Saskatchewan’s children’s advocate has found that the drowning death of a five-year-old boy with autism on his first full day of school on Sept. 11, 2017, was preventable.
Corey O’Soup’s report says a safety plan that had been put in place for the boy was not fully implemented by the time Ahmed showed up for his first day of school.
The boy had special needs and Ahmed’s parents, Hussein Elmmi and Fathiya Nour, and former school staff emphasized his desire to run toward traffic or water.
O’Soup has made 11 recommendations aimed at preventing similar tragedies.
On Sept. 11, 2017, Ahmed was found unresponsive by a pond near École Dundonald School, the Saskatoon school he attended. He was pronounced dead shortly after being taken to the hospital.
It was Ahmed’s first full day of school.
The report detailed that before coming to kindergarten, the school put several safety measures in place to integrate Ahmed into school, including having an EA constantly hold his hand while outside the classroom.
During recess, Ahmed pulled away from his EA and ran toward a slide, his favourite playground activity. The EA became briefly distracted and noticed Ahmed was missing. A search began, and he was ultimately found by the pond.
According to the report, the school and Saskatoon Public School division spent considerable time drafting a safety plan prior to Ahmed’s arrival.
While it had been suspected for some time that Ahmed was on the autism spectrum, he was only diagnosed in the summer of 2017.
O’Soup made 11 recommendations in his report, including the need to better keep and transfer records for students with intense needs and the need for the Ministry of Education to develop a transition policy.
The goal is to ensure better care is taken when a high-needs student like Ahmed maintains the level of support when moving to a different city.
First signs of special needs
Ahmed was born with several medical needs and began receiving speech, feeding and occupational therapy when he was only eight months old. This continued until 2017.
His parents were under the impression Ahmed would lose these services once he enrolled in kindergarten.
In the summer of 2016, Ahmed attended a specialized preschool program in Prince Albert with a staff to child ratio of 4:15. This school focused on language and interaction skills.
The program’s speech and language pathologist prepared a 12-page report detailing Ahmed and his progress throughout the program. The report pointed to signs of speech and developmental delay. Ahmed had not yet been diagnosed with autism.
In September 2016, Ahmed began attending pre-kindergarten in Prince Albert. His parents identified his special needs, including a tendency to run away without regard for his own safety.
Ahmed’s teacher and EA paid a home visit before the start of the school year to better understand his needs and draft a plan on how best to keep Ahmed safe and integrate him into the classroom.
Throughout the school year, relevant reports from educators and therapists were put into Ahmed’s cumulative record, a record of his educational progress, which included relevant medical information.
Moving to Saskatoon
Ahmed’s family decided to move to Saskatoon before the end of the 2016-17 school year after learning they could receive better support for him there once he entered kindergarten.
In the leadup to the new school year, Ahmed’s family worked closely with the Dundonald School’s resource room teacher. She was made aware of Ahmed’s tendency to run away and his fascination with water and traffic.
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The resource room teacher told the children’s advocate office that she too had a similar conversation with Ahmed’s pre-K teacher. Work to accommodate Ahmed’s transition to the new school started just a few days before the end of the 2016-17 school year.
During the summer, the Saskatoon Public School division went through several changes. Most significant to Ahmed’s case, two of the three resource room teachers left.
The incoming principal of Ecole Dundonald School noted a feeling of unease around the changes. The principal added that there was a particularly large number of children with special needs, but it was helpful the resource room teacher and school counsellor had a good historical knowledge of the student body.
A plan was developed over the summer on how best to accommodate Ahmed. His mother, Nour, informed the resource room teacher that Ahmed’s hand must be held at all times when not in the classroom, except when on a slide. Nour also raised concerns about the nearby road and pond.
On Aug. 23, the school’s “resource team,” which included the resource room teacher, principal, vice-principal and school counsellor, met to discuss students with intensive needs, such as Ahmed, and EA supports.
The resource team then met with the EAs on Aug. 28 to discuss students with intensive needs.
Ahmed and his mother visited the school on Sept. 1 for an orientation meeting. The resource room teacher was under the impression they would not be able to make this meeting but was happy to meet Ahmed in person.
During this meeting, Ahmed ran away from his family down a hallway. Nour once again reiterated that Ahmed had a tendency to run away. After Nour said Ahmed could stay at daycare if the school couldn’t take care of him, she was reassured by school staff that Ahmed would have one-on-one support.
Ahmed’s one-on-one EA support was confirmed by the resource team on Sept. 2.
Nour brought him to school on Sept. 6 for what was supposed to be his first full day of school.
She asked the teaching staff to meet Ahmed’s EA. The request was directed to the principal, who escorted the family to Ahmed’s classroom. They met the kindergarten teacher, but the EA was not there.
After waiting “five or 10 minutes” there was still no sign of the EA and Ahmed was taken to daycare.
Nour and Ahmed left with the understanding there would be one-on-one care and constant hand holding outside the classroom. According to daycare staff, Ahmed’s mother said she still felt uneasy about the situation.
Following this event, the kindergarten teacher told the advocate’s office this was when she began to appreciate the level of care Ahmed needed, and her concern grew about how they were going to keep him safe. Staff began to further discuss safety concerns around Ahmed.
Ultimately, it was decided that Ahmed would wear a red safety vest at recess, and facilities management would work on ways to improve classroom door security. Other staff were told be on the watch for Ahmed at recess in addition to one-on-one EA hand-holding.
On Sunday, Sept. 10, the resource room teacher confirmed the availability of the safety vest, plus made additional backup plans, like having some of Ahmed’s favourite videos available for him to watch.
Ahmed’s first day of school
On the morning of Monday, Sept. 11, 2017, Ahmed was dropped off by Nour at daycare. The plan was for daycare staff to walk Ahmed to school. The drop-off went well according to daycare staff.
The kindergarten teacher told the advocate’s office when she went to get the red safety vest out of the classroom closet in preparation for recess, it was gone.
She thought another teacher may have borrowed it, but was not in a position to leave her class because it meant the children would have been unsupervised.
The teacher recalled the morning as chaotic and Ahmed had some behavioural issues, but his EA was never out of arms reach. Another EA helped with Ahmed at times, while also being assigned to another student.
Ahmed’s classroom EA was newly assigned to providing one-on-one care and had not met Ahmed prior to Monday morning. The EA had heard Ahmed had autism and “was a runner.” The resource room teacher was in the classroom that morning and provided tips on how to work with Ahmed.
The resource room teacher left the classroom before recess. A different EA was sent to supervise Ahmed during recess. The kindergarten teacher knew about the EA switch at recess but did not know who the second EA would be.
The recess EA had been advised a week before that she would be working with an intensive needs student at recess, in addition to a different student in a classroom during the morning.
Before arriving at the kindergarten class, she had not received information about Ahmed. In the few minutes before recess, she was introduced to Ahmed, told he liked to run toward the road and water and to make sure she always held his hand. The recess EA did not recall being told about his diagnosis, limitations, safety plan or that he was supposed to wear a vest.
Ahmed went out to recess wearing a blue jacket.
Once outside, the recess EA said that Ahmed tried to pull away but she held on. The second time, Ahmed got away and ran for a slide. The kindergarten teacher was nearby, and the EA said she watched Ahmed closely.
While Ahmed stood near the slide, a staff member approached the recess EA with a student she had worked with previously. There was a brief conversation, and once the recess EA looked back at the slide Ahmed was gone.
A search immediately began, with the recess EA looking for a boy in a blue jacket. Other staff members believed Ahmed would be wearing the red safety vest.
As word spread about Ahmed missing, some staff members were told to look for a blue jacket; others were looking for a red vest.
All the staff knew to look near the roadways and nearby pond.
The report indicates a staff member saw a piece of blue clothing floating in the pond but dismissed it because they were under the impression Ahmed was wearing red. Staff say it was commonplace to see items, such as clothing and shopping carts, discarded in the pond.
Shortly after, it was confirmed to all staff Ahmed was not wearing the red vest and they returned to the blue jacket in the pond. Someone had already called 911.
Two staff members pulled Ahmed from the pond, and one trained in CPR attempted to resuscitate him.
When emergency services arrived, Ahmed was taken to hospital where he was pronounced dead.
The Saskatoon Police Service investigated the incident and determined no charges would be laid.
The office of the chief coroner confirmed that Ahmed’s cause of death was accidental drowning.
Recommendations
O’Soup said in his report they found the school division staff made “eager and thoughtful” efforts to prepare for Ahmed’s arrival through gathering information and developing a plan.
However, O’Soup found not enough was done to put in contingency measures during the times of highest risk.
The advocate found that the Ecole Dundonald School followed their protocols in developing a plan, but did not have the procedures in place to trigger a request of Ahmed’s cumulative record, the document fully detailing his educational and medical needs started in Prince Albert.
O’Soup recommended the Ministry of Education require all schools create cumulative records for all pre-kindergarten children who have special needs.
Furthermore, he said the ministry should conduct an audit of such records to ensure all school divisions have consistent standards in compiling these records and transferring them to other divisions.
For the Saskatoon Public School Division, O’Soup recommends that the transition process for accepting special needs students be amended with greater communication between the sending and receiving schools, that safety procedures are amended especially involving intensive need students in high-risk situations, develop written protocol to mitigate risks posed by City of Saskatoon parks and ponds, and those minimum standards are established for communicating to key staff, including EAs, that they are being assigned to high-risk students.
The advocate also recommended the Ministry of Education, along with all boards of education, conduct a study of all schools to identify external safety hazards and create relevant plans. O’Soup wants this measure to be completed within a year.
Throughout his study, O’Soup found that Ahmed’s right to safety while receiving a public service was not sufficiently upheld.
He concluded by saying known risks were not sufficiently mitigated and Ahmed’s death was preventable.