An independent investigation into the June death of Maryland football player Jordan McNair found that more than an hour passed between the time the 19-year-old offensive lineman began experiencing symptoms of heatstroke and when school officials called 911 to report a medical emergency.

The 74-page report stemmed from an external investigation conducted by Walters Inc., an athletic training consulting firm, into the circumstances surrounding McNair’s death. It was released at the conclusion of a University System of Maryland Board of Regents meeting Friday in Towson.

The report offered new details about the events and the laundry list of errors that led to McNair’s death, and school officials said Friday evening that they intend to implement all 27 of the recommendations related to medical care issues listed in the report. But school and system administrators did not take any immediate actions or make any personnel decisions after learning the investigation’s findings.

Maryland had previously acknowledged that athletic and medical staff failed to properly diagnose or treat McNair after the player suffered heatstroke at a team conditioning workout May 29.

The report highlighted several mistakes that were made in the school’s treatment of McNair, most of them occurring during the crucial hour after the player started exhibiting symptoms of heatstroke. Among the errors: There was no cold tub available, no rectal thermometer on hand and a long delay in contacting emergency medical services.


Jordan McNair, shown in 2016 with his high school team, McDonogh, located outside Baltimore. (Barbara Haddock Taylor/Baltimore Sun)

According to a timeline given in the Walters report, 33 minutes passed from the time McNair began experiencing symptoms to when he arrived at the trainers’ room, and then an additional 29 minutes passed before school officials called 911. Even then, the report said, there was “apparent confusion” as to where emergency responders were to report upon their arrival to campus.

McNair finally arrived at a hospital more than 1½ hours after he first experienced cramps and exhibited signs of exhaustion. He never recovered and died June 13.

When asked whether he believed there was negligence on the part of Maryland, board of regents Chair James T. Brady said Friday evening: “I’m not in a position to make that call at this point in time. I think there is a lot of information we are gathering, and I’m not prepared to make that call. I am prepared to say that the death of this young man is a tragedy. . . . We all feel deeply about that. We are in the process of gathering facts. I’m a fact guy. I like to know what the facts are before we make any conclusions.”

Personnel changes will wait

Media reports alleging an abusive culture within the football program that might have contributed to the player’s death have also rocked the school. Coach DJ Durkin has been on administrative leave since Aug. 11, and Rick Court, the team’s strength and conditioning coach, negotiated a settlement with the school and resigned. In addition, Steve Nordwall, assistant athletic director of athletic training, and Wes Robinson, the head trainer for the football program, have been on administrative leave.

The board isn’t expected to make any recommendations regarding personnel until after it has reviewed the results of a second external investigation it is overseeing. The regents have assembled an eight-person commission to probe the culture of the football program.

Durkin’s fate in College Park — and in many ways, the future of the Terrapins football program — could hinge on the results of that second probe, but there is no timetable for its completion. In a brief update to the board at the start of Friday’s meeting, Robert L. Caret, chancellor of the University System of Maryland, told the regents that review is “proceeding very quickly” and could be completed by the end of the month.

“Whatever decisions need to be made, whatever changes need to be made in what we do, will be decided by the board at that time once they have the facts and the foundation to do that,” he said.

It’s possible the board of regents won’t take up that matter until its next scheduled meeting Oct. 19, which would mean the many issues surrounding the Maryland football program might remain unresolved for several more weeks.

Friday’s report made no mention of Durkin and his involvement with the May 29 workout. Rod Walters, the longtime collegiate athletic trainer who wrote the report, told reporters that the head coach was on the field that day but played no part in the treatment of McNair.

Though school officials did not address the role football coaches played in the events surrounding McNair’s death, Athletic Director Damon Evans said Friday after the report was released that Maryland’s model for athlete medical care is intended to keep coaches “an arm’s length” removed from decisions such as the ones Maryland staffers faced May 29.

“In this case, that day, we had all of our certified trainers, as well as all of our coaches, but each of those individuals have responsibilities,” he said. “In the case of this tragic case of Jordan McNair passing, our trainers were the ones who were handling and attending to him medically.”

Though both investigations were launched by the College Park campus, the system’s board of regents assumed control of both Aug. 17. Maryland entered into a contract in June with Walters Inc. to examine the circumstances surrounding McNair’s death and review the school’s policies and procedures.

Water unopened in locker

McNair apparently had nothing to eat before the May 29 workout and had had only a bowl of cereal earlier that day. The report also states that while each player is typically given a gallon of water to drink before workouts, McNair’s was later found unopened in his locker.

According to Walters’s timeline, the Maryland players began a conditioning test at 4:40 p.m., which followed 16 minutes of stretching and warmups. After the seventh of 10 planned 110-yard sprints, McNair began suffering cramps and exhaustion at 4:53.

“During rep eight, he was bending over at the waist, which is a no-no with coaches,” one unnamed teammate told the investigator.

According to the report, four anonymous players provided Walters with eyewitness accounts to how trainers and coaches responded to McNair as his health deteriorated. After McNair showed visible signs of struggling, one player said Robinson, the team’s head trainer, yelled: “Get him the ‘f---’ up.” Another player said Robinson yelled: “Drag his ass off the field.”

McNair was removed from the field on a motorized cart at 5:22. He was taken indoors to the team training room at 5:26, and, according to the report, he complained of lower back cramps but was able to walk.

Shortly afterward, his condition deteriorated. The report stated that at 5:50 McNair experienced a “mental status change,” yelled at trainers and suffered a seizure. Robinson instructed Nordwall to call emergency responders at that time, but Nordwall instead called a team physician at 5:52. (Neither Robinson nor Nordwall has responded to requests for comment since going on leave.)

Finally, at 5:55, according to Walters’s timeline, school officials called 911 to report a medical emergency. A second 911 call was placed at 6:02, and McNair was finally aboard an ambulance at 6:27 — 94 minutes after he began experiencing heatstroke symptoms.

Medical experts have said that patients have a 100 percent survivability rate when heatstroke is treated promptly and the body temperature is lowered within 30 minutes. According to hospital records, McNair’s temperature reached 107 degrees and wasn’t lowered to 102 until 7:20 p.m.

In the report, Robinson, the team’s head trainer, said though athletic trainers did not give McNair a cold-water immersion treatment to lower his body temperature, he was treated with cold towels. Robinson said staff feared the player might drown in a tub given his size and the athletic trainers’ “smaller stature.”

Walters acknowledged there was surveillance video of the team workout but said it didn’t reveal anything significant about McNair’s condition. He also noted that “information reported to UMD attorney, athletic director, and senior administration two days post event was not representative of activity and care on the field.”

Family received copy

Walters wrapped up his investigation this month, but the board of regents did not see his report until Friday. Maryland President Wallace D. Loh, who was present at Friday’s meeting, also said he didn’t receive a copy of the report until Thursday night.

An attorney representing McNair’s family sent the board a sharply worded letter Thursday, demanding the board halt any public release of the report until the family had a chance to review it. The letter stated the family was worried about McNair’s private medical information becoming public.

The family finally received a copy of the report late Thursday night and had a chance to review it before the board convened Friday morning.

The McNairs have filed three claims with the state, giving notice they plan to sue — one on behalf of McNair’s estate and others on behalf of each parent. The claims all list damages “in excess of $10 million.”

Loh said at an Aug. 14 news conference that the school “accepts legal and moral responsibility for the mistakes that our training staff made.” Both Loh and Evans, who was promoted to athletic director 12 days after McNair’s death, appeared at that news conference to apologize to the McNair family and share preliminary findings of the Walters investigation. The school conceded at that time that McNair never received a heatstroke diagnosis during the team’s May 29 workout and didn’t receive proper treatment from school employees.

While the Walters report listed more than two dozen recommendations for Maryland to improve its protocols, the school already has instituted a variety of measures around the football program, including an increased number of doctors and trainers present at games and practices, the addition of cooling stations at practices, more recovery breaks and increased training for strength and conditioning coaches and athletic trainers.

“What was new to me,” Loh said of the report, “although we have protocols and policies, which are good, but it’s not enough that they are good. They have to be implemented. And there has to be training. And of course that’s where we are short, and we have to do a better job.”

The football team continues its season under interim coach Matt Canada with a home game Saturday against Minnesota, its first Big Ten contest of the year. The players have been honoring McNair throughout the young season, but Canada said this week that they haven’t allowed the external investigations to distract them from their mission.

“All we’re going to do is worry about the football game,” he said. “That’s our job. That’s our charge. And that’s what we’re going to do. I continue to say how proud I am of our players for focusing on their job, on going to school, on playing football and on grieving Jordan, and that’s what they’re worried about.”

Emily Giambalvo and Sarah Larimer contributed to this report.