911 mix-up leads to reprimand of deputy

"Human error" is cited in a fatal fumble.

Published May 18, 2007

BROOKSVILLE - A Hernando County sheriff's deputy received a written reprimand Wednesday for his role in a 911 mix-up that may have contributed to the death of a sick Spring Hill man.

Deputy John Ellis, who was assigned temporarily to dispatch after undergoing back surgery, failed to properly transfer a April 17 call from a residence on Wellington Road to the right fire dispatcher and no ambulance was ever sent.

Ellis sent the call to Hernando County Fire Rescue operator Paul George, who quickly realized the mistake. But when George yelled across the room to tell Ellis to send the misdirected call to Spring Hill Fire Rescue, Ellis didn't hear him and he never waited for an acknowledgment.

Dispatcher Leah Walker heard George's directive and later canceled the call from the system.

The stepson of the 75-year-old man, whose name was not released by authorities, was expecting an ambulance. After waiting for 13 minutes, he tried to drive his stepfather to get help. He made it to a walk-in clinic 5 miles away, where his stepfather collapsed.

Minutes later, the elderly man, who had prior health problems, was pronounced dead at Spring Hill Regional Hospital.

The incident raised questions about the dispatch protocols that changed just days earlier. No policies were changed, but officials reinforced communication procedures.

Neither George nor Walker received disciplinary action.

Hernando County Sheriff's Office officials released the three-page report about the incident Thursday. Maj. Royce M. Decker wrote that dispatch mix-up was the product of "human error."

Officials acknowledged that it is not normal procedure to put deputies in the emergency communications office but that Ellis had 2 1/2 years of previous experience as a certified dispatcher in Hernando. Internal Sheriff's Office documents show that he earned "exemplary" remarks, receiving numerous commendations during his tenure.

The report also noted that the man's family did not hold ill will toward the Sheriff's Office and even came to the office to meet with Ellis and tour the communications center.

John Frank can be reached at jfrank@sptimes.com or 754-6114.