The Los Angeles-based firm, Lewis Brisbois LLP, which delivered its withering critique in a report made public Thursday by Bradforth’s mother, also found that there had been “little to no oversight” of the conditioning drill designed and run by Garden City Community College’s then-head coach — 36 wind sprints of 50 yards each with little rest in between — that, combined with the hot, humid weather, Bradforth’s health, and other factors, led to the young scholar-athlete’s death on Aug. 1, 2018.

Futhermore, the report found, team coaches and trainers, EMTs and even emergency room staff at St. Catherine Hospital in Garden City, Kansas, all failed to recognize and treat Bradforth’s symptoms of heat stroke, which need not be fatal when spotted in time and treated by immersing the victim in a tub of cold water.

“No Garden City Community College athletic training or coaching staff member and no Emergency Medical Service or Emergency Department personnel identified or treated Braeden Bradforth’s escalating symptoms of the exertional heat stroke that caused his death,” the report stated.

The 6-foot-3, 300-lb. lineman had been a standout at Neptune High School, described as a gentle giant, well liked by teammates and classmates who deeply mourned his death.

The report said Bradforth, who suffered from asthma, arrived on the GCCC campus out of shape and, at 315 pounds, overweight, and that special recommendations by his New Jersey doctor written on his athletic waiver were not noticed by his coaches in Kansas. In addition, the report noted, the GCCC campus is much higher above sea level than Bradforth’s native New Jersey, with 9% less oxygen in the air.

After an evening conditioning session — the team’s second practice of the day — in temperatures above 80 degrees with high humidity, the report said Bradforth was allowed to simply skip a team meeting and wander away, alone on an unfamiliar campus, after having shown signs of fatigue during the session.

Unable to enter his dorm, he sat on the ground against a brick wall that was still warm from the day’s heat, before being found by teammates, the report and past accounts said. The players then informed an assistant coach, who contacted the team trainer, who then contacted the head coach before calling an ambulance. In all, 73 minutes passed between the time Bradforth left the football stadium, at 9:20 p.m., and the time he arrived at the hospital, 10:33 p.m. He was pronounced dead at 11:06 p.m.

“Braeden Bradforth’s core temperature was never assessed and no effective method of cooling him was ever implemented by anyone,” the report states. “A contributing cause of death was the failure to timely identify and treat Braeden Bradforth’s exertional heat illness.”

“When treatment is administered within 30 minutes of heat illness and includes identification of elevated core temperature — greater than 104 degrees F — coupled with rapid cooling of the full body via cold water immersion of 55 degrees F, exertional heat stroke death can be averted,” the report states.

The Oct. 28 report, prepared by Louis Brisbois partner Randy Aliment in conjunction with sports medicine consultant Rod Walters, was provided to GCCC after the college’s board of trustees voted in May to authorize the firm to conduct an independent investigation of Bradforth’s death. The GCCC Board of Trustees voted Tuesday night to release the report to Bradforth’s mother, Joanne Atkins-Ingram, who through her lawyer provided a copy to NJ Advance Media.

In an interview Tuesday, Atkins-Ingram said the report supported what she has been saying since her son died.

“Now, with the release of this report the whole world knows what we knew all along: that they did not keep my son safe,” Atkins-Ingram said.

Her lawyer, Jill Greene, applauded the investigation and its report as “incredibly thorough and detailed.”

“This report shows a blatant disregard for this child, for his safety, and a lot of adults made some horrible decisions,” Greene said. “If they had protocols in place, training, perhaps Braeden would still be alive.”

After the GCCC board’s Tuesday meeting, the chairman, Dr. Blake Wasinger, issued a statement saying the intention of releasing the report to Atkins-Ingram was to, “respectfully communicate all of the information that GCCC has about Braeden’s unfortunate passing directly to his family and loved ones.”

The board had authorized the investigation after Bradforth’s congressman, Rep. Chris Smith (R-NJ), led New Jersey’s entire House delegation in a letter demanding the probe, sent last March to GCCC’s interim president, Ryan Ruda, who had been named to the post following Bradforth’s death.

Smith, who has introduced federal legislation to protect scholar-athletes, issued a statement this week saying the college was doing the right thing, and that Atkins-Ingram, “is entitled to every detail in the report.”

GCCC also issued a statement this week reiterating steps the college had taken following Bradforth’s death to better safeguard all of its student-athletes.

They include the formation of a “sports medicine advisory team” made up of team doctors, trainers, and other staff; first aid training for coaches; the hiring of a new trainer and conditioning coach; a policy for recognizing and treating heat-related illnesses and the purchase of ice-bath tubs; hiring an addition campus police officer to ensure 24/7 staffing; and a policy calling for the review of health physicals for all student-athletes prior to any practice or competition.

Jeff Sims, Bradforth’s head coach for his one day as a college football player, has since left Garden City. After last season, when he lead GCCC to an appearance in the 2018 junior college national championship game, Sims moved into the head coaching job at Missouri Southern State University, a four-year college.

Lawyers for Atkins-Ingram in New Jersey and Kansas filed notices soon after Bradforth’s death advising GCCC that she may sue the college. No suit has been filed, but she has until August 2020, under Kansas’ two-year statute of limitations, said Greene.

Sims told NJ Advance Media earlier this year that he had been advised not to talk about Bradforth’s death due to the potential for litigation. And neither Sims nor Missouri Southern Athletic Director Jared Bruggeman responded to requests for comment on Thursday.

Atkins-Ingram said the reforms promised by GCCC were good ones, if they are actually implemented effectively in order to avoid similar fates for other sons and daughters. Meanwhile, the pain of her son’s death has not diminished in the 16 months since then.

“No it hasn’t,” Atkins-Ingram said. “Just for the simple fact that every day I have to relive what happed to him, because it is still happening to children across the nation.”

“It will never end for me,” she said.

Steve Strunsky may be reached at sstrunsky@njadvancemedia.com