Loudoun To Present Findings From Review Of Goose Creek Drowning

LOUDOUN COUNTY, VA — The Loudoun County-Combined Fire Rescue System is scheduled to present its findings Tuesday from a review of how the system responded to the drowning of a teenage boy on June 4 at Confluence Park, where Goose Creek feeds into the Potomac River. The Loudoun County Board of Supervisors requested the presentation following the completion of a "significant incident review," which is a standard procedure by the Loudoun Fire and Rescue system following major incidents.

Fitz Thomas, 16, who had just finished his junior year at Riverside High School in the Lansdowne area, died in the drowning, which occurred near the River Creek community. Thomas, the son of Loudoun NAACP President Michelle Thomas, was swimming with friends across the confluence of Goose Creek and the Potomac River. As they crossed the water, Thomas' friends observed him go underwater, according to the Loudoun County Sheriff's Office.

“It is important that the community know all of the facts surrounding this tragic incident,” Loudoun County Board of Supervisors Chair Phyllis Randall said Monday in a 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.”

The report being presented to the board, "Perdido Bay Terrace Significant Incident Review," is named after the road that leads to Confluence Park. It includes an overview of the June 4 emergency, 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 already been instituted as well as those that are in the process of being implemented to increase the efficiency of multi-jurisdictional incident responses in or around the Potomac River.

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 died at the hospital.

“We recognize how difficult this incident has been for our community; we have been committed to closely examining our emergency response and we are publishing this report in a transparent manner so that everyone can review exactly what happened,” Loudoun County Combined Fire and Rescue System Chief Keith Johnson said in a statement.

A significant incident review team that included staff from Loudoun County Fire and Rescue and Montgomery County Fire and Rescue Service was developed to conduct the analysis. The team conducted a review of all incident details, policies and available technologies for both Loudoun County and Montgomery County Emergency Communications Centers.

The 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 emergency centers in both Montgomery County and Loudoun County. Each of the 911 calls made during the incident originated from cellular telephones, requiring the cellular routing technology to provide location information.

When a call is initiated on a cell phone, the cellular 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. 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, according to the review.

The Washington Post published a feature article last week, headlined "A teenager was drowning. 911 sent help to the wrong place," that chronicled the story of Angela Stefkovich who placed a 911 call on her cell phone on June 5, telling the emergency center that one of her friends — Fitz Thomas — had gone underwater and they could not find him. It took 36 minutes for an ambulance to arrive, according to the article. By then, the teenagers, along with a man who had been walking his dog, had found Thomas, pulled him from the water and started CPR.

The first 911 call was received by Montgomery County at 5:48 p.m., about 5 minutes after Thomas was noticed missing by his friends, according to the Loudoun County review of the incident. Montgomery County first responders were dispatched within three minutes and arrived at the Potomac River about 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 experienced a delay 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 system and route responders to the correct location, according to the report. Loudoun County 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.

Between 6:05 p.m. and 6:35 p.m., several other 911 calls were received by the Montgomery and Loudoun emergency centers during which dispatchers attempted to identify the precise location of the incident and guide first responders to the scene.

The significant incident review concluded 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.

“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.

Several changes to the department’s 911 practices were made immediately, 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 sending water rescue units if the victim is not confirmed to be out of the water. Additionally, Loudoun County’s emergency call center has completed upgrades to the 911 system that will assist telecommunicators in obtaining more accurate location information for 911 cellular calls.

The policy changes already placed into action, along with the implementation of the recommendations in the review, are designed to enable Loudoun and Montgomery counties communicate more efficiently and provide more coordinated responses to incidents in and around the Potomac River in the future, according to the review.