Woman’s death calls into question 911 dispatch practices (Kokomo Tribune)

Kokomo firefighters took 13 minutes to respond to a medical emergency happening less than one mile from the station on July 1, after Howard County 911 Communications dispatchers sent them to the wrong address.

In the meantime, the woman who made the 911 call because she was having difficulty breathing died.

Firefighter Kurtis Reed, who was the officer in charge on the run, thinks the time spent going to the wrong address was a factor in the death of Tammy L. Ford, 50, who was pronounced dead at St. Vincent Kokomo at 2:31 a.m. July 1. Howard County Coroner Jay Price is still investigating the cause of her death.

“I believe that the difference in time being sent to the wrong address played a big part in [Ford] not making it,” wrote Reed, a 15-year veteran firefighter, in a run report obtained by the Kokomo Tribune.

Howard County Sheriff Department 911 Communications Center director Gary Bates acknowledges the tragedy of the situation, but he could not comment further on the response to Ford’s call specifically because the HCSD is investigating the incident in preparation for potential litigation.

“It’s tragic. It’s sad. We don’t want to make any mistakes. That dispatcher is going to have to live with that,” Bates said, noting Howard County’s dispatch responded to more than 220,000 calls in 2014. “Everybody makes mistakes. We try to catch those. … But one’s too many. We don’t want anything to occur like that.”

Fire Chief Nick Glover doesn’t want to speculate on the cause of Ford’s death and whether responding more quickly would have made a difference, but he did say there have been ongoing issues with Howard County’s 911 dispatch relaying correct information to the fire department.

“They do have some very good dispatchers over there who have been there a long time and take pride in their job and take it very seriously,” Glover said. “But it seems like there’s another group that has kind of adopted that ‘oh well, things happen’ attitude.”

Bates said any complaints – whether made by a citizen or officer – are thoroughly investigated, and the communications center will issue a finding.

“When we find those mistakes and it is a valid mistake by the dispatcher, we take the disciplinary action that has to be taken,” he said. “We don’t ever just blow them off.”

Ford called 911 at 1:41 a.m. on July 1 from her fourth-floor apartment at Terrace Towers, 600 block of South Bell Street, and a dispatcher notified first responders at 1:45 a.m., according to a Computer Aided Dispatch report from the 911 Communications Center.

“Howard County 911, where’s your emergency?” a dispatcher answers on an audio recording of Ford’s call.

“Terrace Towers,” Ford answers, and then gives her apartment number when the dispatcher asks “Where at in Terrace Towers?”

“What’s your problem?” the dispatcher asks, and Ford answers that she can’t breathe.

Then a second dispatcher comes on to ask Ford’s name, phone number, whether anybody is there with her and if she can let the officers in when they get there. Ford answers the questions, though obviously struggling to breathe.

“OK, I’ll get somebody on the way, OK?” said the second dispatcher, ending the 1-minute-15-second call.

The dispatcher then mistakenly sent a truck from Fire Station No. 1, 215 W. Superior St., and an ambulance from St. Vincent Kokomo to Civic Center Tower apartments, 200 block of East Taylor Street. The firefighters arrived first and found the apartment numbers didn’t match what dispatch had relayed, so Reed called the dispatch center to check the address. Medics arrived at Civic Center Towers before the error was realized, and they then followed the fire truck to the correct apartment building.

At 1:54 a.m. the location of the emergency is updated in the CAD report, and the firefighters arrive at Terrace Towers at 1:58 a.m., 13 minutes after being dispatched and 17 minutes after Ford called 911. The report says Ford did not have a pulse when the firefighters and medics found her, and she was transported to St. Vincent Kokomo before being pronounced dead. The Kokomo Tribune was not able to contact Ford’s family members as of press deadline.

“We work in a very serious field, and a lot of times seconds make the difference, whether it’s a fire or a medical call or whatever the situation,” Glover said. “Other than the obvious consequences for the citizens or the caller or the victim – whatever the case may be – there’s an impact on our people with the service they provide. They do take great pride and professionalism in what they do. It reflects poorly on them and it also is a burden they have to carry now, personally, of ‘maybe we could have helped this person if we had been there sooner.’”

Dispatchers followed the protocol as Bates explained it.

“When we take any type of medical call, our most important thing is location. Then we ask the person are they conscious and are they breathing,” Bates said, adding that information can tell the dispatcher what type of response is needed. “After that’s determined, we try to get a call-back number. Then, after the call-back number, we try to get their name.”

Dispatchers can stay on the line with the caller if other calls are not coming in. The Howard County 911 Communications Center fields calls for city police, city firefighters, county officers and county firefighters as well as answering 911 calls and administrative calls for the Kokomo Police Department outside of its office hours.

Between four and six dispatchers are working at a time, each operating a console with six different screens that show radio channels, a map that will zero in on where an incident is occurring, the CAD system that records the types of calls being answered and responses dispatched, a site to look up warrants, a query system to run license plates for officers and a screen that shows calls coming in on eight 911 lines. Dispatchers may have to multi-task and respond to more than one call at a time.

“It’s very easy to ‘Monday morning quarterback’ and say, ‘How could they ever make a mistake like this?’” Bates said, noting that dispatchers go through 480 hours of console training before becoming certified. “It’s not that hard to do. It’s tragic, but it’s not that hard to do.”

However, Glover said the incorrect address given for Ford’s call was not an isolated incident.

In addition to sending trucks to the wrong addresses, Glover said there have been other issues in working with the dispatch center, such as recommending trucks from stations that are not closest to the emergency and not sending the rescue truck to situations that warrant the additional aid.

“We’ve had to do some things on our end to fix the mistakes,” Glover said. “We can only go where they send us.”

Sending vehicles from a station that is not closest to the emergency may be a repercussion of the communication center’s new software, which staff implemented in December, Bates said. Information about the layout of Kokomo and all of Howard County, as well as each station’s boundaries, has to be entered into the software, which connects online to a server in Indianapolis.

Staff developed a total of 35 recommendations for what vehicles to dispatch depending on the scenario and location of an incident. There were some “growing pains” with that, Bates said, and if the system goes down for any reason, it’s up to the dispatcher to remember those recommendations.

“It’s such a complicated process making sure the right engines are going based on the boundaries,” Bates said. “Just one little checked box can make the biggest difference in the world. We try to make it the best we can. It’s growing pains and it’s something you just have to deal with.”

To correct the issue of sending trucks from the wrong station, the Kokomo Fire Department has changed how runs are broadcast on its audible paging system. Previously, only the station called on to respond would hear the dispatch information.

“We had to switch that to where all the runs are now dispatched at all the stations so that we can make the corrections and send the proper truck,” Glover explained, adding the change was made months ago.

The fire department also changed the procedure for utilizing its sole rescue truck, which has additional equipment to be used in more serious situations. Because the rescue truck needs to be available to respond to structure fires, the department had requested it be dispatched only to serious accidents. But with dispatch failing to send the rescue truck every time it was needed, the fire department is now having the rescue truck respond to all personal injury accidents in case it’s a serious wreck.

“If there was a vehicle that hit a dump truck or a building or in the water, then we would send the rescue truck also,” Glover said. “We had a lot of issues with [dispatchers] not doing that, so just last week we changed it to if there’s any wreck now we’ll send that truck.”

Bates said sometimes dispatchers are not provided complete information about an accident, so they may not know a rescue truck is required – like in cases where someone is trapped in a vehicle or the vehicle flips.

“If you listen to the 911 call and the dispatcher doesn’t get that there’s entrapment, if the people don’t tell us that information – how do we know?” he said. “If it works better for them to go ahead and send a rescue and then call it off, then that’s better.”

 

Follow-up reporting included:

KPD emails reveal long-running concerns with dispatch, published July 24, 2015

911 dispatchers discuss challenges of job, published Aug. 1, 2015

Concerns about Howard County dispatch being addressed, published Oct. 11, 2015

This piece and subsequent reporting took first place in best ongoing news coverage in the 2016 Hoosier State Press Association awards and was a finalist for Story of the Year.

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