CINCINNATI, OH (FOX19) - Several current and former city and police employees testified at a special meeting Tuesday as city leaders attempted to determine what went wrong when 16-year-old Kyle Plush called their 911 center twice for help -- but didn't receive it and died.
New information received before the meeting stated the system did not crash and was operational throughout his phone calls.
An email sent to the city from Tri-Tech showed:
- The CAD did not crash and was operational throughout the event.
- One of the workstations running CAD in the back-up center was re-started prior to the 2nd 911 call. This workstation was operational at the time of the call and logs show there was normal operator activity before during and after the call.
- CAD does not control or interact with the audio of the 911 calls and could not affect the quality of the voice in the headset.
"I feel blame personally and we are all sorry," Mayor John Cranley said to the Plush family during the hearing.
Cranley said it was brought to his attention that 911 center staffing is down 30 percent.
"Being 30 percent down impacts morale on overtime, on productivity, on turnover... and given the stakes... I hope today we can hear from everybody why we didn't' treat this as serious we would brown-outs or critical loss of police personnel," he said.
In May of 2016, the call center lost 24 dispatchers, which a computer analyst said is a significant drop.
"The job is very difficult. You never know what you're going to get when you answer the phone. It's been a great struggle for two-plus years," ECC Computer Systems Analyst Jennifer King said.
There are still a lot of unanswered questions about why Cincinnati police and a Hamilton County deputy sheriff didn't find Kyle when he called April 10 begging for help. And why information from his second, more detailed call was not shared with them.
"Any deficiencies that may be found on the government's part must be called out, responsibility taken and measures taken to ensure any discovered deficiencies are cured," City Manager Harry Black said.
Kyle died due to "asphyxiation due to chest compression" after becoming pinned by a folding seat in a 2004 Honda Odyssey minivan, authorities have said
"A lot went wrong," Vice Mayor Christopher Smitherman said. "I believe that we'll hear that some balls were dropped. And I plan on pushing accountability."
Smitherman said the 911 call center employment numbers are "stunning."
King agrees and said part of the problem is the time it takes to recruit, hire and train.
At least three investigations are underway to try to determine what went wrong, and the two police officers and deputy who responded to Kyle's first 911 call did not find him.
"This is a death investigation... at the completion of this investigation, we will have those answers. We hope to know what went wrong: human, technical error or combination of both," Cincinnati Police Chief Eliot Isaac said.
The teen was not found until about five hours later after his mother also had called 911 and then his father went to the school, located off Red Bank Road in Madisonville. The father found his son dead inside the van.
"If you're in an emergency you don't get to make two calls. Kyle clearly did exactly what he was supposed to do. It should not take two calls to get the right response," Council Member P.G. Sittenfeld said. "There is no reason Uber should have more specificity then our response center."
Cranley and other elected officials have called for a review of the city's emergency communications center, which is run by Cincinnati police and has been plagued with issues for years.
"The events leading up to Kyle's death are devastating and also raise concerning questions about our City's emergency 911 system and police response," Cranley said last week.
Problems with the 911 call center go back at least four years, he said, and he suspects whatever or whoever failed Kyle needs to be held accountable.
"I'm talking about, obviously the city manager, because the city manager is the CEO of the city, so that's one area, but who else is responsible?" Smitherman said.
Council passed a unanimous motion in February to review the 911 call center after Smitherman toured the site.
"It was about technology and streamlining it and making sure all the systems are communicating with CAD (computer-aided dispatch)," he said.
Elizabeth Christenson, a former worker at Cincinnati's 911 call center, said it was not a technology issue at the facility.
"It became one of the worst working environments... my health suffered," she said. "Disrespect from upper management. We were berated, yelled at, low morale. We have to invest in our people. I don't know how some people are still working there."
Smitherman said he wants to know what improvements have been made since then.
The dispatcher who answered Kyle's second and most detailed 911 call, Amber Smith, has told supervisors she didn't hear Kyle's second and most detailed call, a police report shows. In that call, Kyle gave the model and color of his van and indicated the situation was dire. He indicated he was in trouble and even said: "Tell my mom I love her if I die."
Tragically, that information was never given to police and the deputy searching for him.
When asked if the officers who responded to the scene got out of their vehicles, Chief Isaac said they do not know at this time.
Smith was placed on paid administrative leave last week, a customary move in such situations, but is set to return to work on Wednesday.
"She will not be assuming the position of taking 911 calls or dispatching capacities. She will be assigned to administrative duties," Chief Isaac said.
Smith was honored last year for helping to track a 9-year-old girl trapped in a car while her parents overdosed on heroin on Quebec Avenue, police have said.
The March 2017 call and Smith's fast work to calm the scared child and use cell phone technology to track the location of the family's SUV saved their lives, police have said.
But 10 minutes before she answered Kyle's call, the dispatching system may have malfunctioned, preventing his call from coming through her earpiece, though the recorded version is clear as day, according to the leader of the union that represents Cincinnati police.
"The officers did not receive the information necessary to get them to find this young man and so something went terribly wrong," said Sgt. Dan Hils.
Lt. Col. Dave Bailey said the communication center has suffered issues for at least the last decade.
"The police chief indicated, '... something went terribly wrong' in this instance which seems to suggest some isolated malfunction that occurred to an otherwise functional operation. Nothing could be further from the truth," he said.
Chief Isaac said the investigation could take 10 days.
The city has moved its troubled 911 center from police oversight to civilian management back to the police department with a revolving door of several various managers in recent years.
Issues have included low staffing, inadequate training, system-wide failures resulting in the computer-aided dispatch (CAD) system going down, police radios not working and cell phone call routing leaving some calls unanswered. City officials changed the subcontractor but problems remain.
Butler filed a federal lawsuit last year alleging Black and others were involved in a conspiracy to retaliate against him "for challenging their blatant misuse of state tax funds which should have been utilized for 911 emergency services and instead were unlawfully utilized for general Cincinnati budget purposes."
Butler ran the city's 911 center Jan. 3, 2016 until he was stripped of his managerial duties "with virtually no notice" on Jan. 1, 2017, according to the suit. During his tenure, he warned the police chief in a 2016 report the 911 center "has been negatively impacted by management failures."
Butler claims Black also misused federal Homeland Security grant money.
"City Manager Black's abusive behavior toward (Butler) is merely one example of his pattern and practice of misuse of funds, abuse of power and retaliation against law enforcement officers who challenge Black's unlawful behavior," the lawsuit reads.