The province should put in place an independent body to provide oversight to all 911 operations, says a five-member jury following an inquest into the deaths of Michael Kritz, Stephanie Bertrand, Matthew Humeniuk and Kathryn Missen in 2013.
Kritz, Bertrand and Humeniuk died as a result of a boating accident at Red Rock Point on Lake Wanapitae on June 30, 2013 — Bertrand died July 8 after being in hospital following the accident. Robert Dorzek was the only survivor.
During the Canada Day long weekend in 2013, Humeniuk, Bertrand and Dorzek spent the day at Kritz's camp on Gavin Island, at the northeast end of the Lake Wanapitei.
The night of June 29, 2013, the group boarded a boat Humeniuk was operating to attend a party at the other end of the lake.
Shortly after midnight, Humeniuk crashed the boat onto a small island. All four people on board were thrown from the boat and injured after the crash, according to documents submitted to the Sudbury courthouse.
Dorzek, the only one able to call for help that night, phoned 911. That rescue effort — which took an hour — was hampered by a 911 dispatcher who had trouble finding the crash, despite having been sent a map that included the GPS coordinates of the location.
That same dispatcher instructed Dorzek to light a signal fire to assist rescuers. In the dry conditions, that fire spread and igniting the crashed boat. Kritz died in the fire.
Kathryn Missen 54, died as a result of a medical condition on Sept. 3 after calling 911. Emergency personnel did not respond to Missen's call after the line went silent. Missen was likely suffering an asthma attack and became unresponsive during a protracted call with 911 operators. An OPP officer wasn't dispatched to her home until 90 minutes after the line went dead.
Missen's body was found two days later in her home.
The inquest took place in Sudbury Oct. 15-19, then moved to Ottawa from Oct. 22 until it wrapped up Nov. 1.
In launching the inquest, the Ministry of Community Safety and Correctional Services said the commonality shared among the four deaths concerns Ontario's 911 response system permitted a joint inquest, as two or more deaths appear to have occurred in the same event or from a common cause.
The independent body recommended by the jury is one of 27 recommendations that came from the inquest. A total of 19 of those recommendations were aimed at the province, while the other eight were directed at all municipalities that provide 911 services.
As part of its mandate, that independent body should investigate, respond to and resolve complaints, conduct audits, collect data conduct research, conduct a systemic review and issue an annual report, which should be made public.
Another recommendation to the province would require the Ministry of Health and Long Term Care, EMS, police and fire to establish an interoperable radio channel that would be available to all emergency services during a multi-agency response.
The jury recommended that the province report to to the Office of the Chief Coroner by no later than Dec. 1, 2019 and annually for five years, in an open letter, regarding the progress made with respect to these recommendations.
For municipalities operating 911 services, they must take their own steps to enact any and all recommendations that apply to municipalities by December 2021, whether or not the province requires them to do so.
Breakdown of the recommendations
For the province:
-Ensure timely access by families to all pertinent and comprehensive information related to deaths where 911 services are involved.
-Develop and conduct a public awareness campaign on the purpose of the 911 service, including alternative numbers for reaching police in non-emergency situations.
-Investigate methods to deter inappropriate and accidental (e.g. pocket dialing) use of the 911 service.
-Ensure that conclusions and recommendations of internal reviews conducted in relation to deaths where 911 services are involved are made public to ensure transparency, accountability, and accuracy.
-Ensure that private and public 911 communication centers, Police, Emergency Medical Services, Fire (career and volunteer), (collectively to be called “Emergency Services”), operate on the same or compatible computer aided dispatch (“CAD”) system by December 2023 to allow for immediate sharing of critical information among Emergency Services.
-Require that Ontario and all municipalities insure that their CAD systems have the capacity to:
- Utilize the re-bid feature to request caller location information;
- Allow operators to emphasize critical information; and
- Escalate alerts the greater the delay in dispatching the call (e.g. additional audible or visible alerts at 5, 10, 15 minutes).
-Require the Ministry of Health and Long Term Care (MOHLTC), EMS, Police and Fire to establish an interoperable radio channel that would be available to all Emergency Services during a multi-agency response.
-Require that Ontario and all municipalities ensure that 911 services within their jurisdictions are appropriately staffed, including ensuring that supervisors of 911 call takers and dispatchers
can focus on their supervisory duties without being diverted by routine call taking or dispatching duties.
-Require that supervisors of 911 call takers and dispatchers are trained on the equipment and software used by the personnel they are supervising.
-Require that Ontario and all municipalities provide appropriate supports for 911 call takers, dispatchers and supervisors, including supports for mental health and post-traumatic stress disorder.
-Require that Ontario and all municipalities identify appropriate emergency resources when dealing with a water rescue, including available police or fire boats, launch points, and personnel. This information should be available to all 911 call takers, dispatchers and supervisors through the CAD system.
-Require that Ontario and all municipalities ensure that 911 services within their jurisdictions establish a formal policy, accompanied by comprehensive training, to:
- Permit callers who are unable to verbally communicate their needs to communicate through other means (e.g. silent 911 call procedure);
- Permit front-line Emergency Service responders to communicate directly with a caller where appropriate;
- Govern when a medical-tiered response is engaged, including simultaneous notification;
- Ensure appropriate organizational accountability when there are unnecessary delays in dispatching 911 calls;
- Require 911 call takers and dispatchers to engage their supervisors prior to making decisions beyond their normal training (e.g. instructing a caller to light a signal fire);
- Ensure that supervisors for Emergency Services have the capacity to communicate directly with each other;
- Ensure that front line Emergency Service responders have the capacity to communicate directly with other responders and dispatchers;
- Permit all 911 call takers, dispatchers and supervisors to request and receive updated location information from cellular providers;
- Identify and acknowledge critical information during radio communications (e.g. “Pan Pan Pan” and “Roger”);
- Conduct an internal review where 911 services are involved in a death and concerns have been identified by family or staff, which must include consultations with staff during and following the review;
- Address whether and when the Bell Surveillance and Maintenance Centre is referred to in CAD and the implications of its inclusion; and
- Conduct a debriefing with appropriate staff following a major 911 incident.
-Require that Ontario and all municipalities ensure that bi-directional real-time CAD data, and other data (such as maps), are available to police, fire and EMS first responders on mobile data terminals.
-Require that Ontario and all municipalities install a minimum of three direct telephone lines between and among 911 communications centres (the precise number of lines to be decided based on call volumes and other relevant factors).
-Work with Bell Canada to increase the number of participants that can be on the same emergency call above the current limit of three.
-Ensure active supervisors or designates of 911 call takers and dispatchers have the capacity to monitor CAD information at all times.
-Report to the Office of the Chief Coroner by no later than December 1, 2019, and annually for 5 years, in an open letter, regarding the progress made with respect to these recommendations.
-Investigate measures (including equipment and facilities) to assist 911 call takers, dispatchers and supervisors to effectively and comprehensively listen to information being communicated from callers and colleagues (e.g. when callers are hard to hear or understand).
To All Municipalities in Ontario that provide 911 services
-All Municipalities that provide for 911 services in Ontario should:
- Review current staffing formulas.
- Add clerical help to call centers.
- Review the suitability of 12-hour shift schedules.
- Use local resources (e.g. volunteer fire) to address response time delays.
- Install clearly marked signage to direct responders to local/rural volunteer fire stations;
- Ensure sufficient lighting (through permanent or portable means as appropriate) at launch points (e.g. docks, trail heads) to prevent delays to responders when leaving the launch point.
- Identify a mechanism to urgently engage a dispatcher on a call of a critical or uncertain nature (e.g. “hotshot”).
