Braeden Bradforth: An Avoidable Tragedy and a 'Striking Lack of Leadership'

Report of Independent Investigation

• "There was little to no oversight of the preparation for and execution of the August 1, 2018 conditioning test designed and run by Coach Sims."

• "it became evident there was a failure to properly assess student-athletes prior to the August 1 conditioning test described by one witness as an intense cardio workout. Little attention was given to assess Braeden Bradforth’s level of fitness. No consideration was given to the level of his acclimatization to weather or to the altitude in Garden City"
• "We found a lack of preparation to ensure practice safety, including no planning or training of coaches or the athletic training staff on a venue-specific emergency action plan. There was no plan to address a student-athlete presenting with signs of exertional heat illness."
• "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."
• "Mr. Horton did not record venue specific measurements indicative of weather conditions on the field."
• "When Braeden Bradforth arrived in Garden City, his physical condition should have been evident to the athletic trainers and coaches. He was overweight at 315 lbs., out of shape, and should not have run the conditioning test as designed and implemented"
• "Once Braeden Bradforth began to drift into medical distress, there was failure to plan for appropriate care."
• "Braeden Bradforth’s core temperature was never assessed and no effective method of cooling him was ever implemented by anyone"
• "Braeden had received a full clearance from his cardiologist, Dr. Mitchell Alpert,22 to play football."
• "Braeden was medically cleared for participation in the Garden City Community College football program without restrictions by his pediatrician, Dr. Helen Atlienza."
• "TJ Horton told us that he and his assistant look at every problem identified in the [PPE]. He told us that school policy is to review all physicals before practice begins. Mr. Horton admitted, however, that the athletic training staff did not review the findings in every player’s PPE before the August 1, 2018 conditioning drill."
• "Coach Holman said Braeden mentioned he was concerned about his ability to successfully complete the conditioning test but volunteered Braeden had a great deal of pride and this would cause Braeden to push himself."
• "the coaching staff was not aware that details recorded in a PPE were not reviewed by the athletic training staff before players took the conditioning test. No accommodation for Braeden was made by the coaches in connection with the conditioning test."
• "there was no campus-wide emergency action plan (“EAP”) and no athletic training staff EAP was taught to the coaching staff. She also said that there was no athletic training staff policy or coaching staff policy that would require that a player in distress must drink water, must get into an ice tub or must seek shade."
• "Coach Sims told us that the conditioning test is designed to assess the athlete’s level of condition"
• Coach Sims stated "the defensive line was less than 10 feet in front of him" and "that he did not recall whether Braeden struggled during the sprints, he admitted that he told Braeden, during the time he was running, that I didn’t give you shoes to run slow."
• "Nearly all persons we interviewed that witnessed Braeden run during the conditioning test acknowledged that Braeden had some issue with the run. Some, like Coach Sims, described the issue as a problem with effort; a failure to run through the goal line. Others described physical inability to complete the run in the required time which caused him to bend over, like he was going to pass out, and the like. Whatever the issue was, nobody disputed the fact that there was a confrontation initiated by Coach Sims and directed at Braeden. Clearly there was some difficulty with Braeden’s ability to complete 36 – 50 yard sprints within eight seconds for each."
• "no athletic trainer went to the “Winners Meeting” [post-practice meeting] to see if any player was medically in trouble. Following the conditioning drill, the athletic trainers were engaged in breaking down the equipment before going home."
• Emergency services "provided no heat illness specific treatment for Braeden at the alley or on the way to the hospital"
• "EHS [Exertional Heat Stroke] 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."

It is YOUR CHILD out there. Think about that carefully.

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