More than an hour passed between the time University of Maryland football player Jordan McNair started displaying initial heatstroke symptoms and when university officials called 911, sports medicine consultant Dr. Rod Walters said at a news conference Friday.
During a closed session meeting at Towson University, the University System of Maryland's governing body reviewed the findings from an external investigation into the June death of the 19-year-old offensive lineman. Walters, head of sports medicine consulting firm Walters Inc., then presented the findings from his 74-page report to the media.
University leaders have already said the care they provided McNair was not consistent with best practices.
Athletic training staff did not take McNair's temperature and did not use a cold-water immersion treatment, a technique researchers say has a high success rate for those suffering heatstroke. University president Wallace Loh has previously said the school takes "legal and moral responsibility for mistakes the training staff made" on the day McNair was hospitalized.
Walters' review found that cold-water immersion tanks are generally part of the field setup at Maryland, but they were not on May 29 because football practice switched locations at the last minute.
"If they had done cold-water immersion, it would have been more effective," Walters said. "That's best practices. That didn't happen that day."
But he also said McNair's presentation of heatstroke was atypical. McNair reported cramping about three-fourths of the way through the exercise he was completing. That was at 4:53 p.m.
He wasn't taken off the field until 5:22 p.m. He suffered a "mental status change" and seizure at 5:50. The first 911 call went out at 5:55, and another at 6:02.
The report found the university's "failure to rapidly recognize exertional heat illness is a concern."
"The lack of recognition and assessment of the severity of the event delayed cooling the patient in a timely manner," the report said.
When the severity of McNair's condition was eventually identified, "inadequate cooling devices were used in place of cold-water immersion or cold whirlpools."
When asked if this case displays negligence, Board of Regents chair James Brady said he was "not in position to make that call at this time." He added he wants to gather more facts before making a judgement call.
Murphy, Falcon & Murphy, the law firm representing McNair's family, received a copy of the report late Thursday night.
In August, ESPN reported details from McNair's last practice. Anonymous sources told ESPN that when McNair struggled to complete a sprint, football trainer Wes Robinson yelled, "Drag his ass across the field!"
Robinson, coach D.J. Durkin and Steve Nordwall, who oversees the trainers and strength and conditioning coaches, have been placed on paid leave pending the outcome of an external review.
Strength and conditioning coach Rick Court was also placed on leave before ultimately submitting his resignation.
ESPN also reported the football team fostered a "toxic" culture. A separate investigation into those claims, also overseen by the Board of Regents, is ongoing.
Among the eight people commissioned to review the team's culture are former Gov. Bob Ehrlich, Tom McMillen, a former U.S. congressman and Maryland basketball star, and retired U.S. District Court judges Ben Legg and Alex Williams.
The Walters Inc. review came a day before the Terps will face Minnesota at home in their Big Ten opener.
Loh said the athletics department has already instituted a number of changes to its procedures since McNair's death. The Walters Inc. report could lead to an even larger overhaul.
Brady said the report doesn't change the tragic outcome.
"We can never make up for that loss, but we can and must learn from what happened, how it was handled and make any necessary and appropriate changes to make sure it never happens again," he said.
University System of Maryland chancellor Robert Caret echoed him.
"You can't repair the past, you can only hope to improve the future," he said. "You do wish they had made different decisions at that point in time."
