The Loudoun County-Combined Fire Rescue System on Tuesday presented the findings from a review of the June 4 incident response to the drowning death of 16-year-old Fitz Thomas at Confluence Park, where Goose Creek meets the Potomac River adjacent to Leesburg’s River Creek community.

The “Perdido Bay Terrace Significant Incident Review” is named after the road that leads to Confluence Park. The review includes an overview of the June 4 emergency call, details of the responses by Loudoun County and Montgomery County, Maryland first responders and a list of policy changes, recommendations and safety initiatives that have been instituted since the incident. It also includes measures being implemented to increase the efficiency of multi-jurisdictional incident responses in or around the Potomac River.

“It is important that the community know all of the facts surrounding this tragic incident,” Chairwoman Phyllis Randall (D-At Large) said in a prepared statement. “We asked fire and rescue to report back to us on this because we must know what happened so that the county and members of the community can take steps toward preventing it from ever happening again.”

During the incident, initial 911 calls were routed to Maryland first responders, who couldn’t pinpoint the location of the accident. After numerous communication breakdowns between Loudoun and Montgomery County officials, local first responders did not arrive at the scene until more than 30 minutes after the initial call.

Loudoun County’s findings

On June 4, first responders from Loudoun and Montgomery counties were dispatched to assist with a reported drowning near the confluence of the Goose Creek and Potomac River. Firefighters arrived at the scene to find an unresponsive teenage male with CPR in progress. Fire and rescue personnel immediately assumed patient care and transported him to Inova Lansdowne Pediatric Emergency Room. Thomas could not be resuscitated.

“We continue to extend our deepest condolences to the Thomas family and to all who knew and loved Fitz,” Loudoun County Combined Fire and Rescue System Chief Keith Johnson said in a prepared statement. “We recognize how difficult this incident has been for our community. ”

A significant incident review team that included staff from Loudoun County fire and rescue and Montgomery County fire and rescue was developed to conduct the analysis, according to county staff. The team conducted a review of all incident details, policies and available technologies for both Loudoun County and Montgomery County Emergency Communications Centers (ECC).

The group analyzed a wide variety of data and materials, including, but not limited to:

• 911 call audio recordings;

• Written statements provided by Loudoun County fire and rescue personnel who worked the incident;

• Existing policies and procedures addressing emergency responses along the Potomac River;

• Procedures for the dispatching of mutual and automatic aid resources between Loudoun County and jurisdictions along the Potomac River;

• Mutual Aid Response Agreements between Loudoun County and Montgomery County;

• Current and past practices regarding Potomac River responses;

• Training requirements for ECC staff;

• Staffing and organizational structure of both ECCs;

• Phone calls between the two ECCs with respect to this incident;

• Radio traffic in each jurisdiction; and

• Records and notes from each jurisdiction’s Computer Aided Dispatch (CAD) system.

The significant incident review highlighted technology challenges associated with calling 911 from locations that are close to jurisdictional boarders. Due to the incident’s proximity to the Potomac River, 911 calls from the June 4 emergency scene were received by ECCs in both Montgomery County and Loudoun County.

Each of the 911 calls made during the incident originated from cell phones, requiring the cellular routing technology to provide location information.

When a call is initiated on a cell phone, the cell tower sector presenting the strongest signal to that phone—usually the closest one pointing in the direction of the caller—will receive the call and route it based on the number dialed, according to Loudoun County staff. The 911 call is then delivered based on the physical location of the cellular tower and sector receiving the call, not the caller’s actual location.

During the June 4 incident, efforts to determine the victim’s actual location contributed to a delay in dispatching Loudoun’s first responders.

The significant incident review provides details regarding response times following receipt of 911 calls. The first 911 call was received by Montgomery County at 5:48 p.m. on June 4, approximately five minutes after Thomas was noticed missing by his friends, according to the caller.

Montgomery County first responders were dispatched within three minutes and arrived at the Potomac River approximately 15 minutes later at 6:04 p.m. Loudoun County received its first direct call from the incident scene at 6:06 p.m.

Loudoun call takers were delayed in dispatching rescue crews due to their inability to obtain a physical address or known location of the incident, which was needed to load it into the CAD system and route responders to the correct location, county officials say. Loudoun dispatched rescue crews at 6:16 p.m., and they arrived at the scene eight minutes later at 6:24 p.m., which was approximately 18 minutes after receiving the call, according to the county.

Between 6:05 p.m. and 6:35 p.m., several other 911 calls were received by Montgomery and Loudoun ECCs during which dispatchers attempted to identify the precise location of the incident and guide first responders to the scene. Dispatchers in the two jurisdictions consistently communicated with one another in an effort to share information, transfer callers and identify whether Montgomery County requested a response by Loudoun County. The review shows that the delay in determining the precise location of the incident from callers and the protocol that emergency responses to the Potomac River are within the jurisdictional responsibility of Montgomery County were among the factors that affected the overall response. The Potomac River is part of Maryland.

“While our review shows that staff in Montgomery County and Loudoun County properly followed existing policies and procedures, this incident also revealed that we need to amend Potomac River response procedures to ensure the most appropriate response, which we have already started to do,” Johnson said.

Procedural changes

Loudoun County officials say several changes to the department’s 911 practices were made shortly after the June 4 incident, including the implementation of a dual dispatch policy that requires 911 operators to automatically send fire and rescue units any time a call for assistance on the Potomac River or its tributaries on the Virginia side is initiated from Loudoun County. This includes water rescue units if the victim is not confirmed to be out of the water. Additionally, Loudoun County’s ECC has completed upgrades to the 911 system that will assist telecommunicators in obtaining more accurate location information for 911 cell calls.

In addition to the findings listed in the significant incident review, the report also includes more than a dozen recommendations to improve policies and procedures, staffing levels and training that will strengthen multi-jurisdictional emergency communications and incident responses along the Potomac River. The recommendations include enhancing 911 technologies, better documenting points of interest and vehicle access along the river, expanding 911 operator training and providing safety and prevention education through community outreach.

Reactions

Michelle Thomas, mother of Fitz Thomas and president of the NAACP Loudoun Branch, expressed her frustration before the briefing.

“All you had to do was come with some urgency like it was your child,” Thomas said. “All you had to do is not be lazy that day. That’s all you had to do. You didn’t have to breath breathe into him — you had to give him a shot of survival. Writing a policy is great, thank you for all of that. But that don’t bring my boy back; it doesn’t stop the hurt. I do 15 jobs in this county, and your one job was to come and get Fitz. That’s it. How could you fail us?”

Johnson, the chief of the Loudoun County Combined Fire-Rescue System, said his commitment to Thomas was to be transparent and to never let this incident happen again.

“On that day, on June 4, the policy was that if a person was in the river, that was Montgomery County’s jurisdiction. Again, that is what it is,” Johnson said. “And again, I immediately changed that policy on understanding the magnitude of what occurred. So that’s all I could really offer you. That’s not an excuse. Please don’t take it as that, but I’m just offering that.”

Chairwoman Randall disagreed that Fitz Thomas was in the Potomac River. She pointed out that 911 callers said he was in Goose Creek in Confluence Park located in Loudoun County.

“He wasn’t in the Potomac River,” Randall said. “He was in the Goose Creek in Confluence Park, which is ours, and every single caller told you that.”

Randall also noted, “This one for the county has been such a hard situation, and it’s not just because Miss Thomas is well known in the county, although she is, it’s because we lost a beloved child of Loudoun County, and so it’s been very, very hard all the way around.”

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