Photo by ohad*.

The city released a 13-page report today on the death of Medric “Cecil” Mills, the man who suffered a fatal heart attack near a Northeast D.C. fire station but was not aided by firefighters. The report concludes that five unnamed firefighters and four unnamed Office of Unified Communications employees involved should be disciplined, but does not specify how.

The Deputy Mayor for Public Safety and Justice called for an investigation “due to substantial lapses in judgment and the failure to adhere to established policy and procedures,” according to the report. The investigation found that none of the five people present at Station 26 — including a lieutenant — provided medical care to Mills, despite being aware assistance was needed. In addition, a call taker failed to ask for a quadrant for the address, so units were initially dispatched to the Northwest instead of the Northeast.

The report also provides the following timeline:

At 2:45 p.m. on that day, a civilian approached the fire station and said an individual was in need of help. A probationary firefighter (PF) asked the lieutenant to report to the watch desk. Another individual parked in front of the fire station and informed the PF that a person needed help. The PF then called for the lieutenant again, saying it was urgent, but the lieutenant did not respond. (Speakers in the main bunkroom, men’s bathroom and truck officer’s bunkroom have been manually turned off.) Three other firefighters heard the announcement, and one went to find out what was happening.

The PF informed the firefighter that a person needed help and asked if they could assist, but the firefighter said they needed to inform the lieutenant. The firefighter went to the lieutenant to ask if they should assist, but she requested the firefighter get an exact address. The firefighter failed to do so and instead told the other two firefighters that the “rookie had a man down across the street so I let lieutenant know we should be going on this run” then went to his bunkroom to study. The lieutenant found him there and asked why he didn’t get the address. He responded that he believed the Office of Unified Communications had “finally dispatched” a unit to the correct address, after initially making a mistake.

The Fire Trial Board “will hear the evidence, issue findings of fact, determine guilt or innocence of the employee, and make a penalty recommendation to the Fire Chief, ranging from reprimand to removal.”

The report recommends that four OUC employees — the 911 call taker, lead fire dispatcher, and two EMS radio operators — be disciplined. “The call taker who answered the initial call failed to ask for a quadrant and improperly entered “NW” as the quadrant of the city for the incident” and “did not discover the proper quadrant of the city … until the address was verified.” A dispatcher “did not notice” the updated information and “failed to dispatch the appropriate units to the correct location.” Two radio operators “failed to monitor” the events properly.

“Our members have a duty to respond and protect the lives of those who request their assistance,” DCFEMS Chief Kenneth B. Ellerbe said in a statement. “We will continue to improve our methods and uphold our responsibility to serve District residents and visitors.”

The city also released the 911 call. Mills’ daughter can be heard in the background frantically saying, “He’s not breathing!” The man who called 911 at one point says, “I mean the fire department is across the street.”

Mills’ son, Medric Cecil Mills, III, will testify Monday at a MPD, FEMS and OUC oversight hearing held by Councilmember Tommy Wells.

“I am holding this hearing to address questions and grave concerns, which have arisen after several high profile incidents, as to the effectiveness and coordination of public safety responses and protocols from the District’s Office of Unified Communications, the Fire and Emergency Medical Services Department, and the Metropolitan Police Department,” Wells said in a statement.

The Mills family has called for all involved to be fired. Mills, a 77-year-old employee of D.C. Parks and Recreation, was transported to Washington Hospital Center 20 minutes after the first 911 was placed. He died there.