Dispatch investigating procedures following fatal pond accident

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MISHAWAKA, Ind. (WNDU) - A tragic accident took the lives of two young children and put their mother and 3-month-old sibling in the hospital after their van went into a retention pond in Mishawaka.

It happened on New Year's Eve.

As we've reported before, St. Joseph County dispatch had some trouble locating exactly where the accident had taken place.

On Wednesday, they released a list of "four key shortcomings in the 911 Center response."

16 News Now reporter Zach Horner spoke exclusively with the executive director of the 911 Center prior to the release of the investigation's findings.

Here are those four shortcomings and the response from management:

1. The call taker who was communicating with the mother should have immediately implemented an existing protocol that was in place for instructing someone involved in the situation at hand; instead, time was lost in trying to figure out the location of the vehicle which delayed dispatch of first responders ; it is clear, however, that the mother, on her own, attempted to do the steps suggested in the protocol, namely to open windows, get herself and others free, and get people out of vehicle as soon as possible.

"Generally, the science has proven that we have about one minute to get out of a sinking vehicle," Executive Director of St. Joseph County 911 Raymond Schultz said. "So, while it is important to get responders on the way, it is more important during that situation to get the folks out of the vehicle."

2. The call taker communicating with the mother muted her line approximately two minutes into the incident while she sought assistance on the call; unfortunately, she did not realize her line remained muted while she was giving the instructions prescribed within the protocol. The call taker attempted to resume communication with the mother; again, the mother continued to do the right things to save herself and her children, but this does not excuse failure to unmute the line.

"We do mute our microphones for a moment so that the person on the other end doesn't hear that conversation. Unfortunately on this instance, she forgot that is was muted," Schultz said.

3. A second call taker who was communicating with a bystander missed an opportunity to quickly identify the location of the pond on a map view window on the screen of the computer he was using during the call because the map view was obstructed by an unrelated window opened by the call taker and not cleared during the call; and the second call taker miscoded the incident as an accident and not as a vehicle in water. By not pinpointing the pond location and not selecting the water rescue response option, there was a delay in dispatching a dive team. Miscoding would not have occurred if this call taker would have fully utilized computer aided dispatch software to prompt additional questions, with additional instructions.

"In that area it would have made a difference because it's a border jurisdiction between Clay Fire and Mishawaka Fire," Shultz said. "There could have been a better location. You can actually see the body of water, or the outline of the body of water on the map, had it been visible."

4. During the final moments of the call with the mother, after the call taker finally unmuted her line, the call taker could have given some reassuring or comforting words to the mother, even if
such words would have been palliative only.

"Even if it was just comfort measures at that point, because now we're not hearing anything on our end," Shultz added. "So you don't know if somebody is in the vehicle or not but even if it was just palliative, just comfort measures, we should at least offer those as the call goes on."

Click here for a timeline of events from St. Joseph County dispatch.

This is a developing story. Watch 16 News Now throughout the evening as we dig deeper. This web story will be updated.



To: All media outlets
From: Raymond Schultz, Executive Director PSAP
Re: Crash on University Dr.

The following is an update on the investigation into the 911 response to the December 31, 2019, event involving a van going into a pond on University Drive in Mishawaka, Indiana.

As we know, the van was carrying a mother and her three children; the mother and one child have survived, but two children lost their lives as the van filled with water and became totally submerged in the retention pond.

Three 911 calls regarding this emergency were made. Five departments (three fire, two police) were dispatched. Our investigation included review of procedures in place for responding to such a call, interviews with 911 employees who handled the calls, review of records generated by the computer aided dispatch software as the calls were being processed, listening to recordings, and preparing a comprehensive timeline accounting for several lines of communication regarding the events, including phone and radio transmissions.

While many things were done correctly in responding to the calls, there were four key shortcomings in the 911 Center response:

1. The call taker who was communicating with the mother should have immediately implemented an existing protocol that was in place for instructing someone involved in the situation at hand; instead, time was lost in trying to figure out the location of the vehicle which delayed dispatch of first responders ; it is clear, however, that the mother, on her own, attempted to do the steps suggested in the protocol, namely to open windows, get herself and others free, and get people out of vehicle as soon as possible;

2. The call taker communicating with the mother muted her line approximately two minutes into the incident while she sought assistance on the call; unfortunately, she did not realize her line remained muted while she was giving the instructions prescribed within the protocol. The call taker attempted to resume communication with the mother; again, the mother continued to do the right things to save herself and her children, but this does not excuse failure to unmute the line;

3. A second call taker who was communicating with a bystander missed an opportunity to quickly identify the location of the pond on a map view window on the screen of the computer he was using during the call because the map view was obstructed by an unrelated window opened by the call taker and not cleared during the call; and the second call taker miscoded the incident as an accident and not as a vehicle in water. By not pinpointing the pond location and not selecting the water rescue response option, there was a delay in dispatching a dive team. Miscoding would not have occurred if this call taker would have fully utilized computer aided dispatch software to prompt additional questions, with additional instructions;

4. During the final moments of the call with the mother, after the call taker finally unmuted her line, the call taker could have given some reassuring or comforting words to the mother, even if such words would have been palliative only.

It would be pure speculation to suggest that the outcome could have been changed if call taker response had been different, especially since it is apparent that the mother continued to do the very things she would have been instructed to do by the call taker, but for the missteps outlined above. Further, the infant was removed approximately 30 minutes after submersion, and miraculously survived and has been released from the hospital.

Education, training and experience suggests that there is a short window of time--approximately one minute--from when a vehicle enters a body of water and occupants can escape; this is why figuring out location of a vehicle is not as important as giving instruction to the occupants to help them get out of the vehicle. Our training and the protocols in place for such situations instruct the call taker to immediately switch focus on providing instruction on escaping the vehicle.

A copy of the timeline of events is attached.

We have shared details of the call with the father; after the FACT investigation is completed, the recordings would become available for release; it serves no good purpose to publicize these recordings, and we hope media outlets would respect the need for discretion and decency under these circumstances. The recordings do not need to be played to prove what we have already concluded and acknowledged in this release and the attached timeline.