A series of miscues, poor communication and outright apathy led five firefighters to ignore desperate pleas to treat an elderly man who had collapsed across the street from a Northeast Washington fire station and later died of a heart attack, according to an internal report, made public Friday, urging that all five be disciplined.
Three firefighters who were in the station’s kitchen and a veteran lieutenant heard two announcements by a just-hired firefighter but didn’t immediately react. When one firefighter finally sought out the station’s lieutenant, instructions were unclear or dismissed. Instead of rushing across the street to help, the firefighter retired to his bunk bed to study for a promotional exam, the report produced by the mayor’s office says.
Meanwhile, Medric “Cecil” Mills Jr., 77, lay sprawled in his daughter’s arms in the parking lot of the Brentwood Village Shopping Center on Rhode Island Avenue, directly across the street from the station, for more than 10 minutes.
The report details for the first time the dysfunction inside the fire station that houses Engine 26 and Truck 15 and lays out a timeline showing that Mills and his daughter were anxiously awaiting help that came only when a D.C. police officer flagged down an ambulance that happened to be driving by.
“I’m disappointed. I’m angry,” said Paul A. Quander Jr., the deputy mayor for public safety, who wrote the report. “This should not have happened. There are systems in place to prevent it, but there’s also common sense. You can’t turn a blind eye. You can’t be aware that someone needs help and then go back to the kitchen or back to your bunk. It’s unacceptable. It’s unconscionable.”
Compounding the mistakes that afternoon on Jan. 25, a fire engine, supervisor and a medic dispatched to help Mills were speeding to the wrong address — to a rowhouse 2.6 miles away in Logan Circle: 1309 Rhode Island Ave. NW instead of the same numbered address in Northeast.
By that time, the firefighters inside the station mistakenly concluded that help was coming, the report says. District officials said the firefighters failed to follow department rules and erred by telling bystanders who knocked on their door that they couldn’t respond until someone called 911 and a dispatcher instructed them to do so.
All five firefighters assigned to Truck 15 — the only vehicle there at the time — and four emergency dispatchers face discipline that could range from reprimands to termination if found guilty. The lieutenant, 28-year veteran Kellene Davis, has been charged with a misconduct offense and faces an internal administrative hearing, similar to a trial, on March 4, according to two city officials. She has submitted her retirement papers.
Quander would not describe the charges, citing personnel rules. But he said that one firefighter and the lieutenant are on administrative leave with pay. Remy Jones, the just-hired firefighter, who can be fired without a hearing, has been reassigned. So far, no action has been taken against the other firefighters or the four dispatchers in the Office of Unified Communications.
Davis and other firefighters could not be reached Friday to comment. Ed Smith, head of the firefighters union, said he did not want to comment until he had read the report. He has been critical of how the firefighters handled the incident.
Jones, who graduated from a cadet program two months before Mills died, declined to comment Friday, as did Fire Chief Kenneth B. Ellerbe, who referred questions to Quander.
The Mills family has hired a law firm but so far is seeking only to change the law to make it easier to sue public officials in the District. Attorney Karen E. Evans said Mills’s wife and children were reviewing the report Friday afternoon. She described the report as “absolutely worse than I thought it would be,” saying that the firefighters sounded “cavalier and heartless.”
Evans said that right now, the family is seeking ways to implement reforms. Mills’s daughter, Marie, indicated that her father would’ve said, “ ‘Can’t we send them back for training?’ He would’ve hated for folks to lose their livelihoods over this. He would’ve given them a second chance.”
The fire department will face additional scrutiny Monday when the D.C. Council’s public-safety committee holds a hearing on the incident.
Quander’s report says that after Mills collapsed, a store clerk called 911 at 2:44 p.m. About that time, a bystander approached the front door of the station and told Jones, who was standing watch, that it appeared a man had slipped on the ice and passed out near a liquor store across the street. The 911 call and the bystander’s plea set off a chain of simultaneously bungled but separate events, according to the report.
Inside the station, Jones made an announcement over the public-address system asking for Davis, the lieutenant, to come to the watch desk. A few minutes later, another person drove up to the station in a white Toyota and told Jones, “There’s a man across the street that needs help.” Jones made a second announcement, saying it was “urgent.”
Davis “failed to respond to either request,” the report says.
Three other firefighters were in the kitchen near the back of the station. The report says that all three heard Jones’s announcement. One told another to ask what Jones wanted. Jones asked if they could help the injured man, the report says, but an unidentified firefighter told him that they needed to first check with the lieutenant. The firefighter found Davis in the bunk room, the report says, and she told him to get an exact address for the call.
The firefighter then told a colleague, “The rookie had a man down across the street, so I let Lieutenant know we should be going on the run.” He then “gathered his personal items and study books from his car and went to the bunk room,” the report says.
He never returned with the address, and he later told the lieutenant that he heard that other units had been dispatched so they weren’t needed. What the firefighters didn’t know was that the dispatched ambulance and other vehicles were heading to the Northwest address instead of the Northeast one.
The initial 911 caller gave the address but at first omitted the quadrant. The report says a dispatcher assigned it Northwest. On a 911 tape released by the District, a man can be heard talking to the dispatcher as Mills’s daughter screams: “He’s not breathing! He’s not conscious!”
The caller says there’s a fire station right across the street, but the dispatcher says he needs to log it into the system. He then repeats the address, saying Northwest. The caller corrects him, saying, “Northeast,” and the dispatcher says, ‘Oh, okay — help is on the way.”
The report says the dispatcher did correct the mistake on a call slip but that the correction was overlooked by another dispatcher who takes the calls and broadcasts them over the air. When a second 911 came in with the Northeast location, a dispatcher thought it was a duplicate of the run to Northwest and canceled it.
It took a little over 10 minutes before the address was corrected and help got to Mills, just seconds after the D.C. officer had flagged down help on his own. Mills had collapsed a few seconds before 2:44 p.m. and saw his first emergency medical technician just before 2:56 p.m. He was taken to MedStar Washington Hospital Center at 3:07 p.m., where he died a short time later.