It was the last day of class, and nine-year-old Jeremy Mulumba followed the path of hundreds of thousands of Canadian children by heading off with his school to a water park. But the start-of-summer ritual ended in tragedy.
Playing in a wave pool at a park north of Montreal, he was swept by surging water toward the deep end. A classmate grabbed his shoulder and Jeremy in turn tried to grip his friend's hand, before a second wave pushed Jeremy down below the water's surface.
The Grade 4 pupil was at the bottom of the pool for more than an hour before anyone came to his rescue. He died in hospital.
The string of lapses and the inadequate supervision that led to Jeremy's death, exactly one year ago on Thursday, highlight the risks of water recreation at a time when schools across the country celebrate the end of classes by fanning out to lakes, pools and water parks.
Yet while kids mark the arrival of warm weather by cooling off, water-safety officials this week had some cautionary words. A report by the Lifesaving Society said drownings rose in Canada last year, with sharp increases among children up to the age of 12. New Canadians were cited as being at particular risk.
Still, it was a specific cascade of events that contributed to Jeremy's death at the Mont Saint-Sauveur Water Park in the Laurentian Mountains, according to a report released Wednesday by coroner Catherine Rudel-Tessier.
"This was pretty terrible," Ms. Rudel-Tessier said in an interview. "We can't create a society without risk, but we can take measures to prevent accident deaths like this. In his case, there was a lack of supervision. His death could have been prevented."
Jeremy was playing in the wave pool - promoted as being "as long as the Titanic with waves as high as those on the coast of the Atlantic" - when he vanished.
His friend notified a lifeguard, the report says, and school staff were told the boy was missing. But the water park didn't stop the waves or evacuate the pool. It wasn't until an hour later, after someone spotted something at the bottom of the pool, that a park employee dove in. Yet he didn't bring the body out with him.
When the boy was finally brought out, he was in cardiac arrest.
"Clearly, the lifeguards were warned about the missing child who was last seen in the wave pool," Ms. Rudel-Tessier wrote. "What did they do? Nothing."
The coroner said the design of the pool created a "backwash" effect that could surprise bathers - so much so that the park's lifeguards nicknamed it "the kid trap." Jeremy was probably caught in it, the coroner said.
She slammed insufficient numbers of lifeguards and poor supervision both by the water park and the school, whose staff was unfamiliar with the children's swimming abilities. And she said the school had no procedure in place once a child was reported missing.
A spokesman for the St. Sauveur water park said it has already brought in corrective measures in response to Jeremy's death, including adding lifeguards to the wave pool and upping the number of life jackets at the park. The park receives about 200,000 customers each season, a quarter of them under the age of 12, and the wave pool is the most popular attraction.
According to the Lifesaving Society's report, new Canadians are at greater risk for drowning, and they are four times more likely to be unable to swim than those born in Canada. The society called for water-safety education that targets newcomers, especially for those in Canada less than five years.
Jeremy's parents emigrated to Canada from the Congo about 15 years ago and had sent Jeremy for three years of swimming lessons, though it appeared the boy was not a seasoned swimmer, the coroner wrote in her report.
The tragedy left Jeremy's parents devastated. On Thursday, the first anniversary of their son's death, his parents plan to hold a commemoration at the cemetery where the boy is buried in Laval, just north of Montreal.
"From day one, we thought there was negligence," Jeremy's uncle, Ghislain Muntu, said on Wednesday. "This report says we were right. Jeremy should never have died."