'A recipe for disaster:' Warnings about Cincinnati's 911 system before Kyle Plush's death

The warnings about Cincinnati's 911 system over the past few years have sounded almost as dire as the urgent calls emergency operators receive every day.

"It is a recipe for disaster."

"Disorganized and inconsistent."

"Bordered on dysfunctional."

"Playing Russian roulette with people's lives."

Those descriptions of the city's emergency communications system came from top city officials and others who have struggled for years to fix a connection that citizens count on during life-and-death emergencies.

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It's a system that many of those same officials say failed Tuesday afternoon when high school student Kyle Plush spent a total of 5 minutes and 38 seconds on the phone with two different 911 operators, begging for help as he was being crushed to death in his van in a Madisonville parking lot.

"In the second 911 call, something has gone terribly wrong," Cincinnati Police Chief Eliot Isaac said during a news conference Thursday. "This young man was crying out for help and we were not able to get information to officers on the scene." As chief, he oversees the 911 center.

In the past two years, concerns about the 911 center have been outlined in memos, reports and emails describing a system burdened by poor management, a lack of training, long work hours, unfilled jobs and technical problems.

Employees have accused managers of mistreating them and ignoring their warnings. Managers have complained about inadequate budgets and high turnover.

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And callers in need of help have encountered technical problems, including systemwide blackouts that prevented them from reaching an operator.

"This tragedy may ultimately suggest the problems have not been resolved or that not enough changes have been made," Mayor John Cranley said. "We owe the Plush family and the public a detailed and comprehensive explanation."

Details about Plush's case are still emerging. But 911 records show he managed to make two calls to 911 while he was trapped under the back seat of his 2004 Honda Odyssey. In the second call, Plush provided details about his location, but the operator who took the call, Amber Smith, did not convey the additional information to officers at the scene, Chief Isaac said.

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Smith, who has worked at 911 for four years, is on administrative leave while the situation is investigated, Isaac said.

Smith has twice posted on Facebook about working overtime, most recently last Friday.

And in May of 2017, she, in her own words "vented" on the social media site. "I'm always at work and working overtime... all it does (is) makes us hate our job and hate the people that are off for months... Just feel like venting. That's all. Nothing will change."

Plush was reaching for his tennis equipment in the back of his van Tuesday when the third-row bench flipped, pinning and suffocating him.

Over the course of two 911 calls, a laboring Plush managed to give his location as the Seven Hills School, describe his vehicle as a gold Odyssey and say he was trapped inside and unable to breathe.

Part of the investigation centers around why, when Plush was so detailed, police were unable to find him.

Plush's father found his son's body inside the van almost five hours later.

The city's response to the tragedy has focused on the 911 center's handling of the incident, but concerns about the center and the way it operates are not new.

"Whatever comes out of this investigation – if it involves people, if it involves process, if it involves technology – the city will have a responsibility to be fully transparent and address any deficiencies that are identified," City Manager Harry Black said. "If warranted, personnel actions, organizational changes and process changes may be necessary. The key is, whatever is done, it needs to be expeditious, thorough and transparent."

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Black said problems existed when he was hired in 2014.

"When I got here, the 911 center was a mess," he said. "We have spent a significant amount of money on training, facilities, technology and staffing. There have been improvements, but not enough improvements.

"When you call 911, somebody must always be there to answer the call and to answer the call in the right way," Black added. "There can be no exceptions."

The 911 center has had five directors in the past four years and its budget, which this year is $10.7 million, has been trimmed by about $400,000 since 2016. The number of full-time positions at the center is down from 130 to 122.

In February, city records show the center was short 17 dispatchers and 15 operators.

A summary of a Feb. 8 meeting targeted at making improvements to the 911 center showed employees were overworked and had low morale.

More: Chris Seelbach and Greg Landsman: Time to turn city 911 over to the county?

Two years ago, then-director Jeff Butler, a police captain, warned in a report to Isaac that the 911 center was in trouble. He said the center needed more money, more 911 operators and better training for the staff.

"The entire operation of the Emergency Communications Center has been negatively impacted by management failures," Butler wrote, not long after he took over the center in early 2016.

He said training is "at best disorganized and inconsistent" and routine maintenance was so poor that three 911 call stations were inoperable at the time of his review. He also said employee recruitment was "ineffective" and the center struggled to attract top talent.

Butler was transferred out less than a year later.

More: 'I probably don't have much time left,' dying Seven Hills student says in 911 call

Another harsh critique of the 911 center came in February, when former information technology specialist Elizabeth Christenson wrote a scathing memo after quitting her job at the center.

Christenson said Butler attempted to improve operations before he was moved. But she said previous and subsequent managers either didn't understand the center's mission or belittled those trying to get the job done.

"It is a recipe for disaster that has been mismanaged and ignored too long," Christenson wrote. "The ECS is being set up to fail."

She said mismanagement of the center "poses a threat to members of the public."

Christenson also complained that top city officials treated the 911 center like an afterthought, sometimes installing unqualified or disinterested police officials into leadership positions there. When she tried to bring some of her concerns to City Hall, she said Black berated her until she was reduced to tears.

Black, who previously said the center "bordered on dysfunctional," said he didn't intend to disrespect Christenson and was not disregarding her concerns. He said his goal was to push through necessary improvements that he felt some employees were resisting.

More: Chief Isaac: 'Something has gone terribly wrong,' dispatcher suspended

"Extraordinary measures were being taken to stabilize operations," Black said in February, in response to Christenson's memo. "We have a higher responsibility to the public who expects us to answer the phone when they call."

Sometimes, however, the phone isn't answered. An Enquirer review of police records last year found at least eight systemwide failures totaling seven hours of downtime at the 911 center between June 2016 and March 2017.

One of those failures, which occurred July 18, 2017 shut down the 911 phones for more than three hours.

City officials blame that problem on a subcontractor of Cincinnati Bell, which is the city's 911 service provider. But critics of the system's current structure say it doesn't matter who is to blame because people in need don't care what happens behind the scenes. They just want to get help as fast as they can.

"The city administration is playing Russian roulette with people's lives," Councilman Chris Seelbach said at the time.

Councilman Christopher Smitherman said he will ask for a City Council investigation of the 911 Center and whether the concerns raised in the past few years have been adequately addressed.

"The death of Kyle Plush is horrible & senseless," Smitherman tweeted Thursday. "The city of Cincinnati must do all we can to prevent this from happening again."