ALLENTOWN, Pa. -- In a sweeping mea culpa, Bucks County officials announced Wednesday they had disciplined 11 dispatchers and four supervisors at the call center for botching a 911 call from a disabled Doylestown woman who died in a house fire Jan. 29.
Ten dispatchers were available when Brenda Orr's call came in at 10:31 a.m., but the phone rang six times before an 11th dispatcher, who was already on an ambulance call, picked it up "out of frustration" and put it on hold, said Emergency Communications Coordinator Brent Wiggins.
"None of the 10 dispatchers provided a reasonable explanation as to why they were unavailable to answer that 911 call," Wiggins said Wednesday at a news conference to release the results of the county's internal investigation.
Three of the center's on-duty supervisors, who could have been overseeing the call center, were in a meeting at the time and a fourth was filling out paperwork, he said. "No one was actually listening or monitoring what was going on out on the floor," Wiggins said.
Most of the 15 workers received letters of reprimand in their personnel files, officials said. No one was fired.
Jim Cawley, chairman of the county commissioners, said all of the dispatchers were required to review Orr's 911 call with their supervisors and compare it to a properly handled call.
The county has also overhauled its policy guidelines to prohibit putting 911 callers on hold and to require two supervisors on the floor at all times.
"If there is any good news to be had out of this tragic situation, it is that we are all refocused and redoubling our efforts" at the Emergency Operations Center, Cawley said.
Orr, 53, died from smoke and soot inhalation in the blaze, which gutted her ranch home at 340 Doyle St. Investigators determined it was accidental.
County Fire Marshal Nick Rafferty said it is unlikely Orr would have survived if the call had been handled differently because evidence suggests the fire was fairly advanced by the time she called.
But Doylestown officials have said they will never know for sure.
Authorities suspect that Orr, who had multiple sclerosis and spent much of her time in bed because of her health, had been smoking and the cigarette started a fire in her bed. Rafferty said there were other potential fire sources near the bed, including a heating pad and electrical cords.
Regardless of the cause of the fire, Cawley said, errors were made in handling Orr's distress call, from allowing the phone to ring six times before answering it to placing the call on hold for 26 seconds and speaking discourteously to Orr.
"There were mistakes made, and for those mistakes we are truly sorry," Cawley said. "The loss of Brenda Orr's life was a tragedy, but we do not need to compound the tragedy by undermining the public's trust or faith in our 911 system."
According to a recording of the call, a male dispatcher first picked up Orr's call and said, "911, can you hold one second, please?" Orr replied, "I can't! It's an emergency, nine, one, one emergency, three, four, zero Doyle. Bed on fire!"
When a second dispatcher picked up the call 26 seconds later, she asked Orr for her emergency and Orr again said her bed was on fire and repeated her street address. The dispatcher urged Orr to leave the house. Orr told her she couldn't because she was disabled.
By the time the first firefighters were dispatched, 2 minutes and 9 seconds had elapsed.
County officials said Wednesday that the average dispatch time for fire calls in January was 2 minutes, 24 seconds. And Cawley said the "vast majority" of the 900,000 calls the dispatch center receives every year are handled properly.
Doylestown Police Chief James Donnelly, who brought his concerns about the slow response to Borough Council after the fire, said he hopes the county's reply restores residents' confidence in 911.
"I'm not going to judge the county," Donnelly said. "I just don't want it to happen again for anyone in Bucks County. They depend on the 911 system. Hopefully this will satisfy the public."
Cawley and Wiggins said a new 911 center, scheduled to be completed in summer, will have technology that might have prevented Orr's call from going unanswered at first, such as a system that automatically routes calls to unoccupied dispatchers.
The new center will also be set up to place supervisors at the center of the room, making it easier for them to supervise dispatchers.
Dispatchers belong to the American Federation of State, County and Municipal Employees.
Brenda Orr's parents, Gene and Martha Orr, were not taking calls Wednesday, said a person who answered the phone at their Doylestown home. Her sister Cynthia, of Perkasie, could not be reached.
CLOCK WAS TICKING
A timeline for Brenda Orr's 911 center call Jan. 29:
10:31:09 -- Brenda Orr's call received at 911 center.
10:31:37 -- Call picked up after six rings, placed on hold.
10:32:03 -- Second dispatcher picks up call.
10:32:42 -- Last contact with caller.
10:33:00 -- Police dispatched to fire call.
10:33:18 -- First fire dispatch.
10:34:39 -- Doylestown police officer on scene; heavy fire showing.
10:37:02 -- Borough fire marshal on scene.
10:38:04 -- Fire chief on scene.
10:39:03 -- First fire apparatus responding.
10:40:41 -- Estimated time of arrival of first fire apparatus.
10:43:06 -- Doylestown Fire Company Ladder 79 on scene.
10:55:33 -- Fire chief reports victim located.
Source: Bucks County Emergency Communications report
Corrective actions taken after the Bucks 911 investigation:
Eleven dispatchers, four supervisors disciplined; no one fired.
All dispatchers met one on one with supervisors to review 911 call of Jan. 29 fire, compare it to exemplary call from November.
New policy requires two supervisors monitoring dispatch floor at all times.
New language prohibits putting 911 calls on hold.
Committee formed to review and critique major calls.
Three communications advisory boards, for police, fire and emergency medical services, will review Jan. 29 call to suggest more changes.
Policy being developed to encourage disabled individuals to provide county dispatch with information.
New 911 center, due to open in summer, will improve supervision, automatically send unanswered calls to idle dispatchers, allow for better monitors.Source: Bucks County Emergency Communications report