Last winter, as questions swirled about Chicago Public Schools’ ability to care for its special needs students, an autistic teen entered a pool at Kennedy High School and drowned during gym class.

Fourteen-year-old Rosario Gomez didn’t know how to swim, wasn’t wearing a lifejacket and had significant problems communicating. Just minutes after he entered the water, a lifeguard pulled his body from the pool’s deep end.

Now, as a new school year has just begun, the circumstances that led to the drowning continue to be mysterious and underscore issues about the school district’s ability to care for its highest-need students. Questions remain about how no one noticed Rosario was no longer in the shallow end of the pool even though six school employees were on duty.

Rosario’s family has filed a lawsuit against CPS, but a Better Government Association and the Chicago Sun-Times investigation has uncovered new details surrounding the tragedy, the victim, and the impact of the incident on district’s policies for special education children that critics say are already tragically deficient.

“It’s worrying about the bottom line, that’s what happened,” said Mary Fahey Hughes, director of the advocacy group 19th Ward Parents for Special Education, who also raised questions about the drowning and CPS’ commitment to special ed during a Chicago Board of Education board meeting. “These policies are … not about the safety or appropriateness of services because the kids are not getting the help that they need.”

School officials would not discuss many details of Rosario’s drowning but emailed a statement in which they defended the district’s actions while blaming problems on the conduct of some staffers, two of whom have been fired.

“It is heartbreaking that his life was lost in a school,” CPS spokesman Michael Passman said in the statement. “Tragically, despite appropriate planning and an observance of safety regulations, Rosario did not receive the support he needed that day.”

The school principal, George Szkapiak, was found to have failed to file a report to CPS officials on the circumstances surrounding Rosario’s death, though they were notified and came to Kennedy. Passman says that’s “not the district’s protocol,” but, since CPS officials and emergency responders were immediately notified, “it was determined that a disciplinary action was not appropriate.”

But CPS staffers who were fired for their roles in the incident are also speaking out, saying they have been wrongly blamed for the district’s own inadequacies and lack of safeguards.

Amid a growing fiscal crisis, CPS last year changed its funding strategy for special education – one of its costliest budget lines – and added bureaucratic layers to administering the services. CPS said it made the changes to improve accountability but teachers and advocates accused the district of just trying to save money and hurting kids with disabilities in the process. For the school year that just began, CPS officials have walked back some of the controversial policies.

Into this mix entered Rosario, a freshman at Kennedy, a Southwest Side school not only dealing with CPS’ fiscal issues but also with its own questionable history of how it dealt with special education students.

Indeed, interviews with former staffers paint a picture of confusion and disarray at the pool – an environment that is particularly problematic for children with autism, who need structure.

Parents from Kennedy and other experts also raised questions about warning signs that were apparent before Rosario entered the pool: Why was an autistic child who had difficulty communicating and didn’t know how to swim in a pool in the first place? Why wasn’t he wearing a life vest? And who was watching him?

“He wouldn’t have the ability to ask for help,” Hughes said. “This boy couldn’t talk, couldn’t swim. He shouldn’t have been in that pool without direct supervision.”

Rosario’s mother, Yolanda Juarez, sued the district in March in a wrongful death case, alleging that her son was not properly supervised. The case is still pending and a Cook County judge last month rejected the district’s efforts to have the case thrown out. Members of Rosario’s family, still distraught by his death, declined interviews to comment on the matter, as did the family’s attorney.

But online, Rosario’s aunt expressed outrage.

“We are all devastated and cannot understand how the place your child should feel safe…suddenly becomes the reason why he does not come home,” Delta Cervantes wrote on a GoFundMe page seeking help with funeral costs.

In interviews with teachers and others who knew Rosario, a portrait emerges of a happy young boy who was tight with his family – especially his grandmother who he helped after she suffered a stroke – loved riding his bike around his Southwest Side neighborhood and had such an affinity for trains he knew all the different Metra lines by heart.

For his memorial service, Metra donated two conductor hats and a ticket punch, according to Cervantes.

“He was ready for his long trip to the angels,” Cervantes wrote.

Though he didn’t talk much in school, teachers and others who worked with him over the years remember him always smiling.

“He was just one of those really quiet and gentle kids,” said Rosario’s art teacher Deborah Ryder. “He always looked forward to class.”

On Jan. 25, the day of the incident, Rosario’s physical education course had been in the middle of a six-week swim training program.

During the 1 p.m. class, “music was blaring, as it did every day,” one witness told police, according to documents obtained through the Illinois Freedom of Information Act from the Chicago Police Department.

Records show there were two classes sharing the pool at the time with approximately 70 students in attendance – about 15 of them in special ed. Two gym teachers, a special education classroom assistant, a substitute special education classroom assistant, an instructional assistant and a lifeguard were on duty at the pool.

Rosario, who had “verbal communication delays,” according to police reports, was in the water playing basketball toward the shallow end of the pool, which ranges from three to 12 feet deep.

He was not wearing a life jacket and he was fairly new to being in the water after having spent the first part of the swim program sitting on the sidelines, according to two former employees who were there at the time.

At about 1:10 p.m., Rosario was spotted at “the bottom of the deep end of the pool,” police records show.

Somebody alerted a staff member, who initially said the person at the bottom was “probably training,” according to witness accounts in police reports. Another witness told police one of the employees had been at a desk entering attendance into a computer.

Records show the lifeguard jumped in the water and brought Rosario to the surface before giving him CPR. Rosario was pronounced dead an hour later at MacNeal Hospital in Berwyn.

In court papers, the school district’s attorneys said Rosario was properly supervised with the six employees staffed at the pool.

But public records show only three out of the six possessed a water-safety instructor certificate. According to district policy, “every person who teaches (or assists in teaching) … or supervises students participating in any aquatic activity” must have one.

In the emailed statement to the BGA and Sun-Times, Passman said the aides who did not have the certification “are not required to go through water-safety certification, and it is not their job to conduct water rescues in the event of an emergency.”

Following Rosario’s death, CPS in March terminated Julia Williams, the substitute aide present at the pool, saying she was “negligent in the supervision of a student.” The lifeguard, Calvin Carter, was also dismissed, according to CPS records. Two other employees received warnings while a third was suspended, CPS records show.

In separate interviews with the BGA and Sun-Times, Carter and Williams, trying to defend their reputations, both denied wrongdoing and said CPS was using them as a scapegoat. The two described a chaotic scene at the pool and said proper procedures either didn’t exist or weren’t communicated to them.

Carter said that particular day was a “non-instructional day,” or what they called at the school a “fun day.” Students were spread out in the pool playing water polo, volleyball and basketball while more advanced swimmers were practicing dives, according to Carter and police reports. Those not swimming were either sitting out or walking the perimeter of the pool. He said this was a rare class period in which two classes were combined into one, resulting in about 70 students in the pool at once.

Although the pool wasn’t at capacity, Carter said he didn’t think there were enough adults watching all those students.

“Does this seem right to you? To have that many kids in a pool, from three to 12 feet, with one lifeguard? And two classes, with special ed, with one lifeguard? Come on. Would you have your child in that situation if you knew it?” Carter asked. “That’s a disaster waiting to happen and in this case it did.”

Carter said he was standing at the edge of the pool when another staff member called out seeing a body toward the bottom of the pool. Carter said he scanned the area and still had trouble spotting Rosario because of all the activity. He said a pool of that size should have had an elevated lifeguard chair so he could have had a higher vantage point. He also said he believes special ed students should have their own time in the pool and that aides should get in the water with them.

“Special ed needs special attention, period,” he said. “Attention means one-on-one when they’re in the water.”

As a substitute, Williams said CPS did not provide her with any information about her students’ disabilities or individualized needs. Contrary to a private school where she previously worked that provided a detailed plan outlining what to look for and what to do for each child, at CPS “they just throw you right in,” she said. “You are just working with kids and you don’t even know what they have.”

Williams said she had been regularly substituting at Kennedy since the fall and filling in for a paraprofessional who, district records show, had been absent from work for more than a year. But Williams said she had never worked with Rosario and that no one ever told her he was her responsibility. She said she worked primarily as a one-on-one aide for another boy.

Things changed a few weeks before the drowning when the swimming program had started, she said. Instead of staying with the other boy, she helped three female special ed students in one of the classes since she could assist them in the girls’ locker room. Meanwhile, a male aide took the other boy to the weight room, she said.

What was supposed to happen with regard to supervising Rosario remains unclear, she said.

“This is the problem, there was no set nothing,” Williams said. “Supervision was never set in stone. This is what we did one day, so let’s do it again.”

Complaints about services for special education students at Kennedy had been raised by educators and parents before Rosario’s death.

About four months before the drowning, a former special education case manager and teacher at Kennedy emailed multiple district officials — including the then-head of CPS’ special education department — to outline concerns about special ed services at the school, including the use of long-term subs like Williams.

That former case manager, Cyrous Hashemian, complained multiple times that a paraprofessional was regularly working as an office clerk instead of with students and that teachers were being replaced by long-term subs. He also said that Individualized Education Program meetings, which are meant for discussing the needs of students with disabilities and creating a plan for them, were not being done properly with all IEP team members present and that results were being determined prior to the meetings taking place.

“The alarm bells were there,” Hashemian said in an interview. He was terminated last summer and is fighting the dismissal, saying he was fired in retaliation for speaking out about these issues.

Passman didn’t respond to questions about Hashemian.

Parents of Kennedy students have also raised concerns.

Kimberly Rosario, whose daughter has epilepsy and suffers from seizures, said she complained about staffing levels for aides and nurses.

The staffing issue became especially troubling on the day Rosario Gomez died, she said. Just before the drowning occurred, she said her daughter had a seizure, causing Kimberly Rosario to rush to the school.

After leaving her daughter momentarily with the nurse, Kimberly Rosario returned to find her daughter sitting in a wheelchair unsupervised. The nurse had left for the pool, Kimberly Rosario said.

“When I walked in, my face was probably white as a ghost,” she said. “At any time she can go back into seizure mode, and they know that.”

The girl was OK, but her mom said she is still left with many questions concerning the well-being of not only her child, but others at the school.

“There’s not enough help,” she said. “If you have one [student] having a heart attack, one having a seizure and one falling down the stairs, two of them are not going to get care?

“If the one drowning happened with that one boy, what makes you think something else tragic isn’t going to happen?”