The full investigative report into the death of Maryland offensive lineman Jordan McNair was released Friday evening.

The investigation, which Maryland hired Dr. Rod Walters to conduct, determined that Maryland training staff did not follow proper procedures in addressing the symptoms exhibited by McNair on May 29. McNair was hospitalized that day after struggling through a workout involving a series of 110-yard sprints. He died June 13 from heat stroke. He was 19 years old.

In an August 14 press conference, Maryland president Wallace Loh said the university accepted “legal and moral responsibility” for “mistakes made” by the training staff on May 29 that ultimately led to McNair’s death. During that press conference, athletic director Damon Evans said the training staff “did not take Jordan’s temperature and did not apply a cold water immersion treatment. Walters presented further details on Friday.

Timeline: More than 90 minutes for McNair to be transported to hospital

Walters laid out a detailed timeline of the events of May 29.

• Time from the onset of McNair complaining of cramps to being moved from the field: 34 minutes.

• Time McNair was treated in the training room until his symptoms worsened: 23 minutes, 55 seconds.

• Time from the 911 call to departing the stadium: 37 minutes.

• Time between the onset of McNair’s symptoms to the 911 call: One hour, seven minutes.

• Time from the onset of symptoms following the seventh 110-yard sprint to the departure of the ambulance en route to the hospital: One hour, 39 minutes.

Trainers failed to identify ‘escalating symptoms,’ used ‘inadequate’ cooling devices

Walters said the prehospital treatment for exertional heat illness “should be rapid recognition, rapid assessment, rapid cooling, and rapid advanced medical care” within 30 minutes of the onset of symptoms. Walters said Maryland had adequate policies in place, but did not identify the severity of McNair’s symptoms quickly enough, nor did the training staff have proper equipment for cooling.

Walters also noted that McNair’s case was an “atypical presentation of a heat stroke.”

“While there was a delay in identifying the severity of the symptoms, once these symptoms were identified, there were efforts to cool the patient and address the respiratory concerns,” Walters said.

“The injury evaluation did not include any assessment or documentation of vital signs, including core temperature. There was a 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. No apparatus was used for prompt cooling of the patient. Inadequate cooling devices were used.”

From the report:

When answering questions from reporters, Walters said if the severity of McNair’s symptoms had been identified earlier, “it might have changed things.” He also submitted recommendations for the school to follow moving forward. James Brady, the chair of the Maryland board of regents, said many had already been implemented.

Investigation into football program is ongoing

Other than last month’s resignation from Rick Court, the football team’s strength coach, no personnel changes have been made. That includes head coach D.J. Durkin, who has been on administrative leave for more than a month. In addition to Durkin, head football athletic trainer Wes Robinson and director of athletic training Steve Nordwall — were also placed on leave.

Those employees were put on leave after ESPN published a piece detailing an alleged “toxic culture” surrounding Durkin’s program. Court, who Durkin once described as “the most important hire” he made, was prominently mentioned in the ESPN report.

ESPN’s report prompted a separate investigation into the culture of Durkin’s football program. Brady said Friday that the second investigation is ongoing, but would conclude “soon.”

Maryland’s football team is off to a 2-1 start

With offensive coordinator Matt Canada serving as the interim head coach, Maryland opened the season 2-0. That included an upset of Texas in Week 1. The team paid tribute to McNair on the first offensive play of the season by taking the field with just 10 men.

The Terps followed that win with a road victory over Bowling Green in Week 2. However, the team lost its home opener last week against Temple, 35-14.

Maryland hosts Minnesota on Saturday.

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