A provincial inquest examining the circumstances surrounding the death of a Brantford teen who died at boarding school, wrapped up on Thursday. No one was held accountable, but a jury came up with recommendations to prevent further deaths.
After five years, the family is now getting answers as to what really happened to him.
“Samuel had to die in order to get more protections and recommendations for special needs children in Ontario,” said the Brown family attorney, Saron Gebresellassi.
Saron says they are happy with the 21 recommendations of the 10 day inquest into the death of student Samuel brown.
Not just because of the recommendations, but because they say they now have evidence that could lead to someone being held responsible.
“The Ministry of Education has been withholding records for years, and the evidence only just came out in the last 10 days. it took years of campaigning, in Hamilton particularly, and without evidence you can’t, there is very little one can do, and the ministry has been fighting this for a very long time,” said Saron.
The coroner’s report claimed his death was from natural causes, but an autopsy cited pneumonia.
Samuel was born with a genetic condition that left him blind, deaf and non verbal.
He died on Feb. 9, 2018 ,while attending the W. Ross MacDonald school for the blind, a boarding school in Brantford.
He couldn’t see or speak, and relied on the adults there to take care of him.
Samuel’s mother Andrea Brown testified that the school had notified her that her son was not feeling well 12 hours before he was found unresponsive in his room and was taken to the hospital.
But the family’s attorney expressed that Samuel’s death could have been prevented, and was the result of poor decisions made by school staff, who did not take him to the hospital or seek medical intervention the night he was sick.
The family released a statement saying in part: “Samuel’s parents are grateful beyond words to see the outpouring of support for Samuel.”
There were a total of 21 recommendations:
- One recommendation was directed towards the College of Nurses of Ontario.
- Another recommendation was for the College of Physicians and Surgeons of Ontario.
- And one recommendation was made for the Office of the Chief Coroner.
For the W. Ross MacDonald School, a total of eight recommendations were provided. These included:
- Reviewing the availability of overnight medical resources provided to Provincial and Demonstration Schools with overnight lodgings.
- Ensuring 24-hour on-call availability of medical staff for students staying in lodging.
- Ensuring wheelchair accessibility at all entrances.
- Developing and implementing a system to verify overnight bed checks are being completed.
- Enhancing Student Health Services (SHS) policies to require medical staff to provide written instructions to classroom or residence staff, detailing required medical surveillance.
Additionally, 10 recommendations were made for the Ministry of Education, which included addressing various aspects of student health and safety in educational institutions.
And this is not over for the Brown family. They say no one was held accountable for Samuel’s death.
With this new information, they are considering further action against the school and/or the employee who was the last person to care for him.
She refused to testify for the inquiry in person.
“It was Samuel’s last caregiver named Tamara Sudek. Only she knows what took place between the hours of 2 a.m. and 5 a.m.,” said Saron. “W. Ross Macdonald has very troubling history, there has been a royal commission, there has been a 1991 documenting a history of atrocities”