Almost everyone who spoke Monday at Cincinnati City Council admitted the city's emergency response system failed Kyle Plush on the day the teenager died in his van last month.
Politicians. The police chief. Kyle's family.
But after a month-long investigation and a 50-page report, police wouldn't explain exactly what went wrong or how it could be fixed.
The report found that 911 operators didn't share critical information with police officers on the scene, but it also determined those 911 operators followed proper procedures.
The report found two police officers acted appropriately when they did not get out of their car to search for Kyle, even though they were in the right location and knew someone was trapped in a van in their vicinity.
And it identified several technical problems with the 911 and police dispatch system, but ultimately concluded the systems did not fail and did not significantly interfere with the emergency response.
The findings left Kyle's family, as well as City Council members, struggling to understand precisely how the city failed and what could be done to make sure future 911 callers get the help they need.
Kyle asphyxiated in his van on April 10 after a rear seat flipped over, pinning him under it. He made two 911 calls, providing his location at Seven Hills School, the model and color of his van and an urgent plea that he would die without help.
"We failed Kyle Plush," Councilman P.G. Sittenfeld said. "This was preventable. The least that is owed, is to make sure this never happens again. And it doesn't feel like we are there yet."
Police Chief Eliot Isaac agreed. "There were some failures, and we have to do better," Isaac said.
But when he was asked, repeatedly, to pinpoint those failures, Isaac defended the actions of his officers and 911 operators. The police report did the same, but it also raised questions about the emergency response.
Here are some of them:
Why didn't 911 operators share everything they knew?
In his first 911 call at 3:14 p.m., Kyle explained he was trapped in his van and in serious trouble: "Help me, I'm going to die. I'm in a van at Seven Hills."
The 911 operator, Stephanie Magee, had trouble hearing Kyle for unexplained reasons, but she asked two other operators to listen to a recording of the call to better understand it. She also pinpointed his location from the call, within a few car lengths, based on GPS from the call. That's how she got the exact address, which the dispatcher gave officers.
According to the report, the two police officers dispatched to the scene were told a female was trapped in a van at Seven Hills or in the thrift store parking lot across from the school. Kyle's van was parked in the thrift store lot.
The officers were not told that loud banging or screaming could be heard on the 911 call or that Kyle had said he was going to die without help.
Why didn't the officers get out of their car?
The officers, Brian Brazile and Edsel Osborne, didn't have all the information from the call, but they did get the basics: The general location and that someone was trapped in a van.
It's not known whether the officers had access to the GPS location or just the address.
When council members quizzed Isaac about the officers' performance, he said they acted appropriately based on what they knew at the time. The report also concluded they "met department standards."
The officers, who were on the scene for at least 14 minutes, stayed in their car to cover more ground and view the scene from a "higher vantage point," the report said.
"I believe the officers had the fullest intention to help, but they received limited information," Isaac said. "I'm heartbroken. I've never seen a situation like this."
Why didn't 911 operators hear Kyle's second call?
Amber Smith, the operator who received Kyle's second call to 911 at 3:34 p.m., said she couldn't hear him. The report said the call center experienced technical problems that day, but it doesn't blame those problems for the failure to hear Kyle.
Most of the technical problems appeared to involve the backup system 911 operators were using off-site because the communications center was being renovated. The operators were working at temporary tables and were dealing with background noise that could make it harder to hear calls, the report said.
The report also said the computer-aided dispatch system, which allows 911 operators to communicate with officers on the scene, experienced "connectivity" issues that day, but it concluded the system did not fail during Kyle's call.
Investigators could not confirm whether the operator's headset worked properly, though they found the headset worked properly on dozens of calls before and after Kyle's call.
Why didn't anyone from the school help search for Kyle?
Hamilton County Sheriff's Deputy Douglas Allen, who was directing traffic at the school, ran into the police officers on the scene and asked if they needed help. They showed Allen their computer screen, which indicated a woman was trapped in a van at Seven Hills.
Allen called Magee, the first 911 operator, who told him about the call and gave him Kyle's cell phone number. Allen called the number and decided it sounded like a young man, not a woman, as initially believed.
Allen then met with Robert Horne, director of operations at the Seven Hills School. Horne called Kyle's number and listened to Kyle's voicemail greeting.
Horne agreed it sounded like a young man, but he said no students were reported missing.
The report does not indicate that anyone from the Cincinnati Police Department contacted the school about the 911 call.