Systemic Failures Found in School Policies and Procedures
Report Identifies 23 Recommendations for Rochester City School District to Prevent Future Tragedies
New York Attorney General Letitia James and State Education Department Commissioner MaryEllen Elia today announced the findings of a civil investigation into the facts and circumstances surrounding the tragic death of Trevyan Rowe, a 14-year-old student in the Rochester City School District (RCSD) who went missing on March 8, 2018. The investigation found that systemic failures in school policy and procedures existed at James P.B. Duffy School No. 12, the school Trevyan attended at the time of his death.
“The death of Trevyan Rowe was a tragedy,” said Attorney General Letitia James. “In an effort to ensure that this never happens again, we engaged in a thorough and thoughtful investigation of the policies and procedures in place at the Rochester City School District. It is clear that there were systemic failures at the school and I strongly urge the school district to implement the recommendations outlined in this report. We all have a responsibility to protect our children and we must work together to keep our children out of harm’s way.”
“The untimely death of Trevyan Rowe was a tragic loss that never should have occurred,” said Board of Regents Chancellor Betty A. Rosa. “The Board of Regents is committed to protecting the safety of all students because no parent should ever have to wonder if their child is safe at school. I thank the Attorney General and the State Education Department for their commitment to getting answers for the child’s family and for the recommendations in the report that will help prevent tragedies like Trevyan’s death from happening in the future.”
“The facts and circumstances surrounding Trevyan’s time at School 12 reveal an astounding lack of support from his school,” said State Education Department Commissioner MaryEllen Elia. “The investigation uncovered that Trevyan was failed at every level, from mental health and special education services to procedures to keep students safe at school. We must all learn from this horrific tragedy and recognize the gravity of our responsibility as educators to keep students safe. Every administrator and teacher across New York should read this report and ensure that every recommendation is implemented at their schools. We have a collective responsibility to New York’s children to do no less.”
During the course of the joint investigation, the Office of the Attorney General and NYSED staff reviewed hundreds of pages of policy documents and email correspondence, conducted site visits, and interviewed approximately 50 staff members and members of Trevyan’s family.
Investigation Findings
The tragic facts surrounding Trevyan’s death present a clear picture of a student facing serious mental health issues. While Trevyan received some special education and related services, the investigation found school safety and climate were compromised and policies at all levels were lacking and not consistently implemented. Investigators focused on four main areas: mental health services, including behavioral intervention; special education; attendance policies; and school safety considerations, including transportation. In each area, investigators found systemic failures and inadequacies.
Mental Health Services
This investigation has raised serious questions as to whether adequate responses were taken to refer and provide mental health services to address Trevyan’s mental health issues, specifically his suicidal ideation and depression. The investigation found that there were potentially inadequate and delayed services for mental health treatment; an overly narrow application of behavioral intervention plans; and a consistent lack of documentation when behavior crises occur.
Special Education Services
With respect to special education, the investigation revealed that there were initial delays in providing Trevyan with special education services upon his transfer to RCSD from a school in Texas; an emotional disturbance classification does not appear to have been adequately considered and documented at his Committee on Special Education (“CSE”) meetings; and misunderstandings of disability classifications in a chaotic school climate exacerbated the inability of RCSD to provide assistance to Trevyan through the special education process.
Attendance Policies
The investigation found that RCSD employed overly permissive procedures that allowed school staff to submit their attendance records days, weeks, and sometimes even months after the class in question, and to freely make changes to those records even after submission without meaningful oversight; RCSD had an inadequate and untimely system for parental notification of unexcused absences; and school administrators failed to play any active or meaningful role in ensuring that attendance was taken in a timely and accurate manner.
School Safety & Transportation
The investigation concluded that RCSD employed insufficient procedures to ensure the safety of students during arrival and dismissal. Chronic staff turnover and the use of substitutes within the District, combined with inadequate creation and retention of student records, resulted in students falling between the cracks; RCSD either did not employ a centralized policy for creating or maintaining safety or emergency plans for individual students such as Trevyan, or has not adequately trained its staff on that centralized policy; the general building safety plan at School 12 was not sufficiently known to or understood by staff; and a chaotic school environment existed.
The arrival and dismissal procedures in place at School 12 prior to Trevyan’s disappearance were inadequate to account for the whereabouts of the approximately 900 students milling about at the beginning and end of the school day. Just as it impacted the provision of special education and mental health services at School 12, frequent staff turnover also played a role in the lack of school safety procedures.
Report Recommendations
Trevyan's death does not appear to have been the result of any single event or single failure in school policy. Nevertheless, in an effort to ensure that this tragedy never occurs again, the report identifies policies and procedures that RCSD and other school districts should implement to help prevent and reduce the risk of tragedies from happening in the future.
The report notes that while school districts cannot prevent all emergencies, injuries, or tragedies from occurring, the implementation of the recommendations in the report will reduce the likelihood of events such as the tragic death of Trevyan Rowe. School districts, and those who are employed by them, are in the unique position of having custodial supervision over massive numbers of children every day across New York State. That position comes with tremendous responsibility. It is only by recognizing the gravity of that responsibility, and by relentlessly seeking to improve upon the safety measures put into place on a day-to-day basis at each individual school, that school districts can best seek to avoid another tragedy.
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