By Robert Mills
The Lowell Sun
LOWELL, Mass. — It was 8:27 a.m., on Easter Sunday, when a city 911 dispatcher learned an elderly resident of Bruyere Gardens, on Varnum Avenue, had activated a medical alert device, and that officials at the device company were unable to contact her.
The series of events that would follow over the next 66 minutes of April 4 would lead to that dispatcher being fired, multiple investigations, and the 79-year-old woman dying even as a pair of EMTs stood just feet away outside her locked front door.
“This is a bitter pill to swallow when an organization’s most important mission is the preservation of life,” said Police Superintendent Kenneth Lavallee, who oversees the 911 dispatch center. “To fail in such a way is difficult.”
One minute after receiving the initial 911 call, dispatcher Jason Lumenello sent a Trinity ambulance to the scene — the woman’s unit at Bruyere Gardens, 975-979 Varnum Ave., on the campus of D’Youville Senior Care.
Bruyere Gardens is a 63-unit independent-living facility for those over 62. It has no full-time medical staff.
Lumenello did not send police, according to a Lowell police internal-affairs report obtained by The Sun, and also took a step to essentially cancel an automatically created entry in dispatching computers that would have sent firefighters to the scene.
An internal-affairs investigation would later fault Lumenello for that, finding that he violated procedures. He was placed on paid administrative leave a short time later, and eventually fired, according to City Manager Bernie Lynch.
“He (Lumenello) made the decision to release the call from the fire side, which in effect prevented the fire dispatcher from seeing there was a fire call to that location for a medical emergency,” Lavallee said.
Lumenello, who had worked as a dispatcher on and off since 1999, and had been employed full time since Feb. 9 of last year, cited advice from a union attorney in declining to comment last night. He is appealing his termination.
He was also faulted in the internal-affairs report for engaging in what Lavallee described as “unnecessary, irrelevant small talk that has no place in this situation.”
According to the report from police Lt. Timothy Kilbride, Lumenello said Lifeline employees had requested only an ambulance be sent to the scene, and that he did not believe the call required sending police or firefighters.
“When questioned why he did not send fire or police, Lumenello stated that there was no protocol in regards to the call as he perceived it,” Kilbride wrote in his report. “He stated that, ‘We usually send Trinity. If it escalates any further than that, they usually call back and ask for additional resources or the call gets taken care of by Trinity.’ ”
Seven minutes after the crew from Trinity arrived at the woman’s locked front door and spoke to her through the door, they radioed dispatchers to ask where firefighters were since the door could not be opened.
The woman told the EMTs outside her door that she could not get to the door, according to transcripts included in the report. She sounded “conscious, alert and oriented.”
It is firefighters who have keys to gain entry and the tools to force entry into apartments and buildings around the city, but because they had not been dispatched, they were not even on the way to the scene yet.
Twelve minutes later, firefighters arrived at the scene, but realized they did not have the key to a “lock box” that should have contained a key to the woman’s apartment.
While some firefighters tried to force the door open, unsuccessfully, a fire lieutenant went to another building at D’Youville, the assisted-living facility, and found a nursing supervisor who had a key.
By the time that nursing supervisor let emergency crews into the woman’s apartment, she had stopped talking. She had no pulse when she was discovered by EMTs, who started CPR immediately and requested paramedics to come to the scene.
It was 9:33 a.m., 66 minutes after the woman activated her medical alert device, before she was in an ambulance on her way to Lowell General Hospital. By 10:15 a.m., she had been pronounced dead.
Last Wednesday, Lavallee and Lynch had a face-to-face meeting with the woman’s family to inform them what had happened.
Lavallee and Lynch declined to identify the woman because the Law Department issued a written opinion stating that releasing the name would violate medical privacy laws.
The Sun has determined the woman’s identity, but her son declined to comment when contacted last night. He also declined to confirm that it was his mother involved in the case.
Christopher Dick, director of marketing for Trinity, defended the ambulance crew’s actions that day. He did not identify the EMTs, but said they had five and two years experience, respectively, and were not involved in a recent certification scandal.
“Trinity EMTs are not trained nor do they have the tools to force the door,” Dick said.
Geri Denterlein, a spokeswoman for Bruyere Gardens, said the nursing supervisor who had a key to the woman’s apartment that day was not responsible for responding to medical emergencies at Bruyere Gardens, because firefighters are supposed to have access to all units in the building.
Fire Chief Edward Pitta said the Fire Department investigated the incident, but found no one was disciplined as a result.
Lavallee said he has since ordered additional training for all dispatchers, reached out to other 911 centers for ideas on how to improve the dispatching process, purchased new training software, and reissued the department’s protocols for dealing with emergency-medical dispatch.
While expressing remorse at how this call turned out, Lavallee pointed out that most of the city’s dispatchers do professional work on a daily basis.
“In the overall scheme of things, they’ve saved hundreds of lives over the years, if not thousands, and although this mistake is horrendous, one can’t forget the incredible work our 911 dispatchers do on a regular basis,” he said.
Lavallee added that he accepts responsibility because the 911 center is under his command.
“I take responsibility for this. I’m the leader of this organization and it falls on me,” Lavallee said. “Nothing is going to make this better.”
Minute-by-minute timeline of a call for help
* 8:27 a.m.: Lowell 911 dispatcher Jason Lumenello receives a call about a Lifeline activation at Bruyere Gardens, a 63-unit independent living facility at 975 Varnum Ave. He is told employees of Lifeline have been unable to contact the 79-year-old woman who activated her medical device.
* 8:28 a.m.: Lumenello enters the call into the 911 center’s Computer Assisted Dispatch computer system, which automatically enters the call, classified as “medical-other,” into the Fire Department dispatch system. Lumenello contacts Trinity Ambulance and sends them to the scene.
* 8:29 a.m.: Lumenello “releases” the automatically created entry about the call on the Fire Department side of the computer system, which prevents a separate dispatcher who dispatches firefighters from seeing it.
* 8:34 a.m.: A crew from Trinity Ambulance arrives at 975 Varnum Ave., but cannot gain entry to the 79-year-old’s unit. They speak to the woman through the door, but she cannot reach the door to open it.
* 8:41 a.m.: The crew from Trinity Ambulance contacts their dispatch center to ask for an estimated time of arrival for firefighters.
* 8:42 a.m.: A fire dispatcher in Lowell’s 911 center gets a call from Trinity Ambulance dispatchers asking for an estimated time of arrival on the firefighters en route to 975 Varnum Ave. The fire dispatcher is not aware of the initial call since Lumenello had released it, and doesn’t understand what is happening.
* 8:44 a.m.: The fire dispatcher in Lowell’s 911 center calls Trinity dispatchers back to get clarification on the nature of the call. She is told EMTs are locked out, and dispatches Ladder 4 from the West Sixth Street fire station.
* 8:45 a.m.: Lumenello gets another call from operators at Lifeline asking about the status of the original call. He engages in what Police Superintendent Kenneth Lavallee describes as “small talk” that is “unnecessary and unprofessional.” He then tells Lifeline operators he will try to get a status update, and calls Trinity dispatchers, asking if the call was accidental. Trinity dispatchers respond that the activation was not accidental, and that their ambulance crew is still unable to gain entry. Lumenello advises Lifeline operators that crews in Lowell are going to force entry.
* 8:46 a.m.: The crew of Ladder 4 leaves the fire station on West Sixth Street, and the fire dispatcher updates them that this is a lockout connected to a medical call.
* 8:52 a.m.: The Trinity Ambulance crew calls again asking for an estimated time of arrival for firefighters.
* 8:53 a.m.: The fire dispatcher changes shifts. The crew of Ladder 4 arrives at the scene at 975 Varnum Ave. and notifies new dispatchers that they are there, but unable to locate EMTs. They are unable to open a lockbox containing a key to the unit, because firefighters do not have the proper key to the box.
* 8:59 a.m.: Firefighters make contact with the ambulance crew at the scene. It is around this time that the 79-year-old stops communicating with the ambulance crew. Firefighters are unable to force the door open with hand tools, and realize they need hydraulic tools or a key.
* 9:04 a.m.: The ambulance crew advises Trinity dispatch that firefighters are still trying to find keys for the woman’s door.
* 9:05 a.m.: Firefighters are retrieving hydraulic tools from the ladder truck and still looking for someone with a key.
* 9:10 a.m.: Firefighters inform dispatchers that they have gained entry to the 79-year-old’s unit after finding a nursing supervisor next door who had a key. The 79-year-old is found in full cardiac arrest. EMTs begin immediate CPR.
* 9:33 p.m.: Dispatchers are notified that the woman is en route to Lowell General Hospital.
* 10:15 a.m.: A dispatch supervisor on the day shift learns the woman was pronounced dead at Lowell General.
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