OH Fire Dept. Still Troubled by Patient Death Investigation
Source The Columbus Dispatch, Ohio
The death of Sonia Bray and the Columbus Fire Division's subsequent investigation of paramedics’ role have exposed weaknesses in the division’s ability to hold its employees accountable when they make mistakes.
The Dispatch found that the division’s investigation into why Bray died in early 2011 went dormant for nearly a year, that internal investigators were unwilling to ask necessary questions and that a turnover in investigators led to light punishments for two paramedics and a lieutenant.
In the end, the only people who really were punished are those who rely on emergency services and taxpayers, who are paying a $1.12 million lawsuit settlement.
Bray, 76, went into cardiac arrest after paramedics did little to help her for 25 minutes. Bray never regained consciousness and died a few days later in the hospital.
“I have several issues with the way the entire thing was handled from start to finish,” said George Speaks, the city’s public safety director. “The investigation needed to be better.”
Attorney Gerald Leeseberg, who represented Bray’s family in the wrongful death lawsuit against the city, said he was disturbed by the actions of paramedics and the division's weak reaction in the following 16-month investigation.
“The city has since been very cooperative and expressed regret and said it is trying to improve,” he said. “But if we wouldn’t have pressed this litigation, that wouldn’t be the case.”
This is not the first time questionable investigations and a lack of accountability have plagued the division. A sex scandal at Station 17 included accusations of a cover-up and corruption of the investigation by supervisors. A firefighter was fired in 2014 for bringing his mistress to the firehouse and other indiscretions.
Speaks said such incidents, especially the Bray case, led him to order the Fire Division to come up with ways to improve internal investigations and hold itself more accountable.
Columbus Fire Chief Kevin O’Connor recently was presented with the first draft of recommendations to change how the division conducts investigations. The recommendations include adding a captain to the investigation unit to increase accountability and to consolidate the unit staff members with those who do background investigations on fire employees.
The timeline to enact new standards is unclear at this point, O'Connor said.
Bray was at an MRI facility on Bethel Road in January of 2011 when workers called 911: Bray began having trouble breathing while she was inside the machine.
Transcripts of the 911 call show that before workers hung up, they told a dispatcher that Bray was able to sit up.
Paramedics James Hingst and James Amick arrived but did little to care for Bray for 25 minutes, workers at the facility told fire division investigators. At one point paramedics discussed a pot roast that was cooking back at the fire station.
During this time their supervisor, Lt. Stephen Smallsreed, arrived, talked to the paramedics and left after two or three minutes. Smallsreed told investigators that he never talked to Bray, assessed her or asked what was being done to assist her.
After 25 minutes, Amick and Hingst loaded Bray into an ambulance for a five-minute ride to the hospital. The paramedics barely made it out of the parking lot before Bray went limp and unconscious.
She never regained consciousness and died days later from a heart attack.
Two weeks later, Shauna Wilson, a worker with the MRI center, filed a complaint with the division. She said she was appalled with the actions of the paramedics that day.
Megan Dunn, Wilson’s co-worker, told fire officials, “You know we think that these people come here to help her and really they ended up just hurting her in the long run.”
Members of the division’s Professional Standards Unit interviewed Wilson in February of 2011. The investigators did not interview Amick and Hingst until April.
The questions investigators asked were too basic, O’Connor and Speaks said, and led the firefighters to answers that minimized wrongdoing.
Here’s a sample of the interview: “Would you say this run went slow at certain points? Or, you know, were there certain parts of it that could been hurried up? Or you know, even if it was with a reason? Or was this a standard run for you guys — as far as your experience.”
Both men said it was a standard run.
The investigator’s response: “Okay.”
Investigators interviewed Smallsreed in May of 2011. They told him he was not the focus of the investigation and was there to provide information. But he should have been a focus, O'Connor said.
“I have a bigger issue with his actions, because he’s a supervisor,” O’Connor said. “It’s his job to control the scene and he just left."
After Smallsreed's interview, the investigation sat dormant for nearly a year, records show.
Ned Pettus Jr. — who will replace Speaks as safety director Aug. 1 — was fire chief at the time. Then Assistant Chief Greg Paxton had recently been appointed the division’s executive officer, or second in command, when Smallsreed gave his first interview.
Paxton said last week that when he took the position there were more than 100 open internal investigations that were months old.
“I spent a considerable amount of time trying to get those done and cleared,” he said.
Pettus announced his retirement in early 2012. Before he replaced Pettus as chief, Paxton ordered that investigators re-interview Smallsreed. Paxton also ordered that a different investigator, Lt. Lawrence Stevens, question Smallsreed.
More than a year after Bray’s death, Stevens asked direct questions about why Smallsreed left the scene that day. Smallsreed said he couldn’t recall whether Bray was breathing normally. He couldn’t recall whether Bray was able to speak.
Smallsreed was asked if he thought his paramedics gave proper treatment that day. “Um, I wasn’t there so it’s hard for me to say no because I have no idea what was going on,” he said.
Division records show Smallsreed violated three standards:
• He failed to “supervise the crew in regard to proper care.”
• He left the scene without ensuring that the crew provided proper patient care.
• He failed to follow up in quality assurance once he was notified of Bray's death.
He was ordered to undergo re-evaluation of his competency to be a supervisor and received a written letter of reprimand. Smallsreed appealed his punishment and argued he was not obligated to evaluate and provide care because he was not the first on the scene.
Former safety director Mitchell J. Brown, now a city councilman, first denied that appeal, then relented in a settlement with Smallsreed.
Brown said Thursday that he acquiesced after the division talked to other supervisors and couldn’t get anyone to dispute that leaving the scene was outside normal procedure.
"We felt there was a great chance we’d lose at arbitration and that it would be a waste of money," Brown said.
The division sustained Shauna Wilson’s claim that Amick and Hingst were unprofessional and did nothing to assist Bray.
They received re-training and counseling.
Fire Chief Kevin O’Connor said this week that such an incident would result in much more severe discipline under his administration.
“I can’t answer for how things were handled back then,” he said. “But it would be different now.”
Smallsreed has since retired from the division and could not be reached for comment.
Bray’s son has declined comment through the family’s attorney.
Pettus said this week that the investigation never reached his desk because the punishments were not severe enough to require the chief to sign off. Those guidelines are set in the firefighters' union contract.
“I had no knowledge of that case until after I retired and what I’ve read in the newspaper,” Pettus said.
O’Connor said he is briefed on any such incidents now and keeps tabs on discipline recommendations.
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©2016 The Columbus Dispatch (Columbus, Ohio)
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