Faulty System and Human Error Delayed Medical Help to Kids Who Died in Queens Fire

Faulty System and Human Error Delayed Medical Help to Kids Who Died in Queens Fire
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On April 19, a fire broke out on Bay 30th Street in Far Rockaway, Queens. The first 911 call came in at 11:51 p.m. The first firefighters arrived at the scene five minutes later. They began hosing down the blaze and attempting to rescue the children trapped inside. Firefighters carried two small children out of the house and then searched for any paramedics on the scene, but there were none there.

"The firefighters were saying, 'Where is EMS, where is EMS?' " a neighbor told the New York Post. "He was really upset at the EMTs; all the firefighters were."

Paramedics did not arrive until 12:21 a.m. By then it was too late. Four-year-old siblings Jai'Launi and Aniya Tinglin died of smoke inhalation that night.

"I do know -- we all know -- that something went wrong," Mayor Bill de Blasio said a few days later. "We've got to know why it went wrong. We've got to know how to fix it going forward. It's not acceptable."

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They suspended three FDNY dispatchers and a supervisor for the delay. The city's Department of Investigation opened a review into the incident, and on Tuesday it released its findings.

The FDNY "dispatch system is unduly complicated and unacceptably flawed, and these flaws, combined with human error, delayed medical assistance to two children trapped in the building who ultimately died," the department stated.

As the report detailed, the paramedics' arrival "was impeded by a highly cumbersome ambulance dispatching process that involved interaction between no less than seven staff members" of the police department, the fire department, and Emergency Medical Services.

The investigation "exposed an antiquated, unwieldy system for dispatching ambulances to the scene of an active fire that substantially increases the opportunity for human error. We must start to overhaul this process immediately," DOI Commissioner Mark Peters said in a statement.

The dispatching process passes through a split computer system that "does not allow FDNY and EMS dispatchers to efficiently share critical information, such as the borough where a fire is occurring, so EMS dispatchers typically must wait until they receive a telephone call from an FDNY dispatcher to dispatch an ambulance."

Still, most of the time, emergency dispatchers work through this system smoothly. From January through September, EMS received a call about a fire an average of 1.33 minutes after the fire department got it. But on April 19, it took seven minutes.

The difference with this fire, the DOI concluded, "was primarily due to human error" -- specifically, a "series of errors and miscommunications" between the dispatcher who took the call and her supervisor at the Queens Fire Dispatch Central Office.

The dispatcher, Kathleen Valentine, entered the information about the fire into the computer system seconds after the 911 calls came in at 11:51 p.m. At 11:56, the fire chief on the scene radioed for more resources. Valentine called an FDNY deputy chief to let him know. The way the system works, a notification was then supposed to pop up on her screen "prompting her to call EMS."

It didn't. Instead, the EMS notification came up on the screen of her supervisor, Jacquelin Jones, who had also called the FDNY to dispatch additional fire engines. Valentine, according to the report, then asked Jones to switch the notification to Valentine's computer so that she could make the EMS call.

"However, Jones admitted that she executed the wrong commands," the report states. And so the notification did not pop up on Valentine's screen. "[Valentine] assumed that, because the screen never appeared on her computer, one of her colleagues made the notification to EMS."

The Department of Investigation noted that Valentine had made "an error on duty" before. She had entered "incorrect information" into the computer system in November 2013, and "her supervisors had expressed concern to senior EMS officials about her ability as a dispatcher." Another supervisor also told higher-level dispatch officials that "he believed Valentine was 'a liability' if she was allowed to remain" at the Queens Central Office.

But, as the report notes, Valentine was also in a tough spot that night when the Bay 30th Street call came in. One of her fellow dispatchers "had been in and out of the bathroom all night due to illness." Another "was in the kitchen area" at the time of the call. "In sum, only four of the six FDNY dispatchers on duty were physically at their positions at 11:51:51 p.m., when the FDNY was first notified of the Bay 30th Street fire."

At 12:04 a.m., another call for more resources came in. Valentine called the EMS dispatch center for the first time. The EMS dispatcher replied, "Um...Bay 30th Street, did you guys give us Bay 30th Street? I was just about to call you."

As the phone call recording captured in the background, Valentine asked her colleague, "Did we ever get in touch with EMS on that fire?"

And the colleague said, "No idea. I didn't call them."

Around 30 seconds after the call ended, the ambulance left for the scene.

Send story tips to the author, Albert Samaha



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