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It happened again. DC 911 delayed sending help to someone who died. City officials confirm 11 minutes were lost before DC Fire & EMS crews were dispatched to a man who collapsed on Kennedy Street NW. Three 911 calls were made in the effort to get help for the dying man.
This is the sixth case STATter911 investigated this year where a person died and there were significant delays traced to DC’s Office of Unified Communications (OUC). Five occurred over the past six months. The victim on Kennedy Street, identified by family as Jesse Kyle, makes at least the 10th person in three years whose final moments were met with delays and mistakes by DC 911. Kyle was 69.
DC officials acknowledged the mistakes. They confirmed that staff deviating from protocols resulted a delayed dispatch of DC Fire and EMS. Deputy Mayor for Public Safety and Justice Chris Geldart tells STATter911, “I am confident from immediately after the call and succeeding days we located everywhere where we departed from protocol, or had an issue from this call, and have identified appropriate fixes and put those in place.”
At 10:22 a.m. on September 2, Jesse Kyle collapsed in an alley in the 800 block of Kennedy Street NW. Kyle’s friend, who did not want to be identified for this report, says they were walking to CVS to get medicine for Kyle when he fell. The friend called 911 and said Kyle was on the ground and didn’t appear to be breathing. He says he was told by 911 to roll Kyle on his side. The friend said at this point Kyle began breathing again. According to the friend, the 911 call ended with the call-taker saying she was going to send help.
According to a city official who spoke on background, the call-taker initially sent this call to the nurse triage line. Some low priority calls are first sent to a registered nurse to help determine the most appropriate care for the patient. The call-taker quickly realized this call was not appropriate for the nurse triage line. Instead, it was a high priority call. The call-taker upgraded the call, stayed on the line and told the man help was on the way. Unfortunately, the call-taker didn’t follow the proper protocol for canceling the nurse triage line option. The call was still directed for consultation with the nurses when it should have gone to fire and EMS dispatchers. The tragedy of this call is that it got to neither.
After about four minutes, the man called 911 again and said he was told by a different call-taker help was on the way. That wasn’t true. The city official says that the second call-taker saw the first call for the same address already in the system and assumed help had been dispatched. He didn’t realize it was still directed to, but not answered by the nurse triage line. So, despite two calls to 911, DC Fire and EMS crews were not dispatched. The friend claims Kyle was still breathing during the second 911 call. The man says this time he was on the phone with 911 for an extended period of time.
Another witness who talked with STATter911 confirms she called 911 around 10:33. This woman lives in the neighborhood and was passing by on her way to work. She says Kyle’s friend told her he called 911 a while ago. She too said Jesse Kyle was breathing. It was only after this third 911 call that the DC Fire and EMS Department was finally dispatched. This witness also didn’t want to be identified publicly. The city official says this call was treated as a separate event or incident and went straight to dispatch without delay.
Radio traffic (above) from OpenMHz.com shows Engine 24 and Medic 24 were dispatched at 10:33 a.m. about 11 minutes after the first 911 call. At 10:40, 18 minutes after that initial call, Engine 24 confirmed they were on the scene with a patient in cardiac arrest. Fire and EMS crews were unable to revive Jesse Kyle.
Last week, DC Mayor Muriel Bowser downplayed the significance of the deaths uncovered by STATter911 under questioning from a television producer. Bowser believes the reporting of these cases is cherry-picking when considering the large number of calls DC 911 handles without mistakes each year. A day after Bowser’s comments, a new report was issued by DC’s auditor saying only minimal progress has been made following last year’s audit calling for 911 reforms.
The city official says in the days that followed the mistakes surrounding Jesse Kyle’s death, retraining occurred at DC 911 on nurse triage line procedures. The nurse triage line staff is also seen as the fail-safe for this procedure. The official says anytime they see a call initially sent to them that has been upgraded they are supposed to verify with a supervisor that the call has been dispatched. Apparently that didn’t occur in a timely manner in this case. An after-action investigation and report has been completed that describes the problems that occurred during these 911 calls.
The woman who made the third call tells STATter911 this is not her first bad experience with 911. She’s a longtime DC resident who previously called 911 because her adult daughter was having chest pains. According to the woman, the wait was so long she drove her daughter to the hospital.
Jesse Kyle’s friend said he complained at the scene to police, firefighters and EMS about the lengthy delay getting help. The friends says fire and EMS on the scene told him they were in their quarters just six blocks away on Georgia Avenue when he made the initial 911 call at 10:22 a.m. The friend is wondering if the outcome would have different if those firefighters and medics were dispatched 11 minutes earlier. The friend told STATter911 that his experience shows DC 911 “has no heart and no compassion.”