Mistake at Raleigh 911 center cost 15 minutes in sending ambulance to dying man

James Pasternak called the Raleigh-Wake Emergency Communications Center at 7:57 a.m. on April 5 as he rushed his father-in-law, 63-year-old Steven Tibbetts, a retired Wake County magistrate, to a hospital after Tibbetts became unresponsive.

"I’m driving in a car with my father-in-law. He has a pacemaker, and he is not – he just passed out. I’m trying to get him to WakeMed," Pasternak told the 911 dispatcher.

WRAL News sued the city of Raleigh, which operates the emergency communications center, for access to the 911 calls and other information, and the city relented Tuesday and agreed to release them.

After the dispatcher collected some initial details about the situation, he told Pasternak to pull off the road.

"I need you to stop and pull over to the side of the road, OK, if you want an ambulance," the dispatcher said.

When Pasternak asked how long it would take for the ambulance to arrive, a second dispatcher jumped on the call.

"We can’t give you an ETA. They will get there as fast as they can," the second dispatcher said. "But in order for us to send you an ambulance you have to be stationary. You have to pull over with the patient. It’s your choice. Or you can continue to the hospital. But in order for me to send you an ambulance, you have to be stationary. I can’t give you an ETA."

WRAL News has learned that the first dispatcher was being supervised at the time by the second one, who trains other dispatchers.

"Can I ask you this?" Pasternak said. "He has a pacemaker, and he’s now unresponsive. What is my best move?"

"I’m not authorized to give you medical advice," the dispatcher trainer replied. "The only two options I can tell you sir, I apologize, is you can pull over and I send you an ambulance, or you can continue on to the hospital. If he’s unconscious and he has a pacemaker, I would advise you to pull over so I can send you an ambulance. I can’t tell you how quick they’ll get there, but they will be running lights and siren."

Pasternak then pulled into John Hiester Chevrolet on U.S. Highway 401 in Fuquay-Varina, and after some initial confusion about the street address, the second dispatcher said an ambulance was on its way.

"Take a deep breath. We’ve already got the ambulance on the way. To understand the instructions I’m giving you, you need to be able to hear me," the dispatcher told an increasingly panicked Pasternak at about 8:01 a.m.

But no ambulance had been dispatched.

Pasternak's call was mistakenly routed into a training system instead of the live-call system at the 911 center, so Wake County EMS was never contacted.

At 8:10 a.m., Phillip Allen, a Hiester Chevrolet employee who noticed there was a medical emergency, called 911.

"I think someone’s already called you," Allen told a third dispatcher. "I’ve got a gentleman they’re performing CPR on in the parking lot."

"I do not have a call on that yet. They may still be processing it," the dispatcher responded. "I’m going to get some help on the way. Let me get some information from you."

Shortly before 8:12 a.m., alerts went out to Wake County EMS and a nearby fire department to respond.

Meanwhile, the first dispatcher was back on the phone with Pasternak, getting more details from him and talking him through CPR.

The second dispatcher critiques the first one when he asks Pasternak whether the car dealership has a defibrillator and again when he tells Pasternak to drag Tibbetts out of the car to get him flat on the ground, even if that means hurting Tibbetts.

"I wouldn’t even have asked that question," she said of the defibrillator, "because now he’s walking away from the patient, and if the patient is not breathing, he’s not with the patient."

An EMT who happened to be at the dealership helped Pasternak with chest compressions as the first dispatcher continued to talk him through the situation.

"I feel like I’d have already been at the hospital," Pasternak said about 14 minutes into his 17½-minute 911 call.

Less than two minutes later, at about 8:13 a.m., sirens could be heard on the call.

But help arrived too late for Tibbetts, who was pronounced dead at UNC Rex Healthcare.

Jeff Hammerstein, assistant chief of Wake County EMS, said Wednesday that he couldn't speak specifically about the Tibbetts case, but he said response time is critical when someone's heart stops.

"We need to get an intervention in place as soon as possible, and that could affect the outcome of that person and whether they survive or not," Hammerstein said.

Attorney Bill Young, who represents Tibbetts' family, said they want answers and want to make sure the same mistake doesn't happen again.

"We are working toward a resolution. Having said that, his family understands things like this take a lot of time," Young said. "Everyone involved is interested in that end – ultimately the protection of our community."

Raleigh spokesman John Boyette said changes have been made at the emergency communications center in response to the Tibbetts case.

"The City of Raleigh conducted a thorough review of the events that took place on April 5, identified the issue and has taken extensive steps to ensure that all 911 calls are handled accurately," Boyette said in a statement. "We are always improving our processes and systems and are committed to providing the most reliable and responsive 911 service for all of our Wake County residents."