The mother of Julian Stacey wants lessons to be learnt from the loss of her son. It is with that desire in mind – and the deepest sympathy and respect for the family – that I write this post.
In order to get as complete a picture as I could of what happened in this case, I have read the original decision as well as listened to radio interviews and read numerous news reports. What follows is my summary, and views, of this tragedy.
In 2010, an 11-year-old autistic boy escaped from a respite facility here in Auckland, the facility is called “Spectrum Care.” The boy had the cognitive functioning of a one to two-year old child. He was found, drowned, in a near-by duck pond.
A decision released last week by the Deputy Health and Disabilities Commissioner, found that Spectrum Care had failed in its duties to this child. Julian had been attending the centre since 2006. He had previously successfully escaped from the facility; not once, not twice…: “In 2008 he escaped four times, and then twice in 2009.” (In 2009 he’d attempted escape three times, but was only successful twice. Another report I accessed said he’d attempted to escape five times in 2008 and succeeded twice, so there is apparently some discrepancy in the reporting here, but the point is the same.)
The facility knew clearly and first-hand the risk of escape, labeling the risk as “catastrophic” in their crisis plan, and noting that the child had no road safety sense and was vulnerable to strangers should he escape again. They also knew he was drawn to water, and had noted that the duck pond which was 250 metres away, should be checked first if he’d wandered off.
With them knowing his history of escape first hand, and knowing the multiple and serious risks to his safety in the likelihood of escape, it is shocking to me that this facility – a facility’s whose job it was to keep the child safe in the care of trained and paid employees – failed in this way.
The factors that came together to lead to this outcome, were not seen as fatal by themselves. But in combination, they were deadly. They include the presence of two very new staff members (each with only a month’s experience), among the poor staff ratios at the time (poor staff ratios caused by delayed parent pick-ups that day). Also, crucially, there was a back gate that hadn’t been physically checked for being locked. A gate that could be opened from the outside (apparently intentionally so as to allow emergency access). There was a history of children who played in the park nearby, coming in via the back gate to retrieve lost balls. The focus of trying to make sure Julian didn’t escape was on the front door, but it was through one of these back gates that he ultimately last escaped. (For a summary of the key factors leading to the escape, see paragraph 154 of the decision; all links are provided at the end of this post.)
Since the incident, Spectrum Care has made more safety changes, including a buzzer system to alert staff to doors being opened, which – it must be noted – the mother had actually suggested prior to the death, but that Spectrum Care had considered “un-necessary” at the time. They have also adjusted their staff hand-over process, to make sure the children are kept in sight during hand-overs and that hand-overs are as quick as possible.
The official findings are somewhat critical of Spectrum Care’s attitude and perspective of what happened (see for example paragraphs 118-120, 126, 135-137, 147, and 150. A few specific examples: the Deputy Health and Disabilities Commissioner did not agree that the gate had to be able to be opened from the outside for emergency services, did not think there was adequate reason to focus so much on the front door as the primary point of escape, and did not think the staff had adequately supervised Julian considering his high risks). Spectrum Care also claimed the incident was a result in part of resourcing issues (para 151). The decision did not support this claim.
Spectrum Care has apologized, but only in this past week; two years after Julian’s death. Quite rightly, the mother says the apology is too little, too late, and that an apology earlier would have helped the family to move on. They still struggle with the loss.
When the mother – Natasha Stacey – first got the news of her son’s death, she fell to the ground and screamed. I can’t read the stories of what she went through, of how she reacted, without getting tears in my eyes. Her story is the nightmare of so many families of autistic children, but she has lived that nightmare, and yes we must take whatever lessons we can from this.
Drownings are apparently the leading cause of death for autistic children (and autistic adults), and not just for those with intellectual disability and epilepsy. Where possible, we must teach our children water safety, though that is frequently an extremely challenging proposition with our children (I know it is with my own son). Where the skills are lacking (and even when they’re present) we must let carers of our children know about the higher danger of drowning for our autistic children.
We have the right to insist on adequate staffing and facilities for our children, and where they are not adequate or we do not think we are being listened to, we keep fighting; it is not just our own children who are at risk: Poor safety practices and procedures can impact on all children in that organisations or individual’s care. So don’t tell yourself you’re being a nuisance, or let them make you feel you are being over-protective; when it comes to wandering and drowning, it is a matter of life and death.
My heart and my sincerest best wishes go to the Stacey family. I want them to know that Julian’s death is not just another news story, that his story has been heard. That it touched me and many others, and we will try to learn from it too. And that I, for one, agree with the mother’s view that the staff should have lost their jobs, or at least have been stood down during the investigation, and that Spectrum Care got off lightly for what has happened. The death of a child, especially such a seemingly avoidable death as this, screams for justice, a justice that does not appear to have been done.
Links to resources used in the research for this post:
- “Findings issued on death of autistic child” Radio New Zealand, 25th July 2012.
- “Carers found at fault over autistic boy’s drowning” stuff.co.nz, 25th July 2012.
- “Facility criticised over drowning of autistic boy” New Zealand Herald, 25th July 2012.
- Decision 10HDC00356, Spectrum Care Trust Board; A Report by the Deputy Health and Disability Commissioner, 2012.
- “Mother’s anguish: System failed my son” New Zealand Herald, 26th July 2012.
- “Review of Mortality in Autism Drowning” By Scott Myers, ASAT website.
- “Drowning is leading cause of death among children with autism” 22nd May 2008, SquidKid blog.
- “Summer Safety for Children with Autism” By Susan Moffitt, 16th May, 2011.