CINCINNATI, OH (FOX19) - Less than 12 hours before Michael Foster, 30, was found dead on the floor of his West Price Hill residence, his landlord called 911 and asked for officers to respond to help him.
But police never came.
They were never even dispatched, police records show.
Foster's landlord, William Spivey, wanted police to come to the home on North Overlook Avenue.
He thought Foster was suffering a possible mental condition when he dialed 911 at 10:32 p.m. Oct. 5, 2016, according to a memo for the police chief.
"Mr. Spivey stated Mr. Michael Foster had recently lost his job and was now having a 'mental breakdown' and was lying on the floor acting like a two-year-old and saying he could not hear or see," wrote Sgt. Thomas Mullis of the city's Emergency Communication Center wrote to Chief Eliot Isaac on Oct. 21, 2016.
"Mr. Spivey requested officers respond in order to get Mr. Foster help."
One of the city's senior call takers, LaShonda Harris, talked to Spivey.
But instead of immediately entering an Mental Health Response Team (MHRT) run into the 911 system that would have sent officers to the home, "Harris explained the possible response of officers and why they may not be able to force Mr. Foster to go into treatment," Mullis wrote.
"Mr. Spivey then requested officers not respond so he could attempt to gather additional information as to Mr. Foster's mental state."
Harris closed the run with no officers being dispatched.
A second 911 call about Foster came into Cincinnati's 911 center at 12:18 p.m. the following day.
He was dead in his bedroom on the second floor.
"My son resides here," Marilyn Cowan said, according to a recording of the call released Monday to FOX19 NOW.
He just called me. His roommate did not come down from upstairs. He went up to get him. I just got here and we believe he's deceased."
She requested help and said Foster was "just laying still."
The call taker asked if anyone wanted to attempt CPR.
"I just got here and he feels very hard. No, he's laying on his stomach. There's no response. I don't think CPR would help," she responded.
Photo of the scene released to FOX19 NOW show Foster face down on his left side.
Further review of the initial call received by Harris on Oct. 5 revealed she made no attempts to ascertain the availability of weapons to Foster, who possibly was in a mentally unstable condition, according to Mullis' memo to the chief.
"The narrative of the run was also found to be incomplete and did not accurately reflect all information obtained from Mr. Spivey. Mr. Spivey was also not asked to provide a phone number," Mullis wrote.
Officials with the Hamilton County Coroner's Office said Foster's death was ruled accidental due to subdurral hemorrhage: Blunt trauma to the head from a fall.
The contributory cause was acute and chronic alcoholism.
His death certificate indicates the time frame between onset and death was "hours."
According to his toxicology report, Foster had a very high amount of alcohol in his system, 0.329. That's four times the legal limit in the state of Ohio and the equivalent of drinking a 12-pack of beer.
Foster was only presumptively positive for cannabinoids (marijuana) but that finding was not confirmed, the report shows.
This is another case of Cincinnati police not being properly sent to an emergency. It's an issue that came to the city's forefront this spring when 16-year-old Kyle Plush died in his mini-van despite twice calling 911 for help when he became trapped underneath a third-row, rear seat.
We reached out to police officials and asked if they wanted to comment on the incident, but they declined.
Tom West, president of the union that represents Cincinnati 911 call takers, American Federation of State, County and Municipal Employees (AFSCME) Local 1543 did not respond to three calls over the last month for comment for this story.
We also have reached out to him in writing but did not hear back.
FOX19 NOW requested a copy of the Oct. 5, 2016 call between Foster's landlord and the call taker.
After several weeks, police officials told us that, while a recording of the Oct. 6 call to 911 was retained as part of Foster's death investigation, a recording of the Oct. 5 was not.
It was not clear why. A police spokesman has not responded to that question.
"We have confirmed that the City no longer has the audio for the first or second call on our recording system," elaborated Assistant City Solicitor Ashley Pannell in an email to FOX19 NOW.
"Our recording system sequentially deletes audio automatically that has fallen outside of our retention period. The audio in this case would have been deleted sometime in early 2017."
The call taker's discipline for her handling of the call was still being worked out in early 2017.
Harris' actions, according to Mullis' memo, were in violation of Cincinnati Police Department rules and regulations and disciplinary process, which states:
- Members shall not commit any acts or omit any acts, which constitute a violation of any of the rules, regulations, procedures, directives or order of the department
- A negligent violation which may lead to risk of physical injury to another or financial loss to the city
Emergency Communications Section Standard Operating Procedure Call Taking Guidelines state:
- It is the responsibility of the call taker to verbally verify the incident location, the location of the caller, and the caller’s name and phone number on each and every call
- When a dispute, conflict or confusion arises regarding jurisdictional boundaries or whether a city of Cincinnati response is appropriate, the ECS employee will dispatch appropriate city resources without delay.
- Each incident has been assigned a priority based on multiple factors
- The call taker is responsible for obtaining adequate information from the caller to determine the severity of the incident and assign the proper incident type
- Conduct an efficient and thorough interview for each call received and be mindful to obtain all necessary information
- Input clear and concise information that is easily understandable by dispatchers and responder
- Members shall exercise the responsibility and authority of the position to which they are assigned in accordance with job specifications and work rules
A review of Harris' personnel records at the time of the call showed no previous violations in the past 36 months, according to Mullis' memo.
When we reviewed it, we found records showing she had an Employee Supplement Log (ESL) for Neglect of Duty in September 2015 for sleeping on the job.
An ESL is defined by Cincinnati Police Department Policy as an entry or note in the Employee Tracking Solution which documents personnel work performance, corrective measures, discipline and interventions to enhance employee effectiveness.
These entries are used as supporting documentation for employee evaluation and are not considered discipline.
Harris, 49, was hired as a 911 operator in September 2003, promoted to assistant operator and dispatcher in December 2006 and voluntarily demoted to operator in 2007. She quit in September 2010 and then was rehired as a 911 operator in June 2014.
She was rated "Meets Expectations" on her latest job performance evaluation and noted for performing expected duties "very well."
"She is well respected among her peers and by her supervisors. Harris can be relied upon to complete any task asked of her by her supervisors and is willing to help others in anyway possible. She is thorough, accurate and efficient when taking calls and entering runs."
She has received commendations in her personnel file for her "great" job handling a call with a baby being assaulted and remaining calm on another call handling a hysterical mother whose children were kidnapped.
Harris was rated "Does Not Meet Expectations" for attendance and received "10 chargeable incidents of absence during the rating period" and was in "Leave Without Pay" status three times.
"My goal is to improve my attendance so I can have a higher rating in the next review," she wrote.
"Emergency Communications Section requests (call taker) Harris be issued a written reprimand for the listed violations," the record states. "The violations and the proper handling of such calls will be addressed in detail with (call taker) Harris.
"A training bulletin also is being distributed to all Emergency Communication Section employees reminding them of our sole responsibilities when it comes to the handling of emergency calls for service."
Harris received a written reprimand Nov. 3, 2016, for violating policies and procedures during the call, police records show.
The union that represents call takers filed a grievance on her behalf, calling the reprimand "unjust," a copy of it shows.
Union officials requested the reprimand be removed from her personnel record and that she be "made whole," the grievance states.
The police captain who oversaw the city's 911 center at that time upheld the reprimand and informed the union leader it already had been reduced.
The captain, Jeff Butler, initially requested police administrators launch an internal investigation into Harris' actions, but Harris received the written reprimand without an internal investigation being conducted, records show.
"The approval and issuance of the written reprimand are narrowly and specifically related to her actions involving an emergency 911 call for service," Butler wrote in a Nov. 16, 2016 letter to West at the union.
"The review of the 911 call resulted from inquiries into the appropriateness of actions entered into the Computer Aided Dispatch System (CAD) following the response of the Cincinnati Police Department Homicide Unit personnel to investigate a suspicious death. The ensuing review by the Quality and Assurance Supervisor identified multiple failures to meet call taking guidelines, training standards, failures to dispatch emergency medical and/or police services and providing legal advice to the caller.
"The actions of the Emergency Communications Section personnel failed to meet the basic mandates and responsibilities with the position and rose to the level of more serious Rule violations for the Cincinnati Police Department.
"However, additional factors including overall work performance, training records and initial acceptance in performances were considered in mitigation to reduce the corrective action to a written reprimand."
His letter was copied to the police chief and Joe Wilson in the city's human resources department.
The union proceeded with continuing to try to have the reprimand tossed altogether, according to an email exchange between Butler, West and then-Executive Assistant Police Chief Dave Bailey.
The union had filed grievances on not only Harris' reprimand but ones given to two other call takers, Klia O'Neal and Mary Teal, who were reprimanded for a separate incident on Sept. 10, 2016.
In the September 2016 case, a lieutenant alerted the chief to an allegation of "lack of proper service" in Madisonville.
The 911 center received three calls for service about a naked woman found in the rear of a Bramble Avenue residence, according to the memo written by Lt. Dennis Swingley after Butler asked him to investigate.
The allegation: "Although the unidentified woman alleged she escaped from a neighboring house after being held against her will, personnel from the Emergency Communications Section failed to gather essential information and dispatch appropriate city resources to determine the welfare of the female and the circumstances surrounding her allegation."
Swingley concluded the two dispatchers were found to be in violation of one rule related to work standards, the memo shows. They are required to verify information, properly document calls for service and dispatch officers accordingly.
Swingley recommended written reprimands for both dispatchers.
That was approved by Butler and Bailey, the memo shows.
But ultimately, all three women's written reprimands were reduced to ESLs. Employee Supplement Log (ESL).
That's defined by CPD policy as an entry or note in the Employee Tracking Solution which documents personnel work performance, corrective measures, discipline and interventions to enhance employee effectiveness.
These entries are used as supporting documentation for employee evaluation and are not considered discipline.
"Need to discuss in house policy on absenteeism and caller expectations. There is no way I can believe we have call takers on the floor believing their mission is to find a way to not send proper service calls," Bailey wrote in February 2017 email to Captain David Fink, by then the ECC director and other city officials including Darla Meadors in personnel.
Bailey wrote an email to Butler and West in November 2016 that sheds insight into the quandary administrators felt when issues came up.
"I am aware of the sometimes contentious relationship between management and labor," Bailey wrote to Butler and West in an Nov. 21, 2016 email copied to Wilson and union and city personnel officials.
"It goes with the territory and can be healthy as long as it doesn't become personal. But believe me, in the past year, I have seen how dysfunctional it can become. This does nothing for either side.
"On one hand, management should expect folks to consistently come to work and perform the duties according to the training and rules pertaining to their position.
"On the other hand, employees should expect an adult work environment which acknowledges mistakes do occur and there are times where they cannot meet their obligations to be at work. As long as neither are excessive, generally not a big issue.
"CPD does not endorse heavy handed administration of employees. This leads to the large turnover we have experienced at (the city's 911 center) and creates an environment more analogous to incarceration.
"As far as the Call Taker reprimand issues – I have never known of any training that suggested the call taker has the ability to determine if a caller's situation merits the response of emergency personnel," Bailey wrote.
"Statements such as where we won't respond if she doesn't want to prosecute is not appropriate and is a dangerous assumption not to mention the liability that goes along with it.
"For those who represent these employees and believe differently, I would also question their judgement.
"As far as the shift selection – I believe seniority should be used to select the employee's shift.
"As with the FOP agreement, I see no provision pertaining to actual off day groups? If I am wrong, I will make sure I correct it immediately.
"And, finally, I am disappointed our attempts to make a specific difference in the overall (911 center) operation have been mired in all these personnel disputes. I think all of us could do better."
Bailey was ousted in March by now former City Manager Harry Black. According to the police union president, Bailey was forced to resign.
Butler has filed a federal lawsuit against the city, Black, the mayor and police chief. New allegations added in April allege Isaac turned a blind eye to felony theft for "systematic abuse of police overtime."
An attorney for Butler and Bailey declined to comment for this story.
At the request of Hamilton County Prosecutor Joe Deters, State Auditor David Yost's office is now looking the allegations in Butler's lawsuit, including misuse of 911 funds.
Auditors are completing that work as part of the city's regular annual audit, which is underway now, Yost has told FOX19 NOW.
"There have been no issues with access to information, and everyone has been cooperative with all of our requests to date, and there has not been a need for unaccounted meetings," Benjamin Marrison, a spokesman for Yost's office, wrote in an email Thursday in response to our request for an update on both audits.
"The auditor is unable to provide more information, as the audit work is still underway."
Black resigned in April minutes before he was fired, ultimately over problems with the 911 center in the wake of Plush's tragic death that lost him his majority support on council.
Cranley and other elected officials have called for a review of the city's emergency communications center, which has struggled with problems for years.
Bailey and Butler were among a group of former and current employees who testified about issues with the 911 center during a lengthy public hearing at City Hall after Kyle's death.
Problems 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.
The city also 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 June, daily management of the facility was changed from police to civilian control yet again.
The acting city manager abruptly announced Jayson Dunn, who heads the city's technology department, was replacing a veteran police captain who was just assigned in March to command the 911 center.
The city has hired two independent contractors to take in-depth looks at the current organizational structure of the 911 center and help the city decide once and for all whether it should be placed under police or civilian control.
Findings are expected to be released in the fall, once council returns from summer break.
Council also recently earmarked nearly a half million dollars to make improvements at the 911 center and hire more employees.
And, earlier this month, the city launched "Smart 911," new technology to provide critical information to first responders when calls are made from cell phones and landlines.
This all came as council met every other week since Kyle's death through June to publicly discuss the case and the police investigation into it, which left more questions and answers.
Kyle's father has been asking several questions and urging accountability from the city and its police department.
All failures that occurred the day his son died, he has said, must be identified and addressed so another family doesn't lose a child.
Ron Plush also urged city and police officials to learn from the past and not repeat mistakes such as the response by police and call takers to a report of a shooting in Walnut Hills in January 2017, a story first reported by FOX19 NOW in June.
The response to the Washington Terrace shooting that ultimately turned into a homicide has several similarities to the response when Kyle called 911 twice begging for help but still suffocated to death inside his van.
Ron Plush read our story out loud during one of Cincinnati City Council's final Law & Public Safety Committee meetings.
"It was very disturbing to hear this… and to know that there is a history of this. Again, we can't change this, but we can change what happens in the future," he told council back on June 11.