CINCINNATI, OH (FOX19) - The findings of the two independent investigations into how Cincinnati police and 911 call takers responded to Kyle Plush’s 911 calls was presented on Thursday to City Council.
The investigations clear Cincinnati police’s response to Kyle’s two 911 calls for help as he was trapped inside his minivan at Seven Hills School in Madisonville April 10, but heavily criticizes the 911 center’s handing of the calls.
Kyle suffocated to death and was not found for hours - and he was found by his father who went to look for his son when the 16-year-old didn’t come home.
Ron Plush told City Council he found the report “very disturbing.”
“I have no reason to believe that if someone called 911 trapped in a van that this wouldn’t happen again. What has changed?”
Hamilton County Prosecutor Joe Deters also conducted a separate probe into Kyle’s death and released his findings just before Council’s meeting began.
He said no criminal charges will be filed.
“My sympathy goes out to the Plush family on the loss of Kyle. It is impossible to imagine the pain that they must feel over his untimely death.”
Cincinnati City Council turned to an outside investigation after they and the Plush family were less than impressed by Cincinnati Police’s probe.
It fell short of answering critical questions and City Council members and the Plush family had to pull more information out by asking a series of questions and holding more meetings.
The independent report released Thursday found much fault with the 911 dispatchers’s handling of the call and the police internal investigation into Kyle’s death.
“Systematic institutional failures - especially when a tragic series of small factors and issues align to produce heartbreaking outcomes - tend to be unsatisfying explanations for why bad things happened. It is perhaps easier for us to come to terms with a tragedy that has occurred because of the bad acts of one person, a particular failure, or some concrete cause,” reads the report released Thursday by 21CP Solutions of Chicago.
“It is harder when the cause of that tragedy is diffuse or is a series of issues that, on their own, may not have led to it but, when taken together, set in motion a kind of ‘perfect storm’ that led to a terrible outcome.”
The first call taker,the report released Thursday shows, failed to ask Kyle for his name and assume it was a female and the first 911 call wasn’t entered into system until seven minutes after it came in, the report shows, when the coordinates could have been used right away.
The second call taker switched to a system used to take calls from those who are hearing impaired when she didn’t hear Kyle and never turned it off, the report states. She was not familiar with the system and may have been able to hear him if she had turned it off.
The report also criticized the city’s backup 911 center, saying it had was noisy, distracting and had a bad layout. The 911 center overall has bad policies, is troubled by technical issues and a mapping system only available for call takers to see, not officers in the field responding to situations.
They made several recommendations including involving staff to create a comprehensive strategic planning, letting them process all changes before implementing further major initiatives, implementing a stress management program, retraining, cross-training, improve noise reduction and vet the entire system with full load testing prior to next use.
As for the internal police investigation into the situation, the investigation found it would have been helpful to have video, not just audio, recordings of the interviews with the officers who responded to Kyle’s calls.
They also noted that they had some concerns about some of the questioning and interviewing techniques that police internal investigators used at various points.
“In particular, greater care should be taken in the future to avoid overly leading questions - especially before an officer had been afforded an opportunity to describe events in their own words without excessive prompting or follow-up,” the report states.
They recommended CPD:
- Video record all internal investigation interviews
- Explore training opportunities relating to situations like this, involving trouble or suspicious circumstances
- Implement policies and protocols to ensure that it independently interviews non-CPD personnel that are implicated or involved internal investigations
- provide cross-training to CPD officers on emergency communications and police dispatch. That training should focus on the basic processes and protocols for 911 calls and the various technological tools that emergency dispatch may utilize. This recommendation also was given to the city.
- Should consider roll call or refresher training on its body-worn cameras policy, with an emphasis to use during situations or interactions not involving a specific subject or other core law enforcement activities (such as a stop, probable cause detention, premises, search or the like) and the decision-making process for deactivating the camera. CPD “appropriately sustained” findings against responding officers for shutting off their body cameras before starting to interact with the off-duty deputy sheriff at the scene and before the call was closed.
City Council did take prompt action following Kyle’s death and pledged sweeping changes to emergency response procedures.
They approved $454,000 to increase 911 staff and to improve technology at the 911 center as part of a 12-month action plan.
They took oversight of the 911 center away from the Cincinnati Police Department and returned it to civilian control.
The city also launched a new system called Smart911 designed to make it easier for first responders to find 911 callers in an emergency.
Once people register for it, their emergency information will automatically be displayed to call takers when they dial 911.
As part of those reforms, city council also hired two firms to conduct the independent investigations at an estimated cost of $186,000.
Mission Critical Partners LLC analyzed how dispatchers responded to two phone calls Kyle made from the van, pleading for help after he became trapped by the rear, third-row seat.
They also conducted an comprehensive analysis of the city’s Emergency Communications Center (ECC) and look at staffing, organizational structure, leadership, and technology.
That portion is expected to cost no more than $98,200, city officials said.
21st Century Policing LLC focused on the Cincinnati Police Department’s actions that day and will review the department’s current policies, procedures, and training to identify deficiencies.
The cost was $87,500.
The city sought independent probes after they were left with more questions and answers when, back in May, Cincinnati Police Chief Eliot Isaac presented the results of the agency's investigation into Kyle’s death and response by police officers and 911 call takers.
Kyle’s family have been supportive of the independent investigations, but criticized them Thursday once they saw the final product.
They said they were not comprehensive enough.
They have said they still are searching for answers and won’t stop seeking those in an effort to spare other families that pain.
They also have established a foundation in their son's memory.
“Kyle Plush Answer The Call Foundation” calls for improved 911 systems in Cincinnati and nationally.