GARDEN CITY, Kan. (KSNW) – An independent investigation has been released in the death of a Garden City Community College football player from New Jersey.

On August 1, 2018, 19-year-old Braeden Bradforth, a 315-pound defensive lineman for the Garden City Community College, collapsed and died after a pair of workouts on the first day of organized practice. An autopsy showed exertional heat stroke was the cause.

A timeline included in the report detailed the 73 minutes that passed from the moment Bradforth left the stadium to his arrival at the hospital.

“An effective plan likely would have rescued him from what turned out to be his untimely death,” the report said. “The response time and significant delays between multiple opportunities for effective treatment were a cause of death.”

Assistant football coach Caleb Young told officials Bradforth was “making a stressful moan” when he arrived on the scene, but rather than immediately dial 911 he called the head coach Jeff Sims “for instruction to see how we wanted to handle the situation.”

Young wrote in one email to university officials that while he was on the phone with Sims, players were filling jugs and bottles from drinking fountains to pour water on Bradforth and attempt to make him drink.

The report listed a “a striking lack of leadership” and “lack of oversight” set off a series of events that ended with Bradforth’s death: “a poorly designed and administered conditioning test for an unconditioned, non-acclimated student-athlete, and failure of paramedics and hospital emergency room staff at St. Catherine Hospital to recognize and treat an obvious case of exertional heat illness.”

After Braeden’s death, the Garden City Community College Board of Turstees hired the investigators to conduct an independent review of the case. The team was asked to identify facts that caused or contributed to Braeden’s death. Information was obtained from the college, Garden City; Finney County; attending medical clinics and hospital in Garden City and Neptune, N.J.; and the Bradforth family.

“Now, the world will know exactly what happened to my son, and it was completely preventable, but I feel like they had no regard for my son’s life,” said Joanne Atkins-Ingram, Bradforth’s mother.

No lawsuits have been filed in the case, but Joanne’s Lawyer said it may change, as they leave it up to their Kansas attorney.

“We’re pretty much putting it into his hands as to whether or not he is going to proceed with litigation, but I think this report pretty much supports that decision,” said lawyer Jill Elaine Greene.

Joanne hopes the report will lead to changes, so something like this never happens again.

“I lost my son, but I don’t ever, ever want anyone else to go through this pain because this was preventable,” she said