Samuel Brown Inquest: Day five

The Feb. 2018 death of a deaf/blind student prompted changes at W. Ross Macdonald School, a coroner’s jury heard Friday.

Emily Muli-Ricker highlighted some of the changes implemented by the school while testing at the Samuel Brown inquest on Friday. Samuel, 18, died Feb. 9, 2018 after being rushed to Brantford General Hospital from the provincially-run school.

Samuel died of pneumonia and the inquest, which began Aug. 28, has heard that he had trouble swallowing and, as a result was vulnerable to aspiration and pneumonia. Aspiration is the collection of food, liquids or other substances in the lungs which can lead to pneumonia.

A student at W. Ross Macdonald since he was four-years of age, Samuel stayed at South View Lodge at the school during the week and returned to his Brampton home on weekends during the school year.

Jurors heard how overnight staff found Samuel unresponsive when they tried to wake him at 6 a..m. Feb. 9 to change his diaper. Efforts to rouse him were unsuccessful and 911 was called.

Efforts by both Brantford firefighters and Brant-Brantford paramedic’s to save Samuel were unsuccessful.

Testifying on day five of the inquest, Muli-Ricker said one of the changes focuses on ill students.

“If a student is unwell, especially for those who can’t vocalize, how they’re feeling, the parents do understand that it is their responsibility to pick their son or daughter up and take them home,” Muli-Ricker said.

Muli-Ricker agreed with the suggestion from Roseanna Ansell-Vaughan that the change is to ‘err on the side of caution’ because parents know their kids best and the child’s physician is in the child’s home community. Ansell-Vaughan is legal counsel for the provincial Ministry of Education which operates W. Ross Macdonald School.

Although Samuel had been feeling unwell on Feb. 8 and at one point had a fever and the parents were notified. But school officials including nurses have tested that Samuel’s symptoms were such that he didn’t need to go home or be sent to the hospital.

Muli-Ricker also testified that the school’s physician is now part of the school’s admission committee. The physician reviews the student’s medical files to ensure everything that’s needed to keep the student safe is in place.

As well, the school gathers medical information from a medical form that is sent home annually to families and must be completed by a physician, Muli-Ricker said.

“When that form comes back it goes to student health services and it is review by our nurses and our doctor will also take a look at it,” Muli-Ricker said. “If our doctor has additional questions, he would call the family and he has, in the past, requested further information from the family to contact the treating physician to gather more information.”

Families are required to have the form filled out and returned to the school before the start of the school year, Muli-Ricker said

“We’re very diligent about that, we are not lenient,” Muli-Ricker said. “The medical has to be in place for the student to attend school.”

Muli-Ricker was asked by Ansell-Vaughan “is it fair to say that Samuel’s death inspired some reflection on the need for change?”

“Yes,” Muli-Ricker said.

Muli-Ricker also tested about an inspection conducted by officials from the Ministry of Children, Community and Social Services, earlier this year as a result of a regulatory change that came into effect on Jan. 1, 2023. The inspection reviewed every aspect of the school’s operation over a period of one week with some follow-up over a second week

It was a “very intensive review,” of some of policy, a site inspection, staff, student and nurse interviews, as well as an audit of the school’s medical policies and procedures. The team also did a full review of the school’s log books, Muli-Ricker said.

Muli-Ricker was also questioned by Saron Gebresellassi, counsel for the Brown family.

“What is your biggest take away from Samuel’s untimely death? Gebresellassi asked.

“My biggest takeaway is that we lost a student who we cared for very deeply at the school,” Muli-Ricker said. “My biggest takeaway is about Samuel and his family’s loss.”

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