"It's very striking," to watch the footage of Blessing Moukoko setting out from the shallow end to swim a length with his classmates, Quebec Coroner Louie Normandin said. "You see him go, and you do not see him coming back. … It's very troubling. … We see all of it, in hindsight, and we see all the errors that were committed. "
Quebec Coroner Louis Normandin's voice was thick with emotion as he described the security footage of 14-year-old Blessing Claudevy Moukoko setting out to swim two lengths of the Center Père Marquette pool in Rosemont on the morning of Feb. 15.
Normandin's report, released Monday, details how on that morning, Moukoko, who could not swim, struggled from the shallow end to the deep end and then sunk to the bottom of the pool during a high school swimming lesson. Thirty-eight minutes went before anyone on deck noticed he was missing. The boy died six days later from brain damage from lack of oxygen, the coroner concluded.
"It's very striking" to watch the footage of Moukoko setting out from the shallow end to swim a length with his classmates, Normandin said. "You see him go, and you do not see him coming back … It's very disturbing. … We see all of it, in hindsight, and we see all the errors that were committed. And it hurts my heart, because he's gone. And he was only 14 years old. "
In his report, Normandin concluded Moukoko's death what is accidental but avoable. He recommended schools suspend their swim programs unless and until they can guarantee that such courses are supervised by properly trained teachers and lifeguards. He also said courses on how to avoid drowning, rather than the instruction of swimming techniques, should be the first priority of any basic swimming course offered by schools.
On that morning, Moukoko took part, with 18 classmates, in his third swimming lesson at the municipal pool, as part of a required gym class at nearby Père Marquette high school.
The course was taught by a replacement teacher, who was assigned to teach the swimming class despite the fact that he had not completed swimming courses as part of his physical education degree. The lifeguard on duty, who was fully certified, was helping the substitute teacher teach the course, and so no one was dedicated to lifeguarding at the time of the incident.
Several of the students told police afterward that Moukoko could not swim, was afraid of water, and would cling to the edge of the pool while in the deep end. Still, at 9:02, he set out to do his two lengths. He already had trouble in the shallow end, stopping twice to stand up and catch his breath.
Normandin described how nobody – not the lifeguard, not the gym teacher, not his classmates – noticed that once in the deep end, Moukoko had sunk to the bottom of the pool. The lesson ended with a five-minute free swim, with some swimmers amusing themselves in the shallow end, some diving from the diving board, others chatting on deck. During this time, the teacher and lifeguard were on the deck in the shallow end. No one was on the lifeguard chair, although some students were using the diving board, the coroner notes.
Before heading to the showers, the students went one by one to the teacher to give a self-assessment of the lesson. When Moukoko did not show up, the teacher assumed he had already gone to the change room. (Oddly, the teacher gave Moukoko a score of four out of five on his assessment anyway.)
At 9:40 am, students filing in for the next class began to gather on deck in the deep end. That's when they noticed something so very still in the water, that they thought it was a mannequin. The lifeguard was alerted, she drew in and brought Moukoko, who was in cardiac arrest, to the deck.
He was transported to hospital but the brain injury he suffered was severe and irreversible. He died on Feb. 21, six days after the events at the pool.
No criminal charges will be laid in relation to Moukoko's drowning, the Director of Poursuite Criminelles et Pénales (DPCP) said Tuesday afternoon.
DPCP spokesman Jean Pascal Boucher said that after investigating the police investigation, "the prosecutor assigned to analyze the case informed the family of the deceased that the Crown is not in a position to demonstrate that a criminal act has occurred."
A lawyer representing Moukoko's family, Jean-Pierre Ménard, said the family will hold a news conference Wednesday morning. He would not say whether the family intends to file a civil suit.
The coroner recommends that anyone who gives the school swim courses should have completed 90 hours of training in swimming instruction or possessing a Level 2 instructor certificate. Swimming courses should be run by a teacher, with a qualified lifeguard on duty whose only task is to supervise swimmers, he said.
Junior education minister Isabelle Charest said the provincial government will not suspend school swim courses immediately, although she said the government will follow up on the coroner's report.
"We're still in the process of looking at the recommendations and we'll discuss this matter further," she said. "It's a very tragic incident. I feel very sad and I feel for the family. "
Montreal Mayor Valérie Plant called the drowning of an unbearable tragedy. She called on the School Board of Montreal (CSDM) to take note of the report and take steps to ensure that it does not happen again.
"It just breaks my heart. It's hard for me to think about this teacher who was there when it happened. It's just terrible, "she said. "So let's make sure our kids know how to behave in water and let's make sure that school boards have enough resources so they can make sure everyone's safe."
"Our duty is to make our maximum strengthening our practices in order to avoid something like this ever happening," said CSDM president Catherine Harel Bourdon.
Marian Scott and Philip Authier of the Montreal Gazette contributed to this report