Of all the things that went wrong on the day Kyle Plush died, one of the worst came at 3:35 p.m. when the teenager made his final, desperate call to 911.
A confidential police review, obtained by The Enquirer, found the 911 system failed Tuesday afternoon during that critical call, either because of an unknown technology problem, a mistake by the operator, or some combination of the two.
The bottom line: The operator said she couldn't hear Kyle and, therefore, police didn't get information that could have saved his life.
The failure is crucial because the call – the second Kyle made to 911 – is when the 16-year-old provided his most precise location and frantically conveyed the urgency of his plight while police officers were searching for him.
At that point, Kyle had been pinned by the rear bench seat in his Honda Odyssey for more than 20 minutes and was struggling to breathe. In his first call to 911, at 3:14 p.m., Kyle gave his location as a parking lot near his Seven Hills School.
Police dispatched to the scene didn't find him after driving around parking lots near the school for 11 minutes.
But in the second call, Kyle provided more information. He told the 911 operator he was in a gold Honda Odyssey. He repeated his location as a parking lot at Seven Hills. He assured the operator he was not a prank caller. And he told the operator he was going to die if he didn't get help immediately.
None of that information got to police, according to the review. The operator on that second call said she didn't hear any of it, including the model and color of his car, which means officers searching for Kyle didn't get that information, either.
The officers "cleared the run," meaning they ended their search, at 3:37 p.m., the same minute that Kyle's second call cut off.
The internal quality assurance review is part of a broader Cincinnati Police investigation into what happened in Kyle's case Tuesday. It's not the final word, and it makes clear police still are struggling to answer some important questions.
But the review does shed light on some key moments in the emergency response to Kyle's calls for help.
His first call came at 3:14 p.m., when Kyle told a 911 operator he was trapped in his van. "Help. I'm stuck in a van outside Seven Hills parking lot," Kyle said. "I'm gonna die here."
The review found the operator, Stephanie Magee, mostly did what she was supposed to do during that first call. She dispatched officers to Seven Hills and called Kyle's cell phone back after the call was dropped.
Her primary mistake, the review found, was failing to tell officers she'd also heard banging, screaming and other background noise that might have suggested the call was more urgent.
The second call, 21 minutes later, was a different story. Police Chief Eliot Isaac said Thursday something went "terribly wrong" in the second call.
"This young man was crying out for help and we were not able to get information to officers on the scene," Isaac said.
He didn't provide details about those failures at a Thursday press conference, but the internal review does. It shows that the operator on the second call, Amber Smith, told her supervisors that she couldn't hear Kyle during that call.
According to the review, police and the city's 911 service provider could find nothing wrong with the phone system. The call also was recorded, as all 911 calls are, but that doesn't mean some other glitch couldn't have prevented Smith from hearing it.
The review also found Smith said she tried to document the call when it came in, but she told supervisors her computer screen froze, preventing her from entering any information immediately. That information could have been helpful to police searching for Kyle.
The review, conducted by Smith's supervisors, said she should have attempted to communicate with the caller regardless of what she heard. It suggests she should have asked Kyle to tap his phone or press buttons, and also suggests she should have asked questions that only require a "yes" or "no" answer.
Because the investigation into Kyle's death is not complete, it's not known whether he could reach his phone or if those steps would have mattered. He can be heard calling out to "Siri" repeatedly while on the line, indicating he may have been using his phone's voice-activated call feature to reach 911.
In other words, he may not have been able to hear the operator at the same time she said she was unable to hear him.
At the beginning of the second call, Smith can be heard asking, "Anyone there?" After that, she does not speak again while Kyle repeatedly asks for help and says he will die if he doesn't get it.
"This is not a joke. This is not a joke," he said. "Send officers immediately. I'm almost dead."
The review notes that "there is no acknowledgment" from Smith regarding Kyle's statements over the phone. It then lists several possible reasons why: "Is call taker on the line? Walk away? Head set off?"
The review, as in most reviews of this nature, included a grading scale for everyone involved with the emergency response.
Magee, the operator who took the first call, received a 90 percent rating, which is considered acceptable. Smith, who took the second call, received a 60 percent rating, which is deemed unacceptable.
Evelyn Bailey, executive director of the National Association of State 911 Administrators, reviewed The Enquirer's copy of the internal police review and said a series of problems appeared to escalate the afternoon Kyle made his calls.
"It looks like a really unfortunate combination of technology issues and failures to communicate all the information to the first responders," she said.
