A public safety consultant’s analysis has uncovered shortcomings in the 911 and fire response to a fatal east Wichita apartment complex fire in 2023, but the report said it can’t be determined conclusively that they resulted in the death of an apartment resident.

Sedgwick County Commissioners and Wichita City Council members received a report Monday from the Chicago firm of Jensen Hughes, which analyzed the emergency response to the October 13th, 2023 fire at the Brookhollow Apartments at 8165 East Central.   The fire resulted in the death of 22-year-old resident Paoly Bedeski.

John Mammoser, senior director with Jensen Hughes, said there was no single point of failure discovered that could be linked to Bedeski’s death.  He said the team that conducted the analysis found “systemic shortcomings that, when combined, led to an unorganized rescue effort.”   If the shortcomings had not occurred, “it would have provided Ms. Bedeski with a better chance of early rescue and subsequent increased potential for survival, provided she was still alive.”    Mammoser said, however, that it can’t be concluded “that the shortcomings identified would have absolutely changed the outcome of this fatal incident.”

Bedeski was found by a rescue team in the bathroom of her apartment, and she was removed and provided medical treatment before being taken to a hospital, where she was pronounced dead.  The report said “Ms. Bedeski’s decision to retreat to her (windowless) bathroom is a contributing factor that resulted in her fatality. Despite the fire exposure to the adjacent apartment, Unit 305, being more severe, those residents survived by going to the front bedroom and jumping from the window prior to the arrival of the Wichita Fire Department.”

The report said Sedgwick County 911 dispatchers have what is considered best technology and there is a well-planned training and quality improvement program.  The analysis found that dispatchers are wearing two headsets, with different sounds coming into each ear, making it difficult to understand both sources.    The report said it is entirely possible and likely that the call taker did not understand the apartment number given by Bedeski when she called 911 to report the fire.    The dispatcher did not use an instant recall feature that could have helped in identifying the apartment number.   A delay in putting out a second alarm was identified as a training issue that was addressed by Emergency Communications.

The report found that a number of Wichita Fire Department operational policies were not followed in the response to the Brookhollow fire.   The team found that command of the scene was not well organized and appeared more reactive that proactive.   The report said crews were searching neighboring, uninvolved buildings, and that diluted the search efforts in building 300 where the fire was reported.   The report recommends that searches begin closest to the fire area with a prioritized search and rescue plan.

The report also noted that the fire is still listed as under investigation, and an origin and investigation report should have been completed by now, even if the cause was listed as undetermined with competing theories on how the fire could have started.

The report recommends additional training for 911 staff in the available technology and training to become more familiar with the operations of the agencies they serve.   It also calls for enhanced training for the Fire Department, strengthening command and control during fire incidents, and working toward effective fire investigations.   For EMS, the report recommends working more closely with the Fire Department on the response to fire incidents.    There is also a recommendation for the Fire Department and Police Department to work together to develop policies for assisting with fire scenes.

The report notes that there have been tensions and animosity between the 911 system and some of the agencies it serves, undermining trust and respect.   The report said “it will be crucial to move past previous grievances, whether real or perceived, and focus on building a foundation of mutual understanding, trust and cooperation.”

Wichita and Sedgwick County leaders will use the report to determine changes in policies and practices for future incidents.