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A teenager was drowning. 911 sent help to the wrong place.

Angela Stefkovich and her friends needed help. She called 911 expecting to get it.

“Hi. We’re at River Creek, the club in the back,” the 16-year-old said, her voice cracking with panic. “We’re like, all swimming in the river. We had a friend swimming and he’s under the water, but we like literally cannot find him.”

She thought it would take only minutes for rescuers to drive over and jump into the wide, gentle creek in Virginia that leads to the Potomac River. Angela stayed on the line for eight minutes, giving more details of her location: The name of a nearby park and a description of the gated community with a small dock that’s a popular swimming spot.

“It’s, like, in a small inlet off the Potomac, so it’s not that deep,” the teen said.

What followed was an ill-defined and confused emergency response that began after her call had bounced one state over, to Maryland. A 911 center there launched a protracted boat rescue without looping in their Virginia counterparts. When they finally did so, and when calls started coming directly to Virginia, 911 operators there were slow to react.

It took 36 minutes for an ambulance to arrive.

Fitz Thomas, 16, drowned June 4 in Goose Creek in Loudoun County, Va. It took 36 minutes from the time his friends first called 911 for an ambulance to arrive, as operators dispatched a rescue team to the wrong location. (Family photo)

By then, the teenagers — joined by a man who had been walking his dog — had found their friend, pulled him from the water and started CPR. Fitz Thomas, a 16-year-old who had been excited to enter his senior year of high school, never regained consciousness.

“The feeling that all of us kids went through was complete hopelessness,” Angela said in a recent interview. “We called at least eight times.”

Montgomery County, Md., and Loudoun County, Va., the jurisdictions that responded to the calls and are separated by the Potomac River, said they have improved some policies even as they continue to investigate how things went wrong. What can already be seen — based on a review of 911 recordings and dispatch reports — lays bare how immediate 911 responses are still not guaranteed at a time when smartphones can summon an Uber to the spot where customers are waiting.

The 911 center struggled to immediately map a precise location for Angela, according to the recordings and reports. And she could not zap over a photo or video of the scene playing out before her. But technological shortcomings have long-burdened 911 systems, originally built for landline phones, meaning that traditional, rigorous questioning and careful listening are as critical as ever in learning the basics of any emergency: Where is it and what is going on?

Those efforts failed in the search for Fitz, experts said, after the Montgomery call center locked onto a flawed, open-water rescue the moment Angela said the word “river.” Then, as Angela and other callers offered both counties more details about a drowning in a Virginia creek, chance after chance was missed to correct that course.

“Too much routine. Too little curiosity of what was going on,” said Glenn Marin, a 40-year veteran of the 911 industry who serves as an expert witness.

It’s not clear that a faster response would have saved Fitz’s life. The teen was underwater for several minutes before the first call. But noting how many operators and supervisors were involved in the response, Marin said both centers need to address their operating cultures.

“If they don’t fix that, it’s only a matter of time before they have another disaster of a response like this,” he said.

People put their canoe in the water at the River Creek community in Leesburg, Va., which sits along the languid Goose Creek before widening into the Potomac. The larger body of water separates Loudoun County, Va., and Montgomery County, Md. (Michael S. Williamson/The Washington Post)

IT WAS STILL close to 90 degrees late the afternoon of June 4. Six teenage friends met up along the languid creek that was becoming their summer hangout: Swimming, lounging on floats, talking up on the dock. To their left, about 100 yards away, the creek opened into the wide Potomac River.

Fitz’s arrival, as always, portended a mood of relaxed joy.

At just 5-foot-7 and 146 pounds, he was a tough running back on the football field, but would cut up with dances in the locker room and school hallways. He made friends with ease.

“He could bring people together,” said his football coach, Brian Day. “These days, kids just need someone who makes the room okay. You could see it in the other kids: ‘Fitz is here, so I can be myself.’ ”

Soon after the group arrived at the creek around 5:45 p.m., Fitz and another teen started to swim across — about 180 feet. His friend made it, looked back, and couldn’t see Fitz. The first thought among the group: He was playing a joke, maybe crouching near the tree-lined banks. They started searching. From the bank, Angela pulled out her iPhone and tapped 9-1-1.

Decades ago, in an era of land-based phone lines, 911 calls stayed in the jurisdiction where they were dialed. Nowadays, with smartphone calls directed by tall towers, 1 in 10 calls get bounced into a neighboring jurisdiction, according to a trade group, the Alliance for Telecommunications Industry Solutions. The problem is especially common along river boundaries.

Angela’s call was answered just before 5:49 p.m.

“Montgomery County 9-1-1. What’s the address of the emergency?”

Angela didn’t know the address, but provided the name of the neighborhood and said she and her friends were at the dock. “You drive all the way back, like at the very back, the park down at River Creek, like on the Potomac,” she said.

In Angela’s mind, she was using Potomac to describe a nearby landmark, not the precise body of water where Fitz had slipped under.

“From the Virginia side or Maryland side?” the call-taker asked.

“Virginia side,” Angela said.

The call-taker began typing information that two minutes later would be used to dispatch firetrucks and boats, which still would have to be hauled at least 14 miles to the water’s edge in Maryland.

“How many minutes ... How long ago did he go under?” the operator asked.

“Like five,” Angela said, bursting into tears.

As the teen regained her composure, the operator asked Angela to describe Fitz and to describe herself.

“Listen carefully,” the call-taker said. “This could be a very dangerous situation so ... do not go in the water at all.”

Amid that warning, she again asked Angela for her location.

“Confluence Park is like exactly where we are,” Angela said. “Confluence Park in River Creek. That’s what the park is called. We just looked on Google Maps.”

A 911 call yields a 36-minute response

Frantic teenagers called 911 earlier this summer after their friend Fitz Thomas went underwater in a Virginia creek. Dispatchers struggled to determine which state should respond.

Emergency routes by:

Poolesville

MD.

VA.

MONTGOMERY

COUNTY

Edwards Ferry

Boat Ramp

MARYLAND

Area where

teens were

swimming

River

Creek

Club

VIRGINIA

LOUDOUN

COUNTY

Leesburg

Dispatch response timeline

MD.

VA.

5:49 p.m. First 911 call made in Virginia but answered in Maryland.

5:52 p.m. Maryland sends boats to Edwards Ferry Boat Ramp from stations up to 20 miles away.

6:05 p.m. Maryland notifies Virginia of its operation. Does not request help.

6:06 p.m. Virginia starts

receiving 911 calls about a drowning.

6:10 p.m. Fitz’s friends find him and pull him ashore, but are unable to revive him.

6:16 p.m. First boat arrives at ramp but breaks down in water. No other boats are launched.

6:16 p.m. Virginia sends first ambulances.

6:25 p.m. First ambulance arrives. It had been four miles away from scene.

A 911 drowning call yields a 36-minute response

Frantic teenagers called 911 earlier this summer after their friend Fitz Thomas went underwater in a Virginia creek. Dispatchers struggled to determine which state should respond.

Emergency routes by:

VA.

Poolesville

MD.

VA.

Edwards Ferry

Boat Ramp

MARYLAND

MONTGOMERY

COUNTY

Area where

teens were

swimming

River

Creek

Club

VIRGINIA

LOUDOUN

COUNTY

Leesburg

Dispatch response timeline

MD.

VA.

5:49 p.m. First 911 call made in Virginia but answered in Maryland.

5:52 p.m. Maryland sends boats to Edwards Ferry Boat Ramp from stations up to 20 miles away.

6:05 p.m. Maryland notifies Virginia of its operation. Does not request help.

6:06 p.m. Virginia starts receiving 911 calls about a drowning.

6:10 p.m. Fitz’s friends find him and pull him ashore, but are unable to revive him.

6:16 p.m. First boat arrives at ramp but breaks down in water. No other boats are launched.

6:16 p.m. Virginia sends first ambulances.

6:25 p.m. First ambulance arrives. It had been four miles away from scene.

A 911 drowning call yields a 36-minute response

Frantic teenagers called 911 earlier this summer after their friend Fitz Thomas went underwater in a Virginia creek. Dispatchers struggled to determine which state should respond.

MARYLAND

VIRGINIA

Dispatch response and emergency routes by:

Beallsville

MONTGOMERY

COUNTY

Poolesville

5:49 p.m. First 911 call made in Virginia but answered in Maryland.

5:52 p.m. Maryland sends boats to Edwards Ferry Boat Ramp from stations up to 20 miles away.

6:05 p.m. Maryland notifies Virginia of its operation. Does not request help.

6:06 p.m. Virginia starts receiving 911 calls about a drowning.

6:10 p.m. Fitz’s friends find him and pull him ashore, but are unable to revive him.

6:16 p.m. First boat arrives at ramp but breaks down in water. No other boats are launched.

6:16 p.m. Virginia sends first ambulances.

6:25 p.m. First ambulance arrives. It had been four miles away from scene.

MD.

Edwards Ferry

Boat Ramp

Area where

teens were

swimming

River

Creek

Club

VIRGINIA

LOUDOUN

COUNTY

Leesburg

Note: Scale varies in this perspective.

Sources: Montgomery and Loudoun counties, and USGS.

Maryland routes were determined using GoogleMaps.

A 911 drowning call yields a 36-minute response

Frantic teenagers called 911 earlier this summer after their friend Fitz Thomas went underwater in a Virginia creek. Dispatchers struggled to determine which state should respond.

MARYLAND

VIRGINIA

Dispatch response and emergency routes by:

Beallsville

MONTGOMERY

COUNTY

Poolesville

5:49 p.m. First 911 call made in Virginia but answered in Maryland.

5:52 p.m. Maryland sends boats to Edwards Ferry Boat Ramp from stations up to 20 miles away.

6:05 p.m. Maryland notifies Virginia of its operation. Does not request help.

6:06 p.m. Virginia starts receiving 911 calls about a drowning.

6:10 p.m. Fitz’s friends find him and pull him ashore, but are unable to revive him.

6:16 p.m. First boat arrives at ramp but breaks down in water. No other boats are launched.

6:16 p.m. Virginia sends first ambulances.

6:25 p.m. First ambulance arrives. It had been four miles away from scene.

MARYLAND

Edwards Ferry

Boat Ramp

Area where

teens were

swimming

River

Creek

Club

LOUDOUN

COUNTY

VIRGINIA

Leesburg

Note: Scale varies in this perspective.

Sources: Montgomery and Loudoun counties, and USGS.

Maryland routes were determined using GoogleMaps.

AT 6:01 P.M., 12 minutes after Angela’s call, Montgomery County fire and rescue vehicles — with at least three of them pulling boats — were en route to a launching point.

But they didn’t have complete information. One of Angela’s most salient descriptors — a shallow inlet on the Virginia side — hadn’t been typed into Montgomery’s internal emergency-response system, according to the Montgomery County records. Firefighters were instead told by their dispatchers to conduct a “swift-water rescue” in the Potomac River.

At 6:05 p.m., Montgomery’s 911 center told Loudoun’s center about the mission.

“Hey, Loudoun, it’s Montgomery,” a supervisor said. “Just giving you a heads up that we are heading to our Edwards Ferry Boat Ramp for a water rescue. There is like six or seven people in the water. One is in distress. And they supposedly have originated at the River Creek Country Club, which is your side, right?”

“Yeah, I think so,” the Loudoun 911 dispatcher responded. “Do you need us to respond or do you want the sheriff’s office to respond at all?”

“They are not asking, our units are not asking us,” the Montgomery supervisor answered. “I’m just giving you a heads up kind of as a notification, in case you get a call, too.”

“Okay, absolutely. I’ll go ahead and let the sheriff’s office know, too. Just so they’re aware.”

The sheriff’s office, which serves as the principal police agency in Loudoun County, wouldn’t be notified for another 10 minutes, according to an office spokesperson. With the rescue still being handled by Montgomery, Loudoun’s firefighters and EMTs weren’t yet dispatched.

The Maryland-Virginia border was historically drawn along the Virginia side of the Potomac, effectively giving Maryland jurisdiction over the river. A natural, modern-day consequence: Montgomery County formed agreements with Virginia jurisdictions to handle river rescues.

That agreement appears to have dictated the emergency response in Fitz’s case, even when callers continued to stress help was needed at a Virginia park.

“My overall impression is that somehow the river-rescue policy overrode any practical or common-sense considerations, and that shouldn’t happen,” said Heather Hunt, who previously ran the Minneapolis 911 center and now consults with agencies on best practices.

“These calls showed a painful series of missed opportunities and a lack of urgency,” said Hunt, one of four 911 experts who reviewed the call recordings and dispatch reports for The Washington Post.

Recordings from Montgomery County show that about 10 minutes into the call, the 911 center tried to make use of RapidSOS, a data platform it began using at least six months ago that can help pinpoint a cell caller’s location. It’s unclear if RapidSOS was used earlier in the incident. “Apparently, the call center didn’t fully avail itself of technology they no doubt possess,” said John Melcher, a past president of the National Emergency Number Association who for 15 years headed up the 911 network in Harris County, Tex., which covers the Houston area.

In this case, call-takers also seemed too focused on standardized questions, experts said.

Such scripted questions, part of call-taking software systems, help bring structure to 911 center work and ensure key details are gathered. But every emergency is different, the experts said, and operators must have the latitude to quickly depart from those questions when necessary to understand what a caller needs.

Marin said the 911 recordings and documents indicate a problem bigger than any one person.

“River, river, river, that’s what Montgomery fixated on, with Loudoun only too willing to go along. Everyone just bought into this narrowly defined rescue,” Marin said. “This isn’t about the call-takers. I think that they were a product of their culture, a victim of their culture. They made mistakes because of their environment and training.”

Montgomery and Loudoun counties each provided dispatch reports describing their response. Loudoun released its 911 center recordings; Montgomery gave its 911 recordings to the Thomas family, who shared them with The Post.

Officials in both counties declined to comment on details of the rescue effort, citing their ongoing reviews.

“We owe it to Fitz and his family to make sure that we look at every aspect of this,” said Dinesh Patil, assistant chief of the Montgomery Police Department, which runs the county 911 center that is staffed with both police department and fire department dispatchers. Montgomery’s review will address technology, protocols and conversations the 911 operators had with callers.

Montgomery’s 911 center, like many nationwide, is understaffed and the subject of constant recruiting efforts, Patil noted. There are 54 vacancies of the 185 positions at the center, which leads to mandatory overtime and increased stress, he said.

Laura Rinehart, a spokeswoman for Loudoun’s fire department, said it also has undertaken a broad look at the incident and its 911 center. “We’re putting policies in place so that a delay of this nature never happens again,” she said.

Though Fitz Thomas’s friends stressed to 911 call-takers that there was a drowning in a Virginia park, some calls were routed to Montgomery County, Md., dictated by a long-ago agreement that gave it jurisdiction over all emergencies in the Potomac River. Virginia emergency personnel weren’t dispatched to the scene until 27 minutes after the first call was made. (Michael S. Williamson/The Washington Post)

LONGTIME RESIDENTS OF the River Creek development, Ed and Sharon Koorbusch often take their Newfoundland for evening walks near the creek. They did so on June 4, hardly surprised to see teenagers along the water. A short time later, they heard shouts of panic.

“We can’t find our friend!” Angela yelled.

Ed Koorbusch knows the creek well — having kayaked and fished there for years. He ran over and jumped in to help. The experienced scuba diver had the teens line up on either side of him so they spanned the width of the creek. They slowly moved parallel to the banks, swimming down to the 8-foot bottom and coming up for air.

On the bank, Angela’s best friend had dialed 9-1-1. Her call was picked up by Loudoun County’s center, in Leesburg.

“Hi we called about someone in River Creek,” she said. “Someone’s drowning.”

“Okay, I’m going to transfer you to Montgomery,” the Loudoun 911 operator said.

More than two minutes passed as confusion only grew.

“And this is in Montgomery County?” a 911 operator asked.

“It’s in Leesburg,” the teen replied. “Virginia.”

“This is Montgomery,” the operator responded. “They just transferred you to us.”

Montgomery County rescuers were starting to arrive at the Edwards Ferry Boat Ramp on their side of the Potomac River. As they waited for the boats, still 10 minutes away, all they saw were two men fishing. The terror unfolding at the creek was more than a quarter mile away.

One of the rescuers checked in on his radio.

“Right now, we don’t have anybody visible on either side of the river, north or south,” he said. “Speaking with a couple of people here at the boat ramp, they did not see anybody waving or trying to signal to anybody that they were in distress.”

At some point during the incident, Loudoun’s 911 call-takers typed “Confluence Park” — the name callers had told them — into their internal mapping system, but the location wasn’t recognized, according to the county.

It took about three minutes for Ed Koorbusch and the line of teenagers to find Fitz at the muddy bottom. They pulled him onto the dock as two people on the bank described the rescue to 911 call-takers.

“They found him! They found him!” a 17-year-old girl shouted. “He’s dead. We need, we need medical assistance right now!”

“Ma’am, stop yelling and listen,” the call-taker responded. “What county are you in?”

“Loudoun County.”

“Stay on the line.”

The Montgomery 911 operator then patched her Loudoun counterparts in to the call as the two discussed whether Montgomery would continue to supervise the rescue.

“It looks like we are handling it,” the Montgomery operator said. “You can hang up. I’m going to talk to her.”

The Montgomery 911 operator asked the teen to put the call on speakerphone at the dock.

“I’m going to walk you through doing chest compressions,” she said, and began calling them out. “Keep pumping. One, two, three, four.”

Ed Koorbusch did so. One of Fitz’s friends held his head, another held his arm. Mud and water were coming from his nose. He wasn’t breathing.

“He’s got a pulse, he’s got a pulse,” someone said, fueled by hope. “I don’t know,” she added. “I don’t know.”

The 911 centers continued speaking with each other, piecing together that a teen had been pulled to land in Virginia — easily accessible to a road. At 6:16 p.m., Loudoun County dispatched its own rescue crews.

At that same time, Montgomery’s first boat arrived at the Maryland side of the Potomac River. It soon entered the water then broke down and had to be rowed back.

A Loudoun ambulance pulled up to the creek at 6:25 p.m.

Michelle Thomas, right, with her husband Delroy and children Adrian and Anna at a June 7 vigil for their son Fitz, who drowned a few days earlier at the confluence of Goose Creek and the Potomac River. (Renss Greene/Loudoun Now)

LESS THAN TWO miles away, Michelle Thomas had just returned from Harris Teeter with her son Fitz’s favorite dinner — steak and scallops. A pastor and head of the Loudoun branch of the NAACP, she is well-known in the county.

Her husband, Delroy, cooked while the two fell into their kitchen routine: chatting and singing. Upstairs was their daughter Anna, 12, who is set to enter the seventh grade.

At 6:45 p.m., a loud knock summoned Michelle to the front door.

She opened it to find several of Fitz’s friends and a man she didn’t recognize. Fitz had been in an accident, they were telling her, he was being taken to the hospital. Thomas’s mind raced to the worst.

“Is Fitzy dead?” she blurted.

The man stepped forward, halting the teens from answering: “Mrs. Thomas you’ve got to go to the hospital.”

She dropped to her knees in prayer. Delroy paced behind her. Anna appeared. The girl’s teeth started to chatter. “I don’t want Fitzy to be dead,” she said.

The man offered a ride to the hospital. Moments later, the minister found herself in Don Shea’s passenger seat, clutching a bible, cross and a bottle of anointing oil. “Let’s pray for strength,” he told her.

A 49-year-old IT professional, Shea had spent the afternoon playing golf on a course that winds along the creek and river. The blare of sirens compelled him to the water’s edge. He ended up taking two of the teens to Fitz’s home.

At Inova Loudoun Hospital, Shea and Thomas made their way to the emergency room area. “Don’t leave me,” Thomas told him.

Thomas’s close friend arrived, taking Shea’s spot. Nurses and doctors came in: Nothing they tried was working.

Just before 8 p.m., Thomas was let into her son’s room. She was soon joined by her husband and their kids, Anna and Adrian. They had nearly two hours with Fitz — to touch his face, hug his shoulders, tell him no one would ever forget his name.

Hundreds gather at a June 7 vigil for Fitz Thomas. The 16-year-old was a tough running back on the football field, but would cut up with dances in the locker room and school hallways. “He could bring people together,” said his football coach, Brian Day. (Renss Greene/Loudoun Now)

TWO WEEKS LATER, Michelle Thomas was in a Loudoun County government conference room, trying to understand why it had taken so long for help to get to Fitz. The county’s fire chief and top elected official were among those at the table. They listened to recordings from Loudoun’s 911 center.

Thomas later made a similar visit to Montgomery, listening to more of the recordings.

She heard Angela pleading for help. She heard radio traffic from Montgomery County’s rescuers, making it clear it took 27 minutes for their first boat to arrive at the Maryland side of the Potomac.

She heard Sharon Koorbusch, talking to a 911 operator: “It doesn’t take 35 minutes to get here. It takes five.”

Thomas has vowed to do all she can to prevent future delays. She helped launch the “FitzIt” campaign designed to push Loudoun and Montgomery to improve 911 technology and training.

The counties already have made changes to their policies for rescues in the Potomac River. Montgomery will maintain jurisdiction, but will now seek immediate help from Loudoun.

For its part, Loudoun also will send rescuers to any emergency near the river’s shore. Loudoun also embarked on a “River Atlas” effort to make sure all place locations, such as Confluence Park, are part of their 911 center computer systems.

Thomas visits Fitz’s grave often. He lies in what five years ago was a largely forgotten cemetery for enslaved people. She had worked to restore and preserve the historical burial ground, and it is a place of both grief and comfort.

Last month, as she was there on her birthday, Thomas tried to compose a Facebook post but was so distraught it came out as garble. Reading it two miles away was one of Fitz’s closest friends, Christian Yohannes. He called her.

“Pastor Michelle. Where are you?” he asked.

“I’m visiting Fitz at the burial ground,” she answered.

“Don’t leave. We’re on our way.”

Minutes later Christian drove up followed by several other cars. Ten of Fitz’s former classmates were there. “We told you,” Christian said, hugging Thomas, “we’d always be there for you.”

Antonio Olivo contributed to this report. Photo editing by Mark Miller. Video by Zach Purser Brown, Kolin Pope and Jayne Orenstein. Cartography by Laris Karklis. Copy editing by Briana R. Ellison. Designed by J.C. Reed.

Michelle Thomas is comforted by her daughter, Anna, as they visit Fitz Thomas’s grave in Ashburn, Va., last month. Thomas recently helped launch the “FitzIt” campaign designed to push Loudoun and Montgomery to improve 911 technology and training. (Michael S. Williamson/The Washington Post)

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