During the November 3, 2021, Board of Supervisors meeting, the Loudoun County Combined Fire and Rescue System (LC-CFRS) will present an update on its progress toward implementing emergency response improvements that strengthen multi-jurisdictional emergency communications and incident response in and around the Potomac River. The update stems from the Perdido Bay Terrace Significant Incident Review (PDF), which was conducted following the tragic drowning of 16-year-old Fitz Thomas at Confluence Park on June 4, 2020.
The Board meeting is scheduled to begin at 5:00 p.m. on November 3 at the Loudoun County Government Center (1 Harrison St. SE, in Leesburg). The meeting can be viewed on the county’s cable channel (Comcast Channel 23 or Verizon Fios Channel 40), or online at loudoun.gov/meetings. The Board’s meeting documents, including LC-CFRS’s staff report, are published at loudoun.gov/bosdocuments.
Significant Incident Review Status Update
Significant incident reviews are routinely conducted to evaluate responses to major, critical, and other high-priority incidents. These evaluations seek to identify the facts surrounding an incident and provide recommendations for improvement. This practice helps to continually improve the actions of all first responders. The significant incident review process may, for example, identify how to better detect, diagnose, and mitigate similar incidents more quickly and more efficiently in the future. The process to develop findings and recommendations may take weeks, months or even years to analyze actions and decisions that were made in seconds or minutes.
During its review of the June 4 drowning incident, LC-CFRS identified 42 distinct tasks to improve policies, procedures, staffing levels and training. The tasks include enhancing 911 technologies, better documenting points of interest and vehicle access along the river, expanding 911 telecommunicator training, and providing safety and prevention education in the community.
“We’ve made tremendous progress in a relatively short amount of time,” said LC-CFRS Chief Keith Johnson. “While our review showed that staff in Montgomery County and Loudoun County properly followed existing policies and procedures during the June 4 incident, we remain committed to doing anything we can to improve our emergency communications system and incident responses.”
To date, 37 of the 42 tasks are either 90 or 100 percent complete. The remaining tasks are at least 50 percent complete. The in-progress tasks are on track to be fully implemented in the coming months. The completed public safety improvements include the following:
A complete list of the public safety improvements identified in the significant incident review, which includes the progress of each task, is posted on the county’s website at loudoun.gov/incidentreview.
Improving 911 Call Center Technology
Loudoun County remains committed to continually improving emergency communications systems. The county and region have made significant progress over the past year.
Emergency Services Internet Protocol Network (ESInet)
Loudoun County was among the first two jurisdictions in Virginia to transition from legacy, analog 911 equipment to the Emergency Services Internet Protocol Network (ESInet). The ESInet is a highly secure, resilient network. One of its most important features is the ability to route 911 calls based on a caller’s physical location.
Loudoun County implemented the ESInet on August 25, 2020. The system implementation began in 2019 and was almost complete at the time of the June 4 drowning incident. While several other Northern Virginia localities have also implemented the new technology, all adjoining 911 call centers must be using the ESInet system for it to work optimally.
Emergency 911 (E-911) Border Response Workgroup
Following the June 4 drowning of Fitz Thomas, the Virginia Department of Emergency Management (VDEM) formed the E-911 Border Response Workgroup. The workgroup, under the authority of the Virginia Secretary of Public Safety and Homeland Security, is comprised of Thomas’ mother, Pastor Michelle Thomas, fire and rescue communications staff, and other statewide stakeholders. The workgroup was formed to assess the deficiencies related to the timely routing of emergency calls to the appropriate 911 public safety answering point (PSAP) across either state or county borders. The workgroup investigated five functional areas related to 911 systems and processes: governance; technology; equipment operations and mitigation strategies; 911 personnel and training; and funding and compensation.
The workgroup presented its final report to the General Assembly in April 2021. The workgroup’s recommendations include developing a best practices guide for cross border 911 call processing, improving wireless 911 location accuracy, and addressing telecommunicator compensation, reclassification, recruitment, training and retention. The report and other information about the workgroup are posted on the VDEM website.
Review of Incident Facts
LC-CFRS has identified and implemented a number of positive changes over the past 15 months; however, the facts available to the county indicate that the emergency response did not cause the death of Fitz Thomas.
“The changes and improvements to our policies and procedures that we’ve made over the past year and are working to complete now make us better, but sadly, they would not have saved young Mr. Thomas because he was under water far too long,” said Chief Johnson. “We recognize how difficult this unfortunate accident has been for those who knew and loved Fitz Thomas and I pray one day those who mourn him will feel some comfort knowing that their loss has inspired and will continue to inspire meaningful change across our community.”
Continued Fact-Finding Efforts and Transparency
Loudoun County remains committed to evaluating all of the facts in this incident to better understand the circumstances surrounding Thomas’ death. Because Thomas’ medical records and autopsy report are not public, Loudoun County does not have access to the totality of evidence in this incident, which limits the county’s ability to consider other possible policy development and/or procedural changes.
The county extended an offer to the Thomas family to conduct a review of the cause of Thomas’ death by a jointly selected, independent medical examiner. The county agreed to share the cost of the independent review. The Thomas family declined the county’s offer.
Since the June 4, 2020, incident, Loudoun County has remained committed to transparency.
The Loudoun County Combined Fire and Rescue System continues to work toward completing the tasks identified during the significant incident review that will help improve emergency response in the future. Continued progress updates on this effort will be posted on the county’s website at loudoun.gov/incidentreview.
# # #