TOWSON, Md. (WJZ/AP) — The University System of Maryland Board of Regents released its investigation findings into University of Maryland football player Jordan McNair’s death Friday.

The independent investigation finds University of Maryland culpable in the death of Terrapins football player Jordan McNair.

The report is classified as an “Independent Evaluation of Procedures and Protocols Related To the June 2018 Death of a University of Maryland Football Student-athlete,”

The investigator said there was a failure to rapidly realize heat illness concerns in McNair.

Rod Walters said the University has a “good system” already in place, but they did not implement it as quickly as they should have and some protocols were not followed that day.

“Hindsight is 20/20. I think if we would have identified it earlier, it might have changed things, but I think we have to have a plan. We have to identify those escalating symptoms and if they are elevated, if there is something abnormal, have a treatment plan,”

They said they should have rapidly taken action to cool him down, all of this should have taken place within 30 minutes.

The 74-page report recommended several changes including ready availability of ice immersion baths.

UMD Chancellor Dr. Wallace Loh, said there were many things they were doing since early July after he had done his interviews.

“What I want are recommendations to make sure that this tragedy never happens again, that we do everything possible for the safety and well being of our students.”

Student-athletes’ water and temperature levels are now being monitored before, during and after activities.

The report also reiterated that medical staff should have full autonomy.

When asked if in the past medical trainers at the campus were pressured by the coaches, athletic director Damon Evans said to his knowledge, that was not the case.

“Our trainers have always been in charge, we have the physician-directed model, as Dr. Loh has stated, our doctors have worked closely with our trainers to make the determinations when student-athletes are clear to play,” Evans said.

The findings were shared with McNair’s family before they shared the report with the public.

McNair died of heat stroke after a workout for the University of Maryland’s football program in May.

The board had two investigations running, one into the death of McNair, which was released today, and a commission to investigate the culture of UMCP football program.

The second investigation is still ongoing, it was commissioned earlier this year.

The board voted August 17 to take over the investigations.

USM Board Of Regents Vote To Take Over McNair, Football Program Abuse Investigation

The University also apologized, taking legal and moral responsibility for McNair’s death, releasing a statement of apology August 14.

“The university accepts legal and moral responsibility for the mistakes that our training staff made on that fateful workout day,”  said University of Maryland President Wallace D. Loh during a press conference.

University Of Maryland ‘Accepts Responsibility’ For Death Of Jordan McNair

Wallace also released a statement Friday after the investigation’s official release of findings:

“Dear University of Maryland community,

I would like to share with you this update following today’s Board of Regents meeting on the tragic death of our student-athlete Jordan McNair. In August, Athletic Director Damon Evans and I met with Jordan’s parents to apologize personally for the mistakes made in Jordan’s care by our athletic trainers.

In June, we retained a national expert in sports medicine and athletic training, Rod Walters, to conduct a comprehensive review of the policies and protocols related to the health and safety of our student-athletes. We requested recommendations on what changes should be made to ensure a tragedy like this never happens again. We are committed to this.

The entire Board of Regents received the final report from Rod Walters today. Since he was retained, he has been also advising the Athletic Department on needed improvements, and they have already begun implementing some of his recommendations even before receiving the final report.

Actions to improve the safety of the training and conditioning sessions include: adopting new technology to improve how we monitor the ambient temperature and modify practices accordingly; implementing mandatory hydration testing and emphasizing longer and more frequent recovery breaks. The Athletic Department also increased the number of doctors and trainers present at football practices and games. In July, Rod Walters began expanded training for the staff on the implementation of the emergency action plan. An online portal was established so that our student-athletes could share any concerns. The Walters report highlighted the fact that we have a physician-directed model for athletics trainers, who are licensed by the state and are under the supervision of a licensed physician.

There are additional recommendations in the final report, such as establishing an athletic medicine review board that will review procedures and protocols regarding student-athlete safety. The Athletic Department has committed to implementing all of the recommendations.

Our actions, and our commitments, are available at www.umd.edu/commitment.

The Board of Regents also assumed control in August of a separate commission investigating allegations surrounding the culture of our football program. The Chair of the Board of Regents announced today that results of this commission will be forthcoming.

The safety and well-being of our students remains paramount. I will continue to update our community on all of these efforts.”

McNair’s parents have spoken out against the head coach, DJ Durkin, who is still on administrative leave.

Parents Of Jordan McNair: ‘Fire Coach, Keep President’

“Our son’s death cannot and should not be a political football for competing factions or agendas or to settle prior scores,” the parents of Jordan McNair wrote in a statement.

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