Inquest into botched 911 call begins in Ottawa

An inquest into the September 2014 death of a Casselman, Ont., woman begins today in Ottawa.

54-year-old Kathryn Missen of Casselman, Ont., died in 2014 after calling 911 during an asthma attack

Brenda Missen is the sister of Kathryn Missen, who died during an asthma attack after calling 911 on Labour Day in 2014. She was found dead in her home two days later, and an OPP officer was later demoted. An inquest begins this week. (Kristy Nease/CBC)

Kathryn Missen could usually manage her asthma attacks on her own, but this time was different.

In the late afternoon of Sept. 1, 2014, the Casselman, Ont., woman dialled 911. She was in medical distress. Her family has an audio recording of the call, but haven't been able to bring themselves to listen to it.

"We've been told that there's about 44 seconds of her struggling to speak, and then just wheezing and moaning, and not able to state what her emergency was to the operator," said Kathryn's sister, Brenda Missen.

The 54-year-old was living alone at the time. She was found dead two days later after concerned neighbours called 911.

'She hasn't said anything'

In OPP jurisdiction, 911 calls are first routed to operators in North Bay, Ont., who ask callers whether they need police, paramedics or firefighters.

Calls are then forwarded — depending on where the call is coming from — to operators at one of five regional OPP call centres. Those operators gather more information from callers and then forward the calls to 911 dispatchers.

Kathryn's call was routed to North Bay, where the operator heard a woman on the line but couldn't understand what she needed. The operator then forwarded the call to a regional call centre in Smiths Falls, Ont., about 100 kilometres away from Kathryn's home.

"We think that [Kathryn] fell unconscious at that point. So when the Smiths Falls call taker got the call and was told by the North Bay operator, 'I have a woman on the line, I don't know what she wants, she's still on the line, she hasn't said anything' — unfortunately, that did not convey that there was a woman in medical distress on the line," Brenda Missen told CBC Radio's Ottawa Morning last week.

"So the Smiths Falls operator, she was trying to make voice contact with Kathryn and there was nothing, by this time, on the line."

Officer dispatched but didn't go

The Smiths Falls operator called the Bell maintenance centre to see if there was a technical problem with Kathryn's phone line, and Bell confirmed there was "trouble on the line."

"So in [the operator's] mind and then in the dispatcher's mind ... this was pretty downgraded in severity, in emergency. It doesn't mean you don't go to the call. OPP's policy is you go regardless of whether there's a technical malfunction," Brenda Missen said.

We know that everybody was doing the best they can at the time in a very high-stress work environment.- Brenda Missen

The 911 dispatcher had other things going on, and the call wasn't dispatched for another hour and 36 minutes. Right before ending her shift, the dispatcher called the Russell OPP detachment and told the constable that the call was old and appeared to be a technical malfunction.

"And the constable who was dispatched to the call basically didn't go, forgot to go to the call.... In his mind, too, it was vastly downgraded. It was not an emergency," Brenda Missen said.

"We know that everybody was doing the best they [could] at the time in a very high-stress work environment."

Officer demoted, inquest called

That OPP officer, Const. David Dionne, was charged with two counts of neglect of duty, and pleaded guilty at an OPP disciplinary hearing in January 2017.

In February 2017, OPP Supt. Robin McElary-Downer demoted Dionne from first-class constable to second-class constable for a period of two years, which will amount to about $32,000 in lost salary.

The coroner's inquest was announced in early February 2017, and will examine whether flaws in the province's 911 system and the co-ordination of emergency responders may have contributed to Kathryn's death, as well as the deaths of three people in Sudbury, Ont., in a boating incident in 2013.

There should have been some people checking on those employees to make sure they're OK.- Brenda Missen

The hearing relating to the Sudbury incident started in that city Monday and continues until Friday, and the Missen case is scheduled to be heard in Ottawa from Oct. 22 to Nov. 2. Kathryn's three sisters and daughter will be there.

"I think it's going to be really tough, very tough to hear. We know the details, we've read them, we've read the reports, but I think to be right there in that room listening to those details is going to be very hard," Brenda Missen said.

"My anger is directed at the system that failed her, not at individuals who I do believe were trying to do the best that they could."

They want the 911 call system to be streamlined, and 911 call centre operators, dispatchers and police to be better managed.

"There should have been some people checking on those employees to make sure they're OK. 'Why is this call still on your screen, is there something going on with you?' We want to make sure that the employees themselves, both uniformed constables and the civilian employees ... are able to do their job with people looking out for them."

CBC Radio's Ottawa Morning