911 Please Hold - Not a Joke
Saturday, February 09 2008 @ 02:51 pm EST
Contributed by: CBrining
911 Response In Fatal Fire Criticized
From the The Intelligencer
By Christin Kristofic
DOYLESTOWN, Pa
When Brenda Orr called 911 the morning of Jan. 29 to report that her bed was on fire and she couldn’t get out, the phone rang seven times before an operator picked up and put her on hold.
It was almost a full minute from the time Orr dialed 911 before another operator picked up and asked about her emergency.
Click read more for full atricle and 911 Audio
A minute, Doylestown police and fire officials said, that could have helped them save her.
“We’re concerned about the minute that’s missing,” Doylestown Police Chief James Donnelly said this week. “Had we had that minute, I’m not saying for sure that we could have saved her, but we would have been a minute closer.”
Doylestown Fire Marshal David Cell said there is no way of telling how fast the fire spread. But Orr, who had multiple sclerosis and was bed-bound, had a lot of material in her bedroom that would have fueled the flames.
“Response timing is critical to the safety of the residents and the people who are there to protect them,” Doylestown Council President Det Ansinn said.
“We need to understand from the county what happened and what can be done to not have that happen again. We have a tragedy here. And there’s always questions following a tragedy. We want to make sure we do our best as a borough to limit the possibility of a tragedy happening again.”
Bucks County officials acknowledged proper procedures were not followed in responding to Orr’s call, but would not discuss the case in detail.
Click here to hear the 911 call
Through a right to know request filed with Doylestown, The Intelligencer obtained the emergency communications log, a police report, the county fire marshal’s report, internal memos from police and a recording of the 911 call that sets out the sequence of events:
Brenda Orr called 911 from her home phone at 10:31 a.m., when she woke and discovered her bed was on fire.
County Fire Marshal Nick Rafferty speculated in his report that the fire was already well advanced when Orr woke up.
Her 911 call rang in the Bucks County emergency communications center seven times — and 27 seconds elapsed — before a male dispatcher answered and said: “911. Can you hold one second please?”
Orr answered, “I can’t. This is an emergency. 911 emergency. Three-four-zero Doyle. Bed on fire.” But, on a recording of the call, it sounded like the man had already stepped away from the phone.
No one spoke for another 27 seconds.
County officials will not say what happened or why no one spoke to Orr during that time.
A female dispatcher picked up the phone 55 seconds into the call and asked for the location of the emergency.
Since Orr was calling from her home phone and the county has what is known as an “enhanced 911 system,” Orr’s address showed up on the dispatcher’s computer screen. County Director of Emergency Communications Brent Wiggins said the dispatcher still had to ask for the address to make sure it was correct. There was nothing in the 911 system to indicate that Orr was disabled.
Orr calmly and clearly repeated her street address — “Three-four-zero Doyle (Street)” — three times as the dispatcher asked what township or borough she lived in.
After Orr told the dispatcher that she lived in Doylestown, the dispatcher asked if Orr was still in the house.
“Yes,” Orr answered.
“All right. Well, you wanna get out of the house?” the dispatcher asked.
“No! I’m disabled,” Orr answered. “The bed is fully inflamed.”
Then Orr went silent.
For the remainder of the recording, the dispatcher is heard trying to talk to Orr and asking a coworker if she should stay on the line.
The emergency response
Police, fire and EMS logs show local agencies were dispatched at 10:33 a.m. — two minutes after Orr dialed 911.
Doylestown Cpl. William Doucette arrived at Orr’s house a few seconds later. Officer Paul Kreuter, who is also a firefighter, followed at 10:34 a.m.
Kreuter kicked open the front door and attempted to crawl through the house to Orr, according to his report. The fire was too big and the smoke was too thick for him to get very far into the house.
He and Doucette went to the back of the house and kicked open the door.
Kreuter attempted to crawl through the house again to get to Orr, but the smoke was too thick.
Firefighters arrived on Doyle Street at 10:35 a.m. — two minutes after they were initially dispatched and four minutes after Orr’s call.
The fire log shows Cell arriving on the scene at 10:37 a.m., but he said this week that he had arrived at Orr’s home and attempted to rescue Orr before the firefighters arrived and before he reported his location to the county communications center.
Cell went into the house once without an air pack; he had hoped Orr would be easily accessible and he could rescue her without too much equipment. He said he got halfway down the hall to Orr’s bedroom before the smoke became too thick for him to go any farther.
Cell ran out of the house and found the first crew of Doylestown firefighters and a truck full of water had arrived from the Shewell Avenue station. He grabbed an air pack off the truck and went back in.
He said he made it to Orr’s bedroom door, where he saw nothing but heavy black smoke.
“I felt a lot of heat,” he said, guessing it was a couple hundred degrees in the bedroom. “That’s an indication of flashover, when everything in the room — all the stuff and the gases — catches on fire all at once.”
If he had gone into the room during flashover, Cell said, he would have had second-degree burns all over his body even with the protective gear on.
Cell and a crew of firefighters went back in the house, in another attempt to rescue Orr.
They made it as far as the bedroom door.
“My helmet melted and everybody’s gear melted, so we backed out,” Cell said.
They grabbed the hose on the truck and went back into the house with water. Cell said they got halfway down the hall before a piece of the ceiling fell on his head and one of the firefighters threw him out of the house — at 10:46 a.m. He was treated for his injury and taken to Doylestown Hospital on Warrington ambulance. The rest of the firefighters went into the bedroom to put out the fire.
Most of the fire was extinguished by 11:13 a.m.
And firefighters reported to county communications that it was completely under control at 11:47 a.m.
County Fire Marshal Nick Rafferty, who had arrived at Orr’s home about an hour earlier, went into the home to investigate the fire. He found the charred remains of Orr’s mattress, bedroom furniture, small electrical appliances, power strips, books and magazines, cigarettes, lighter, matches, an ashtray, food and plates.
He found Orr’s body lying in a kneeling position on the floor next to the bed.
Orr’s friend, Fran McCabe, later told police that Orr had an anxiety attack the night before and might have taken a sleeping pill. McCabe spent the night at Orr’s house, woke her in the morning and gave her a pack of cigarettes. Whether she went back to sleep is unknown.
McCabe told police Orr had a habit of smoking in bed and her mattress was covered in burns from her cigarettes. There was also a power strip on the bed and another on the floor near the bed, with several pieces of electronics equipment plugged into them.
Donnelly said the fire was caused by careless smoking, although the official fire report leaves the cause as undetermined.
The investigation
Police asked the county for copies of the emergency communications logs and a recording of Orr’s phone call as part of their investigation of the fire.
After he listened to the recording, Sgt. Scott Brobst wrote a memo to Donnelly, saying, “There appears to be a problem with the initial call that Brenda Orr made to the 911 dispatch center.”
The memo outlines the timing of the rings. Brobst notes that “all 911 calls are supposed to be answered within four rings.” County officials would not confirm if that is their protocol.
The Pennsylvania Emergency Management Agency’s Public Safety Emergency Telephone Program dictates that emergency calls must be answered by trained dispatchers within 10 seconds of the call at least 90 percent of the time.
Brobst’s memo also notes the additional delay created when Orr was put on hold.
“While this almost one-minute delay may not have changed the outcome of this incident, we will never know if a rescue of Brenda Orr could have been effected if there was not a delay. In 40 seconds a fireman or police officer probably could have searched and exited the entire home. Could this have been long enough to make a difference?” Brobst wrote.
“This issue needs to be addressed and resolved with the Bucks County 911 Center.”
Donnelly received the memo Monday morning. He asked communications room supervisor Dennis Forsythe about the delay.
A memo from Donnelly to Doylestown borough manager John Davis and Fire Marshal Cell said Forsythe told Donnelly the dispatcher had been disciplined.
Donnelly also asked First Assistant District Attorney David Zellis if the delay might be a case of criminal negligence or involuntary manslaughter, and Zellis said it was not.
Zellis said Thursday: “There’s no crime here. There would have to be recklessness or gross negligence. And in this situation, that wasn’t the case at all.”
He also said the dispatcher did not intend to delay the response to Orr’s call.
“This is an unfortunate tragedy that happened,” he said. “But that does not mean it translates into a crime.”
County spokeswoman Stacey Hajdak said emergency communications officials have been investigating the incident since it occurred.
A single-page press release issued Thursday by the county states: “The investigation disclosed that internal practices were not followed. Corrective action was taken, including staff retraining. Additionally, our employees were offered access to the employee assistance program for counseling services.”
Hajdak said she could not provide details about the practices that were not followed, identify the dispatchers or say what corrective actions were taken; she said it’s a personnel matter.
She could not say what — if anything else — the county has done to prevent the incident from happening again in the future.
The official response
Commissioners Charley Martin and Jim Cawley did not return calls for comment.
Commissioner Diane Marseglia said she learned about the call Tuesday and listened to the recording with Cawley Wednesday.
“It’s hard to listen to because you know what happens in the end,” she said. “When you listen to something afterwards, you feel like you just want to jump in and tell everybody what’s going to happen and what they need to do. It’s incumbent upon everybody, in the memory of that person, to find out how we can make sure this never happens again.”
Marseglia said she was told the male dispatcher who first picked up Orr’s call was on another line dispatching an ambulance at the same time, and had asked someone else to grab the phone.
“I think we need to set up the phone system so that if someone is busy, it can go to an open line,” she said.
Marseglia said she wants to examine the county’s emergency call system and related protocols, and make any changes necessary to prevent another delayed response.
Doylestown Council President Det Ansinn said the county’s official lack of answers, aside from Marseglia’s remarks, is unacceptable.
He and other borough officials still want to know why it took so long for a dispatcher to answer Orr’s call, why she was put on hold, what happened while she was put on hold, why it took the dispatcher so long to send help and what the county will do to ensure it never happens again.
“No comment is not a sufficient response for our first responders and our law enforcement officials,” he said.
“We’re looking for a response from the county. Our hope is that we do receive more than what the press received…With a loss of life, we are going to get answers.”
Ansinn pointed out that every municipality in the county relies on the emergency communications center.
“Everything hinges on this and we need to have confidence in this system.”
Elwood Fire Rescue
https://www.evfc160.com/main/article.php/20080209085148335