Airway & Respiratory, Communications & Dispatch, News, Patient Care

Final Words to 911: ‘I Can’t Breathe’

FULTON COUNTY, Ga. — Darlene Dukes gasped for air but got little comfort from the Fulton County 911 operator who took her final call and misdirected help that could have saved the dying woman, a 911 tape released Thursday shows.

Flaws uncovered by Dukes’ death has the county moving to take a much closer look at the county’s 911 operations.

During the Saturday call for help, operator Gina Conteh, a 12-year veteran with Fulton’s 911 system, appeared to handle several calls while trying to find Dukes’ address. She waited more than halfway through the 25-minute call before even asking about Dukes’ well-being, a recording of the call shows.

Only when Dukes finally fell silent on the phone did Conteh ask, “Are you OK?”

“I can’t breathe,” were Dukes’ last words.

Dukes died at Emory Johns Creek Hospital at 3:01 p.m. Saturday, according to police reports.

She was suffering from a blood clot in her lungs when she called 911 Saturday at 1:01 p.m., and she waited more than an hour before an ambulance arrived at her Johns Creek apartment.

The mishandled call was made public this week, and, as criticism has poured in, county officials have rushed to assure the county’s nearly 1 million residents the emergency response system works.

“Never in its 33-year history has an incident occurred like the one that happened last Saturday,” said Fulton County Manager Zachary Williams. He announced on Thursday an outside agency will be hired to audit “the entire 911 system.”

Conteh is at the center of controversy about Fulton’s emergency response. The veteran operator mistook “Wales” Drive — in Johns Creek — for “Wells” Street in southwest Atlanta. She subsequently routed the first ambulance nearly 28 miles off course.

Conteh was fired, county officials said, and a full investigation is under way. She could not be reached for comment Thursday. Reporters made several attempts on Wednesday and Thursday to contact Conteh, including driving to her Lilburn home Wednesday evening.

The operator was fired because “established procedures were not followed,” Williams said. “[This] was not about a lack of training.”

The auditor will report to Williams, not 911 director Rocky Moore, who has been accused by local ambulance providers of failing to correct longstanding problems with the county’s emergency center.

Fulton County 911 director Moore said the job performance of all 911 operators is evaluated monthly, based upon national standards. A random sampling of calls, including emergency calls such as the one placed by Darlene Dukes, are evaluated and the operators must receive 95 percent compliance rating. They are not fired immediately if they don’t meet that standard. They are judged on a case-by-case basis, Moore said.

“Most of it deals with the ability to calm a caller down,” Moore said. The operators are expected to be compassionate and use “calming techniques” in order to acquire complete information about the caller. An operator’s demeanor is included in monthly performance reviews.

Moore would not answer questions about Conteh’s demeanor on the call with Dukes.

Conteh seemed at times to have her hands full with other calls, both while Dukes was conscious and after the ailing woman had passed out.

Moore said call takers “are required to multitask.”

But Butch Beach, who oversees the Georgia Public Safety Training Center’s training for 911 operators and dispatchers, said the call taker should have “one call at a time, and is completely focused on that victim or person in distress.”

The Atlanta Journal-Constitution acquired a copy of the 911 call through the Georgia Open Records Act, and the audio points to numerous missteps, as well as several missed opportunities to lead an ambulance in the right direction.

Gasping for air, Dukes gave her address; “602 Wales Drive.”

Conteh repeated the address.

“Six-Oh-Two, Wales Drive?” the 911 operator said. “I do have an ambulance on the way there.”

Conteh asked Dukes a second time for the address.

“Just confirm for me to make sure that I have your address right, 602 Wells Street … W-E-L-L-S Street?” she said. “Is that correct?”

Dukes struggled to correct her.

“Drive …” she said between labored breaths.

“Drive?” Conteh repeated back. “OK. You said that’s Wells Drive.”

“Please hurry,” Dukes pleaded and then went silent.

“The lady went unconscious,” Conteh said in response.

The recording reflected that when Conteh spoke with a Grady Memorial Hospital dispatch supervisor to get help, she acknowledged that the cellphone call came from a north Fulton location.

“It was a cellphone,” she said. “This may not even be it because it says Jones Bridge Road. That’s north.”

While on the phone with the Grady dispatcher, Conteh appeared to be overwhelmed with multiple calls.

“Yeah, I need some help,” she said. “I have an alarm company holding, and two calls they’re going to dispatch.”

The Grady dispatcher asked Conteh the name of Dukes’ apartment complex and quickly zeroed in on where the call originated.

“She gave me St. Andrews apartments, you don’t know where that is?” Conteh asked. “She gave me 602 Wells Drive.”

The dispatch supervisor, whom Grady officials refused to name, listed the correct location.

“The only thing I’ve got [for] St. Andrews apartment is in Alpharetta off Jones Bridge,” he said of the address located in what is now Johns Creek. “There’s not one in Atlanta.”

Conteh then called an Alpharetta dispatcher, who knew nothing of the ambulance request.

“Do you have an ETA for Jones Bridge Road?” she asked.

“I don’t know what you’re talking about,” the Alpharetta operator responded.

Staff writer Rhonda Cook contributed to this article.