An independent investigation examining the events that led to the death of football player Jordan McNair has determined that Maryland is at fault for failure to follow proper procedures.

The investigation, headed by Dr. Rod Walters, was completed and a press conference was held on Friday evening to announce the findings.

McNair collapsed during an organized team workout in May. He was diagnosed with heat stroke and died a week later.

A timeline was established during the investigation, noting major gaps between actions by the training staff.

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Thirty-four minutes past from the time McNair first experienced cramps to when he was taken off the field. It was one hour and seven minutes from the time he first experienced symptoms to when 911 was called and 99 minutes total until he left in an ambulance.

“There was a failure to identify symptoms and aggressively treat it,” Walters said in the press conference. “There was a delay in identifying the severity of symptoms.”

Walters also said that a best practice is to identify heat stroke and immerse the subject into a cold tub within 30 minutes of symptoms. He did not state whether those actions would’ve saved McNair’s life.

According to Walters, Maryland’s head athletic trainer, Wes Anderson, told investigators that McNair was not placed into a cold tub because of his size. Due to “Convulsive movements” McNair  was exhibiting, the training staff feared he may drown.

Cold towels and ice packs were used in an attempt to cool down McNair.

Walters also said that head coach D.J. Durkin was present at the organized workout, but did not participate in giving any care to McNair.

This was the first of two investigations to conclude for Maryland. Another ongoing investigation is examining an alleged “toxic culture” created under Durkin.

Durkin remains on paid administrative leave as the investigation continues.

Findings from the investigation into Maryland policies and procedures will be made available to the public.