COLUMBIA, Mo. -- University of Missouri officials failed to follow policies for medical emergencies when freshman linebacker Aaron O'Neal collapsed and later died during a 2005 summer workout, according to legal documents obtained by The Associated Press.
The university agreed in March to pay $2 million to O'Neal's parents to settle a lawsuit. But the sworn testimony of several key university employees who supervised the workout show a series of missteps.
Athletic department employees also showed an unfamiliarity with potential exercise-induced complications caused by sickle cell trait despite NCAA, school and professional association requirements. O'Neal carried the inherited blood disorder that affects an estimated 8 percent to 10 percent of African-Americans.
The school's strength and conditioning director, who supervised the workout, testified he lacked the necessary professional certification to be hired.
And the athletic department's sports medicine director rejected requests from concerned colleagues and players to examine the 19-year-old reserve linebacker even after he exhibited signs of medical distress, legal documents show.
Deposition transcripts were provided to the AP by a person close to the lawsuit who requested anonymity because of the case's sensitive nature.
O'Neal's death has loomed large over a Missouri football program that under coach Gary Pinkel vaulted into the national championship chase in recent seasons. The school kept his empty locker intact. Players and coaches chanted his name before and after games and cited his memory as inspiration.
But the July 12, 2005 death also raised questions about player safety and a school's responsibility to monitor its athletes' pre-existing medical conditions. The debate isn't limited to Missouri: In March 2008, Central Florida wide receiver Ereck Plancher -- like O'Neal a 19-year-old redshirt freshman with sickle cell trait -- died in an offseason conditioning session. His parents have also sued the school.
Missouri agreed in March to pay O'Neal's parents, settling a 3½-year-old suit before trial. The settlement includes language that attributes no fault to Pinkel, athletic director Mike Alden, sports medicine director Rex Sharp, strength and conditioning director Pat Ivey and 10 other current or past university employees.
Sharp, Ivey and Alden did not reply to AP interview requests.
"People here feel that this book is closed," university spokesman Chad Moller said. "The most important issue for all of us was the tragic loss of Aaron."
O'Neal, a 6-foot-3, 220-pound redshirt freshman, began to struggle about 45 minutes into the hourlong workout. Players wore shorts, T-shirts and cleats but no pads. He completed the first four of six agility drills without problem, but began to falter during the fifth drill, which he was told to repeat.
By the final drill, O'Neal complained of blurry vision. At one point, he sunk to his hands and knees. When a 300-pound offensive lineman completed the drill first, O'Neal was ordered to repeat it three more times.
"I'm trying," he said, when told to jog and not walk back into line. "I'm not weak. I just can't go on."
O'Neal eventually slumped to the ground and was helped off the field by a teammate to a nearby locker room.
In a deposition last August, Ivey testified that he expected Sharp to examine O'Neal at that point. But Sharp declined -- and rebuked wide receiver Brad Ekwereku for "babying" O'Neal by squirting water on the player's head.
Sharp later testified in his own deposition that he did not assist O'Neal "because he thought he was a recovering athlete and I've seen that in my years of experience many times."
Ivey said he turned his attention to dealing with a small group of reporters who saw the workout. Testimony shows that Ivey and others supervising the session were worried the performance by O'Neal and several other players would create negative publicity.
Once in the locker room, O'Neal's condition worsened. Two strength coaches left the area before strength coach Josh Stoner decided to flag down a campus landscaping truck, which then carried an unconscious O'Neal to the team offices rather than a hospital one-quarter mile away.
The athletic department's Emergency Action Plan advises employees to call 911 "as soon as the situation is deemed an emergency ... or is life-threatening."
University employees also offered conflicting accounts about the frantic moments after O'Neal was taken from the stadium but before he made it to the hospital.
Sharp said once in his office he saw O'Neal in the truck. He testified that he hesitated to call 911 because Stoner came inside and said "I need help," but didn't mention O'Neal by name. Stoner testified he immediately identified O'Neal as the player needing help.
And once Sharp went outside to the truck, he left his cell phone behind, further delaying the call for help. Another trainer inside the building then called 911. O'Neal died soon after he arrived at University Hospital, about 90 minutes after the workout ended.
O'Neal's official cause of death, according to the former Boone County medical examiner, was viral meningitis. But that was later discredited, and several outside experts cited sickle cell trait.
At least 13 college football players with the inherited blood disorder have died from exercise-induced trauma, according to the National Athletic Trainers Association. In 2007, the group issued a report urging colleges to screen for sickle cell trait. Missouri tests its athletes only at their request.
Missouri's sports medicine handbook stipulates that Sharp and his assistants be familiar with the medical literature concerning sickle cell trait. In his deposition, Sharp said he was not aware of the requirement.
Sharp, the school's head athletic trainer since 2006, was named assistant athletic director for sports medicine in 2008. Ivey, a former Missouri defensive end who played for three NFL teams, was appointed assistant athletic director for athletic performance in 2007.