A new report obtained first by FOX 5 blames a delayed response by D.C. Fire and EMS to a choking toddler on both technical errors and human mistakes.
The 18-month-old boy went into cardiac arrest and later died after waiting more than eleven minutes for help to arrive.
As FOX 5 first reported back in March, help was in a Tenleytown fire station just three blocks away, but was never put on the call. Now, this new report is explaining why.
The exhaustive 47-page report was compiled over several weeks and lays the blame on unreliable tablet computers, 911 dispatchers and a fire lieutenant who knew the child was in trouble, but failed to act.
Early on a Friday morning last March 13th at a home on Warren Street in Northwest D.C., 18-month-old Martin Cuesta began choking on some grapes. At 8:36 a.m., a call was placed to 911.
According to this report, four minutes went by before dispatchers at the 911 center dispatched help to the house.
But instead of sending Engine 20 and Ambulance 20 parked inside a fire station three blocks away, help was sent from Engine Company 31 more than a mile away.
According to the report, 911 dispatchers didn't know, but should have known that two units had vanished from the computer-aided dispatch.
Why did they vanish? The report says tablets became disconnected and were not signaling their location to the 911 center.
The report says it is a problem that was common knowledge among the firefighters working at the station.
Part of the blame for the delayed response, which was just three blocks up on Warren Street, is being leveled at the lieutenant who was in charge of Engine 20 at the Tenleytown station that day.
The lieutenant acknowledges that he knew the call went out for a choking child, yet he didn't respond because their engine wasn't dispatched. He also told the investigators that he could have picked up the phone, called the 911 center and put Engine 20 on the call, but he did not.
According to the report, when Lt. Guy Valentine was asked if he had a responsibility to take the call and possibly save the life of an 18-month-old child, he said, "Not if I'm not dispatched."
The report goes on to say, "Lieutenant Valentine, by his own admission, did not know the address of 4246 Warren St. NW was three blocks away from his firehouse."
The report also stated, "Lieutenant Valentine … knew there were problems with the tablet system that could have caused his unit not to be dispatched."
"Overall, December of 2014, and you even reported on it, we were voicing our concerns and we were voicing them very loudly about the rollout of new technology from the 911 center," said Ed Smith, president of the D.C. Firefighters Union. "I'm of the opinion it starts and stops with that crappy rollout of that technology."
What does Smith think about Lt. Valentine?
"We have had other instances where officers have been disciplined for responding undispatched," he said. "Now you can pick up the phone and ask for permission, but again, going back to the 911 center, if the system is working and is working correctly, an officer can safely assume the system is selecting the closest available unit to respond."
According to the report's timeline, it took eleven minutes for help to arrive.
In April, we talked to the toddler's father.
"What do you think the feelings can be for a father or for a mother who loves her son like that?" Jose Cuesta told us then. "I have already stated there is sorrow. We are also angry. We are disappointed."
We tried to reach Lt. Valentine through the union and by email, but were unsuccessful.
The Cuesta family has not yet seen the report.