Jurors urged to demand complete 911 overhaul
Jurors are expected to call for a drastic overhaul of Ontario’s 911 service — everything from the current call takers’ answer of “police, fire or ambulance?” to the need for legislation to govern the service — as they began deliberating Tuesday after a two-week inquest into the province’s emergency response network.
The inquest examined four deaths and was held in two parts. Last week, jurors heard in Ottawa about the death of Kathryn Missen, 47, who called 911 on Sept. 1, 2014, in the middle of an asthma attack, yet never had police or paramedics show up to her Casselman home.
The week before, in Sudbury, jurors examined the deaths of Michael Kritz, Matthew Humeniuk and Stephanie Bertrand, who died as the result of a boating accident on Lake Wanapitei in July 2013. Their 911 call drew a confused response from multiple agencies, compounded by dispatchers’ difficulty in finding the accident location.
Coroner’s counsel Prabhu Rajan read a powerful statement from Kritz’s family before delivering a long list of suggested recommendations to the jury.
“It breaks our hearts to know that (Michael’s) last word was ‘help’,” the statement said. “But there was none for him ...
“There were so many mistakes that night that somehow, listening to the testimony, seemed insignificant to those who made them. But in the end, those minutes and seconds counted. They added up to Michael’s life.”
During the inquest, jurors heard evidence from 911 call-takers and dispatchers, the OPP officer who neglected — and eventually forgot — that he had been sent to Missen’s house, a forensic pathologist, an assistant deputy minister for the Ministry of Community Safety and Correctional Services, technical experts on telephone and 911 systems, and others.
It was a “massive amount” of information, Rajan acknowledged before suggesting 34 recommendations to be considered, some with as many as 15 sub-sections.
The first several suggestions are that the province enact legislation to lay out what is required of the 911 service, that there be adequate oversight and an independent means to respond to complaints.
The 911 service is a hodgepodge, with some large police forces running their own call centres, the OPP covering much of rural Ontario while paramedic and fire services manage their own dispatchers.
“There are lots of little pieces of the pie,” Rajan said, “but there is not one person or body or ministry that says, ‘We’re in charge of this.’ ”
At the micro level, jurors are being asked to consider limiting the shift lengths of call-takers and dispatchers and to question how a 911 operator answers the phone.
“What’s the first question? Is it ‘police, fire or ambulance?’ and you’ve got to choose quickly? Well, you heard evidence that that might not be the most important question, that the first question should be ‘where?’ ”
Jurors were also asked to consider better training and support for 911 workers, several of whom were clearly distraught as they testified about mistakes and oversights that played a role in the deaths.
Since the jury’s recommendations will be non-binding on the province, Rajan encouraged jurors to urge municipalities to step up and do their part to improve 911 service.
The five-person jury is expected to deliver its recommendations to presiding coroner Dr. David Cameron on Wednesday morning.