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:
- LC-CFRS internal policy was changed within days of the June 4 incident, now requiring public safety telecommunicators to dispatch LC-CFRS crews to all incidents in or along the Potomac and Shenandoah Rivers when 911 calls are received at the Loudoun County Emergency Communications Center (ECC). Loudoun fire and rescue units are now sent to any potential incident on our joint waterways regardless of jurisdictional responsibility.
- LC-CFRS staff worked cooperatively with fire and rescue leaders within the Metropolitan Washington Council of Governments and as a result, regional policies and procedures were changed to provide updated direction on processing and dispatching 911 calls along the Potomac River.
- A comprehensive, interactive Regional Potomac River Atlas was developed jointly with mapping and operations staff from the Counties of Fairfax, Montgomery, Frederick, Jefferson, and Washington to be used by personnel in Emergency Communications Centers or in the field to locate access points along the river.
- Signage was installed to provide warnings and geographical location references at Confluence Park, to highlight potential dangers and enable 911 callers to easily identify their location. In the future, these signs will be installed at water access points across Loudoun County.
- Increased staffing in the LC-CFRS ECC through new positions approved by the Board of Supervisors in the adopted fiscal year 2022 budget.
- A countywide review of landmarks was conducted, and 240 commonplace names were added to the Computer Aided Dispatch (CAD) system. These include areas of interest that may not have a physical address associated with them, such as Confluence Park. This enhancement will help 911 call takers to dispatch first responders to these locations more quickly. The department has also developed a process for adding new locations and updating information as occupancies change.
- Conducted countywide public informational outreach regarding water safety and best practices for swimming in and around public waterways.
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.
- Time of Drowning: The timeline below has been developed based on the 911 calls and other open-source information.
- Thomas was reported to be underwater for at least five minutes before his friends noticed he was missing and placed the first 911 call.
- The first 911 call on June 4 was received by Montgomery County at 5:48 p.m.
- First responders were dispatched by Montgomery County within three minutes of the first 911 call and rescue crews arrived on the Maryland side of the river approximately 15 minutes later at 6:04 p.m.
- Loudoun County first became aware of the incident at 6:05 p.m. when the Montgomery County ECC contacted the Loudoun County ECC to advise they were responding to the Edwards Ferry Boat Ramp in Maryland for a water rescue. Montgomery County did not request any operational resources from Loudoun County.
- Loudoun County received its first direct 911 call from the incident scene at 6:06 p.m. LC-CFRS crews were dispatched at 6:16 p.m. and personnel arrived on the scene in Confluence Park at 6:24 p.m.
- Thomas had been underwater for more than 25 minutes when his friends and bystanders located him in the water and pulled him to the shore at approximately 6:09 p.m.
- After removing him from the water, bystanders began cardiopulmonary resuscitation (CPR) with direction from the Montgomery County ECC. Published reports indicate that mud and water were coming from his nose during CPR.
- On average, people drown within four to six minutes under warm water, suffering irreversible brain damage during that time due to oxygen deprivation followed shortly by cardiac arrest and death.
- Upon arrival at the incident scene at 6:24 p.m., LC-CFRS initiated emergency medical care and transported Thomas to Inova Loudoun Hospital.
- Thomas arrived at the hospital at 7:06 p.m.
- Pronouncing Time of Death: Published reports indicate that Thomas was pronounced dead at the hospital at 8:04 p.m.
- Under the Code of Virginia, authorized personnel may pronounce a death under certain circumstances; however, that pronouncement may not correspond to the individual’s precise moment of physiologic death.
- The law states, in part, that a person shall be medically and legally dead if in the opinion of a physician “there is the absence of spontaneous respiratory and spontaneous cardiac functions and, because of the disease or condition that directly or indirectly caused these functions to cease, or because of the passage of time since these functions ceased, attempts at resuscitation would not, in the opinion of such physician, be successful in restoring spontaneous life-sustaining functions, and, in such event, death shall be deemed to have occurred at the time these functions ceased.”
- In this case, first responders and emergency department personnel attempted to resuscitate Thomas for a prolonged period of time before he was pronounced dead. The time of death listed on the death certificate, which is typically the time when resuscitative measures are ceased, does not account for the length of resuscitative efforts.
“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.
- Within days of the drowning, Chief Johnson and senior county officials met with the Thomas family and their attorneys to discuss the emergency response and to release recordings of the 911 calls.
- The victim’s mother was appointed to a state workgroup through which she has direct access to information about the region’s efforts to improve 911 call technology and associated procedures, as well as to influence future efforts by the region’s emergency response organizations.
- The victim’s family received multiple oral and email updates from Loudoun County officials over 16 months regarding the county’s efforts to improve its policies and procedures.
- The county published the Perdido Bay Terrace Significant Incident Review online on August 31, 2020, and System Chief Johnson and staff presented it to the Board of Supervisors at its meeting on September 1, 2020.
- Following the one-year anniversary of the publishing of the significant incident review, the county has reported its progress on implementing policy and procedural improvements and will continue to update the victim’s family and the public as needed.
Future Updates
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.
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