A report on the death of Mongolian Groom in the Breeders’ Cup Classic at Santa Anita says veterinarians missed opportunities to remove the gelding from the $6 million race because of time constraints or deficiencies in the process used to evaluate horses.

In the 20-page report issued Wednesday, Dr. Larry Bramlage identified six suggested improvements aimed at refining safety and evaluation protocols for future events.

Mongolian Groom, a 4-year-old gelding, suffered what Cup officials described as “a serious fracture” of his left hind leg in the late stages of the Classic last November, which was shown on national television. Four vets recommended that he be euthanized.

Bramlage’s six recommendations were:

— pre-identify horses before arrival at the event with histories of concerns to be looked at

— focus responsibility for individual horse exams. Seven regulatory vets looked at Mongolian Groom a total of 10 times and Bramlage concluded that had there been fewer people, a more focused assessment may have resulted

— improve the quality of on-track observations leading up to the event

— create space in the barn area where regulatory vets could observe horses on the extra security list jog in a circle for observation

— make diagnostic imaging part of the pre-race exams for selected horses

— take advantage of all available video footage of horses before the event

“It is hard to fault a process that had a 99.6% accuracy rate,” Bramlage said, noting that of the 229 horses that competed in last year’s world championships, Mongolian Groom was the only one to be injured.

After the event, the Breeders’ Cup board of directors hired Bramlage, of Rood and Riddle Equine Hospital in Kentucky, to conduct an evaluation of Mongolian Groom’s pre-race condition and injury, as well as all pre-race safety and evaluation protocols in place for the two-day world championships.