GARDEN CITY, Kan. -- A report into the death of a Kansas community college football player strikes down hard on the coaching staff, school and medical personnel.
It notes that several things contributed to the 19-year-old Braedon Bradforth's death, starting with a lack of leadership at Garden City Community College.
"He was a great, great young man," Braeden's dad Sean Bradforth said, "just trying to live his dream of getting into the NFL."
That dream was cut short after his son died of a heat stroke following his first practice at the Kansas community college.
"It's a huge hole," Bradforth said.
More than a year later, his family is still feeling the loss.
"The last time I saw my son he was getting on a plane to never return," Braeden's mom JoAnne Atkins-Ingram said.
Braeden's parents said the independent investigation into their son's death confirmed their worst fears.
"It's sad that my son literally died pleasing a coach," Atkins-Ingram said.
The football player from New Jersey collapsed and died after two workouts in August 2018. An autopsy found he died of heat stroke.
"I think there were multiple events, multiple times in the timeline in which someone could've stepped, done the right thing and we wouldn't be here today and Braeden would be alive," said Chris Dove, an attorney representing Braeden's mom.
When he was found on the ground outside the dorm, first the head coach was called, then the athletic trainer and finally 911. The report says that was 16 minutes later -- and about 40 minutes after practice.
"Pulse is running about 160 unknown history on the patient of anything," an emergency responder said the EMS call.
From the time Braeden left the stadium to his arrival at the hospital, 73 minutes had passed, according to the report.
"I think there's concerns about once the treatment was there and what was done at the hospital," said Shawn Foster, an attorney representing Braeden's dad. "There's some issues with that for us."
The report says Braeden's temperature was never documented by medical staff. The key piece of information to make the diagnosis -- missing.
"This is totally preventable," Bradforth said. "Recognize the signs of heat stroke."
The review also finds school staff failed to asses athletes prior to the conditioning test.
"You had trainers, athletic trainers who didn't recognize the signs of heat illness?" Atkins-Ingram said. "Really?"
His parents are concerned about the lack of hydration at practice and the lack of training in coaches.
"We had trusted our kids to be in the hands of adults," Bradforth said. "We send our kids to school one way to be returned to us in a box."
"Although Braeden will never come back," Atkins-Ingram said, "this could possibly save someone else."
No lawsuits have been filed in the case.
Foster said he talked with the school's attorney Thursday afternoon, but that the internal investigation was just a starting point, not a conclusion.