CINCINNATI -- More than a month after a teen suffocated inside his minivan, Police Chief Eliot Isaac is expected to give his most comprehensive report on the case yet.
Cincinnati City Council's Law and Public Safety Committee will meet at 9 a.m. Monday to hear from Isaac what went wrong the day Kyle Plush died.
The 16-year-old called 911 twice as he was trapped in his vehicle in the parking lot of the Seven Hills School. The second 911 operator said she couldn't hear him, and two police officers sent to the scene didn't find him.
Heading into Monday's hearing, these are some of the big questions that remain:
How did Plush become trapped in his van?
"The young man was trapped in the third row bench seat, and it is called positional asphyxiation," Deters said. "We are actively trying to identify experts to assist in us in this investigation."
We don't yet know how, exactly, that seat trapped him: Did it come loose? If so, why?
Why couldn't the second operator hear Plush?
Plush's second call to 911 was critical, because that's when he gave the make, model and color of his minivan.
But Amber Smith, who answered that second call, said she didn't hear him. At one point, she sent a TTD, or telecommunications device for the deaf, message to him. That's something an operator might do if they believe the caller was hearing-impaired or unable to speak. An internal review found she followed procedure in doing so.
If Smith truly couldn't hear Plush, the internal review found she should've taken steps to determine if someone was on the line -- like asking him to tap the phone twice or press #2 on the phone, or asking only questions that required yes/no answers. In this case, though, it might not have mattered: Plush couldn't hear the 911 operator in his first call or respond to her questions.
The police department placed Smith on administrative leave for several days.
Editor's note: WCPO has not broadcast or published Plush's 911 calls due to their graphic nature and out of respect for his family.
Cincinnati's 911 center has had different technological problems over the past few years. In October 2016, routing from cellphones left some calls unanswered. In August, the city announced it would drop its subcontractor after more than a year of problems, including a three-hour window last July when people couldn't hear the audio on incoming and outgoing calls.
The center also has suffered from inadequate staffing, including among information technology professionals. And on the day Plush died, the few IT workers were preparing to move 911 operations from a temporary location at Spinney Field back up to the normal home on Radcliff Drive.
Some council members wondered why a recording system captured Plush's second call if Smith couldn't hear him. City officials say those are two separate systems.
Why didn't operators communicate with each other after getting two calls from same number?
Smith said her terminal froze up during Plush's second call. A consultant said that's not uncommon in 911 centers.
Smith did try to call Plush back twice.
Did she ask her coworker about the first call when both came from the same number? And what is the 911 center's policy on handling repeat calls from the same telephone number within a short time frame?
Did Cincinnati officers go to the address in the dispatch run?
Officers Edsel Osborn and Brian Brazile, riding double as Unit 2232, responded to investigate Plush's first call. They were dispatched for a female caller trapped inside a van; the first 911 operator, Stpehanie MaGee, apparently believed Plush's high-pitched cries for help came from a woman.
The address on that run was 5471 Red Bank Road, the parking lot across the school where Plush would later be found dead.
Did the officers ever search that lot?
Videos from their body-worn cameras show Osborn and Brazile turn into the parking lot south of the Seven Hills School Resale Shop. Plush's van was parked in the lot north of the shop, on the same side of Red Bank Road. They make a U-turn, and then turn back onto Red Bank and then into another lot across the road, near tennis courts and a baseball field.
Did the officers get the GPS coordinates from Plush's phone?
MaGee indicated she got his location -- possibly in a thrift store parking lot across the street from the school -- from "Phase II." That's shorthand for a requirement, from the Federal Communications Commission, that wireless providers have to give 911 centers the latitude/longitude coordinates of cellphone calls.
The latitude/longitude coordinates MaGee obtained were within feet of where Plush would be found dead later that night.
Did officer have access to those coordinates, and could that information have helped them locate Plush?
"There's no reason why Uber should have more specificity than our emergency response system," Councilman P.G. Sittenfeld said.
However, speakers including Black and former Assistant Police Chief David Bailey said faulty technology was not necessarily the issue; indeed, the issue might lie in over-reliance on technology investment as a cure-all to problems that originated in the way personnel were trained and treated.
"We've got all these systems," Bailey said. "What do you do with them?"
Did the officers get out of their patrol vehicle to search?
Footage from Osborn's and Brazile's body-worn cameras does not show them ever exit their vehicle to look for Plush.
The two videos show about 3 minutes of the search from two different perspectives. Isaac previously said the officers spent about 11 minutes searching but didn't find anything.
Cincinnati Police Department spokeswoman Tiffany Hardy said the videos are the entirety of what was recorded.
Sgt. Dan Hils, police union president, said they turned off their cameras when they talked with a Hamilton County deputy who directs traffic at the school.
According to department policy, officers will activate their cameras when arriving on scene for all calls for service. They may deactivate the camera after clearing a call.
There is also dash cam video from the patrol vehicle, but that's not yet been released.
It's unclear if Osborn or Brazile ever came back on the radio to ask for clarification about the caller or vehicle. They tried calling Plush's cellphone, but got no answer.
The priority on the dispatch run was "yellow," while the alarm level was "normal."
Did anyone search the lot where Plush's van was parked?
The deputy who directs traffic at the school said he looked in the thrift store parking lot but only saw one van -- and it wasn't Plush's. In talking with Cincinnati's 911 center, he indicated he believed he was looking for a woman -- apparently from MaGee's notes that Plush was a female caller.
A security camera points out toward the lot. If that camera is in working order, its footage has not been shared with the public yet.
Also, it's possible the deputy might not have considered where Plush parked to be part of the "thrift store" parking lot itself: Two lots on the same side of the street are connected, but Plush's van was parked in the lot that's farther north, not immediately in front of the store.
Were any school personnel notified about Plush's call?
Seven Hills School leaders have not said what happened during the Plush incident beyond a statement expressing condolences.
Two officers talked with the deputy about why they came to the school. But we don't yet know if anyone contacted school personnel to explain the search.
And are there procedures in place to communicate with school administrators if a 911 call comes from their campus?
Could software changes have saved him?
Hamilton County Prosecutor Joe Deters, who launched his own investigation, claimed there are simple software changes the city of Cincinnati could make "right now" that would've prevented Plush's death. The city hasn't detailed those changes in its multiple hearings about the 911 center over the past few weeks.
The Cincinnati Fire Department uses a GPS-based system to locate the vehicle nearest to an emergency scene, for faster dispatching. It's not clear if the police department uses that same technology.
Lt. Steve Saunders, police spokesman, said there is no GPS tracking on patrol vehicles, though it's used in other city equipment such as snow plows.
Who is at fault?
This is perhaps the biggest question of all.
Did a component in the minivan malfunction? Did 911 operators and dispatchers do enough to help Plush? Did officers follow procedure in their search? Should someone at the school have noticed Plush was missing?
Or, as former city manager Harry Black hinted last month, was Plush's death a combination of many small failures that compounded into a tragedy -- a so-called "sentinel event" when "bad things happen in a complex system." According to the National Institute of Justice, such events can point to underlying weaknesses in that system.