A food service worker failed to follow a “sip before serve” policy when floor sealant was served instead of milk to 14 people Tuesday morning at a summer youth program, two top officials at the food service company told the Juneau School District Board of Education during a special meeting Friday.
“One of the first things we checked was if the individual had gone through the training. He did,” said Derrell Webb, vice president of operations, food and facilities management for NANA Management Services. “This sip before service means this would have been detected.”
The failure was among numerous missteps detailed by NMS and Juneau School District officials regarding the incident at Sít’ Eetí Shaanáx – Glacier Valley Elementary School. The investigation to date shows the trigger point for the mix-up was large pouches of the sealant known as Hillyard Seal 341, which has a milky white color, being mistakenly delivered with and stored next to large pouches of milk.
One of the biggest complaints by parents of children affected was a multi-hour delay before they were notified about the incident, which district officials acknowledged was a mistake.
“There was a delay in parent notification which was longer than it should have been,” stated Kristin Bartlett, the district’s chief of staff, in a letter sent to parents before the meeting. “This caused families to learn about the situation from other people, which is not best practice.”
District and NMS officials emphasized the investigation is ongoing and corrective actions are being implemented.
Among the actions already taken is the district halting its hot meal service for all summer programs in favor of grab-and-go meals, Superintendent Bridget Weiss told the school board.
“As a result each of those boxes will have an individual container of milk” instead of being served from a bulk container as happened Tuesday, she said.
Board members also asked city attorney Robert Palmer to initiate the process of hiring a third-party investigator to present a report about the facts of the incident and recommended corrective actions. The request was not a formal vote, which will be necessary if a decision is made to spend funds for an outside investigation.
“I think it would be good to have a fresh look at this and have a third party who is as objective as possible so we can look at the public with confidence at the end of the day and say if we are at fault,” said Emil Mackey, the board member who proposed the investigator. “Even if we are not at fault, we are responsible for them so we need to know how this happened.”
Mackey said the information presented to date by NMS and the district, including during a visit he made to the school Friday morning, appears to be accurate and “I don’t think anything nefarious happened.” But he said that possibility as well as ensuring missteps are detailed by a party without ties to local officials and institutions is important.
“I think we’ve heard the truth, but we need to take that extra step so that the public realizes we’ve heard the truth,” he said.
Parents of five students who drank the chemical testified during the meeting. Three of those parents said their children may not return to the RALLY program due to the child’s or parental concerns.
“It’s hard to get her to eat anything, but she really wants to attend RALLY,” Rhyan Nydam said about her daughter. “All of her friends are there. It’s hard to explain why we may not be going back.”
Casey Walker, who said all three of his children have been in the RALLY program and his youngest was among those drinking the floor sealer, said that while anger and demands for details about what did happen are understandable, what matters most to him now is how officials respond going forward.
“The biggest thing that I would like to see as a parent is just the constant follow-ups and being in the loop of what’s going on,” he said, adding “within reason everyone needs to be on the same page in terms of making sure it never happens again, and in any sort of aftermath any risk our kids could have been put in or have to deal with in the future is mitigated.”
The Juneau Police Department was expected to complete its investigation into the incident as soon as Friday, after which it will present its findings to the district and possibly prosecutors. The State of Alaska Department of Environmental Conservation Food Safety and Sanitation Office is also investigating, visiting and approving the facility for continued operations Wednesday as the agency conducts a more detailed probe.
Bartlett’s letter to parents offers details officials have already learned during the first three days of the investigation by police, district, DEC, NMS and other entities.
The letter notes a pallet of floor sealant was mistakenly delivered at the same time as four pallets of shelf-stable milk to a district food commodity warehouse in the spring of 2021.
“This warehouse is reserved for food items only for JSD,” the letter stated. “The pallet of floor sealant remained untouched in storage with other food products until this week when NMS ran short on milk and sent staff to retrieve shelf-stable milk.”
Three boxes of floor sealant were picked up from the warehouse Tuesday morning by an NMS driver and delivered to the three schools where RALLY programs are taking place this summer, which besides Glacier Valley are Harborview Elementary School and Mendenhall River Community School. The boxes at the other two schools were not opened.
At Glacier Valley an NMS food service worker poured the contents of the floor sealant into cups and served them, with 12 students and two adults ingesting up to three fluid ounces of the chemical.
“The RALLY site manager immediately contacted poison control for instructions, which included drinking water and getting medical attention if any discomfort continued,” Bartlett’s letter states, adding “students were monitored by staff and some students were taken by parents for medical treatment at Bartlett Regional Hospital or their medical provider.”
NMS released a statement, read by President Eric Billingsley during the school board meeting, detailing its response to the incident.
“Our safety team was immediately dispatched to Juneau on the day of the incident to investigate and assess every contributing factor to determine how this happened,” the statement notes.
“The investigations are ongoing and there is still much we may learn. To prevent a similar event from ever taking place in the future, we are implementing a corrective action plan that includes additional safety measures and renewed checks and balances. We deeply regret this mistake and the distress to families and other members of our community.”
NMS has contracted food services with the district since 2018, and the school board was scheduled Tuesday to take a final vote on extending the contract through the 2022-23 school year. But that item was removed from the agenda after the RALLY incident and, while it was on the agenda at Friday’s meeting, board members said considering the extension is not realistic for now.
“We are not going to take final action on this item given that the investigation is ongoing,” Board President Elizabeth Siddon said.
The extended contract would pay NMS an additional 7% during the coming year, funded by corresponding increases in the prices of meals. Board members expressed concern about the increase and suggested alternatives to NMS should be evaluated.
However, the contract with NMS expires June 30 so board members agreed district leaders should discuss a short-term operating arrangement with the company to ensure food services are provided for the short-term future.
• Contact reporter Mark Sabbatini at firstname.lastname@example.org