University of Maryland President Wallace Loh vowed to follow all of the recommendations of an independent report on the death of Terps offensive lineman Jordan McNair that faulted athletics training staff for failing to quickly recognize or effectively treat his heatstroke symptoms.

After Dr. Rod Walters, president of sports medicine consulting firm Walters Inc., presented his findings Friday to the University System of Maryland Board of Regents, Loh told the campus community in an email that the athletic department is committed to decisive action on student-athletes’ safety and had already made a series of changes, some of which Walters called for in his report.

New steps include implementing mandatory hydration testing and emphasizing longer and more frequent recovery breaks; installing technology to monitor for potential heat-related illness based on temperature, humidity and other factors at every venue; and expanding staff training on using the emergency action plan.Jordan McNair

The report noted that the university already places its licensed athletic trainers under the supervision of physicians employed outside the athletic department. More of both now attend football practices and games, Loh said.

Maryland Athletics first contacted Walters’ firm on July 13, the day the 19-year-old died, to request a review of the incident as well as of the policies in place to ensure athletes’ health and welfare.

“I said to him, ‘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,’” Loh said following a news conference at Towson University, where the regents had met

The report was shared the night before with the McNair family and released with their approval, regents Chair James T. Brady said. Loh and Athletic Director Damon Evans have apologized to McNair’s parents for the mistakes made in their son’s treatment.

It provided a detailed timeline of the events of May 29 that led to McNair’s death from exertional heatstroke. Walters reported that McNair, a 341-pound redshirt freshman, ran seven of ten 110-yard sprints in the team workout on the turf practice field, then started showing signs of exhaustion. With teammates physically supporting him, he struggled through the final run. Trainers reported that afterward, he complained of back pain and fatigue, and was sweating profusely and hyperventilating, all signs of heat-related illness.

But 34 minutes passed between the times he first showed distress and was taken off the field, and it was more than an hour before 911 was called, according to the report. Trainers also never measured his temperature, saying his skin didn’t feel hot.

In the Gossett Team House, they gave him cold towels and water and had him walk around. McNair then began yelling at them—a change in mental status that Walters said was a clear indication of heatstroke—and a trainer called the team physician, who had the staff call 911. Although cold-water immersion is the most effective treatment, Walter said, trainers put ice packs on him rather than move him into an available large cold whirlpool bath. “Due to the concern of size of the student-athlete and the smaller stature of the athletic trainers providing care, there was fear of drowning,” Walters reported hearing from the head football athletic trainer.

“The literature tells us that if we identify heatstroke within 30 minutes of a heatstroke, and do cold-water immersion and we identify the elevated core temperature, that is best practices,” Walters said at the news conference. “That didn’t happen that day, and that’s all I can say.”

The report also cited last-minute changes in practice venue from Maryland Stadium to Cole Field House to the outdoor artificial field, which resulted in staff rushing to get emergency equipment to the site. In addition, construction in the area “added to the confusion,” as an ambulance was sent to the upper parking lot instead of the field level, and no one was immediately sent to meet the paramedics.

Walters provided a list of preliminary insights and recommendations in July as the football season neared, leading to the first round of new procedures and staff training to protect student-athletes’ safety. These included increasing the number of doctors and trainers present at football practices and games and expanding training for the staff on the implementation of the emergency action plan.

Following media reports in August of a culture of bullying and intimidation in the football program, head coach D.J. Durkin and members of the training staff were placed on administrative leave, and the strength and conditioning coach, Rick Court, resigned.

The university created a commission of legal and sports experts to investigate the allegations about the football program, and the regents are now overseeing it. That investigation is ongoing.

Maryland has already put into effect many of Walters’ 20 recommendations, a number of which focus on the emergency action plan and processes for combatting heat-related risks during practice and conditioning.

Others that Maryland Athletics will follow are to ensure appropriate cold-water immersion devices are available at every practice or conditioning session; develop and share easy-to-understand, venue-specific emergency action plans with all relevant administrators and staff, and to post and adjust them as needed; to develop other heat-related policies and protocols; and to establish an athletic medicine review board to review procedures regarding student-athletes’ health and welfare.

“President Loh and I are wholeheartedly committed to the safety and well-being of our students,” Evans, the athletic director, said in an email to the Terrapin community and parents on Friday night. “We will do everything in our power to prevent a tragedy like this from ever happening again.”

Walters said he had interviewed all of the football coaches and trainers on staff and four student-athletes in preparing his findings. The report does not address Durkin’s role, he said, because Durkin was not involved in treating McNair, and his investigation focused on protocols and procedures, and how they were followed.

When asked if the university had been negligent, Brady said the board was still gathering information and he was “not prepared to make that call.”

“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,” he said.

In comments to the media, Loh said that any personnel decisions would be addressed after the second investigation is completed.

The football team, meanwhile, has dedicated its season to McNair, including creating a football scholarship in his name, wearing helmet stickers with his number, 79, encasing his locker in glass and naming the new Cole offensive line room for him. Moments of silence were held before the Texas and Temple games. No players will wear his number until after what would have been his graduating year, 2022.

Read the report at the University System of Maryland website.