More details emerge in death of 911 caller
Grady official says operator a ‘scapegoat’
The Atlanta Journal-Constitution
Published on: 08/07/08
Police and paramedics responding Saturday to a Johns Creek woman in distress struggled for nearly half an hour to keep her alive until an ambulance arrived, according to Johns Creek police officers.
The delay in responding to the dying woman’s 911 call was even greater than Fulton County Emergency Management officials initially reported, according to a police report released Wednesday.
The Johns Creek police officer who worked to revive the woman while waiting on an ambulance, said he was frustrated by the series of mistakes leading up to her death.
Darlene Dukes, 39, died from a blood clot in her lungs. The mother of two boys, ages 15 and 11, was at home alone when she began to feel ill and called Fulton 911.
Dukes was in respiratory distress but was able to tell the 911 operator the name of her street and stayed on the line for 18 minutes before she fell silent.
The first ambulance Fulton County dispatchers sent to help Dukes was sent to a wrong address inside Atlanta city limits, nearly 28 miles away. By the time the error was discovered and emergency workers redirected, Dukes had fallen silent on the phone.
The problem with Dukes’ call was discovered when an operator in Grady Memorial Hospital’s emergency call center "Googled the name of the apartments and figured they were… not in southwest Atlanta," said Eric Ossman, the medical director for Grady ambulance service. Grady was dispatched in error the first time.
Fulton officials said the operator misheard the street name as Dukes struggled to speak, sending rescue crews to Wells Street in Atlanta rather than Dukes’ Wales Street address in Johns Creek north of Atlanta.
Fulton’s 911 director Alfred "Rocky" Moore said Tuesday that the operator was fired because she should have noticed the call came from a cell tower in north Fulton, not Atlanta.
Moore did not return phone calls Wednesday and refused to talk to a reporter in person.
Dukes called Fulton County 911 for help just after 1 p.m. Saturday, but due to the mix-up, the first emergency responders didn’t arrive until about 1:39, according to police records. An ambulance arrived just after 2 p.m., and Dukes didn’t reach Emory Johns Creek Hospital until 2:18 p.m., according to police reports.
Johns Creek police Cpl. James Harris raised a red flag after Dukes died at 3:01 p.m., noting the discrepancies in the response time.
"I saw what had happened, and said, ‘Not on my watch,’ " the 17-year law enforcement veteran said Wednesday.
Harris was the second officer to arrive at her home 25 minutes after she placed her call.
They found Dukes not breathing and began administering CPR while Harris, a fellow officer, and Fulton County Fire paramedics also at the scene called repeatedly for an ambulance.
"The firemen had already been asking for an ETA," with no response, Harris said.
When he tried to get help on his police radio, he was told the nearest ambulance was about 13 minutes away.
"I said, ‘That’s not good enough! We’ve got a woman in full arrest,’" Harris said.
Twice before the ambulance arrived, Dukes’ heart began beating again, but she kept slipping away.
Hours after Dukes died Saturday, Harris requested records from Fulton Emergency Management Agency to learn more about what led up to the incident.
When Fulton EMA refused, he filed a written request for the audiotape of her call to 911 and transcripts, both of which are public records. He was still waiting for them on Wednesday night.
"It’s just hard to wrap my mind around it," Harris said. "That you have the possibility to do some good for somebody and you just can’t because of somebody else’s errors."
But Ossman, with Grady’s ambulance service, said Wednesday that one operator should not be blamed for Dukes’ death.
Ossman said Dukes’ death is an indictment on an emergency call center that has long suffered mismanagement, short staffing and inadequate training.
Fulton, he said, was trying to make the fired operator the "scapegoat."
"Unfortunately, this poor woman has been terminated," he said. "She has been categorized as being at the root of all this. In reality, these issues were happening in the communications center at Fulton County long before this woman. This is not about one bad employee. … This one poor woman is not responsible for all this."
The Saturday afternoon distress call from Dukes came to the county’s emergency center, bouncing off a cellphone tower outside Atl
anta, yet the operator dispatched a Grady ambulance. Grady only answers ambulance calls inside Atlanta while Rural/Metro Ambulance handles calls north and south of the city.
"The phone [call] hit a cell tower that was 27 miles away from the address that they dispatched Grady EMS and [Atlanta] fire [department] to," said Ossman.
In a prepared statement, Moore said, "We want the citizens to understand and be confident in the 911 system. Our employees are trained properly. They answer millions of calls a year."
Dukes’ family, in Atlanta from New York on Tuesday, were angry to learn of the 911 delay from reporters rather than from the county.
When she learned of the delay, mother Ida Dukes seemed stunned. "Her sons are being destroyed by their mother’s death. Something went wrong and I’d like to find out what."