Investigation: 'Poorly designed and administered conditioning test' led to Garden City CC player's death

Braeden Bradforth died of heat stroke after running 36 50-yard sprints in a conditioning drill at Garden City Community College. (Photo by M. Anthony Nesmith/Icon Sportswire via Getty Images)

A “striking lack of leadership” at Garden City Community College helped lead to the death of defensive lineman Braeden Bradforth, according to an independent investigation.

Bradforth died of heat stroke on Aug. 1, 2018. He was declared dead approximately two hours after he participated in an extremely rigorous conditioning test administered by the Garden City football coaching staff that included 36 50-yard sprints.

“A cause of Braedon Bradforth’s death was a poorly designed and administered conditioning test for an unconditioned, non-acclimated student-athlete,” the report states.

Per the report, which you can view in full here, the 315-pound New Jersey native arrived on campus the day before the conditioning test. He was also not treated properly once signs emerged that he was suffering from heat distress.

“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 said.

An athletic trainer at the school told investigators that there was no emergency action plan in place for the football program and no plan at all for how to deal with players suffering heat-related distress.

Bradforth found in an alley after conditioning test

The report details numerous accounts of Bradforth’s struggles to complete the conditioning drill structured by head coach Jeff Sims.

“He told us that the 50-yard sprint within an eight-second time for each roughly equates to the exertion of a player during an average play,” the report states. “He told us that the sprints were broken down into four sets of nine repetitions with eight seconds between each repetition and two minutes of rest between each set.”

After the drill that concluded at 9:20 p.m., Bradforth was still struggling. He walked a different direction than where a team meeting was located. He was then found sitting down in an alley and dazed approximately 30 minutes after the conditioning practice concluded at 9:50 p.m.

Paramedics were not called for over 10 minutes from when Bradforth was first discovered by teammates. An assistant coach made a call to Sims and a call to the team’s head athletic trainer T.J. Horton before an ambulance was called as Bradforth was struggling in the alley.

It was reported by multiple sources that many student-athletes brought water to the alley and poured it on Braeden's head,” the report states. “We were told Braeden would stick out his tongue like he wanted water. There were players standing around but Mr. Horton does not recall who those players were. A couple other coaches showed up as well. We were told Braeden opened his eyes, but it was just a blank stare.”

Bradforth died 30 minutes after getting to ER

According to the report, the ambulance transporting Bradforth arrived at St. Catherine Hospital at 10:36 p.m. He was declared dead at 11:06 p.m. He was not treated for exertional heat stroke.

When Braeden Bradforth arrived at the hospital, he was in obvious medical distress (Glasgow Coma Scale of 4, identified as a code red) and was having difficulty breathing. The cause of his condition was not recognized by the attending physicians despite what [paramedic] Ms. Macias recorded in her narrative report. Braeden Bradforth was not assessed or treated for exertional heat stroke (“EHS”) at the hospital. Upon review of the post-mortem records, Dr. Holschen (FACEP Board-certified Emergency Medicine and Board-certified Sports Medicine Physician,Associate Professor, Department of Emergency Medicine Loyola University, Chicago, IL) stated EHS was not included in the differential diagnosis, possibly due to the lack of information provided of patient history, though this history was noted by the Paramedics in their assessment.

Sims — who you may recognize from watching Netflix’s “Last Chance U” — is no longer the coach at Garden City. He was hired as the coach at Missouri Southern University ahead of the 2019 season. He said in August at a media day ahead of his first season at Missouri Southern that “God has a plan” when he was asked about Bradforth’s death.

- - - - - - -

Nick Bromberg is a writer for Yahoo Sports

More from Yahoo Sports: