Ohio widow: 911 glitch proves system ‘needs to be fixed’

July 15, 2009 06:52 AM

By Tom Feran
The Plain Dealer Reporter

NORTH OLMSTED, Ohio — When Nicola Ortner’s husband collapsed from an apparent heart attack in their North Olmsted home on Father’s Day, she called 911. The dispatcher answered immediately, sent help to the street address and stayed on the line to give Ortner CPR instructions.

But the street the ambulance was dispatched to was 20 miles from Ortner, who had one hand on the phone while using the other hand in a frantic struggle to revive her husband. The ambulance was in Independence.

By the time the dispatcher learned of the error, “I was in a panic,” Ortner recalls.

Her husband had stopped breathing.

Outside their home, the couple’s 16-year-old daughter was in tears as she waited in the driveway for the van the dispatcher insisted was on their street - MacKenzie Drive.

“I said, ‘MacKenzie Drive? It’s MacKenzie Road, North Olmsted,’ ” Ortner remembers.

“The 911 operator said, ‘North Olmsted?’ It didn’t dawn on me she didn’t know.”

The dispatcher then called North Olmsted police. Fire-rescue paramedics arrived within three minutes - but almost 20 agonizing minutes after the call to 911.

Steve Ortner, 56, would be pronounced dead on arrival at St. John West Shore Hospital.

“I don’t know if it would have made any difference if they got here in time,” Nicola Ortner says, “but there’s something wrong with the system. There’s a monumental screw-up somewhere. Something needs to be fixed.”

City and county officials maintain it has been fixed. They said an unusual combination of circumstances led to the error - and it wasn’t caught because of a 911 system flaw that North Olmsted Safety Director Lisa Thomas called “so big I could drive a truck through it.”

Murray Withrow, director of the Cuyahoga Emergency Communication System, which coordinates 911 calls in the county, said the gap was closed by safeguards ordered after the incident. All calls are now verified by community and ZIP code, he said.

When Nicola Ortner dialed 911, her call went to the dispatcher for Independence - “who did answer, ‘911 Independence,’ ” Ortner says. “But I didn’t think that much of it because everything is centralized. I thought it was the first open line. It didn’t dawn on me she didn’t know I was in North Olmsted. It’s a shock to find your call doesn’t go where you think.”

Officials discovered her call was misrouted mainly because of the way the Ortners’ address was entered in a computer database when the family changed their phone service a year before.

They listed their street name as “MacKenzie,” the same spelling as on a street sign near their home. But it is not the spelling listed in the county’s master street guide used by EMS. That spelling is McKenzie. Thomas, in fact, has found four different recorded spellings for the North Olmsted road.

The spelling in the database automatically directed the Ortner call to Independence, a city that has a street spelled the way the Ortners listed theirs. To add to the problem, the street numbers on the Independence drive largely match those on the North Olmsted road.

Further complicating the situation was the Ortners’ change to a bundled phone and cable TV package, with digital phone service using VOIP, or voice over Internet protocol.

Withrow said the misrouting of the call would not have happened before the family’s switch. “It’s a little confusing because the technology has developed so quickly,” he said.

Withrow said his agency has toughened requirements for VOIP service providers, so that dispatchers will now see displays of street address, city and ZIP code for all 911 calls.

Similar problems are unlikely to happen with callers using cell phones, which now account for 70 percent of 911 calls, Withrow said. The 911 service sends a signal to the cell phone that automatically returns the caller’s location.

Thomas said North Olmsted police have since tested the homes of the Ortners’ neighbors and found one home phone that directed a 911 call to Independence.

The routing was corrected, she said, and the new verification standards should ensure that what happened to the Ortners will not be repeated.

“It’s going to make a difference to somebody,” Nicola Ortner says. “It might be Steve’s legacy that he saved a life down the road. You want to know the ironic part? He was a computer engineer. He probably would have fixed it in no time at all.”

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