The casket of firefighter John Ulmschneider. (Marvin Joseph/The Washington Post)

A federal investigation reviewing the 2016 fatal shooting of a Maryland firefighter found that 911 public safety call takers did not warn first responders that the possibility of guns had been reported at the scene and that volunteer firefighters were not wearing a common uniform the night of the incident that made it clear who they were.

Those flaws and others contributed to the fatal shooting of Prince George’s County firefighter John “Skillet” Ulmschneider while he answered a 911 call to check on someone’s welfare, according to the fatality investigation report released last week by the National Institute for Occupational Safety and Health.

In light of the findings, federal investigators recommended police departments, not fire departments, handle initial calls for a welfare check. Investigators also recommended public safety agencies make sure first responders ask for and get important safety cautions — such as that weapons may be present at a scene — as they are dispatched.

The federal report reviewed the public safety response on April 15, 2016, when career and volunteer firefighters were called to the Temple Hills home of Darrell Lumpkin.

Lumpkin’s worried brother had called 911 after he could not reach his then-61-year-old sibling, who suffered from diabetic episodes. Believing Lumpkin was having a medical emergency inside, firefighters broke into the home after loudly knocking and announcing themselves.

As the door swung open, Lumpkin fired on them, killing Ulmschneider, 37, and seriously wounding volunteer firefighter Kevin Swain and Lumpkin’s brother.

John Ulmschneider, about 15 years ago. (Prince George's County Fire/EMS Department)

Lumpkin was incoherent from a diabetic episode when he fired, his attorney later said, and shot whom he thought were intruders.

A grand jury declined to charge Lumpkin with murder or manslaughter, but he pleaded guilty to a weapons charge. Lumpkin died last year before serving his four-year prison sentence.

Prince George’s public safety agencies will review the federal report and internal recommendations to develop and make policy changes, said Mark Brady, a spokesman for the county fire and EMS department. Their plan is expected to be presented in the next 45 days. The changes will be in addition to others the department has rolled out since the fatal shooting, Brady said.

“We’ve been taking actions since that unfortunate incident to make things better,” Brady said.

When Lumpkin’s brother called 911 that night, according to the federal report, he told call takers he had knocked on the door of his brother’s home but not gotten a response.

“The call taker asked the caller if any weapons were in the house and the caller stated that there could be firearms inside,” the investigative report said.

The communications center for 911 calls “did not have a process for entering this type of critical information into the computer-aided-dispatch system. The information about the possibility of weapons in the house was not forwarded to the responding units,” the report said.

Andrew K. Pantelis, president of the union representing firefighters and paramedics in Prince George’s County, said that was “the most glaring component of the report.”

“Perhaps they might have taken different actions,” Pantelis said, had the firefighters been flagged that guns might be on hand.

The report also suggested police should be the “primary agency initially assigned to ‘check on the welfare’ of occupants.”

Firefighters were assigned to respond to Lumpkin’s house after the initial 911 call. Police were dispatched later as firefighters were working to break down the door.

“If the police on the scene identify the need for fire and EMS, we should be dispatched,” Pantelis said. But firefighters shouldn’t be the first called out “to these types of incidents to better protect our members and our employees.”

Investigators also recommended fire departments consider standard guidelines for on-duty dress so residents can clearly recognize public safety personnel.

Volunteer firefighters at the Lumpkin scene were not wearing fire department uniforms, and some had on “athletic-type shorts, tee-shirts and athletic shoes,” the report said.

The county is reviewing how it prioritizes and dispatches 911 calls, Brady said. The department also is working with volunteer fire departments and the union to review the recommendations.

Brady said some of the federal report’s other suggestions, such as outfitting firefighters with ballistic vests, are being implemented.

Police officers and fire recruits will also be trained in how to improve how they communicate and work together when responding to scenes.

The department’s Safety Investigation Team has completed its internal evaluation of the events around the 2016 shootings, which top commanders are reviewing, Brady said.

A summary of the internal report is expected to be released publicly sometime in December, according to a memo Fire Chief Benjamin Barksdale issued.

Pantelis said the union has called for the release of the full report.

Given “the death of a public servant, the public interest weighs heavily toward disclosure of all facts pertaining to the incident and the interests of justice would be ill-served by failing to release them,” Pantelis wrote in a letter to the fire department that was initially reported by

In his memo, Barksdale said the department was committed to adopting recommendations from the federal and internal reports to “keep all safe.”

“No loss of ours will be in vain,” Barksdale said in his letter.