BOSTON (WHDH) - Paulette Sadberry’s heart broke the day she held her 58-year-old brother Don’s hand and watched him die. But her grief quickly turned to anger after learning the Boston EMT’s in the ambulance sent to save him got lost.

“It makes no sense! 911 failed my brother and because of that he lost his life,” Sadberry said.

One night in early February Don was on the phone with his girlfriend when he began desperately wheezing and gasping for air. The next thing Don’s girlfriend heard from him was a cry for help. She immediately called 911.

The ambulance sent to help Don was owned and operated by the City of Boston – part of the Emergency Medical Service known as EMS. EMS operates 51 ambulances, and in most cases they are the ones responding to 911 calls throughout the city.

According to the EMS report on this incident the call for help can in at 6:07 p.m. An ambulance was dispatched at 6:09, and the EMTs reported they were at the location at 6:12. But they weren’t. They didn’t get to Don until 6:22.

Where were they in those crucial ten minutes?

Paulette said the EMS Chief admitted to her they were actually at the wrong end of Don’s street. And as they knocked on several doors trying to find him, he went into full cardiac arrest.

That’s when she realized he was never going to wake up. She said the person he was, was gone.

Don died days later, and that’s when Paulette began questioning EMS.

Sadberry contacted the captain of the department, who gave her a short answer.

“He told me his people got lost and he was sorry for my loss and that was the end of the conversation”, Paulette said.

But that wasn’t the end for Paulette. She began to do her own research.

“For an ambulance to get lost on street where only 4 houses exist is beyond my comprehension,” she said. “I think that’s unacceptable. That’s unacceptable.”

Unacceptable and avoidable because Paulette said the EMS Chief admitted the ambulance sent to help Don may not have had GPS.

In fact, a source inside EMS told 7News not all EMS ambulances have GPS; the satellite system most drivers use to find their way around. And many of the GPS units the city does have in their ambulances don’t work.

Perhaps more surprising, 7News has learned Massachusetts doesn’t require ambulances to have GPS.

State Representative David Linsky said Don didn’t have to die, and shouldn’t have died.

“We’re talking about a hundred dollars, a couple of hundred dollars per vehicle. That’s crazy,” Linsky said.

As the chair of the house committee that oversees the agency that licenses all ambulances in Massachusetts, Linsky said he will now push for a law requiring GPS.

“It simply makes sense and will save people’s lives” he said.

That won’t bring Don back, but when seconds count Paulette said she hopes it will help others.

“All of us might need 911. Would you like them to get lost? I want this to be corrected so this doesn’t happen to another family. This is life or death,” she said.

7News repeatedly asked EMS for an on camera interview but instead they sent us an email that said in Don’s case the house could not be immediately located.

“In this particular case, EMS arrived on the street just over five minutes after the call was entered and the Fire Department also arrived on the scene. When the house could not be immediately located, both EMS and Fire spent several minutes working with dispatch to confirm the actual number of the house and continued to search the street on foot for the correct location. The time of day, the dark conditions and the recent heavy snowfall contributed to a search than was more difficult than normal. “EMS takes any loss of life very seriously and our greatest sympathies are with this patient’s family and friends. As part of its Policies and Procedures, the Boston Public Health Commission and Boston EMS regularly review all such incidents to determine the facts and to assess the effectiveness of all current response protocols. We are examining our response to this call and it is currently under investigation by the Commission and Boston EMS.”



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