Cindy Alvarado, a 13-year-old girl with cerebral palsy, had been lethargic and breathing more rapidly than normal that day at school. Her teacher was concerned and called for the nurse. But at the end of the day, Cindy was placed on a D.C. school bus with the nurse's urgent note tucked away.

After an hour-long bus ride to her foster home in Fort Washington, Cindy, who used a wheelchair and was unable to speak, had stopped breathing and was turning blue. Soon she was pronounced dead at a hospital.

Hours later, her foster mother found the nurse's note at the bottom of Cindy's backpack. It read: "Please evaluate re: emergency room ASAP."

The details of Cindy's Sept. 26 death are in a newly released report by University Legal Services, a federally mandated watchdog group for the mentally retarded and disabled. An autopsy found that Cindy died from volvulus, an abnormal twisting of a segment of bowel that can be fatal if untreated, the report states.

"It defies all nursing standards and common sense to place a child that needs emergent care on an hour-long bus ride with buried instructions for the parent to seek emergency medical treatment," concluded nurse investigator Andrea Procaccino, the Legal Services consultant who wrote the report.

Based on the report's findings, the D.C. Department of Health plans to ask its Board of Nursing to review the case. "We are very concerned about protecting the health of these medically fragile children," said Walter Faggett, the department's interim chief medical officer.

Legal Services learned of Cindy's death in April and launched an investigation, which included a review of records from C. Melvin Sharpe Health School in Northwest, where Cindy was a special education student, and interviews with the school's transportation staff.

D.C. school officials received a copy of the report Friday. Four attempts to reach Interim Superintendent Robert C. Rice were unsuccessful. Veleter M. B. Mazyck, the school system's attorney, said officials have been cooperating with an investigation by the D.C. Child Fatality Review Committee, an independent group. Schools spokeswoman Lucy Young said, "We categorically deny any wrongdoing of any kind."

LaGrande Lewis, principal of Sharpe, a special education school that serves 203 students with severe physical and emotional needs, said she regrets Cindy's death. She said members of her staff told her it was not uncommon for Cindy to cry in pain from her ailments, which included gastrointestinal reflux and a seizure disorder. The school's only nurse, identified by Legal Services as Vandalia Joyner-Taylor, did not return several telephone calls.

"The school nurse goes above and beyond to help sick students," Lewis said.

The Legal Services report is critical of Joyner-Taylor, who wrote the note found in Cindy's backpack. Investigators said there was "no indication that the nurse assessed or responded appropriately to [Cindy's] abnormal vital signs."

Joyner-Taylor still works at the school and is employed by National Nurses Service Inc., a company with three offices in the Washington region that provides nurses to private and public institutions. The president of National Nurses did not respond yesterday to telephone messages left at his office.

Joyner-Taylor is in a school nurse program run by Children's School Services, a subsidiary of Children's National Medical Center.

In an Oct. 21 memo sent to the D.C. Health Department, Children's School Services concluded that Joyner-Taylor's actions surrounding Cindy's case did not violate nursing standards, said Ray Sczudlo, president and chief legal officer for the medical center. He said Joyner-Taylor has been a nurse for more than 20 years and has worked at Sharpe for more than nine years.

"We compared what was done to an appropriate standard of care, and we did not feel she breached the appropriate standard of care," Sczudlo said. "There was no cause to take action" against her. The medical center and the health department would not release the memo.

The Legal Services report provides a glimpse of the last day of Cindy's life.

Before she left home that morning, her foster mother, Nora Carmichael, noted that Cindy had vomited a small amount of clear liquid. As a precaution, she checked the child's feeding tube, and everything was fine. At 9:20 a.m., after Cindy had reached school, Carmichael called the school, told an administrative assistant about the vomiting and said she wanted the school nurse to check on Cindy.

School records indicate that the assistant wrote down the message, but "there is nothing in the record to indicate that this information was relayed to the nurse or that the nurse went to assess" Cindy until hours later, according to Legal Services.

Cindy's teacher had noticed that Cindy was crying and sleeping more than usual and that her eyes looked weak. About noon, the teacher contacted the nurse.

The report said the nurse recorded Cindy's temperature as 99.6 and her blood pressure as "alarmingly low" and found that Cindy was taking 28 breaths per minute and was whining. According to the report, the nurse did not record a pulse.

The school records indicate that the nurse said she called Carmichael about 1 p.m. and left a message. But Carmichael told investigators that she never received a call. At the end of her shift at 2:30 p.m., the nurse wrote a note to the foster mother about Cindy's condition: "Appears very uncomfortable -- crying at intervals -- also seems lethargic, respirations rapid. Please evaluate re: emergency room ASAP." Someone placed the note in Cindy's backpack.

After school, at 3 p.m., Cindy was placed on the bus. Her eyes didn't look right, the driver told the school aide. But the aide reassured the driver that Cindy always looked that way and that she was fine. The driver kept an eye on Cindy during the ride to Fort Washington, where the girl had lived with Carmichael for nearly seven months.

When the driver approached Cindy to help her off the bus, the girl was not breathing and was blue. Cindy was rushed to the hospital, where she was pronounced dead.

School transportation administrator David I. Gilmore, appointed by a federal judge to take over the special education bus system, said the bus driver is still troubled by the death.

"I think this child was put on the bus in not very good shape, and I wish we had been in a better position to recognize that," he said.

Carmichael still grapples with the death of the girl, whom she regarded as her daughter. She said she is haunted every time she sees a yellow school bus.

"It's something that you never really get over," Carmichael said. "This was my child, who I loved and care about. . . . It is difficult to lose a child, especially in the manner that this all occurred."

Cindy had her medical limitations, but she communicated her feelings, Carmichael said.

"She would kick her feet when she felt joy, even just when a person touched her," Carmichael said. "She could smile, and you knew she appreciated what you did. . . . She was just a magnificent little kid."

Staff writers Henri E. Cauvin, Sewell Chan and Jamie Stockwell and researcher Bobbye Pratt contributed to this report.