LAKELAND, Fla. (WFLA) – It’s been nearly six months since tragedy struck and a 76-year-old woman died while on the phone with 911 inside her burning Lakeland home.

This week, a report summarizing a post-analysis investigation completed by an outside agency was released to the public. The report done by ESCI appeared to confirm many of the findings 8 On Your Side’s Melissa Marino has uncovered since the November fire.

This is a timeline of the tragic fire and Melissa Marino’s investigation:

Nov. 23, 2018:

Polk County Fire Rescue is called to a house fire on Rockridge Road in North Lakeland. Loretta Pickard was home when the flames broke out. She died in the fire, just five days before her 77th birthday.

The ESCI investigation found Polk County Fire Rescue had no contact with Pickard’s family the night of the fire or in the following days.

Nov. 26, 2018:

Polk County Sheriff Grady Judd contacts the county manager about the fire.

According to the report from ESCI, Sheriff Judd reached out to County Manager Jim Freeman three days after the fire to express his concerns about what happened. ESCI says an effort to look at the deadly fire more closely didn’t happen until the sheriff voiced his concerns.

Nov. 29, 2018: 

Injuries to two Polk County Fire Rescue personnel are reported six days after the fire. 

The ESCI report says the injuries were “reported and documented as having occurred on the scene…both injuries were similar in nature and were documented as first-degree burns to the arm and face due to close proximity to the fire for a prolonged period. The affected personnel were not treated for these reported injuries and only reported them after the fire on November 29, 2018.”

Feb. 7, 2019:

8 On Your Side breaks the story that Loretta Pickard was on the phone with 911 for 20 minutes pleading for her life while her home burned around her.

According to the 911 call, Loretta managed to stay on the phone and talk to the 911 dispatcher for 12 minutes after hearing sirens.

“They know I’m in here right?” she is heard asking on the call.

She took her final breaths while on the phone as the dispatcher assured her crews were coming in to rescue her.

Feb 8, 2019:

8 On Your Side reveals discrepancies about what happened the night Loretta died.

Deputy County Manager Joe Halman Jr. told Melissa Marino first responders tried to rescue Loretta, but claimed it was too hot. A log we obtained between dispatchers and fire crews tells a different story.

According to the log that was brought to 8 On Your Side’s attention by a source in Polk County Fire Rescue, firefighters did not attempt to get into the home or check around it. In fact, they never mentioned the person trapped inside. 

The log shows that a dispatcher told the firefighters several times that Loretta was inside, where she was located and that she was still alive. Yet there is no record in the log of any search, rescue attempt, or any mention of the victim from firefighters on scene.

8 On Your Side also learned that Captain James Williams, the person calling the shots at the scene, sents a Snapchat video showing the fire at Loretta’s home. Williams was suspended for 24 hours without pay for sending the Snapchat.

Feb. 11, 2019:

Melissa Marino reports dispatch reveals the first crew that responded to the scene of the fire did not attempt to rescue Loretta.

The 911 dispatcher sent at least six transmissions to fire rescue letting them know someone was trapped inside the home. Capt. Williams can be heard acknowledging the information in audio that was obtained by 8 On Your Side.

Capt. Williams then reported over the radio that they were going into “defensive mode,” meaning they started to fight the fire from the outside.

8 On Your Side learned that Polk Fire Rescue’s policy, and industry standard, is to have two firefighters on the outside before two firefighters go in.

Halman told us that doesn’t apply in a situation involving life and death. But according to radio transmissions, Capt. Williams waited instead of sending anyone in.

“When you get here I need your help up at the structure – two in, two out – so we can make entry and see if anybody’s inside please,” he is heard saying to another crew.

A few minutes later on the dispatch call, a chief came on the radio and asked if there was entrapment. Williams replied that it was “too far gone for us to even attempt to make access to the structure now.”

The captain clarified that he was not asking him to make access but was asking if anyone confirmed there was entrapment. Despite the dispatcher repeatedly notifying the crew that someone was trapped inside, Captain Williams appeared to believe no one was inside.

Feb. 12, 2019:

Polk County Commission Chairman George Lindsey says he wants answers about what happened following our initial series of investigations into the fire.

Feb. 13, 2019:

8 On Your Side learns Polk County changed its 911 policies in December, one month after the fire.

“We determined that the call taker followed the protocols and procedures,” the sheriff’s office said in a statement. “We also determined that we would add to our protocols to include a more urgent, repeated, declarative instructions in the rare situations where there is a structure fire and the caller is still inside or possibly trapped inside.”

Feb. 14, 2019:

Polk County Manager Jim Freeman asks for an independent investigation into the fire that killed Loretta following our 8 On Your Side reports.

Feb. 18, 2019:

Amid her investigation into the deadly fire in November, Melissa Marino reveals that Polk County Fire Rescue is dealing with a major firefighter shortage.

We found firefighters were being forced to work mandatory overtime. At the time, the county had about 80 to 100 vacancies.

Feb. 19, 2019:

8 On Your Side breaks the news that Capt. Williams has been put on administrative duty.

A county spokesperson told us Williams was transferred from his field position to administrative work while the investigation into the November fire continued.

The same day that news broke, Loretta’s loved ones brought their concerns to Polk County commissioners.

Feb. 20, 2019:

A county spokesperson announces Emergency Services Consulting International (ESCI) has been hired to conduct the post-incident analysis of the deadly fire.

County officials also met with the firefighters’ union on Feb. 20 to discuss the firefighter shortage. The two parties were unable to come to an agreement.

Feb. 22, 2019:

Chip Osowski reports new video has surfaced in the investigation into the November fire.

Williams had previously been suspended for the Snapchat he sent from the scene of the fire at Loretta’s home. Fire officials told 8 On Your Side Williams claimed it was the only time he had sent a video from a scene.

Chairman Lindsey told us the county would be conducting a full investigation into the new video.

Feb. 26, 2019:

8 On Your Side obtains a new post-incident analysis report on the fire conducted by Battalion Chief Jeremiah Gilley.

The 45-page report concluded that Capt. Williams’ inexperience and the magnitude of the scene likely caused him to become overwhelmed. 

It also suggested that a more thorough walk around the home should have been done to try to find a way inside to save Loretta. 

March 6, 2019:

ESCI, the outside agency hired by Polk County, officially begins its investigation into the deadly Lakeland fire.

March 12, 2019:

8 On Your Side breaks the story that Capt. James Williams has resigned from Polk County Fire Rescue.

Capt. Williams was under investigation for allegedly lying under oath about taking videos at fire scenes. Sources told 8 On Your Side that Williams was allowed to resign March 12 after several weeks on desk duty.

March 15, 2019:

Loretta’s family tells Chip Osowski they are outraged over Williams’ resignation letter.

In his letter, that was obtained by 8 On Your Side, Williams said he “made a few mistakes along the way” but never put a patient’s life or wellbeing at risk.

“The media does what they do best and twist the truth for ratings,” he added.

April 5, 2019: 

Loretta’s family tells 8 On Your Side they have filed an intent to sue Polk County Fire Rescue and the sheriff’s office.

Attorney Chris Borzell told us the legal action was intended to prevent other families from going through what Loretta’s family went through.

May 6, 2019:

Polk County releases the post-incident analysis from ESCI on the fire that killed Loretta. 

The report appeared to back up many of the findings 8 On Your Side had already revealed. 

May 7, 2019:

Polk County commissioners hold a board/staff work session to discuss the findings in ESCI’s report. 

ESCI gave a presentation to the board outlining what they found while looking into the deadly fire and the recommendations they had moving forward. Officials and investigators then held a news conference to answer questions.

Shortly before that question and answer session began, 8 On Your Side broke the news that Polk County Fire Rescue Chief Tony Stravino was retiring. County officials then confirmed in the news conference that Stravino “tendered his intent to retire” and would be leaving within the next 30 days.

DOCUMENTS OBTAINED BY 8 ON YOUR SIDE:

What did the ESCI report find? 

The report completed by ESCI confirmed many findings of our previous 8 On Your Side investigations.

In the report, ESCI notes the difficulties crews faced when responding to the fire back in November. They stated the home was in a heavily-wooded area and was surrounded by trees. There was also no marked address on the home or main road.

“The home was not visible” from the road and access to the structure was challenging, the report states. They also noted there are no fire hydrants directly near the home.

Capt. James Williams was the captain of Engine 6 (E6) – the first crew that arrived at the scene that night. According to the report, Capt. Williams “chose to forgo bringing Water Tender 6, stating that he wanted to keep the integrity of his crew together should they need to make a rescue of an occupant.”

ESCI found that Capt. Williams’ crew got to the scene at 7:22 p.m. They also found that the dispatcher announced five times between 7:09 and 7:12 that someone was trapped in the home. However, they did state that, “it may not have been apparent to all responding crews that the caller reporting the entrapment and the victim were on in the same.”

The report states that the dispatcher again mentioned that someone was trapped at 7:25. That information was acknowledged by E6. But according to the report, “it was not until after Engine 6’s arrival and upon questioning by Battalion Chief 1 that dispatch reported that, ‘Command, we are still landline there is somebody inside the structure’ and noted the location as the kitchen.” According to ESCI, that happened at 7:30. That was more than 3 minutes after the last contact with Pickard.

After the fire, ESCI found Polk County Fire Rescue personnel did not receive any follow-up or debriefing of themselves or their crews. There was an effort to look at the incident more closely to figure out what happened, but ESCI says that didn’t happen until the county manager was contacted by a concerned Polk County Sheriff Grady Judd on Nov. 26 – three days after the fire.

ESCI also found that there was no contact with Pickard’s family the night of the fire or in the days following the incident.

In their report, ESCI noted that the initial arriving officer (Capt. Williams) “was relatively new in his position with limited experience and likely had not been faced with an incident like this before.”

According to ESCI, Capt. Williams reported he and his firefighter tried to do a 360-degree survey. But ESCI says “the officer’s focus on the involved side of the home thwarted his attempt” to make that full walk. That would have allowed him to “ascertain more about the progression of the fire, survivable space entry or egress points and other hazards as is standard protocol,” ESCI wrote.

At 7:25, logs show Capt. Williams radioed in saying he needed the next arriving crew to come straight to the house for a “two-in/two-out” to possibly enter the home. But ESCI says the lack of the initial 360-degree survey by Williams made the reconnaissance ineffective.

ESCI notes that the information that was gathered by the call-taker was very good and that the call-taker kept in contact with the caller up until communication was lost 20 minutes into the fire. That was five minutes after Engine 6 reported they were on scene.

“Based on the timeline, radio communication logs and discussion with responders, there was no indication that the E6 crew was either focused on or in a mode to perform a search and rescue after the initial size-up as described,” ESCI wrote in the report.

ESCI also noted that Captain Williams had “tunnel vision” that resulted in him focusing on only one part of the situation rather than the whole losing situational awareness.

According to ESCI, neither Capt. Williams nor his firefighters brought forcible-entry tools, a Thermal Imaging Camera or a pressurized water extinguisher to the structure to help them get inside or search to execute a victim rescue.

In their report, ESCI states that Pickard’s body was found near a door that would have been hidden from the initial-arriving crew when standing on a different side of the home. But if the 360-degree survey could have been completed, ESCI says the door would have likely been seen.

According to ESCI, two injuries to responding firefighters were reported and documented from the fire. The report states they were both similar in nature and were documented as first-degree burns due to their close proximity to the fire for a prolonged period. But ESCI found the affected personnel were not treated for the reported injuries. They also found the injuries weren’t reported until Nov. 29 – six days after the fire.

One of the key findings that ESCI noted in their report was that information provided by the caller is “vitally important” to units assigned to the incident. ESCI found that, in this incident, the caller provided “considerable information about the structure, her location within the structure, her condition, and access points to enter the structure.” All of that information was put into the CAD and showed up on mobile computers. But ESCI found the first arriving unit had a computer that was out of service. That means none of the information was available to the crew of E6.

During interviews with fire officers, ESCI said it was clear that “a majority of these officers are concerned with officer training, mentoring and development of the existing officer cadre as well as the newly-promoted and those aspiring for promotions.” 

Another key finding ESCI noted in their report was that “there was no indication that E6 was in a mode to perform a search and rescue” after arriving at the scene. 

“The officer and firefighter reported that they did not take any tools or other firefighter equipment with them to the scene,” the report states. “This may further imply the crew was not in a search and rescue mode.”