The Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Child Care Services 15 Mulberry Street, Springfield, MA 01105 Date: AMENDED INVESTIGATION REPORT Complaint 20190 Facility 400331 Name of Facility: Frederick L. Chamberlain School Address: 17 Prospect Street, Middleboro, MA 02346 I. Complaint/Incident Summary On May 7, 1999, the Office received a mandatory incident report from the Frederick Chamberlain School in Middleboro, MA regarding the death of a resident. The report alleged the following: h, three residents (Child A, Child B, and Child C) were being driven to school by Staff A when the vehicle rolled over. Child A died in the accident. The other passengers were at- Hospital and their condition was still unknown. Staff A was driving his own vehicle when the incident occurred. 11. Summary of Investigation Activity The case was assigned to this lnvesti gator on May 7, 1999 and received on May 10, 1999. An investigation was conducted between May 10, 1999 and May 14, 1999. An investigation occurred at the site on May 12, 1999 with an officer from the Middleboro Police (Of?cer A). An entrance interview was conducted with Staff A and Attorney A. The investigation brochure was distributed to Attorney A. The investigation activities with Officer A included three child interviews (Child B, Child C, and Child D). Additional investigation activities on this day included an interview with Staff E, a review of Staff A's record, a review of transpo1tation policies, and brief interviews with Staff and Staff D. A interim exit interview was conducted with Licensee A, Licensee B, and the Program Director on this day. A second day of investigation occurred at the site on May 14, 19.99. The investigation activities included a limited inspection of the accident scene, a review of a written document, an interview with Staff A in the presence of Attorney B, an interview with Staff I, and two child interviews (Child and Child F). An exit interview was conducted with the Program Director and Licensee A. Additional investigation activities included telephone interviews with three staff (Staff F, Staff G, and Staff H) and telephone contacts with Officer B. Summary of Findings Amended Report: Citation 307(1) was amended by the Director of Investigations after receipt of a letter from the program dated August 6, 1999 which questioned the phrasing of this citation. Transportation Policies and Procedures: Staff stated that she is the Residential Director at the program. Staff stated that the residents who live at the Prospect Street dormitory use transportation to get to the campus school. The school uses two vans plus staff vehicles for "over?ow" residents. Staff receive a van safety training to learn about rules on seat belts, completion of forms, and other safety information. Staff stated that all residents must wear seat belts and staff should also wear seat belts. The staff to child ratio in the van is one adult per frve residents. The vehicles stay together in "caravan" formation while travelling. A staff person will pull over if there is a problem on the vehicle and the other vehicles stop to give assistance. Child is the only resident who has permission to drive his own vehicle. This only occurs on?. It was a house decision that Child stay within the caravan while driving and not be the front or rear vehicle. Child never transports any residents in his car. Staff stated that the school vans carry first aid kits, but she does not believe there are kits in the staff owned vehicles. This Investigator was given written transportation polices to review. The policy stated that the school ?shall ensure that any vehicle used for tranSportation and the drivers, thereof, conform to the appropriate state and federal requirements pertaining to equipment/licensing.? The policy further stated that the drivers ?do not exceed the Speed limit at any time." Licensee A stated that the program covers liability for staff owned vehicles which transport children. The program has recently transferred to a new insurance company On and will attempt to get the required paperwork for this Investigator. This Investigator was given a?Certif1cate of Liability Insurance? from Hanover Insurance Company. The certi?cate showed $1,000,000 coverage for liability that included staff owned vehicles. Information Regarding the Accident: Staff A was given instructions by Attorney not to discuss anything that occurred on the street of the accident (w Street). Staff A stated that the morning routine was relatively normal and the vehicles left for the school around 7:45 am. on that Friday morning. The vehicles attempted to be in caravan formation per program policy. Child was supposed to be driving his own vehicle between two staff vehicles, but on this day he was the first vehicle in the caravan. Staff A followed Child driving his own Pathfinder vehicle with Child A, Child C, and Child as the passengers. Staff A believed that all of his passengers were wearing seat belts before he left the house. Staff was next in the caravan driving a school van and Staff was the last vehicle in the caravan also driving a school van. The vehicles drove down their usual route attempting to stay together, but having other cars come between them because of stop signs, traf?c lights, and the dif?culties of the rotary. Staff A stated that at one point he lost sight of Child B's vehicle, but saw him pulled over at the side of the road (area of Staff A stated that he expected Child to go behind him, but Child pulled out in front of him. (The interview regarding the accident was terminated by Attorney at this point because it would involve the activities 011? Street. Attorney also refused to have Staff A answer questions regarding his driving history at the school). Child (-) gave a description of the accident. Child stated that he was seated in the front passenger seat next to Staff A. Child was seated in the back seat behind StaffA and Child A was sitting in the back seat behind Child C. Child stated that he was wearing a seat belt. Child described the beginning of the trip in a manner that was consistent with Staff A. Child stated that he saw Child B's car pulled over on the side of the road near an ice cream stand and observed Child pull his car in front of Staff A's vehicle. Staff A commented, "Nice driving, (Child in a sarcastic tone. Child stated that they followed Child B's car to the area where the accident occurred. Staff A wanted to get in front of Child B's car. Staff A "floored it" and went very fast. Child estimated the Speed to be sixty miles per hour. Child stated that Staff A's car was in the "other lane" which he described as the lane for on- coming traftic. Child stated that he believed Staff A was racing Child and not just trying to get in front of him. Child stated that there was a hill and Child pulled over before the hill. Staff A went over the hill, lost control of the car, hit the telephone pole and snapped it in half. Child stated that the next thing he knew he was upside down in the car. Child stated that he was pulled out of the vehicle by Staff and was checked by Staff who is an EMT (emergency medical technician). Child stated that he was immediately taken to the hospital and found to have a broken wrist. Child gave a description of the accident. Child described the beginning of the ride in a manner that was consistent with the other interviews. Child stated that she was not wearing her seat belt on this trip because she could not find the "latch" which was described as the place to attach the seat belt to the seat. Child also described Child being pulled over at the side of the road at? and pulling out in front of Staff A's car. Child stated that everything was fine until they reached Child stated that Staff A wanted to pass Child B's car. Child did not know how fast Staff A was driving at that point because "it's a bumpy road and you feel like you are going faster because of the bumps". Child stated that Staff A pulled his car into the on-coming lane next to Child B's car. Child stated that it seemed like Child began Speeding up next to Staff A's car in a "race type thing". Child stated that Child was going the normal speed until Staff A tried to pass him. Child stated that there was a bump ahead in the road where the two cars were racing. Child stated that she got "nervous and scared" because she didn't know if there were cars coming from the other direction. Child described Staff A's car and Child B's car racing side?by?side down the road for more than a few seconds. Child began to slow down his car. Staff A went to turn his car to pass Child B's car, lost control of the vehicle, and tried to turn the vehicle back on the road. The back end of the car where Child A was sitting hit a telephone pole. The car spun in circles and the car ?ipped over two or three times. Child described hearing glass shattering around her and finding the medication box resting on her shoulder. Staff A was thrown in-between the front and back seat. Child described having Staff help her out of the van. Child stated that she was taken to the hospital and found to have only cuts and bruises from the accident. Child (0 gave a brief description of the accident. Child stated that he was in the front vehicle on the day of the accident. Child stated that staff usually W311i him to be between two staff vehicles, but it's not policy. Child initially stated that he was pulling over on when Staff A drove past him and lost control of the car. Child stated that Staff A appeared to be going between thirty and forty miles per hour when he was passing. Child amended his first statement to say that he was either already stopped or pulling over when Staff A passed him. Child stated that he believed Staff A lost control of his vehicle because of dirt on the road due to construction and because (Spon utility vehicles) have a roll-over problem. Child stated that Staff A's vehicles back wheels hit dirt, the car slid, hit a telephone pole, and rolled over. Child stated that he drove to the school to get help after the accident occurred. A staff person reported discussing the accident with Child shortly after it occurred. Child stated that Child approached her at the accident site and stated, ?Don't tell the truth." Of?cer stated thathdoes not have a posted speed limit so the speed limit is determined by the distance between the houses. Of?cer stated that the legal speed limit on that road is forty miles per hour. There is a solid yellow line on the road to show a ?no passing zone". The area where Staff A attempted to pass Child does not have visibility of on?coming traf?c and passing is not allowed where there is an obstructed view. Of?cer A stated that Staff A is being charged with vehicular homicide, driving to endanger, and speeding. Of?cer A stated that he interviewed Staff A in the hospital. Staff A stated that Child had slowed down to let him by on the road. He did not know how fast he was going. He was going past Child and lost control of his vehicle. Staff A did not know he had knocked down a utility pole. Of?cer A stated that Staff A's vehicle was registered and inspected. Staff stated that he was the ?rst person on the scene of the accident. Staff stated that he has been an EMT for thirteen years. Staff stated that he never saw how the accident occurred because he was on the other side of a hill and had no visibility of either vehicle. Staff stated that he estimated StaffA to be travelling between thirty-?ve and forty miles per hour before the accident occurred. Staff stated that he never observed Staff A attempting to pass Child B's car. Staff stated that he came over the hill in the road and observed Staff A's vehicle ?ipped over onto its roof. Staff stated that he is positive all occupants of Staff A's vehicles were wearing seat belts. Staff stated that his EMT training has taught him to check on seat belts to help evaluate the extent of injuries. Staff deseribed calling out to each person in the car and receiving an answer from everyone except Child A. Staff stated that he pulled Child from her seat belt and dragged her out of the car so he could reach Child A. Staff stated that he removed Child A from her seat belt as she was taking her last breath. Staff described conducting rescue breathing and CPR on Child A until the ambulance arrived. Staff 1-1 stated that she was the second person to arrive at the accident scene. Staff stated that Child A was being removed from her seat belt and being taken from the car by Staff C. Staff did not know whether Child was wearing a seat belt. Child told her that she was not wearing a seat belt because it didn't work. Staff did not think Staff A was wearing a seat belt from the way he was positioned between the seat of the car when she arrived. Staff stated that Child and Staff A were already out of the vehicle when he arrived at the accident scene. Staff con?rmed that Child was wearing a seat belt. Limited Inspection of This lnvesti gator rode in the school van with Licensee A and the Program Director clown . The road was observed to be a relatively narrow, two lane road. The ride appeared rough at forty miles per hour due to bumps and hills in the road. There was some construction dirt on the road. There was a hill before the accident scene as described by staff. Background Information on Staff A: Staff A stated that he was hired by the agency in as an overnight awake child care staff. Two weeks prior to the incident he was promoted to overnight supervisor. A review of Staff A's record showed appropriate hiring documentation (application, criminal history check, and three telephone reference checks). There was an annual evaluation on record for every year with the exception of 1998. Staff A has current training in ?rst aid and CPR certi?cation. Staff and residents consistently described Staff A as a responsible, dependable worker who interacted well with the residents. Many of the residents described Staff A as their favorite staff. Licensee A and the Program Director stated that they have never received any complaints regarding Staff A's transportation of children. Staff A stated that he received two speeding tickets - Officer A confirmed this information and stated that there was no other criminal history on record. Child stated that he has ridden with Staff A and Staff A is a very good driver. Child stated that he never felt unsafe riding with Staff A or any other staff. Child could not say whether Staff A was driving at the Speed limit. Child stated that he has ridden a lot with Staff A. Child stated that Staff A used to do the "racing thing" a lot, but he had felt safe with him. Child stated that Staff A would race the school vehicles and other vehicles. Child stated that most of the racing occurred last year, but not recently. Child stated that he reported the racing to his parents, but never informed any staff about it. Child stated that she has driven with Staff A before and he likes to drive fast. Child stated that he has a radar detector in his car. Child described the driving as "living on the edge like a video game?. Child stated that she has felt unsafe on before the accident because it is so bumpy. Child stated that Staff A has tried to pass the school van on that road before, but the van increased speed and wouldn't let him pass. Child stated that another staff person (Staff F) hated to drive with Staff A because he drove too fast. Staff stated that she quit her position at the school because she was upset over the accident. Staff stated that one month prior to the accident she reported an incident to her supervisor (Staff I). Staff stated that she was riding with Staff A and ten residents on the school van down Staff A was driving reckless and fast. Staff stated that she looked at the speedometer and it registered between eighty and eighty~f1ve miles per hour. Staff stated that she reported the incident to StaffI and he said he would take care of it. Staff stated that she rode with Staff A on only one other occasion after this incident. She instructed Staff A not to risk her life or the residents life by speeding before the trip began. Staff stated that Staff A drove more slowly oanifty miles per hour) on that day, but was still above the speed limit. Staff stated that she refused to drive with Staff A after those two incidents. Staff stated that she told two other staff (Staff and Staff H) about her experiences with Staff A. Staff stated that she had no direct knowledge of Staff A?s driving. Staff stated that there were rumors from staff that Staff A drove too fast. Staff stated that she had a conversation with Staff regarding Staff A's driving. Staff told her that Staff A was driving too fast and she was very upSet. Staff stated that she believed Staff was upset about the driving and told her to report it to the supervisor. Staff I-I stated that she has no direct knowledge of Staff A's driving. The staff are suppose to ride in a caravan, but they inevitably get separated by other cars. Staff recalled a conversation about two or three weeks ago with StaffF. Staff told her that she was refusing to ride in a van with Staff A because she was afraid of his driving. Staff did not know whether Staff had reported her concerns to a supervisor. Staff stated that one time she rode on the van with Staff A to bring it back to the school. There were no residents on the van at this time. Staff A began driving the van a little fast and it made her uncomfortable. Staff stated that she asked Staff A to slow down and he complied. Staff stated that she didn't report this to anyone. Staff I stated that he has never received any complaints regarding Staff A's driving from either residents or staff prior to the incident. StaffI denied ever receiving a report from Staff about Staff A driving too fast. Staff I was unaware that Staff had refused to ride with Staff A. Since the incident he has heard from Staff that she had a conversation with Staff regarding Staff A's fast driving. Child stated that Staff A is a very kind man and she has heard that Child A's death was an accident. Child stated that she wanted to tell me something out ofjustice to Child A even though she really likes StaffA. Child stated that Staff A races while driving residents. The object is to get to the school the fastest. Child stated that she has never ridden with Staff A, but this is something she has observed while riding in other vehicles and heard from other residents. Child estimated that Staff A goes fifty or sixty miles an hour on Old Center Street. Child stated that Staff A is her favorite staff person and there is nothing wrong with his driving. This Investigator noted that Child appeared sad and asked if she was okay. Child stated that Staff A had just visited her dormitory a short time before this interview. This Investigator terminated the interview. Additional hiforniation: Staff A stated that he did not have a first aid kit in the at the time of the incident. Staff generally reported that first aid kits are maintained in the school vans, but not the staff owned vehicles. Staff generally reported that there is no procedure in place to assure that a staff owned vehicle is registered and inspected. Residents and staff reported being very strict about the use of seat belts. It was reported that all residents are seat belted before the vehicle moves. Some residents try to "sneak" removing the seat belt, but the staff stops the vehicle if this is observed. Child did not think Staff A checked all residents for seat belts on the day of the accident. Staff A stated that he checked the residents in back for seat belts when he placed the medication box between Child A and Child D. Staff stated that Staff A never checked the residents for seat belts on the two occasions she rods with him. Staff A stated that it is the responsibility of the bus monitor to check seat belts on the school van. The Frederick Chamberlain School received a letter dated May 8, 1998 which was forwarded from the Middleboro Police Department. The letter was from a town resident who resided on Pleasant Street which is used by the school as a transportation route. The letter stated that a number of vehicles have been excessively speeding on that road. These vehicles appeared to be owned by the F.L. Chamberlain School because of the presence of students inside them. The Program Director and Licensee A stated that they were extremely concerned when they read this letter and sent a memo to all staff regarding the importance of abiding by all laws. A copy of this memo was given to this Investigator. Staff reported having their supervisors review transportation rules with them in response to this letter. The Program Director and Licensee A stated that there are other programs in the area which also transport students in vans down Pleasant Street so it was never determined whether any F.L. Chamberlain vans were at fault. Addendum to Report: This Investigator received a telephone call from Licensee A on May 18, 1999. Licensee A stated that she spoke to Staff as part of the internal investigation process. Staff told her that Staff had received weekly supervision meetings with Staff and never once voiced her concerns about Staff A's speeding while transporting children. These supervision meetings were documented and signed by Staff F. Additionally, Staff reported that she spoke to Staff I after the accident about her conversation with Staff regarding the speeding issue. Staff stated that Staff I's reaction to her information made her believe that he had never received this information in the past. Licensee A stated that this supports her belief that Staff never appropriately reported her concerns to anyone in a supervisory role. IV. Non-compliances See attachment. Investigator: Judy Pasko Complaint Number: Program Information: Program Program Name: Statement of Non-compliance 20190 Tel: 5089460036 400331 Chambedain International School 17 PROSPECT ST MA 02346?1823 Date of Report: 3/ 2] 2000 Licensee Information: Tel: 5089477825 1400330 Chamberlain Intematjonal School Licensee ID: Licensee name: 1 PLEASANT ST MIDDLEBOROMA REGULATION STATEMENT OF Through interviews, it was learned that a staff person has :Through a review of one staff record, it was learned that one staff person was lacking a 1998 annual evaluation. An OCCS investigation found Ereasonable cause to believe that one resident died and two other residents were injured when a staff person transported residents in an inappropriate manner. The staff person attempted to pass another _vehicle on a road in a ?no-passing zone" at an excessive speed and lost control of the vehicle. The vehicle hit a telephone pole and ?ipped over causing the one fatality and injuries to two other residents. Through interviews, it was learned that the program does not have a procedure to assure that all staff? rowned vehicles used to transport residents are registered and inspected in accordance with state laws- PLAN (Describe how, when and by whom, jDate correction has been I will be made. Please be Especi?c) 5 Through interviews, it was learned that a staff perscm transported residents in a vehicle without a ?rst aid kit. Print Date: Judy Pasko Licensing Specialist I have reviewed the above non-complianm and have specified my plan and date of correc?on for each non-compliance. SIGNATURE: DATE: Print Date: 9f301'2014