Samuel Brown Inquest: Day Three

Support staff at the W. Ross Macdonald school knew Samuel Brown had a history of congestion but didn’t know he had a history of pneumonia, a coroner’s jury heard Wednesday.

“I suppose if we had more medical information about Samuel that would have been helpful, a little bit more of (his medical) history and what to watch for,” Dianne Harris said in response to questions from Maria Stevens, counsel for the inquest.

Harris was the team lead on duty when Samuel, a student staying in student lodging at the provincially run school, was found unresponsive when staff tried to rouse him at 6 am on Feb. 9, 2018. Samuel was rushed to Brantford General Hospital by Brant-Brantford paramedics and was declared dead at the hospital.

Samuel, a deaf-blind student at W. Ross Macdonald, was 18 when he died of pneumonia.

Although Samuel lived at the school during the week, he returned to the Brampton home of his parents – Gladstone and Andrea Brown – on weekends.

Jurors were told during earlier testimony that Samuel had difficulty swallowing and was prone to aspiration, the accidental lodging of food and liquids in his lungs. Aspiration can lead to pneumonia.

A coroner’s inquest into Samuel’s death began Monday and continued Wednesday with testimony from Harris.

As the team lead, Harris was overseeing the care of students staying in students lodging at W. Ross Macdonald on the nights of Feb. 8 and Feb. 9, 2018.

Harris started work at 10:30 pm on Feb. 8 and, upon arrival, reviewed an email from student health services telling her that Samuel had been unwell. The email said Samuel had been given Tylenol at 9 pm because he had a fever.

The email told Harris to check on Samuel at 1 am and to take his temperature.

Harris told jurors that she and two staff members – Stephanie Rymon-Lipinski and Tamara Cudek – used an ear thermometer to check Samuel’s temperature at 1 am as instructed.

At that time, Samuel’s temperature was within the normal range and he appeared comfortable. Although Samuel was experiencing some congestion, Harris said that wasn’t unusual for him.

Harris said she and others believed Samuel had a cold and, given that his temperature was normal, she thought he just needed to sleep.

In earlier testimony, jurors were told that Rymon-Lipinski and Cudek became alarmed when they couldn’t get Samuel to wake up at 6 am on Feb. 9. They had gone into Samuel’s room to wake him up and change his diaper.

Harris said she was in another building when she received word that staff were having problems rousing Samuel.

Harris rushed over to the Southview Lodge on the school campus to Samuel’s room.

“Samuel was not responding. He was not waking up,” Harris said.

Harris said that when she couldn’t get a response from him, she knew they had to get help because something serious was happening.

A 911 call was made, and Brantford firefighters and Brant-Brantford paramedics were sent to the scene.

During testimony, Harris said that she wasn’t aware that Samuel had a history of pneumonia, which had resulted in hospitalization in the past.

Harris said there have been changes at the school since 2018. Students who are unwell either go home or to a hospital, Harris said.

Harris also answered questions from Saron Gebresellassi, a Toronto lawyer who is representing the Brown family at the inquest.

“We all make mistakes Ms. Harris. Would you agree with me that perhaps mistakes were made?” Gebresellassi asked.

“No, I won’t agree because I don’t know if this could have been avoided,” Harris said. “I don’t know if this would have been picked up that this was going to happen.”

Gebresellassi asked “ you would have done nothing differently, Miss Harris?”

Harris said “I don’t think there’s anything I could have done differently because I did everything in my power and everything that I thought was the right thing to do at the time based on how Samuel presented when I did my check.”

Gebresellassi then asked what she thinks could be done to prevent a death like Samuel’s from happening again.

Harris cited the change in policy that requires parents or a guardian to pick up ill students and take them home.

“If we don’t have any ill students at our school, then that would prevent this from happening in the future,” Harris said.

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