USAFA Cadet Death

a_cadet said:
and cadre / PP were over-exaggerating to scare those who weren’t actually that sick. I understand cadets will do anything to skip training but after my experience, I can’t help but feel people who were legitimately super sick were ignored because it was “just Jack’s hack.” The actual medical providers were fine if not overzealous
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I was about to ask what a Form 18 was, but I did the legwork: Cadet Illness/Injury Report (AFCW Form 18)

I found it in this fascinating document: https://www.usafa.edu/app/uploads/AFCWI-36-3501-Cadet-Standards-and-Duties-Signed-12-Aug-2020.pdf

The military, in many training situations, is guilty of exactly what you described.
"Hello four Ranger candidates complaining about hypothermia in the year 1995 - get tough - do you want to graduate?"
(Later that day - all four dead).

I get it. All trainers want an experience to be challenging, and they don't want to provide an out for complainers. I plead guilty, myself. And I am not saying (not in the slightest) that is remotely what may or may not have happened with this poor cadet. I am awaiting further info from USAFA.

However, I have not seen a situation where someone with the authority to break procedures at their discretion does not suffer when that break goes south on them, i.e. they are taking full responsibility.

We are entitled to know how this poor, young lady died in such a [purportedly] tremendously-supervised environment.
 
usafa1993 said:
I was about to ask what a Form 18 was, but I did the legwork: Cadet Illness/Injury Report (AFCW Form 18)

I found it in this fascinating document: https://www.usafa.edu/app/uploads/AFCWI-36-3501-Cadet-Standards-and-Duties-Signed-12-Aug-2020.pdf

The military, in many training situations, is guilty of exactly what you described.
"Hello four Ranger candidates complaining about hypothermia in the year 1995 - get tough - do you want to graduate?"
(Later that day - all four dead).

I get it. All trainers want an experience to be challenging, and they don't want to provide an out for complainers. I plead guilty, myself. And I am not saying (not in the slightest) that is remotely what may or may not have happened with this poor cadet. I am awaiting further info from USAFA.

However, I have not seen a situation where someone with the authority to break procedures at their discretion does not suffer when that break goes south on them, i.e. they are taking full responsibility.

We are entitled to know how this poor, young lady died in such a [purportedly] tremendously-supervised environment.
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Reminds me of what happened in 2022 with the BUD/S trainee’s death
 
a_cadet said:
I don’t know what happened or in what context she didn’t receive medical care. But I saw a lot of people who were visibly very ill being told to go back to training under the threat of failing basic during second beast. As far as I know after missing more than the allowed time myself, they only actually failed a couple people (mostly those with chronic issues) and cadre / PP were over-exaggerating to scare those who weren’t actually that sick. I understand cadets will do anything to skip training but after my experience, I can’t help but feel people who were legitimately super sick were ignored because it was “just Jack’s hack.” The actual medical providers were fine if not overzealous, but I guess they had to be because Form 18s were pretty regularly ignored even by cadre.
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Avery's death didn't happen during basic training. Basics had returned from Jack's Valley over a month prior to her passing (although I understand that Jack's Hack can linger for quite a while after BCT!)
 
USAFAGradMom said:
Avery's death didn't happen during basic training. Basics had returned from Jack's Valley over a month prior to her passing (although I understand that Jack's Hack can linger for quite a while after BCT!)
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Jack’s hack does linger for months. I’m still coughing on and off + experiencing unusual shortness of breath. I know when she died. If she was coughing more and more like the autopsy report said, everyone would have assumed jack’s hack. It’s completely normalized for it to be that bad.
 
We know that Avery died from sepsis. Sepsis can manifest very, very quickly -- 12-24 hours.

I have personally spoken to several doctors and nurses about that. In summary, until you know which bacteria caused it, you don't know if any medical decisions prior to her death could have stopped it.

In other words, let the on-going investigations into the medical decisions proceed to their conclusion. At this point, everything is supposition.

As for Jack's Hack -- USAFA medical did an evaluation in 2009. It was determined that the primary causes were rhinovirus and other common viruses. Basically, you bring in a bunch of basics from around the world and they bring all their local viruses & bacteria with them. You can do an internet search to find the report. "“Jacks' Hack”: Respiratory Illness During Basic Cadet"
 
I understand Jack's Hack but I feel this year was way worse with so many different things going around. Personally my son ended up with the traditional Jack's Hack cough but also double ear infections, sinus infection, and some virus that caused him to repeatedly throw up for about 3 weeks (adenovirus?). He was so sick that he lost about 15 pounds from all the vomiting. I know the clinic was overwhelmed and I am so incredibly sad for Avery, her family, and her squad mates.
 
Swiss_Miss said:
I understand Jack's Hack but I feel this year was way worse with so many different things going around. Personally my son ended up with the traditional Jack's Hack cough but also double ear infections, sinus infection, and some virus that caused him to repeatedly throw up for about 3 weeks (adenovirus?). He was so sick that he lost about 15 pounds from all the vomiting. I know the clinic was overwhelmed and I am so incredibly sad for Avery, her family, and her squad mates.
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I'm so sorry. I hope your cadet has recovered,. Being sick stinks. Being sick during training stinks even more.
 
I have a current C1C, and I tend to me more a lurker on these pages, but this one I just can't. It is well known among cadets, parents, grads, and staff that access to care for cadets on base is hard. The clinic is overwhelmed especially when school starts, and many are turned away with no care. For a freshman like Avery, its even harder- no car, restricted to base, learning how to advocate but that curve is steep, not knowing how to navigate military insurance ( mine is a senior and I still dont know how), no established relationships yet with sponsors or the military pipeline of people to lean on or ask for help. So many times I have stepped in to help my own or a sponsor kid navigate the system, and while I know the mantra is trust the system, I have seen the system fail cadets I am close to. But how would avery or her parents know that?

as parents we are told to trust the system, cut the cord, let our kids figure it out, and that the academy leadership and military has been " doing this forever" and they will be fine. Except Avery was not fine. I have heard countless other stories of cadets who had to fight way to hard to get care, and some of those were within hours of a much worse outcome.

The system needs an overhaul. access to care and education about care needs an overhaul. What can we do? How can we make sure this doesnt happen again? How can we, in Averys honor, make the system better for the future of USAFA and the cadets?
 
SpiritCommitteeLiaison said:
We know that Avery died from sepsis. Sepsis can manifest very, very quickly -- 12-24 hours.

I have personally spoken to several doctors and nurses about that. In summary, until you know which bacteria caused it, you don't know if any medical decisions prior to her death could have stopped it.

In other words, let the on-going investigations into the medical decisions proceed to their conclusion. At this point, everything is supposition.

As for Jack's Hack -- USAFA medical did an evaluation in 2009. It was determined that the primary causes were rhinovirus and other common viruses. Basically, you bring in a bunch of basics from around the world and they bring all their local viruses & bacteria with them. You can do an internet search to find the report. "“Jacks' Hack”: Respiratory Illness During Basic Cadet"
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The type of bacteria is right there in the report.
 
Glider78 said:
I have a current C1C, and I tend to me more a lurker on these pages, but this one I just can't. It is well known among cadets, parents, grads, and staff that access to care for cadets on base is hard. The clinic is overwhelmed especially when school starts, and many are turned away with no care. For a freshman like Avery, its even harder- no car, restricted to base, learning how to advocate but that curve is steep, not knowing how to navigate military insurance ( mine is a senior and I still dont know how), no established relationships yet with sponsors or the military pipeline of people to lean on or ask for help. So many times I have stepped in to help my own or a sponsor kid navigate the system, and while I know the mantra is trust the system, I have seen the system fail cadets I am close to. But how would avery or her parents know that?

as parents we are told to trust the system, cut the cord, let our kids figure it out, and that the academy leadership and military has been " doing this forever" and they will be fine. Except Avery was not fine. I have heard countless other stories of cadets who had to fight way to hard to get care, and some of those were within hours of a much worse outcome.

The system needs an overhaul. access to care and education about care needs an overhaul. What can we do? How can we make sure this doesnt happen again? How can we, in Averys honor, make the system better for the future of USAFA and the cadets?
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This is an absolute failure and heads need to roll.
 
There will have been a JAGMAN death investigation along with a detailed medical report per required guidelines.

This is a Navy reference, but the JAGMAN is a standard DoD reference to lay out the facts, including documented systemic errors and weaknesses, arrive at conclusions supported by facts, make recommendations.

As I recall, there is only one required finding from a JAGMAN death investigation, whether Cadet Koonce was in the line of duty when she died (she was).


Following that, there may an exploration of UCMJ culpability, including non-punitive (administrative) and punitive courses of action, as directed by appropriate authority.

USAFA’s reporting senior and staff JAG will be following closely. It may be a case where an outside investigating officer is brought in, if root causes seem to include chain of command error.

There is a process.

And now that I have dutifully expressed all this in a just-the-facts manner, I am still
😔😢.
 
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This cannot be glossed over. She asked for and DID NOT RECEIVE adequate medical care. She had been sick for weeks. There is clearly a systemic problem at USAFA. The cadets do not get appropriate medical care. It is a leadership failure and heads do need to roll. I too would like to know what can be done to make sure this does not happen again.
 
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