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A young Manly Sea Eagles player died after taking part in a training session that was "more likely than not inappropriate", the magistrate who oversaw the inquest into the death says.
Keith Titmuss had taken part in a two-hour training session on November 23, 2020, when he became agitated and suffered several seizures.
He was taken to Royal North Shore Hospital, where he suffered a cardiac arrest.
An inquest earlier this year heard paramedics checked the 20-year-old's body temperature three times after he collapsed at training because they could not believe it had reached almost 42 degrees Celsius.
Mr Titmuss died of exertional heat stroke (EHS), the inquest found.
Deputy State Coroner Derek Lee today concluded the training session was "more likely than not inappropriate", given a range of factors including the hot and humid conditions during the indoor part of the session.
The inquest heard Mr Titmuss was at the lowest level of fitness comparatively in the player group.
Since at least late 2023, when Manly became aware of the correlation between EHS and the death of Mr Titmuss, the club and NRL have taken steps to improve player welfare.
A review of the NRL heat policy is also underway.
Magistrate Lee recommended that review consider several changes, including mandating a 14-day period of controlled training load acclimatisation following an off-season or extended break for players.
It should also consider screening and classifying players for EHS risks, the mandatory reporting of every EHS incident and identifying what cooling strategies should be implemented for outdoor and indoor training sessions, he said.
Magistrate Lee also recommended Manly make improvements to its record-keeping policies.
Titmuss remembered as a family man
Mr Titmuss was remembered by family and friends as kind, gentle, respectful and unassuming.
He was known to be "very much a family man" and a larrikin.
Outside the court, his mother Lafo Titmuss said understanding the cause of death had been years in the making as she thanked the deputy state coroner for his work.
She said she hoped the recommendations would lead to an emphasis on the NRL's heat policy and an understanding that the impact of heat should not be underestimated.
"Keith loved life and he loved rugby league. He just did the work," she said.
"He had such belief in himself and he was so looking forward to making a mark in the rugby league world."
'This can't happen again'
Manly boss Tony Mestrov said it had been an incredibly difficult period for everyone, but particularly the family.
He said the club intends to take up the recommendations.
"This can't happen again in the game, we all understand that," he said.
"And we don't want it to happen under Manly's watch ever again."
In a statement, an NRL spokesperson said the league acknowledged the findings.
"We express our deepest condolences to Keith's family and friends," the statement said.
"The NRL has already commenced work on the coroner's recommendations and will commission experts to further review our policies and update them to ensure best practice."