By Dustin Luca
The Salem News
TOPSFIELD, Mass. 鈥� A family is suing the town and leaders in the Fire Department, alleging their handling of a pediatric emergency in 2021, along with an internal policy concerning the use of outside mutual-aid ambulances, were responsible for the death of their 8-month-old infant.
Town officials and their attorneys, as well as fire personnel named in the suit, either didn鈥檛 respond or declined to comment on the case, which was filed in Salem Superior Court on July 21. The fire officials include Lt. John Boyle, a paramedic on the call, and town fire Chief Jennifer Collins-Brown, who the lawsuit alleges conspired on an internal policy to decline out-of-town ambulance services when town EMS staff are available.
The suit centers on an early-morning emergency call June 5, 2021. The baby was battling acute bronchopneumonia, struggling to breathe, and being held by his father when he 鈥渟uddenly stopped breathing.鈥� The parents immediately called 911 and began performing CPR on the baby as they learned to do in a class and guided by a dispatcher over the phone.
The baby was placed on a flat surface 鈥� the floor 鈥� to ensure the CPR was effective. That CPR stopped when police arrived, as the first officer in the door picked up the baby and left the home to await the ambulance. As the 911 call ended when police arrived, the mother of the baby could be heard in the background saying the officer holding her son 鈥渋s not doing anything.鈥� The father then asked, 鈥淎ren鈥檛 you going to give him CPR?鈥� as the call ended.
鈥楤otched response鈥�
The first officer at the scene entered carrying a bag of medical gear, which included an automated external defibrillator, according to the lawsuit. The bag was dropped at the entrance to the home as the officer approached and picked up the baby, and took him outside while tapping his chest to simulate compressions. The bag of gear was left in the home, where it remained untouched throughout the call, the suit says.
From the moment the baby was picked up by police, he didn鈥檛 receive any fresh air via ventilation, and he wasn鈥檛 intubated until after he arrived at the Beverly Hospital emergency department at 2:38 a.m. Once he was intubated and his airway was cleared, 13 doses of epinephrine were needed to get the baby鈥檚 heartbeat back, which was officially noted at 3:13 a.m., the lawsuit indicates.
After being transferred to Boston Children鈥檚 Hospital, the baby was diagnosed with a severe hypoxic ischemic injury to the brain, a condition caused by the brain receiving too little oxygen. 鈥淗is parents withdrew mechanical support the following day. (The baby) passed away on 6/6/2021,鈥� the suit reads.
What transpired between the time first responders arrived just after 2 a.m. until 2:38 a.m. 鈥� during which time Topsfield EMTs were solely responsible for the baby鈥檚 care 鈥� is the main subject of the lawsuit. It also highlights a years-long practice at the Fire Department to prefer to send town EMS staff to calls instead of more advanced life-support ambulances from private companies.
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An out-of-town ambulance capable of pediatric advanced life support was dispatched and then canceled by Topsfield the night of the call, though the company continued to drive to a rendezvous point in Wenham, waited for an opportunity to take over, and watched as a police escort and the Topsfield ambulance sped by.
鈥淭he case is tragic. This was an 8-month-old boy,鈥� said Adam Satin, an attorney with Boston-based Lubin and Meyer representing the family and baby鈥檚 estate. 鈥淭he evidence is going to be very clear he died needlessly because of the botched response by the people named in the complaint, who were expected to provide competent emergency services, but failed to do so.鈥�
Report: 鈥楪rossly failed鈥� in care
The details surrounding the emergency response June 5, 2021, are the subject of a scathing 18-page report from the state鈥檚 Office of Emergency Medical Services. The office鈥檚 investigation, closed in late 2021, specifically lists six violations of state standards of care. Five cite specific treatment protocols violated by Topsfield firefighters, and a sixth targets the Police Department for 鈥渇ailure to provide effective CPR or AED,鈥� which is noted to be 鈥渘ot within OEMS jurisdiction.鈥�
Three of the four town EMTs reported in their interviews that this call was their 鈥渇irst infant cardiac arrest,鈥� and one of them also indicated the call represented their 鈥渇irst time intubating an infant.鈥� That effort was ultimately unsuccessful, in part because the ambulance was being driven unsafely, according to the OEMS report.
鈥淎ll four EMTs (involved in the response), from start to finish, grossly failed to take care of this patient appropriately, primarily by failing to provide effective CPR or AED therapy and cardiac monitor rhythm assessment,鈥� the OEMS report reads. 鈥淭here were multiple clinical failures by all the EMS personnel in this call.鈥�
The report specifically names four Topsfield firefighters, who are all EMTs 鈥� Jeffrey Horne, Jason Murley, Lt. John Boyle and Jonathan Hallinan 鈥� as principal parties. Boyle and Hallinan are also trained as paramedics. It makes repeated references to Topsfield police Officers Daniel Bell and Joseph DeBernardo, as well, the first who arrived the morning of the emergency. An Ipswich police officer was also briefly on the scene to provide mutual aid if necessary.
DeBernardo was first in the door, entering the home with a bag containing an AED and leaving with only the baby, where he was joined outside by Bell and waited nearly six minutes for the ambulance. During the wait, the report notes, both officers 鈥渟eem to have not continued effective CPR, nor did they deploy an AED.鈥�
Beginning with the ambulance鈥檚 arrival, the report lists several failures by those responding:
- Horne, an EMT, arrived in the town ambulance and exited with a second bag containing medical gear and an AED, but it was left on the ground and abandoned when the ambulance left
- Horne and Murley, a second EMT, 鈥減ut the patient on the stretcher, but did not provide ventilations, nor did they apply an AED鈥�
- Murley drove the ambulance, waving off a police officer鈥檚 offer to drive because the ambulance had 鈥減artially defective brakes,鈥� thus taking an EMT away from caring for the patient
- Murley 鈥渄rove in a manner that concerned the crew of the patient compartment. ... The driving prevented them from performing a second intubation attempt鈥�
- Boyle and Hallinan were picked up by the ambulance en route, Hallinan after a fire extinguisher discharged inside a town truck; that incident required a clean-up of the truck and brushing off Hallinan鈥檚 clothes before entering the ambulance and joining the situation
- 鈥淏roselow tape,鈥� a tool commonly used in pediatric emergencies to estimate a baby鈥檚 weight and determine equipment sizes and medication dosages, was 鈥渘ot used until the hospital requested such near the end of the transport鈥�
The report also indicates that while in the ambulance, the baby was 鈥渟imply placed and secured directly on the stretcher,鈥� as the ambulance lacked a harness 鈥渢o accommodate the patient鈥檚 small size.鈥� It notes the baby鈥檚 mother was in the back of the ambulance the entire time 鈥� allowing her to witness the quality of care her child received and recognize inaccuracies in the 鈥減atient care report鈥� the town wrote to document the call.
The initial complaint to OEMS alleged that the Topsfield Fire Department 鈥渇alsified information鈥� in the PCR. The town had reported the baby was getting effective CPR throughout the call.
鈥淲ith regard to the allegation that the PCR was falsified, the department is unable to make that determination,鈥� the report indicates. 鈥淐PR is not only chest compressions, but also ventilation, and but for the brief time during which Hallinan applied the BVM (bag-valve mask), this patient was not ventilated. However, the Department cannot determine whether this reflects a lack of understanding of CPR, or is a knowing statement of false information.鈥�
鈥淭he report basically says they almost didn鈥檛 know what CPR was,鈥� Satin said. 鈥淭hey weren鈥檛 providing CPR of any sort that would provide any benefit to this child, and he lost oxygen as a result, and his brain died.鈥�
The report criticizes the Fire Department for failing 鈥渢o report this incident to (OEMS) in accordance with the serious incident reporting requirements.鈥� It also emphasized that the town 鈥渁ddress the issues around the Topsfield (police) first responders鈥� actions in this case, in which they broke the 鈥榗hain of survival鈥� in the CPR process this patient had begun receiving鈥� from his parents.
Suit: Internal policy responsible
The OEMS report effectively ends there, but the lawsuit goes on to address a department policy on mutual-aid requests that led to Topsfield handling the call instead of a better-equipped, out-of-town company.
The suit outlines that the policy was captured in a town Fire Study Committee report in 2015, when then-Capt. Collins-Brown confirmed 鈥渢he existence of the cancellation policy and custom鈥� to the committee.
鈥淥n information and belief,鈥� the suit reads, 鈥淏oyle and (Topsfield fire Chief Jennifer) Collins-Brown had actively undertaken efforts to generate political support to create and fund permanent full-time EMS services, to be provided by the Topsfield Fire Department, as both the primary first response and transport ambulance. ... Such efforts had led to this policy or custom to exclude its primary competition, Northeast Regional Ambulance, from calls that might be handled by Topsfield, which resulted in decreased utilization of Northeast鈥檚 Regional Ambulance.鈥�
The night of the call, Hallinan鈥檚 first act was to 鈥渞equest the dispatch of a mutual aid paramedic ambulance from Northeast Regional,鈥� according to the OEMS report. However, the lawsuit indicates that 鈥淐ollins-Brown and Boyle, at all relevant times, had formulated this policy, custom and practice regarding the regular cancellation of Northeast Regional Ambulance intercepts.鈥�
During the call, as the town ambulance picked up Boyle, he 鈥渋mmediately directed Murley to cancel the Northeast Regional intercept,鈥� the suit reads.
鈥淭his cancellation occurred at 2:23 a.m.,鈥� 15 minutes before the Topsfield ambulance arrived in Beverly, the suit reads. Northeast Regional still drove to a rendezvous point on Route 97 in Wenham, one the Topsfield ambulances drove past with Northeast at the ready. After Topsfield鈥檚 ambulance sped by, the company was 鈥渘ever contacted to provide support or assistance for the remainder of the trip.鈥�
鈥淲hat鈥檚 particularly egregious, not only from a legal perspective but more-so for me as a parent of small children ... the ranking officers from the Fire Department called off and canceled the ready, willing, and able assistance of the more qualified pediatric advanced life support certified ambulance that was essentially their competition,鈥� Satin said. The cancellation came 鈥渇or one reason and one reason only: So they can build up their own experience and skillset of their personnel in real-time emergencies like this.鈥�
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