(CNN) - More than an hour passed before a University of Maryland football trainer called 911 after a player, who later died, first showed symptoms of heatstroke, states an independent report issued Friday.
Jordan McNair, a 19-year-old offensive lineman, died June 13, weeks after taking part in an offseason conditioning session at Maryland's turf outdoor practice field in late May.
The report, compiled by a sports medicine company, cites five issues with McNair's treatment:
• Failure to assess his vital signs, including core temperature;
• Failing to quickly recognize he was having heat illness and not properly treating him as his condition worsened;
• Not having proper cooling devices, such as immersion tanks, near the workout site;
• Having to retrieve respiratory aids in a "trauma bag"; and
• Not giving emergency responders best directions or sending someone outside to meet ambulances.
"The literature tells us that if we identify heatstroke within 30 minutes ... and do cold water immersion, (when) we identify the elevated core temperature, that is best practice. That didn't happen that day," Dr. Rod Walters, who submitted the report, said at a news conference Friday.
Walters said he did not make a determination as to whether McNair's death was an accident or due to negligence. He said McNair's case wasn't the usual heatstroke event with the typical outward symptoms.
McNair took turn for worse, staff called 911
On May 29, McNair, a redshirt freshman, was taken from the field, where the air temperature was 81 degrees, at 5:22 p.m. That was 34 minutes after he said he was having cramps and was bending over at the waist.
About 28 minutes after he was taken from the field, in the training room, McNair's mood dramatically worsened -- a sign of heatstroke -- and a trainer called the team doctor, who advised calling 911, the report says.
It had been one hour and seven minutes since symptoms were first noticed. There was a chance to save McNair, the report indicated.
"Even if the symptoms were not identified on the field, if core temperature had been assessed with the change in mental status at 17:50 p.m., there might have been the opportunity to reverse the patient's core temperature," it says.
Because McNair then began having a seizure and respiratory distress, trainers called authorities a second time to request another ambulance with advanced cardiac life support.
When asked why the staff didn't use a cold whirlpool to treat McNair, the head trainer told Walters they feared the lineman, who weighed 341 pounds on May 29, could drown.
Instead they used drinking water, cold towels and ice packs. Walters called them inadequate.
Several players who were interviewed said McNair looked exhausted on the field after the seventh of 10 110-yard sprints.
One said the head trainer yelled for assistants to "get him the (expletive) up," and another player reported he told them to drag his (expletive) across the field."
McNair completed two more sprints on his own, but needed help from teammates on the final one. He was taken to the training room as the rest of the team moved to grass field for football drills.
University has taken responsibility
In August, Athletic Director Damon Evans and university President Wallace D. Loh apologized to McNair's family during a meeting in Baltimore.
Loh said he told the family the "university accepts legal and moral responsibility for the mistakes that our training staff made on that fateful workout day."
Loh said he also told McNair's family: "The university owes you an apology. You entrusted Jordan to our care, and he is never returning home."
At that time, the university placed its football coach, D.J. Durkin, and some members of the athletic staff on administrative leave.
Official promises safer environment for athletes
"I wish that we could say that we could bring Jordan McNair back to life," James Brady, president of the board of regents, said Friday. "That would be the greatest thing that we could possibly do. That cannot be done, and the tragedy that the McNair family has had to deal with cannot be overcome.
"But we can use this experience to make student-athlete safety much better and more focused than it might have been in the past."
Brady said he was not in a position to say the trainers were negligent, citing the fact that the board of regents has commissioned another investigation that will decide whether any coaches or trainers need to be disciplined or fired.
"We are in the process of gathering the facts," he said. "I like to know what the facts are before we make any conclusions."
He said announcements will come in the "not-too-distant future."
Since McNair's death, the university has added cooling stations, started testing players' hydration at practice, increased the length of breaks, put more trainers and doctors at events. Staff has also received more training from Walters, the school said.
It also will use cold tub therapy at summer workouts. Tanks were not available at the session where McNair suffered heatstroke because the team changed plans on venues and didn't set them up at the practice fields.
The report has additional proposals, such as establishing an athletic medicine review board, Loh said Friday in a letter to the university community, adding the athletic department will be implementing all recommendations.
"The safety and well-being of our students remains paramount," Loh wrote.
Maryland's football team is 3-1 after defeating Minnesota 42-13 Saturday. Maryland players wore stickers with McNair's number on the helmets. They also wore stickers for a former Minnesota player who died this week at age 22 from cancer.
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