WARRENSVILLE HEIGHTS, Ohio — After Betty Morrison, 71, called 911, she waited nearly 11 minutes for help to arrive at her door. By the time Warrensville Heights firefighters arrived, she had no pulse.
Dispatch recordings revealed firefighters responded to the wrong house.
Even more troubling, a Cuyahoga Co. Sheriff's Office investigation found the incident wasn't the first time Warrensville Heights emergency workers made this type of critical mistake.
"We were devastated at that report," said Amelia Gray, Morrison's daughter. "We had no idea that things were being run the way they were being run."
The call for help
On 9:37 a.m. on September 5, 2017, records show Morrison called 911 because she was experiencing an asthma attack. In the recording, you can hear Morrison struggling to breathe.
During the call, Morrison clearly states her address is 19219 Lanbury Avenue. She also confirms it is her address when the dispatcher repeats it back to her.
There is no recording of when dispatcher Lynnesha Hamilton radioed Station 1 to dispatch Morrison's call for help.
At 9:40 a.m., one of the two firefighters radioed dispatch to confirm her address.
In the recording, the firefighter said, "Responding. 19419 Lanbury."
Hamilton did not correct them. In fact, she did not respond at all.
Five minutes later, the firefighter radioed dispatch again about Morrison's address.
"Can we get an address check on this, please?" he said.
Twenty seconds later, Hamilton responded with the correct address and repeated it. She said, “19219. 19219.”
At 9:47 a.m., the firefighter radioed dispatch and said they were "on scene" at Morrison's home. One minute later, the crew requested additional manpower because Morrison was in full cardiac arrest. They then transported Morrison to Southpoint Hospital where she was pronounced dead.
Marcus Morrison, Betty Morrison's youngest son, and Gray said no one told them firefighters responded to the wrong address the day their mother died. Official records make no mention of the mistake.
Morrison's children said they only learned about the error because the neighbor who lives at 19419 Lanbury told them firefighters stopped at her house first.
Determined to understand what happened, Gray wrote a letter to Mayor Brad Sellers. Sellers then asked the Cuyahoga Co. Sheriff's Office to investigate the incident.
The investigation found the mistaken Morrison address was not an isolated incident. It found firefighters repeatedly responded to wrong addresses as the result of systemic failures in the city's emergency systems.
One firefighter said there are issues "at least a couple of times a month."
In a lawsuit filed by the family, another said he recalled "more than 20 incidents of wrong addresses" prior to Morrison's death.
It is no wonder so many mistakes were made.
Instead of a computer or phone system, Warrensville Heights first responders said they used a "scratchpad of paper" or "whatever is around to write on" to record the addresses of emergency locations.
The investigation also found the city had no training, policies or procedures in place related to dispatching emergency crews. One firefighter said most things are done by "word of mouth" and there is "no set actual method" for taking a call from dispatch.
The investigation also found the city's dispatchers are overworked and understaffed.
There was only one dispatcher on duty per shift. One firefighter said dispatchers are "usually overwhelmed" and firefighters said dispatchers sometimes fail to respond to their radio calls.
The report said the city's dispatchers have several responsibilities, along with answering and dispatching emergency calls.
It said those duties included writing arrest warrants, reports, and responding to citizens who showed up at the fire station. Their responsibilities also included the feeding and care of inmates in the city's jail.
The expert's opinion
“Having one dispatcher doing eight things, including taking care of prisoners, I think is really stretching that dispatcher’s abilities to be efficient," said Dr. Don Locasto, an emergency medicine specialist and former paramedic.
At News 5's request, Dr. Locasto reviewed the sheriff's office report and a lawsuit filed by Morrison's family.
Dr. Locasto recommends small cities join regional dispatch centers, where there are 911 call-takers and multiple emergency dispatchers.
"You try to build a system that’s going to reduce the errors that occur and in a larger regional center where they send out the calls via computer the chances of an error is much slimmer," he said. "Having a more efficient, up-to-date system to transmit critical information of where you’re going, what you’re doing, what you’re going for, is critically important."
The 911 system
Dr. Locasto also said most cities had electronic dispatch systems in place by 2017 and were no longer writing down addresses by hand.
"When I was a paramedic, that’s how it was done. It was kind of done by paper. And that was back in the ‘80s," he said.
"What that would say to me, is either they’re resistant to change and moving into progression into what is new or they don’t want to invest in their dispatch center," he said. "They still want to have control over their own dispatch and they don’t see the value in a regional dispatch center."
However, Dr. Locasto said minutes matter, especially in cardiac arrest.
"You have about four minutes once somebody goes into cardiac arrest to start getting them revived and basically every minute that goes by you lose survival of about ten percent," he said. “That’s why systems are set up to make sure that people get to the right place at the right time quickly"
The city's response
News 5 requested an on-camera interview with Mayor Bradley D Sellers. He declined to respond due to the pending litigation.
In an email, Warrensville Heights' Law Director Teresa Metcalf Beasley sent us the following response:
"I am the Law Director for the City of Warrrensville Heights and the Mayor forward your request for an interview. As you are aware, the City does not comment on pending litigation and we are not able to grant your request at this time. Thanks."
During a city council meeting over Zoom on Feb. 16, city leaders also refused to respond to questions about their emergency response systems.
The mayor said, "The city’s policy has always will be to not comment during periods of litigation.”
When asked if there is anything they would like residents to know about calling 911, she said, "Our position is not to comment on pending litigation, regardless of how you frame the question."
After multiple requests, city officials provided answers to our questions about their 911 operations Monday.
In an email, officials said they have no plans to join a regional emergency communications center. Instead, officials said a Safety Committee recommended the city upgrade its own system back in 2016.
Since Betty's death, Warrensville Heights has modernized its emergency operations.
The email said the city implemented Active911 in 2020. According to its website Active911 is "a mobile app that coordinates with dispatchers to send notifications to emergency first responders." The city also placed automatic vehicle locating systems inside fire and police vehicles.
Officials wrote they have a "fully operational dispatching station" in their dispatch center, have purchased more monitors and surveillance cameras, improved voice recording capabilities, and installed an upgraded 911 system. They also wrote they have "fully integrated dispatching between police and fire" and have "fully equipped and computerized all first responders' vehicles."
The email also said "dispatchers' duties no longer include jail checks."
The family's loss
"You would never think that people are operating like this in 2017," said Marcus Morrison. "How many 911 calls have been missed because dispatch might have been doing something else?"
It's been more than three years since his mother died of respiratory arrest while waiting at her front door for help. Her children said they still grieve her loss.
"She was just a loving person," Morrison said.
He said their mother was selfless, a caring community member, and focused on her family. The retired teacher, who "never met a stranger," also still worked part-time with children who have special needs.
"I wake up and the first thing I think about is, ‘Wow. My mom’s not here'," said Gray.
She said she and her mother sometimes talked several times a day. She said she misses her mother's guidance and wisdom.
"It doesn’t get better, it gets bearable," she said. "The pain never goes away."
"She wasn't just my mom, she was my friend," Gray said.
They said their grief has been compounded by the fact that emergency workers in their hometown made a critical mistake and failed to disclose what happened .
"It’s a slap in the face," he said. "You think, 'Hey, my mom, she passed and that was it. And come to find out, admittedly, you know, these times that they put down were false. Admittedly. They falsified documents. It’s a huge letdown."
"This didn’t have to happen," said Gray. "My mom wasn’t afforded the opportunity to even have a fighting chance to live."
"She just had an asthma attack. Those are preventable. She’s had asthma attacks before," she said. "Never did I think it would end in death. But, I guess if you don’t get the help you need then that’s the outcome."
Warrensville Heights: 3 — Partially complied with information requests
The city eventually provided some information about 911 improvements. The mayor also personally returned investigator Sarah Buduson's call after she requested an interview, but the city used the lawsuit they're facing as an excuse to avoid questions they can and should answer.