when the RGX team brought her in and continuously throughout the evening. “Each time I observed her after she arrived, Decedent was laying down and appeared to be resting comfortably,” reads Giron’s declaration. 

Another statement in support of the MAPS motion for summary judgment, submitted on January 31, 2022, cites several depositions and declarations asserting that medical staff was monitoring Gatlin, checked in on her and took her vital signs while she was in the Zendo. “To the sitters and other MAPS volunteers who saw Decedent in the Zendo Tent, she appeared to be on an LSD trip,” reads the statement. The same statement also cites a deposition which asserts that Gatlin’s condition deteriorated at 1:00 a.m. on Sunday, May 28 and that RGX Medical called an ambulance at 1:07 a.m.

During a talk at the Palenque Norte speaker series at the 2022 Burning Man gathering, Giron said that Zendo services at Burning Man currently 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. 

Giron said that medical volunteers have always been a consistent part of Zendo services at Burning Man, but did not cite Lightning in a Bottle, noting that “every event is different, so over the years our protocols have emerged and shifted and changed.” 

Settlement Controversy 

When the Gatlin family reached a settlement with Do Lab and RGX in 2021, Doblin says that MAPS was not invited to participate. 

“They settled without even consulting with us,” Doblin told Lucid News in July, adding that there was a prior mediation in the case from which MAPS was excluded, as well. Doblin also confirmed that MAPS attorneys asked the judge to issue a summary judgment in the case and that this request was denied, leaving MAPS open to a jury decision about damages and liability. 

Following the settlement, attorneys for MAPS filed a cross-complaint against the Do Lab, RGX Medical, Gottlieb, and up to fifty unnamed cross-defendants associated with the case, asserting that they these parties alone are legally responsible for the damages alleged in the Gatlin lawsuit. 

In July, 2021, James Farinaro, an attorney for Gottlieb and RGX Medical answered the MAPS cross-complaint alleging that it was barred by the statute of limitations. 

Doblin says that when the Do Lab, RGX Medical and Gottlieb settled with Gatlin’s family, they should have insisted that the family withdraw the lawsuit. “I feel fundamentally betrayed by LiB and RGX, particularly by LiB and their lawyers,” said Doblin. “Now we’re the only ones left in the case, defending ourselves, having to pay all the lawyer’s bills.”

In the July 12, 2022 motion to the court, MAPS states that “in order to avoid wasting the donated money MAPS uses to help veterans and others, MAPS initially limited its participation in the case. Do Lab took the lead on all discovery. When the insurer for Do Lab settled the claims against Do Lab and Gottlieb, MAPS was forced to conduct discovery.” Discovery is the process that determines what evidence will be presented in court during a trial. In their court filings, it appears that MAPS was relying on Do Lab to address the complaint. 

The motion states that MAPS made “reasonable attempts” to settle the case at and after the Mandatory Settlement Conference (“MSC”).” MAPS asserts in its motion that the Gatlin family members who filed the lawsuit offered to “compromise” with MAPS for a $1 million settlement. “Then, Plaintiffs increased their demand multi-fold without explanation.” The motion filed by MAPS notes that the Gatlin family was asserting that “discovery is closed,” meaning that the plaintiffs had presumably already gathered the evidence they considered necessary to support their arguments at a jury trial.

Preparing for Trial

In July, Doblin said that MAPS was still in ongoing negotiations with the Gatlin family, but had not been able to reach an agreement for a settlement. “Settlement is a business decision in the sense that it costs a lot to defend yourselves,” said Doblin. “So we are exploring settlements, but we do not feel we had any medical responsibilities.” 

While Doblin argues that the Zendo assumes no medical responsibility while caring for guests, the jury might be asked to consider whether Zendo personnel had a non-medical responsibility to summon medical providers in a timely manner during the six hours in which Gatlin’s family says she became progressively more sick. 

The case could raise questions about the legal or common-sense responsibility of people caring for someone in clear medical distress to get prompt medical assistance. While MAPS may effectively deny medical responsibility, the question before the jury could well hinge on whether Zendo staff and volunteers acted in a way that any reasonable person would be expected to. 

“The current theory of our liability is that our people should have overruled the medical staff, which seems a little bit iffy of an argument,” said Doblin in July, suggesting that medical personnel did not express concern over Gatlin’s condition. He also asserts that a friend of Gatlin’s visited her at various points of time when she was at the Zendo. “If we had a duty to overrule the medical staff, so did they,” he said. 

As legal negotiations in the Gatlin case have been ongoing for four years and the complaint has been available online since at least 2020, the lawsuit has already been the subject of discussion and impacted harm reduction services like those the Zendo Project provides. Protocols such as medical intake, assessment of arriving guests and continuous medical supervision of those people may continue to be informed by this case. 

The Zendo Project Leaves MAPS

Giron confirmed during her talk at the Palenque Norte speaker series that the Zendo Project is in the process of becoming a nonprofit organization independent from MAPS.

“It’s still going to be in relationship with MAPS and receiving support and sponsorship in certain ways,” said Giron of the Zendo Project, which ran two peer support locations at this year’s Burning Man gathering. MAPS and the Zendo Project declined to comment on how the Zendo Project spinoff might impact the future liability of either organization. 

Legal briefs filed by MAPS assert that Zendo volunteers are covered by the Good Samaritan law which offers legal protection to people who give reasonable assistance to those who they believe are injured, ill or otherwise incapacitated. Some Zendo volunteers believe they are protected by this law. The Gatlin plaintiffs argue in reply that this legal protection does not apply because MAPS received a donation from LiB, and Zendo volunteers receive free tickets to events, which acts as a form of compensation.

MAPS would not comment on how the case or a possible settlement or jury award might impact its legal or financial position as the MAPS nonprofit and its wholly owned for-profit, MAPS Public Benefit Corporation, move towards FDA approval of its Phase 3 clinical trials investigating MDMA-assisted therapy for PTSD.

Ann Harrison, who has consulted for the Zendo Project and contracted with RGX Medical for services, provided research including publicly available legal documents for this story. 

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