A “striking lack of leadership” by representatives of Garden City (Kansas) Community College contributed to the death of Braeden Bradforth in August 2018, and among those criticized was then-head coach Jeff Sims, now the head football coach at Missouri Southern State University.

An external review of the circumstances leading up to the player's death found "there was little to no oversight of the preparation for and execution of the August 1, 2018, conditioning test designed and run by Coach Sims. This lack of oversight set off a series of events that ended with the death of Braeden Bradforth.”

The external review tasked with investigating Bradforth’s death by exertional heat stroke also reported "there was a failure to properly assess student-athletes prior to the August 1 conditioning test described by one witness as an intense cardio workout.”

Bradforth's mother, Joanne Atkins-Ingram, said the report validated her suspicions and that of her lawyer, Jill Greene, that Bradforth "was not cared for in an appropriate, timely or responsible manner."

"The more that I talk about it, the more it seems really real at this point," Atkins-Ingram said. "It was over a year ago that this all started. After reading this report, it validates everything we’ve been saying up to this point. They really did not take care of my son."

“Not only did they not take care of Braeden, but my take on this is this report confirmed exactly what we suspected all along," Greene said. "However, it is shocking and appalling to realize the level of incompetence and just outright disregard for the safety of a child who was entrusted to these adults. There were terrible choices that were made by adults, and to me, it’s just incomprehensible.”

Sims declined comment when the Globe contacted him Thursday. He said, “I am not allowed to talk publicly about the report.”

The death of Bradforth has drawn national attention and has led to a call by members of Congress to review and prevent exertional heat stroke deaths among athletes.

On Thursday, U.S. Rep. Chris Smith, R-N.J., called Bradforth's death "utterly heartbreaking in that it confirms that Braeden's death was 100% preventable."

Earlier this year, Smith introduced the resolution calling for bipartisan legislation to establish a federal commission to look into exertional heat stroke.

73 minutes

Bradforth, from New Jersey, arrived in Garden City on July 30 seeking an opportunity to play for the GCCC football team. The 19-year-old defensive lineman was found unconscious outside of his dorm room after a practice on Aug. 1 and died later that night at a local hospital.

Hours before being declared dead, Bradforth had taken part in a conditioning test that required players to complete four sets of nine 50-yard sprints on a night when temperatures hovered around 80 degrees. Players were granted eight-second breaks between each sprint and two-minute breaks between each set. The report also noted that water was made available to all of the players throughout the workout.

“When Braeden Bradforth arrived in Garden City, his physical condition should have been evident to the athletic trainers and coaches,” the report states. “He was overweight at 315 lbs., out of shape and should not have run the conditioning test as designed and implemented. A cause of death was a poorly designed and administered conditioning test for an unconditioned, nonacclimatized student-athlete at an altitude (elevation) with nine percent less oxygen than he was accustomed to at him home in Neptune, N.J.”

The community college received Bradforth’s medical records and other necessary forms to participate with the football program when he arrived on campus. Three days before his arrival in Garden City, Bradforth also received a required physical examination by his personal pediatrician, Dr. Kristen Atienza, who noted in her evaluation of Bradforth that he was cleared without restrictions but also made a recommendation specific to diet and exercise.

The report notes that Atienza’s recommendation was not noticed by the GCCC athletic training staff until after Bradforth's death. The recommendation also was not communicated to Sims or any of the coaching staff prior to Bradforth’s participation in the conditioning test.

The college was not adequately prepared to ensure the safety of players during practice or to deal with exertional heat illness, according to the report. The community college’s athletic training staff and the coaching staff, as well as emergency medical personnel, also failed to identify or treat Bradforth’s escalating symptoms of the heat stroke that caused his death, investigators found.

The probe, which was requested by the college in May, included a timeline that detailed a 73-minute span between the moment Bradforth left the football practice to his arrival at the hospital. Players found an unconscious Bradforth at approximately 9:50 p.m. in a “narrow and hot alley with limited air flow” outside of his dorm. After Sims, assistant coach Caleb Young and head athletic trainer T.J. Horton were each made aware of the situation, emergency medical service responders were called at 10:01. EMS responders arrived to the scene at 10:09 and transported Bradforth to St. Catherine Hospital in Garden City by 10:33 p.m. Bradforth was declared dead at 11:06 p.m.

“Once Braeden Bradforth began to drift into medical distress, there was a failure to plan for appropriate care,” the report states. “An effective plan likely would have rescued him from what turned out to be his untimely death. The response time and significant delays between multiple opportunities for effective treatment were a cause of death."

Death by exertional heat stroke can be averted if the illness is identified and properly treated within 30 minutes, according to the report.

The report noted that Young, the first coach to arrive to the alley to tend to Bradforth, told officials Bradforth was moaning when he first came in contact with him. He then called Sims to seek instruction for how to handle the situation rather than calling 911.

In an email to school officials, Young stated players were pouring jugs and bottles of water on Bradforth and attempted to make him drink while Young was on the phone with Sims.

No legal action has been filed in the case.

"Right now, we're still trying to just digest everything," said Greene, the lawyer for Bradforth's mother. "From a legal perspective, Chris Dove is our Kansas attorney, and it's in his hands at this point as to whether we move forward with litigation. I think it's beyond dispute that this report supports our position that the school was clearly negligent in their care of Braeden and how they handled this emergency."

Contact Jared Porter on Twitter at @JaredRyanPorter.

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