An independent investigation has pinned the death last year of a 19-year-old Jersey Shore athlete on a "striking lack of leadership" at a Kansas college.

Braeden Bradforth, a Neptune High School graduate, died Aug. 1, 2018, from heat stroke after attending a high-intensity workout at Garden City Community College.

A probe commissioned by the college's Board of Trustees in May concluded last month that Bradforth's death could have been prevented if the school had bothered to properly assess the physical condition of student athletes and if the school had developed an emergency response plan for athletes who suffer heat illness.

The 48-page report submitted by sports medicine consultant Rod Walters and Randy J. Aliment of Los Angeles-based law firm Lewis Brisbois, found a "striking lack of leadership by President Herbert Swender, Athletic Director John Green, Head Football Coach Jeff Sims, and Head Athletic Trainer TJ Horton, during the weeks and months leading up to August 1, 2018.

"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. This lack of oversight set off a series of events that ended with the death of Braeden Bradforth."

U.S. Rep. Chris Smith, R-N.J. 4th District, on Thursday called the report "heartbreaking." He and Bradforth's mother, Joanne Atkins-Ingram, have pushed for a federal commission that would develop ways for high schools and colleges to reduce exertional heat stroke​ in athletes.

“We must do all we can to identify the signs and treat this life-threatening medical emergency before it takes another athlete,” Smith said in written statement. “Since Braeden’s death 15 months ago, more athletes have been stricken with exertional heat stroke—and many before Braeden, including the June 2018 death of Jordan McNair, a University of Maryland football player.”

The report noted that while Bradforth's doctor had him "cleared without restrictions" for participation in athletics, the doctor noted that he needed to diet and exercise. The report said that college officials did not realize this note on his medical forms until after his death.

Nevertheless, the report says that Bradforth was an overweight 315 pounds, which "should have been evident to the athletic trainers and coaches."

The report also noted that the conditioning test was "poorly designed and administered" and did not take into account that the altitude in Garden City resulted in 9% less oxygen than Bradforth was used to at the Jersey Shore.

The report said that after Bradforth became ill, he "should not have been permitted to wander off alone on an unfamiliar campus."

Bradforth ended up trying to get to his dorm room "through a narrow and hot alley with limited airflow. When he could not enter the building through a locked door, he sat down and rested his head against a brick wall that likely continued to radiate heat."

He was found by teammates almost a half hour later — the amount of time that it takes to administer an effective treatment for exertional heat stroke, the report notes.

"From that moment forward, we noted poor implementation of an emergency response," the report says. "Garden City Community College had no training in place for this situation and no Emergency Action Plan. A contributing cause of death was the failure to have and implement an effective Emergency Action Plan."

In a written statement released on Tuesday, the college said it "values student health and safety" and noted actions the school has taken to improve its athletics practices, which included the following:

— Convening a Sports Medicine Advisory Team
— Hiring a full-time athletic trainer
— Requiring all coaching staff to complete first aid and CPR training annually
— Hiring a strength and conditioning coach
— Implementing immediate follow-up wellness checks with players who leave practice
— Developing policy to recognize and treat heat-related illness
— Modified practice times to account for heat
— Purchased ice tubs
— Implemented policy for thoroughly reviewing health physicals

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