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Pa. county investigates dispatching error after patient dies

An ambulance was initially sent to the wrong location in a 911 call where a man died from a heart attack

The Citizens’ Voice

WILKES-BARRE, Pa. — Vincent Marcario was resting in bed at his home in Kingston, looking forward to the Thanksgiving feast he had stayed up late preparing with his sister, when the day took a tragic turn.

Lying in bed, Marcario, 46, had a heart attack that proved fatal. Family members, who struggled to preform CPR in a cramped bedroom until help arrived, believe a 911 dispatch error might have cost Marcario his life.

The death occurred six months after a woman died in a fire in Mocanaqua after a 911 dispatcher sent fire departments to the wrong municipality.

In Marcario’s emergency, Kingston Fire Chief Frank Guido confirmed an ambulance responding to the 911 call on Nov. 27 was dispatched to Gates Street in Wilkes-Barre instead of South Gates Street in Kingston. He said he submitted an incident report to the county about the error after he learned his crew saw the dispatch error on the computer logs.

Mary Hayes, who called 911 when her brother had the heart attack, said she has lived at 36 S. Gates St. for the last four years with her family and knows she told 911 the correct, full address, even spelling out the name of the street. The call taker asked her if it was Kingston Township or Kingston Borough, she said. Hayes, 50, told the call taker she didn’t know, but the address was behind Kirby Park.

“I don’t know how they could screw that up with Wilkes-Barre,” Hayes said.

She estimated it took between 15 and 20 minutes from the first 911 call until an ambulance arrived. She said she used her cellphone, but it doesn’t save the time calls are placed. Guido couldn’t say how long until the dispatch error was caught, but said once his crew realized there was a mistake, it took three minutes until an ambulance was on scene.

Fred Rosencrans, executive director of Luzerne County’s 911 Dispatch Center, confirmed there’s an investigation, but said he couldn’t comment further because it is a personnel issue, referring questions to county solicitor David Pedri, who also said he could not comment.

Asked in detail about the mix-up, he said, “I can tell you it’s pretty accurate,” but he declined to say whether any disciplinary action has been taken or what the outcome of the investigation was.

“It’s a very sensitive situation whenever it involves personnel,” he said. “I understand the public wants to know, but my official comment is it’s a personnel issue and it has been investigated.”

Paula Schnelly, president of the local American Federation of State, County and Municipal Employees chapter — the union for 911 call takers — declined to comment on whether any disciplinary action was taken against a 911 dispatch employee.

“I will say this: the 911 center is understaffed,” she said.

One or two weeks before his fatal heart attack, Marcario was diagnosed with congestive heart failure, but he was fine while helping prepare Thanksgiving dinner, Hayes said.

“He wanted his ham and turkey,” she said, adding she wouldn’t let him steal any stuffing while preparing the meal.

Night owls, Hayes and her brother finished making the meal shortly before sunrise, Hayes said. Some family members, including Marcario and his sister, were already at the house — Marcario’s mother Marie Marcario Weidemann, 74; his adopted brother and sister Danny Marcario, 19, and Julie Marcario, 17; and his nephew Leo Ravalli, 18.

Marcario was in bed in his upstairs bedroom when chest pains started, Hayes said. He couldn’t call out for help because he was short of breath, but was able to wake Ravalli by tapping on the dresser. Once Ravelli saw something was wrong, he got his mother, Hayes.

Marcario’s mother and sister, both former nurses, came into the room, and Hayes called 911 once she realized he was having a heart attack.

Weidmann said she sat with her son while Hayes went to turn on the porch light for EMS. Before Hayes made it downstairs, though, her mother called for her to come back up.

“I was holding his hand and the only thing he kept saying was, ‘Mom, mom. I can’t breathe,’” Weidmann said.

That’s when he stopped breathing and his hands and face went ice cold, according to the family.

Weidmann pounded on her son’s chest, but the force hurt her hands because of nerve problems she suffers.

Hayes then had her mother call 911 back to tell the dispatcher they were starting CPR. The 911 caller said they had to get Marcario on the floor to have a steady surface to place him on in order to preform CPR.

Hayes said there was little room on the floor, but Danny Marcario was able to get his older brother off the bed. Hayes stood bending over her brother because she couldn’t kneel next to him and used her body weight to compress his chest while Danny Marcario did the breathing.

“I was putting everything into it,” Hayes said.

But the family’s efforts were to no avail. By the time help arrived and transported Marcario to Wilkes-Barre General Hospital, it was too late.

If 911 dispatched EMS to the correct address the first time, Hayes said, “I firmly believe they could have saved his life.”

Earlier this year, there was a 911 dispatch error in a fatal fire. County 911 records show dispatchers sent fire departments to the wrong location while responding to a house fire in Mocanaqua that killed 52-year-old Michelle Dzoch.

When the fire was reported to 911 at 10:47 a.m. on May 15, dispatchers first sent fire departments to 76 Main St. in Conyngham Borough instead of 76 Main St., Mocanaqua, Conyngham Township, according to dispatch records obtained by The Citizens’ Voice via a Right-to-Know request. Those locations are about 15 miles from each other.

Sugarloaf Fire and Rescue, Hazle Township Fire and Rescue and Valley Regional Fire and Rescue were initially dispatched, the closest one of which is more than 15 miles from Mocanaqua.

The Mocanaqua Fire Company was dispatched at 10:52 a.m., and records show it was an additional six minutes before crews were en-route to the fire, which was 0.1 mile away from the fire department building. Two call center employees were initially suspended without pay, but one of them was subsequently fired as a result of the 911 mix-up.

The center relies heavily on phone company records, including between 170,000 to 180,000 records for land lines alone in the county, Rosencrans had said.

He noted that many communities have similar names and the same street names, and out-of-area phone providers have been known to list addresses in the wrong municipalities.

At the meeting of Luzerne County Council on Tuesday night, Councilwoman Kathy Dobash called for council to conduct an investigation into the error, saying the 911 call center needs to have public oversight.

“I can’t believe this happened again. I can’t believe there’s another death,” Dobash said. “It’s about time that the manager takes responsibility and that we get the truth out there.”

Solicitor David Pedri said council has authority to perform some investigations and that he would prepare a memo outlining the process. He was instructed to report back at next week’s meeting.

“As a director running a center that’s the seventh-busiest in the state, that’s the kind of stuff that keeps me up at night, to be honest with you — thinking about the amount of data that’s out there that could be wrong,” Rosencrans said in a June interview. “When I had a data department of seven, years ago, and now I’m down to one person, it’s almost impossible to scrub the data to where I want it to be.”

As a result, call-takers are trained to assume that the data is wrong on every call, he said.

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©2014 The Citizens’ Voice (Wilkes-Barre, Pa.)