Polk County board of county commissioners admits critical mistakes were made the night Loretta Pickard died in a house fire.
On Tuesday, a day after the incident report on the fire was released, Polk County Fire Rescue Chief Tony Stravino announced his retirement.
The 76-year-old woman was on the phone with 911 dispatchers for nearly 20 minutes while smoke from a fire was filling her home.
For eight of those minutes, Polk County Fire Rescue was outside and did not know Pickard was still alive in the home.
Pickard was found right inside the door hours after the home was destroyed.
Since November, ABC Action News has uncovered multiple policies, standards and rules were broken the night Pickard died while on the phone with dispatchers.
Three months later, commissioners hired Emergency Services Consulting International to investigate the November 2018 fatal fire after multiple reports showed one of it’s captains, James Williams, shared a snapchat video of the fire raging.
The post-analysis incident report, released Monday, found five critical mistakes made the night of the fire.
Verbal critical CAD notes were not relayed via radio
According to ESCI, the first engine to arrive at Loretta Pickard’s home did not know for eight minutes that there was a person inside the home.
The report says the computer which was in the engine was not working and the notes that they firemen would usually access for information was unattainable.
Even though Polk County dispatch relayed the critical information that someone was trapped inside the home, that information was solely relayed through CAD and not radio.
All team members responsible for situational awareness
ESCI went on to note that even though the first engine and the men responding did not know someone was in the house when they first arrived, other engines on their way to Pickard’s home did know a victim was inside because their computers were functioning properly.
However, none of the firemen relayed the information to the first crews responding, because they assumed they knew.
While investigating this specific incident as well has Polk County Fire Rescue previous work, it was apparent to ESCI that officers are in need of additional training simulation.
Due to the high number of emergency calls and not fires, ESCI explained it would be beneficial to have additional fire simulations and training to improve decision making skills.
One of the most critical mistakes, according to ESCI, was that the first engine did not bring rescue tools.
This includes forcible entry tools, thermal imagining cameras or a pressurized extinguisher.
Investigators say this is highly unusual.
ESCI says the pre-alert to rescue crews was used properly in this case but is not used overall throughout all emergency situations and can be used to improve response times.
While not in the top five most-critical mistakes, it was noted by the ESCI that Polk Fire Rescue did not reach out to the Pickard family the night of the fire or days afterwards.
A debrief analysis of the incident was also not completed, which according to the ESCI is highly recommended in all incidents including a loss of life incident.
In the process of investigation, Captain James Williams, one of the first on scene that night resigned.
Williams was originally suspended for a 24 hours shift after admitting to snapchatting the deadly fire.
The Polk County Fire Rescue Chief, Tony Stravino announced his retirement Tuesday morning.
The county manager confirming to ABC Action News, Stravino will enter retirement in the next 30 days.
Polk County board of commissioners says recommendations to enhance the department will be enacted upon immediately and offered multiple apologies to the family of Loretta Pickard.
In an interview following the release of the incident-analysis report the family tells ABC Action News they plan to sue the county.