TOWSON, Md. -- Members of the Maryland athletic training staff failed to quickly diagnose and properly treat the heatstroke symptoms of 19-year-old offensive lineman Jordan McNair on May 29, according to a report released Friday.
McNair died June 13 from heatstroke, and had the athletic training staff provided him adequate care, "there might have been the opportunity to reverse the patient's core temperature," according to the report from Walters Inc.
McNair was admitted to a local hospital with a body temperature of 106 degrees.
"Hindsight is 20/20," said Rod Walters, who was hired by Maryland to conduct the investigation. "I think if we would have identified that earlier, it might have changed things."
The report said there was a delay of 34 minutes between when McNair first started cramping during the May 29 workout to the time he was taken off the field. It took 1 hour, 7 minutes to call 911 from the onset of symptoms and another 32 minutes before he left in an ambulance to the hospital.
"Though in distress and assistance of two athletic training interns," McNair was walked around the field for 34 minutes after becoming symptomatic, according to the report. After 911 was called, McNair suffered a seizure, and his "jaw was clenched and he was having convulsive movements" as described by head athletic trainer Wes Robinson.
According to the report, Robinson was questioned about why McNair wasn't put in a cold whirlpool following the change in his status and seizure activity. According to the report, Robinson answered that there was a "concern of size of the student-athlete and the smaller stature of the athletic trainers providing care, there was fear of drowning."
"Obviously we've looked at it. We've seen that there were some shortcomings," Maryland athletic director Damon Evans said. "Some of the policies and procedures weren't followed accordingly like they should have been, but that's what we're learning from this report, and that's what we've got to do to ensure. We've got to educate, we've got to continuously go through our policies, our procedures, our protocols to make sure our staff is informed of what they need to do should situations like this arise."
The findings were made public Friday at Towson University following a closed meeting of the University System of Maryland board of regents -- almost three months after the first of two investigations began.
On June 19, Maryland announced the hiring of Walters, a nationally recognized sports medicine consultant, to investigate the details of the workout and whether McNair received necessary treatment.
According to the report, four players were interviewed.
Player No. 1 said Robinson yelled across the field to "get him the f--- up." Player No. 2 said McNair could barely stand but was walked back toward the position drills. Two interns were intertwined with his legs trying to hold him up. This player also said the coaches preach a "no quit" mentality. Player No. 3 said a trainer was helping McNair and "Wes yelled, 'Drag his ass across the field.'" Player No. 4 said, "During rep eight [of 10 110-yard sprints], he was bending over at the waist, which is a no-no with coaches." Player No. 4 said his locker was near McNair's "and he gave the perception that he was not prepared for the [conditioning] test."
Walters said the injury evaluation "did not include any assessment or documentation of vital signs including core temperature."
"There was the failure to identify escalating symptoms associated with exertional heat illness including assessing vital signs, identifying the condition and aggressively treating the patient's elevated core temperature," Walters said. "No apparatus was used for prompt cooling of the patient. Inadequate cooling devices were used such as cold towels, ice packs, etc. The pre-hospital care of exertional illness should include rapid recognition, rapid assessment, rapid cooling and rapid advance care within 30 minutes of the onset of symptoms."
According to the report, a last-minute decision May 29 to move the practice from Maryland Stadium (where there was construction) to Cole Field House (where there was poor field availability) and then ultimately to the practice fields was also a contributing factor. The athletic training staff had to "rush to get hydration products" and other emergency equipment to the turf fields. Cold-water immersion tanks were not part of the setup that day, though they are typically. It also didn't help that there is construction around Cole Field House, and the ambulance went to an upper parking lot instead of the field level; nobody was immediately sent to meet the ambulance, which "is a failure to follow an established plan," according to the report.
The USM board of regents is still waiting for the results of a second investigation, which consists of eight people tasked with looking into allegations of verbal abuse and bullying within the football program. There is no timetable for the conclusion of that investigation, which is why no personnel decisions were announced Friday.
Maryland coach DJ Durkin was at the May 29 workout, but when asked about his role in it, Walters said, "The report does not get into all of that."
"He didn't provide any care," Walters said. "My deal was the procedures specific to the protocol at the University of Maryland and were they followed that day."
Walters said he interviewed all of the coaches, athletic trainers and strength coaches. According to the report, the assistant coaches were asked five questions: "Describe the field conditions on May 29. Did you see any players in distress during the conditioning run? Was there concern by the staff for Jordan's weight? Do you know what a seizure is? Did you witness a seizure in Jordan McNair on 5/29?"
There was a sign-up sheet for the players to talk to him, Walters said, and there was an announcement to the team about it.
The Walters Inc. investigation included two more interviews that were passed onto the second commission. One was from a parent "expressing concern over the pressure her child had endured during time with the football team." The second was from an athletic training student "expressing concern for the handling of a couple of student-athlete injuries and the intervention between the head football athletic trainer and the student."
Maryland officials on Friday handed out a release detailing how the university is responding to the results of the investigation, and one point was an increase in the number of doctors and trainers at both football practices and games.
Asked how the school can ensure that the doctors and trainers -- not the head coach or strength coach -- will have the final say over the return of an injured athlete, university president Wallace D. Loh said, "They are not allowed to do it, and furthermore getting somebody back on the field is a determination of the physician, not the coach."
"Can the coach try to persuade? I suppose so," Loh said, "but the coach will be out of line."
On Aug. 14, after ESPN reported McNair was admitted to a local hospital with a temperature of 106 degrees, Loh revealed preliminary findings from the Walters Inc. report and said, "The university accepts legal and moral responsibility for the mistakes that our training staff made."
"The death of this young man is a tragedy, let there be no doubt about it, and we all feel very deeply about that," James Brady, the chair of the USM board of regents, said Friday. "But we are in the process of gathering facts, and I'm a fact guy. I like to know what the facts are before we make any conclusions [about whether the school is morally and legally responsible]."
Durkin was suspended in August as the allegations of abuse and disparagement in the program were investigated. Matt Canada will be the Terrapins' interim coach for a fourth game Saturday against visiting Minnesota. Robinson and director of athletic training Steve Nordwall were also placed on leave last month.
Loh has said all suspended staff members deserve "due process," and he wanted to wait until the two external investigations were completed before making any decisions. In August, the USM board of regents assumed control of both investigations.
McNair's parents, Marty McNair and Tonya Wilson, have said Durkin should be fired.
According to a copy of his contract, Maryland would need to pay Durkin roughly $6.5 million in a buyout. The contract stipulates that the school owes him 65 percent of what is left on his deal through the end of the 2021 season.
On Aug. 10, ESPN published a report in which two current Maryland players, multiple people close to the football program, and former players and football staffers described a culture based on fear and intimidation that centered around former strength and conditioning coach Rick Court, who has since resigned. Last month, in a special four-hour meeting held in Baltimore, the board asked the office of the state attorney general to represent Maryland on "any and all legal claims related to Mr. McNair's death."
A spokesperson for the office of the attorney general said it had no comment on Friday's report.
Friday's meeting began at 9 a.m. ET, and the board voted unanimously to go into closed session just before 11 a.m. It was unclear throughout the day whether the entire report would be released as planned because attorneys for the McNair family didn't receive the findings until late Thursday night. In a letter to the board of regents Thursday, attorney Hassan Murphy wrote, "The family has the right to review the report and insist on redaction of any material that would violate Jordan's privacy rights or violate federal state health privacy laws."
McNair's family decided against redacting any private information, however, because "Jordan's parents strongly feel that it is the broader conversation regarding the health and safety of student-athletes which is most important," Murphy wrote in an email to the office of the attorney general Friday afternoon.
Murphy requested the report be given to the attorneys and the family before it was released to the public and cautioned that any premature release could "subject the university and those responsible for such release to serious civil and criminal liability."
The office of the attorney general provided the documents around 11 p.m. Thursday.
Last month, Murphy's law firm filed "notice of claim forms," which are formal letters notifying the state of the parents' intent to sue. The filing, which does not guarantee a suit will be filed, is required by law to give the parents the right to file a formal lawsuit within a year.
The filing claims an amount of damages "in excess of $10 million" for each parent and the same amount to Jordan's estate for his pain and suffering prior to his death, for a total liability of more than $30 million.