On September 1, 2014, Kathryn Missen called 911 in the midst of a severe asthma attack. She struggled for breath and couldn’t utter what was happening. Within a minute, she fell unconscious.

Through a series of miscommunications and failures, nobody responded to Missen’s call. The 54-year-old was found dead two days later in her home with the phone receiver just out of her grasp.

Missen’s case is one half of an ongoing inquest held by the chief coroner’s office into how the 911 system failed callers. The other is a 2013 boat crash on a lake in Greater Sudbury where three people died.

The inquest, presided over by Dr. David Cameron, began in Sudbury and moved to Ottawa last week to focus on Missen’s case.

System to blame, not individuals

“We didn’t want to blame individual people for what happened. The call takers and dispatchers are working in extremely high-stress environment, they’re all doing the best they can. They’re in that job because they want to help others, the same with the police constable,” says Brenda Missen, one of Kathryn’s three sisters attending the inquest. “It was such a domino effect, it wasn’t just one thing that happened, there was a whole chain of errors, we wanted to look at the system.”

Her two sisters, Nancy Beverly and Lynne Missen Jolly, along with Kathryn’s daughter, Harriet Clunie, all nod their heads as Brenda explains the first few days of emotional testimony.

Doug Sanders was the first to answer Missen’s call when it was routed to the North Bay office he was supervising. Many smaller municipalities like Casselman will contract out the handling of 911 calls through the OPP. All those calls are routed initially through the North Bay office. During Sanders’ testimony, he cried and apologized to the family. The next day, local Russell OPP officer David Dionne, also apologized. Dionne was dispatched an hour and a half after Missen called and believed it was a faulty connection. He never checked in at Missen’s address. Dionne was demoted and disciplined last year after pleading guilty to two counts of neglect of duty last year.

Gavin Hayes, the director of the Association of Public-Safety Communications Officials, was the last to testify and confirmed many of the complexities of the 911 system: calls are re-routed from North Bay to local PSAPs (public-safety answering points), which was Smith Falls in Missen’s case; fire, police and ambulance services each have their own computer-aided dispatch (CAD) system; and these CADs can rarely communicate with one another. Hayes, who testified he has been diagnosed with PTSD, also said there should be a better support system for 911 operators who may be struggling with mental health issues.

Missen’s family says the goal of the inquest was to get at the heart of the system’s issues like those raised above. The inquest will also allow recommendations be made to address these issues.

Left without a voice

In addition to streamlining communications, Missen’s family is also pushing to have a protocol to deal with 911 callers who can’t speak.

Clunie says there are many reasons why a 911 caller may not talk, ranging from a medical emergency in her mother’s case to someone hiding in a home invasion or a victim of domestic abuse.

The family would like to see implemented a similar system to the one in Massachusetts, where callers can use the keypad to request different services and answer yes or no questions from the operator.

They’re also looking for change in how investigations are done, hoping to bring in an independent third body instead of relying on internal police investigations.

Brenda says they were pushing for an inquest “from day one” but were initially denied by the regional coroner after the OPP concluded its investigation into the matter. During that time, both she and Clunie said it was a “frustrating” process trying to get any information about the investigation. Finally, the family appealed with the chief coroner’s office and was only granted an inquest in February last year.

Long-term effects

The recommendations that result from the inquest are exactly that: recommendations. They aren’t bound by law.

The recommendations will be presented to the five-person jury that will deliberate for as long as necessary in order to adopt, amend or refuse them.

“We’re hoping that jury will recognize what the serious problems are in the 911 system, and even if they don’t accept all the recommendations, that they come up with their own… and ultimately see some change to the system,” says Brenda.

Once adopted, the family says it’s been told it’ll have a role to play in the enforcement of the recommendations. To Brenda, that means continuing to talk about the event and the outcome. As a writer, she says she always knew she would write a book about her sister’s death. She’s started writing the story in “installments” on her website.

Lynne says the push for inquest allowed the family to anchor their grief into concrete action.

Clunie says it’s also extended beyond her family.

“We hadn’t met the call takers, but we’d been at the hearing for the police officer and we told him that we didn’t place blame on him. That was healing for everybody,” she says. “The police officer and both dispatchers said they carry my mom with them throughout their work forever. One said they used my mom as her compass and the police officer said he dreams of my mom often and that she’s standing and smiling.”

Correction: An earlier version of this story read that all 911 calls in Ontario were routed through North Bay. It’s all 911 calls where a municipality contracts with the OPP specifically which go through North Bay. The Review regrets the error.