No Internal Probe Done after Two LODDs in Kansas City, MO

When two of its firefighters died in the line of duty over the past year, the Kansas City Fire Department did not order or conduct formal after action reviews that the KCFD’s own guidelines suggest should happen following such incidents.

The department confirmed on Tuesday that it conducted no internal review after the drowning death last September of 33-year-old Kyle Brinker. It confirmed a day later that it also did not conduct a review after paramedic Graham Hoffman, 29, was stabbed to death by a patient in the back of an ambulance in April.

Typically, the department has investigated line of duty deaths due to anything other than job-related health conditions. The department decided that was not necessary for the two most recent fatalities, and a spokesman stressed that while the reviews are suggested as part of the department’s general guidelines, they are not mandatory.

“After an informal review of both incidents, it was determined that an official AAR would not be needed to understand the events and the subsequent outcomes, or to determine a course of action if needed,” department information officer and Battalion Chief Michael Hopkins said in a written response to the Star.

“Gathering the individuals involved and forcing them to relive their experience would not have served a beneficial purpose for anyone.”

When should reviews happen?

The department’s guidelines say the purpose of after action reviews is to understand why something happened and to learn from the experience.

They specifically list that formal reviews are appropriate when an incident: creates media attention, creates a large dollar loss, or results in a near miss, serious injury or death, among others.

Local media covered both Brinker’s and Hoffman’s deaths in their immediate aftermath, as well as their funerals, and Kansas City has since paid Brinker’s wife more than a million dollars over his death on the job.

On Wednesday, Hopkins said that reasons for conducting an official review include the “complexity of the incident, multi-jurisdictional or multi-battalion response, obvious policy and procedure breakdowns, and communication breakdowns, to name a few.”

He said neither death met that threshold.

The National Fallen Firefighters Foundation says fire departments should always conduct after action reviews following a line of duty death. The organization says that volunteer and career fire departments nationwide can benefit from the lessons learned in hopes of saving lives.

“Conducting an after-action review, or debrief, enables crew members to analyze what happened, why it happened during an incident and what improvements can be made,” says the foundation, which honors firefighters who died in the line of duty with a ceremony each Memorial Day weekend in Emmitsburg, Maryland, home to the National Fire Academy.

“The key to successfully using the AAR as a tool for culture change in the fire service is that it has to be done after every incident, no matter how small or seemingly routine for, as we know, many firefighters die in connection to what are perceived to be routine calls,” according to the foundation.

Previous investigations

When Kansas City firefighters Larry Leggio and John Mesh died 10 years ago fighting an arson fire in the city’s Historic Northeast area, the department conducted an internal investigation and issued a 71-page report that recommended changes aimed at avoiding similar line of duty deaths.

The investigation’s starting point was the after action review of the incident.

The federal Fire Fighter Fatality Investigation and Prevention Program also issued a report after Leggio and Mesh died. The taxpayer-funded program set up in 1998 does not have the resources to investigate every line of duty death nationwide and did not look into the deaths of Brinker and Hoffman.

In an email to the Star, Hopkins said the National Fallen Firefighters Foundation is “a wonderful organization who is doing excellent work.”

He noted that he and Fire Chief Ross Grundyson recently appeared on the foundation’s “After Acton Review” podcast, in which they discussed the 2015 incident that killed Leggio and Mesh and two earlier instances in which multiple Kansas City firefighters were killed.

But Hopkins said that while KCFD appreciates the foundation’s work and recommendations, “KCFD is not required to adhere to them.”

Eleven Kansas City firefighters have died in the line of duty in the years since Leggio and Mesh perished when a building collapsed on them during that arson fire on Independence Avenue, according to the local firefighters’ union website.

Brinker’s was the first line of duty death since then attriibuted to something other than COVID-19, cancer or suicide.

Hoffman death inspired reform

Hoffman’s followed seven months later. The circumstances surrounding his killing were known publicly soon after the attack. While the department conducted no formal internal review, Hopkins said the KCFD has been working with union leaders to implement strategies and tactics aimed at de-escalating tense situations that could lead to violence, as well as defensive training.

“The training will take place in 3 phases and is being provided to our members via an outside company with a background in these disciplines. This process is on-going and not complete,” Hopkins said.

Brinker’s drowning did not lead to a search for lessons that might be learned from it. Not until the Star reported the circumstances of his death on Aug. 6 did the department confirm that he drowned in the swimming pool at Gladstone Community Center last Sept. 17 during what the department last week described as an annual swim test.

Previously, the department said only that he died after “suffering a medical emergency during a training exercise” and did not disclose other information about what happened or where.

Timing discrepancy

The Star began making inquiries after the City Council on July 31 approved a nearly $1.1 million payment to Brinker’s wife to settle a workers compensation claim for what the council ordinance said was death on the job due to “an accident.”

An after action review in Brinker’s case might have cleared up a key discrepancy surrounding his death: How long was he underwater before rescuers attempted to revive him?

In a statement released on Friday, Chief Grundyson said that two spotters entered the pool immediately after Brinker showed signs of illness and went below the surface in 4 to 4 ½ feet of water.

“They reached Firefighter Brinker, pulling him to the surface and swiftly removed him from the pool. He was rapidly evaluated and patient care was rendered.”

Yet the autopsy report obtained by the Star this month said Brinker was underwater for about 30 seconds after he was observed suffering from cardiac arrest. If so, why did it take that long for the spotters to remove him from the pool if, as Grundyson claims, they reached him immediately.

Grundyson did not provide specifics as to what sources of information he based his account. It’s unclear if he relied on written reports and witness statements gathered that day, or recollections of those who were there months later to prepare his statement.

Hopkins did not elaborate when a reporter asked for further explanation on those points.

“As to what source material was used by Chief Grundyson for the statement released on Friday,” Hopkins said, “it was obtained from the information gathered during the review of the incident and combined with his nearly 30 years of institutional knowledge of the Kansas City Fire Department and its operations. Knowledge gathered while serving the department as a Firefighter, FAO, Captain, Battalion Chief, Deputy Chief, Assistant Chief, and Chief of the Department. Along with more than 35 years as a licensed paramedic, he is confident in the information that has been provided.”

Hopkins said he did not know why the autopsy report said Brinker was submerged for 30 seconds or who the sources of that information were. Thirty people were in the pool area at the time, he said, but only seven were focused solely on the four swimmers and relied on their perceptions of the time that elapsed.

“Since we could not provide a consensus exact time we used the terms immediately and swiftly, because those are the terms that were used consistently by those actually responsible for entering the pool and subsequently removing him from the pool,” Hopkins said.

The Star has submitted an open records request with the city of Gladstone for any surveillance video footage that might exist and might inform the timeline of events that day.