An independent inquiry into the heatstroke death of a Garden City Community College athlete concluded key factors in the fatality were the meager oversight of a football conditioning test and lack of overall leadership by the president and other college officials.

The report prepared by the Seattle law firm of Lewis Brisbois indicated existence of an effective medical response plan might have saved Braeden Bradforth, a 6-foot-4, 300-pound lineman from Neptune, N.J., who collapsed in August 2018 after struggling through the test, which required players to run three dozen 50-yard sprints. He took the training test after only two days in Kansas.

The independent analysis, which conflicted with conclusions of GCCC's internal examination, said there was little or no oversight over preparation and execution of the running test designed by head football coach Jeff Sims. The report said the test wasn't properly designed for unconditioned athletes not yet acclimated to the state's altitude and weather conditions.

The law firm's assessment also said there was a "striking lack of leadership" by GCCC President Herbert Swender, athletic director John Green, head athletic trainer TJ Horton and Sims. All four of these employees left the college amid the scandal.

"The lack of oversight set off a series of events that ended with the death of Braeden Bradforth," the new report said.

Involvement of the Seattle law firm came after GCCC's internal review found no wrongdoing by the college or its employees, a finding that a Bradforth family representative described as self-serving mockery of the teenager's death.

Bradforth's mother, the family's attorney and a New Jersey congressman demanded deeper examination of the incident and the JCCC's trustees relented about nine months after the death. The inquiry by the law firm cost about $200,000.

"I’m relieved, I’m sad, I’m angry, I’m exhausted," Joanne Atkins-Ingram, Bradford's mother, told the Asbury Park Press in New Jersey. "This has really been a long process to just come to know what we’ve known all along. But to actually see it in writing, for me it kind of validates this fight we started, and that we are doing the right thing."

Atkins-Ingram said findings of the 44-page independent report didn't alter the loss of her 19-year-old son to heatstroke but could lead to better safety protocols for other athletes.

U.S. Rep. Chris Smith, a New Jersey Republican, said the report summarizing the independent investigation was "utterly heartbreaking in that it confirms that Braeden’s death was 100% preventable."

"In a very special way, Joanne’s incredible love and devotion to Braeden inspired this report precisely so that no other parent has to suffer what she has, the loss of a child from something that could have been prevented," the congressman said. "Its findings must now serve as the basis for new protocols and protections going forward."

Smith introduced bipartisan legislation to establish a federal commission comprised of health professionals to develop recommendations on how to reduce exertional heatstroke in high school and college athletes.

"It is my hope that through the enactment of a Braeden’s Commission we will identify best practices for the prevention, recognition and treatment of exertional heatstroke," Smith said.

Sims, who left GCCC to become head football coach at Missouri Southern State University in Joplin, Mo., initially told reporters a physician theorized Bradforth died of a blood clotting disorder. Sims subsequently told KCUR death of the lineman was unfortunate but that "God has a plan."

GCCC issued a statement in conjunction with release of the new report declaring student safety and health "to be of the utmost importance on our campus" and that steps had been taken since 2018 to improve procedures across the campus. The college's sports medicine advisory team and the college's athletic director's office will be responsible for reviewing safety concerns regarding athletes at the school, the statement said.

The advisory group and athletics department will consider recommendations for altering "processes, procedures or facilities which would directly benefit the safety, health and security of GCCC student-athletes."