District Fire Department officials conceded yesterday that the death of a Northeast man Sunday followed a long series of blunders in which an ambulance crew left a fire station without knowing exactly where it was going, failed to read a city map, drove to two incorrect locations, was not monitored by emergency dispatchers, and took 40 minutes to arrive at the man's home.

Mozone Kelly of the 1600 block of 11th Place NE died about 10 a.m. Sunday, shortly after relatives, who had given up waiting for the ambulance, wrapped the hemorrhaging man in blankets and drove him to D.C. General Hospital. Relatives said yesterday that Kelly, 38, was married and had two sons.

"We're not making excuses," said Capt. Theodore Holmes, spokesman for the Fire Department. "We just can't tell you why the people involved did not do what they were supposed to do. Clearly, it was their responsibility. They just did not do their jobs."

Holmes said fire and ambulance officials met yesterday to analyze the mistakes in Sunday's incident. The two ambulance crew members and two 911 employees are being reviewed by supervisors, Holmes said.

The department also will devise a plan to monitor the whereabouts of ambulances once they have been dispatched on emergency calls, to make sure that they are not delayed, Holmes said. No such procedure now exists, he added.

Family members, who said last night they had not received a call or visit from the Fire Department about the delay, reacted angrily to the department's explanation.

"This is something that's going to stick with us for the rest of our lives," said Macleta Oliver, Kelly's sister. "They may or may not have been able to save him, but now we'll never know. I could accept that it might have been my brother's time to pass away, but I can't accept them saying they were just lost."

The city's ambulance service was heavily criticized last year for careless dispatching and slow ambulance response times. There were eight reported cases in which patients died after D.C. ambulances were slow to reach them.

Holmes said Sunday's incident "certainly has a chilling effect on the average citizen who has been bombarded in the past 10 months or so with our problems."

Kelly's relatives said they called 911 three times in less than 10 minutes Sunday morning. They first called about 9 a.m. after Kelly, who relatives said had a blood disease, began bleeding profusely from the mouth and nose. Nancy Oliver, one of Kelly's sisters, said the family made two more calls, the last one to tell dispatchers that Kelly had fallen unconscious at 9:07 a.m.

Each time, family members said, they were told by dispatchers that an ambulance was "on its way now."

Holmes confirmed the family's account and said a dispatcher called an ambulance at a fire station on the corner of Rhode Island Avenue and Fourth Street NE.

But Holmes said the crew was confused by the dispatcher's directions, which placed Kelly's home at 11th Place NE, just off Holbrook. The dispatcher did not specify that Kelly lived off Holbrook Terrace, and not Holbrook Street, which is nearly a quarter-mile from Kelly's home.

Unsure where 11th Place was located, the ambulance crew asked firefighters at the station for help, Holmes said, and were given wrong directions. "They {the firefighters} thought it was off of Michigan Avenue," Holmes said. The location suggested by the firefighters is more than two miles from Kelly's home.

Without looking at a map, Holmes said, the ambulance crew departed from the station and initially drove to Holbrook Street NE. There they failed to find Kelly's home.

At that point, Holmes said, the crew followed the firefighters' suggestion and headed for the 1600 block of Michigan Avenue. They did so, Holmes said, without reading the city map in their ambulance, which would have shown both Holbrook Terrace and 11th Place only a short distance away.

After driving two miles to Michigan Avenue, they again did not find 11th Place NE, and for the first time they read the index of the city map, Holmes said. But the index did not list any location for 11th Place NE, he said.

"They realized then that certainly they were lost, and called for the dispatchers' help, who told them that they should drive to Holbrook Terrace," Holmes said. He said they arrived at the address at 9:38 a.m. By then, relatives had driven Kelly to the hospital.

In addition to the ambulance crew's errors, Holmes said, the employee who took the third 911 call should have increased the priority of the case after learning Kelly was unconscious. If that had been done, Holmes said, a paramedic unit or fire company would have arrived at Kelly's home in three minutes. The 911 crew also should have realized that they had not heard from the ambulance, Holmes said.

"No one realized until the ambulance finally called back that they were lost," Holmes said. "It was just a combination of things that led us to this incident. The ambulance chose to ride around the city rather than call right away for help, and the call-takers just didn't communicate with one another."

Holmes said Fire Chief Theodore R. Coleman, whom he described as "visibly shaken" by Sunday's incident, yesterday issued a new order in response to Kelly's death.

Henceforth, Holmes said, the District's 21 ambulance crews are never to leave a station "without knowing precisely where they were going."