The Navy failed to follow protocols, including implementing stringent social distancing guidelines and prematurely releasing dozens of sailors from quarantine, which ultimately led to a massive coronavirus outbreak onboard the USS Theodore Roosevelt last March, according to a newly released report by the Department of Defense.

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The report, released Monday, took aim at top brass on board the ship who "did not effectively implement mitigation measures for the majority of the crew." The negligence proved fatal to one sailor who died from COVID-19 while more than 1,200 others tested positive for the virus. 

Lapses in leadership included the decision to release between 900 to 1,000 sailors from quarantine ahead of the recommended two-week period after they had been exposed to the virus because the area in which they were being kept was becoming "crowded and unmanageable." 

This, while spaces on the ship designated for social gatherings and common areas, including the gym, remained open, further exacerbating the spread of COVID-19. The command investigation also determined that leadership continued to perform urinalysis tests for illegal substances, which should have been considered non-essential during the COVID-19 outbreak.

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The report revealed that findings from outbreaks onboard both the USS Theodore Roosevelt and the USS Kidd were used to strengthen the health and safety protocols for all Navy ships throughout the coronavirus pandemic. 

The Roosevelt's Capt. Brett Crozier was ousted from his position shortly after the outbreak on the San Diego-based ship that was docked in Guam at the time, after sounding the alarm about the need to offload sailors from the ship due to the COVID-19 outbreak.

Crozier was fired by Secretary of the Navy Thomas Modly after Crozier wrote a letter warning that the outbreak had created a dire situation on the carrier and urged that the nearly 5,000 sailors on board be evacuated. The letter was later leaked to the press. 

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Modly was later forced to resign from his post after berating Crozier in an address to the crew aboard the ship, the audio of which was also leaked to the media.