Multiple 'Failures' Blamed in Disabled Child's Death
An independent investigator for the New York City schools issued a report last week that chronicles the complex circumstances surrounding the death early this year of an 8-year-old district student with multiple disabilities.
It also details school system failures that the report says eliminated the chance for the schools to intervene and possibly prevent the death.
Quentin Magee, who had severe cerebral palsy and a seizure disorder, was confined to a wheelchair and unable to speak as well as dress, feed, or clean himself, according to the report from Edward F. Stancik, who as the special commissioner of investigation has broad, independent authority to look into a wide range of matters in the city schools. (See Education Week, Sept. 29, 1993.)
Medical evidence concluded that Quentin died on Jan. 20, some time between 4 a.m. and 8:45 a.m., when he arrived by bus at Public School 396 in Brooklyn. The escort paid by the schools to ride with students on the bus cannot say whether the boy was alive or dead when she wheeled him onto the bus or during the ride to school that day because she did not think her job description included looking at or touching the children, the report says. Many students sleep on the long bus ride, which for Quentin began around 7:15.
According to the report, an autopsy found the cause of death was a "dangerously toxic level"of phenobarbital, a drug normally administered by Quentin's mother to control his seizures. Also contributing to his death were the seizure disorder itself, severe dehydration, and pneumonia.
Although the report does not answer the question of exactly when Quentin died and on whose watch, it does call on city school officials to take certain actions "to help prevent a future tragedy."
"This is a combination of failures at work here," Mr. Stancik said in an interview last week. "If the schools had done everything right, could they have saved him? Maybe yes, maybe no."
The report recommends that the schools: clarify their attendance-monitoring rules and improve school employee training, review school emergency procedures, speed the transfer of students' school and medical records, examine bus escorts' training, and seek disciplinary action for a nurse at Quentin's school and two senior district-level administrators--one in nursing, the other in specialeducation.
Though school staff members expressed concern about Quen-tin's emaciated appearance days before his death, the report concludes that a school nurse did not make enough effort to get in touch with his mother and doctor. School nurses decided not to perform cardiopulmonary resuscitation on Jan. 20 because they thought Quentin had been dead too long.
Quentin, who weighed 27 pounds when he died, had been absent for 37 consecutive days without the schools taking sufficient action, the report says. He had transferred from a school in Queens in last October but did not report to his new school in Brooklyn until January. Quen-tin's school did not receive his medical records until the day he died; educational records arrived three days later.
Schools Chancellor Ramon C. Cortines in a statement spelled out specific remedies he pledged to carry out to address each of the Mr. Stancik's recommendations, as well as reassigning the school nurse and sending the bus escort to retraining. He is also considering disciplinary action for the nurse and the two other employees recommended for sanction in Mr. Stancik's report.
"Parents, particularly, have the ultimate responsibility for children," Mr. Cortines said in his statement. "[But] that cannot be an excuse for the school system to shirk its responsibilities."
Mr. Stancik has turned over his findings to the Brooklyn district attorney's office and other public agencies. A spokeswoman for the prosecutor's office said the matter is open and under investigation.
Barry Washor, a lawyer for Quentin's mother, Margie Magee, said she maintains that the schools and other city agencies are responsible for her son's death.
According to Mr. Stancik, Ms. Magee invoked her Fifth Amendment right against self-incrimination when asked to cooperate with his inquiry.