The New York State Attorney General's office released a report regarding their investigation into the death of Trevyan Rowe, a Rochester teen who died one year ago.

Rowe's body was retrieved from the Genesee River on March 12, 2018 — five days after he originally went missing during a school day. Rowe, a 14-year-old autistic student, was last seen leaving School No. 12, of the Rochester City School District. His family said they did not know he was missing until he did not get off the bus with his sister later in the day. 

While the AG's report said "The investigation found that systemic failures in school policies and procedures existed" at School No. 12, the report ultimately concluded "Trevyan's death does not appear to have been the result of any single event or single failure in school policy."

RCSD officials said back then that protocol is for calls to be made when a child is not in school. Trevyan's family said they were never notified. As a result of the investigation, the AG's report is urging the RCSD to implement certain recommendations that could prevent future tragedies like this.

“The death of Trevyan Rowe was a tragedy,” said Attorney General Letitia James in a press release. “In an effort to ensure that this never happens again, we engaged in a thorough and thoughtful investigation of the policies and procedures in place at the Rochester City School District. It is clear that there were systemic failures at the school."

The findings of the report, and the subsequent recommendations for the district, emphasize changes in mental health services, special education services, attendance policies, as well as school safety and transportation. The specifics of these recommendations can be found in the full report below.

“The facts and circumstances surrounding Trevyan’s time at School 12 reveal an astounding lack of support from his school,” said State Education Department Commissioner MaryEllen Elia in a press release. “The investigation uncovered that Trevyan was failed at every level, from mental health and special education services to procedures to keep students safe at school."

Over the course of the report, investigators say they 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. 

The investigation concluded with:

"The report notes that while school districts cannot prevent all emergencies, injuries, or tragedies from occurring, the implementation of the recommendations in the report will reduce the likelihood of events such as the tragic death of Trevyan Rowe. School districts, and those who are employed by them, are in the unique position of having custodial supervision over massive numbers of children every day across New York State. That position comes with tremendous responsibility. It is only by recognizing the gravity of that responsibility, and by relentlessly seeking to improve upon the safety measures put into place on a day-to-day basis at each individual school, that school districts can best seek to avoid another tragedy."

Last month, the Monroe County District Attorney's Office announced the case was officially closed and that no criminal charges would be lobbied.

Rowe's disappearance kick-started thousands of volunteers to canvas the area to aid in the search efforts, and his subsequent death brought a reeling community together in the wake of tragedy.

Last summer, the Autism Council’s Service Center was dedicated in memory of Rowe, along with the entire Rochester autism community. The center offers training, certifications and resources for autism families and professionals. It will also serve as a place to let families with autistic children know what to do and where to go. 

Changes recommended for RCSD, as reported by the investigation:

Mental Health Services

"This investigation has raised 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."

Special Education Services

"With respect to special education, the investigation revealed that there 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."

Attendance Policies

"The investigation found that RCSD 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."

School Safety & Transportation

"The investigation concluded that 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."

Mayor Lovely Warren said in a statement that the report proves more could have been done to save Trevyan: 

"The failures of adults at almost every turn led to Trevyan’s death. The joint report should serve as a clarion call to the school district that it must act expeditiously to ensure all of our children receive the support that they need -- especially our most vulnerable special education students. The City is ready to assist the district and Commissioner Elia as it implements solutions to prevent such a tragedy from happening again."

Read the full 145-page report: