That's the conclusion the state Education Department and attorney general's office laid out in a report on the investigation of Rowe's death. The 14-year-old student rode the school bus to School 12 as usual on March 8 last year but instead of entering the building, walked away and was later found dead in the Genesee River. His absence wasn't noticed until he didn't arrive home after school that day.
State Education Commissioner MaryEllen Elia and New York Attorney General Letitia James announced their findings this morning. "During the course of the joint investigation," they said, "NYSED and AG 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."
Among the investigation's findings:
- There are "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."
- "[T]here 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."
- The Rochester school district "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."
- "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.
Failing Trevyan Rowe: inside the state’s reportThe report is primarily a statement of the facts uncovered in the investigation, with little commentary. But it is a scathing indictment of the district, with a list of almost unimaginable mistakes and deficiencies.
Trevyan had moved to Rochester from Arkansas and Texas, where he had been a special education student. He entered the Rochester school district in April 2013 and, because of delays in getting his records from his previous school districts, he was classified as a general education student. A month later, he was classified as “learning disabled.”
From the outset, the report says, “Trevyan was known to have experienced traumatic events, but he was not recommended for in-school counseling.”
During his five years in the Rochester district, “Trevyan exhibited increasingly problematic behaviors” and expressing suicidal thoughts, the report says. “Over the ensuing years, he became confused and panicked during a fire drill, wandered away from classes when he reportedly became overwhelmed, and had the Mobile Crisis Team at Strong Memorial Hospital called on him on at least three occasions in or about November 2013, sometime in the fall of 2016, and in September 2017.”
“By the time Trevyan was a fifth grader,” the report says, “he was observed writing suicidal statements in his school notebooks, and would occasionally raise his hand to ask off-topic questions about attempting to kill himself during class lectures. Nevertheless, for the entire period from fifth grade until his final school year at RCSD (2017-2018), school staff who became aware of Trevyan’s behaviors and severe emotional issues, including social workers, recommended that he receive only outside mental health counseling, but did not recommend in-school mental health counseling.
“Staff’s focus on community mental health services continued for years despite repeated indications that those recommendations would not, or perhaps could not, be carried out, even as Trevyan’s behaviors increasingly affected his studies at School #12.”
In the fall of 2017, when he entered seventh grade, Trevyan’s behavior problems worsened, the report says. But he had been assigned to a new special education teacher, who wasn’t aware of his history of mental health problems. His records said he had a learning disability, but ”said little, if anything, about depression or suicidal ideation,” the report says.
At the end of a school day around September 20, the report says, he threatened to run between the school buses to hurt himself. He told a school safety officer that he wanted to kill himself, but he told a school social worker that he didn’t want to. The social worker called the Mobile Crisis Unit, asked them to check on Trevyan at home, and the social worker and a School 12 administrator drove him home.
“Upon their arrival,” the report says, “one or more of Trevyan’s siblings came to the door and said that his mother was asleep. The social worker and school administrator left the home without speaking to Trevyan’s mother, and before the Mobile Crisis Unit had arrived.”
“Following this incident,” the report says, “there is no evidence that any actions were taken by anyone in the RCSD to address possible safety concerns regarding Trevyan’s suicidal ideation or his potentially unsafe behavior during arrival and dismissal.
“At a counseling session with the social worker on October 2, 2017, Trevyan reportedly discussed wanting to become a ‘terrorist.’ The next day, October 3, 2017, his special education teacher observed him writing the word ‘die’ all over his paper, so she notified the social worker, who came upstairs to speak with him about it. Trevyan expressed reluctance to discuss what he had written, and said that it was not about himself.
“In an email to Trevyan’s school administrator, the social worker said that Trevyan ‘just needs more than what school counseling can provide.’ It does not appear that a suicide assessment form was completed at that time, nor did any of these additional events apparently prompt staff to write a safety or emergency plan for Trevyan. Additionally, there is no indication that the district-wide school safety plan was sought or reviewed to ascertain how to deal with an implied or direct threat of suicide, which such plan is required to address.”
New York State’s education law, the report says, was amended in 2016 to require school districts to have “policies and procedures for (1) responding to implied or direct threats of violence by students, teachers, and other school personnel as well as visitors to the school, including threats by students against themselves, including suicide; and (2) contacting parents, guardians or persons in parental relation to an individual student in the event of an implied or direct threat of violence by such student against themselves, including suicide.”
“As a result,” the report says, “SED provided schools with resources on understanding the warning signs of depression, suicide and other mental problems. RCSD is required to certify that all staff are trained in mental health when they submit their Basic Educational Data System (BEDS) data to SED in October of each year.”
And yet for several years, staff at the school apparently failed to recognize that Trevyan’s behavior was consistent with serious mental illness.
Contributing to the problem: in July 2017, in an effort to improve its special education services, the district restructured its special education department. In the process, it laid off 22 of the 38 special education “coordinating administrators,” the people who facilitate the evaluations and annual reviews of the district’s students with disabilities. As a result, the report says, “schools within the district were left scrambling to fill the void.”
Instability in the district
“At School 12,” the report says, “the results were nothing less than chaotic. The principal concluded that the burden was too onerous to place on one single administrator,” so the responsibilities were split up among other staff. And staff told the state’s investigators that they felt the RCSD didn’t train them well for their new responsibilities.
News reports frequently note the Rochester School District’s frequent turnover – not only in superintendents but in other key staff as well. That apparently also contributed to the district’s failure to respond properly to Trevyan’s needs.
“Over the last three years,” the report says, “School 12 went through at least five different individuals acting as principal, four vice principals in charge of ever-changing grade levels, three social workers, two Center for Youth staff members, two speech pathologists, and countless clerical staff members in charge of attendance and other matters.”
The person who had the office of principal the day Trevyan walked off from school was a “per diem” principal who had been assigned to the school in mid-January. She had a background in education, the report says, but she had not worked for the Rochester district before. “Other than being given a binder containing district policies (none of which pertained to student wanderings or elopement), the district had not given her any training before placing her at School 12.”
And she was away from school that day attending a meeting, the report says. Her substitute had already left the building by the time Trevyan’s parents arrived looking for him at the end of the school day.
“In the years that Trevyan was enrolled in RCSD, his special education services were to be overseen by no fewer than eight individuals with various titles including a revolving door of Coordinating Administrators of Special Education.”
And when they left, “they took any knowledge of Trevyan’s past crises and special education needs with them.”
The district’s ‘attendance’ problemsAmong the numerous shocking revelations at the time of Trevyan’s death was that most of the school staff didn’t know he was absent. Two teachers, in fact, had marked him present that day. While earlier awareness may not have prevented his death, the tragedy exposed a major, ongoing failure in the district: its lax attitude about recording children’s attendance.
This is not a new discovery. Until a few years ago, the default setting for the district’s attendance computer program was “present.” Teachers had to manually change it to “absent” for children who didn’t show up. And improving attendance has been a high priority for recent superintendents. And yet the district’s policies, actions, and oversight of attendance taking has been weak.
“Accurate attendance taking,” the state’s report notes, “is essential to ensuring the wellbeing of minors during the school day when they are not under the supervision of parents, legal guardians, or other caretakers.”
“The district’s policies contain problematic loopholes and inaccuracies, and even contradict other documents provided to District staff,” the report says.
And while the district requires teachers to file absence reports daily, and requires administrators to be notified when teachers fail to do that, data that the school district provided to the attorney general and the state Education Department “reveals delays and changes being made to attendance records at School #12 for weeks and occasionally months after the date in question.”
And, the report says, “not a single administrator interviewed reported having ever seen, let alone completed and distributed, the Teacher Unsubmitted Attendance Notification or any other form of follow-up and/or reprimand of teachers relating to chronic lateness and/or inaccurate attendance recordkeeping.”
“Perhaps most concerning,” the report says, “is the fact that no efforts appear to have been made to track attendance records over time in order to identify those teachers who are chronically late and/or inaccurate in their record-keeping.”
“Not only are the District’s practices and lax enforcement inconsistent with its stated policies,” the report says, “but they send a clear message to teachers that attendance policies are not a main priority, despite the fact that accurate and timely attendance is the only way to account for the whereabouts of the approximately 900 students who attend School #12 every day.”
Supervising students’ arrivalAlso a problem: the school’s policies, training, and behavior related to staff supervision as children are arriving and leaving. School 12 was originally an elementary school. It now serves kindergarten through eighth grade. More students arrive at the same time in the morning and leave at the same time in the afternoon. And yet the school’s policy for supervising those periods of the day – and the staffing – is the same as when it was an elementary school.
The school’s arrival and dismissal plan “consisted of staff assignments, whereby select staff members were assigned to ‘posts’ located inside and outside the school,” the report says. “The plan lacked crucial details, however, such as where staff should stand within the general posted area, which direction they should face once there, and what exactly they should be monitoring, let alone what do in an emergency such as an elopement.
“The only posted staff members who had any hope of seeing Trevyan when he got off the school bus and left school property were those who were supposed to be located outside in the front of the building. There were five such outdoor posts under the plan, to which eight staff members were assigned. Even those staff members, however, rarely stood outside far enough to have seen where Trevyan disembarked onto the sidewalk. Rather, in the absence of specific instructions from the plan itself, many of those staff regularly stood at or near the building entrances, or even just inside the doors, especially on cold days.”
The state’s report ends with a lengthy list of recommendations, covering policies and procedures related to mental health, special education, transportation, and school safety. And at a press conference Tuesday afternoon, school district officials talked about changes they have made in procedures related to taking attendance in school. Those changes address some of the recommendations in the report from Elia and James.
Taking attendance, however, is only one of the problems cited in the report. And while other parts of the incident weren’t addressed because of pending litigation related to Trevyan’s death, the district is facing an enormous challenge. To correct the problems the report identifies will take not only changes to policy and procedure but in training and oversight, areas the district hasn’t excelled in.
It will also take a recognition by the community that the school district is not a mental health provider and can not be expected to be.
This is a developing story, and the article will be updated.