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When armed robbers broke into a Houston home in 2005, Joyce John was forced to endure the sound of her parents being shot as the young woman tried to dial 911 from her bedroom using the family's Internet phone service, which failed to connect.

The incident exposed flaws in how the new industry was operating in the U.S. and Texas lawmakers moved quickly to investigate, forcing several changes - including making sure the service worked when 911 is dialled.

In Canada, a similar investigation into one of this country's more troubling 911 tragedies has moved much slower.

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Eight months after the death of 18-month-old Elijah Luck in Calgary, emergency dispatchers are still waiting for regulators to act, by introducing tougher rules for how 911 calls are handled using Internet phones.

A Globe and Mail investigation indicates several key decisions - including Alberta's determination not to hold a fatality inquiry - have impeded the probe. Meanwhile, regulators are at odds with Internet phone companies over what the federal rules governing 911 calls actually say.

Elijah Luck died in Calgary in late April after confusion over the family's address led to an ambulance being dispatched to the family's former residence three provinces away in Mississauga, Ont.

Since it is difficult to tell where Internet phone calls originate, those companies are required to keep special 911 addresses on file for the 250,000 online phone users in Canada, in the event a caller can't speak or is difficult to understand.

The Luck family informed the phone company, Comwave, of their relocation to Calgary. However, the company says it did not change the Luck family's 911 address, only their billing address.

While the death has raised questions of consumer responsibility and company conduct, the incident has also raised concerns about federal oversight. The Lucks say they were not told of the address problem and had no way of knowing. Federal regulators have since acknowledged they did not monitor whether companies were making this risk clear to consumers.

But the investigation into the death has raised further issues that emergency officials now fear regulators are not looking at closely enough.

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A day after Elijah's the death, Tom Sampson, Calgary's chief of Emergency Medical Services, was the first to investigate the botched 911 call.

However, when Mr. Sampson placed a test call to 911 using the Luck family's Internet phone, he said there was no response after numerous rings, though he did not recall how many rings it took before a dispatcher picked up.

"It took some time for the phone to be answered," Mr. Sampson said in an interview. It was a concern the Luck family had also raised.

When the Canadian Radio-television and Telecommunications Commission (CRTC) allowed Internet phone services to operate as telecom companies in 2005, the regulator allowed them to operate their own 911 call centres. It was an unusual move, but it was meant as a temporary solution, since connecting Internet phone services to emergency dispatchers in each city was difficult and expensive. These call takers were to receive information from callers and pass it to emergency crews in the appropriate city.

Mr. Sampson said the person who answered his call refused to share her location and other basic details with Calgary EMS, which slowed its investigation. Though emergency call centres rarely disclose their location as a security measure, Mr. Sampson was trying to determine how the call was being routed.

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"We identified ourselves…They were reluctant. I think they knew something might have been up, but we identified right away that there was a [problem]" Mr. Sampson said.

"We asked to be put through to Calgary 911 dispatch and we eventually did get through but it was a substantive delay."

Federal regulators, who oversee the telecom sector and 911, have not conducted their own tests. The CRTC's report on the matter draws mostly on Comwave's explanations of the incident.

Mr. Sampson said the delay concerned him. He said regulators should look into the matter.


In Alberta, provincial authorities closed the books on Elijah's case soon after the toddler's death, choosing not to hold a fatality inquiry.

It is not unusual for deaths involving 911 mix-ups to be put to a fatality inquiry in Canada, since the process helps establish what led to the tragedy. However, documents obtained through access to information laws indicate that Alberta's Medical Examiner decided within days not to proceed with an inquiry.

Notes kept by Karen Colabella, a senior medical investigator at the medical examiner's office indicate Calgary EMS wanted the matter investigated, but the province disagreed.

"EMS called me to see if a delayed response complaint would be investigated," Ms. Colabella wrote on April 30. "I advised this is a no case and to follow up with this complaint in their normal fashion regarding missed calls."

Then on May 1, Ms. Colabella checked with a superior after questions were raised about whether the province would step in.

"I discussed the concerns of EMS regarding the delayed call to 911 due to this Internet phone problem with [Dr. Sam Andrews, assistant chief medical examiner] He has advised there is no reason to take on this case."

Alberta figured an inquiry wasn't necessary because the cause of Elijah Luck's death was clear: He had been born with numerous health problems and died of heart failure, the province concluded.

But a fatality inquiry would have compelled all parties involved, including Comwave, the family and medical crews, to testify on the matter and establish the facts, while hopefully eliminating conflicting evidence.

Inside the CRTC, there was hope that an inquiry would be called in Alberta. Internal e-mails show the regulator inquired to see if the province would investigate - but the province said no. That closed the books on the case as far as Alberta was concerned. It also left the file solely in the hands of the federal telecom regulator.

In Ottawa, the CRTC spent the first two weeks after the death trying to refresh itself on what requirements were set in 2005 for the Internet phone industry, also known as Voice-over-Internet Protocol, or VoIP.

On May 6, James Ndirangu, a CRTC analyst who handles 911 issues for the regulator, sent an e-mail to a colleague saying the regulator was "investigating the tragic VoIP 911 incident in Calgary" and needed to see what the CRTC required Comwave to tell customers about potential problems with 911.

The response to Mr. Ndirangu indicates the CRTC had problems with the company's documents as far back as 2005, when Comwave missed deadlines to file paperwork on its proposed consumer alerts.

The internal e-mails also show CRTC officials called for a top-level meeting with CRTC Chairman Konrad von Finckenstein to discuss the death.

In one message, John Traversy, executive director of the CRTC's telecom division, asked staff to put together a comparison of Canada's Internet phone regulations and those in the U.S. His e-mail also mentions, "legal assistance will be required."


Unlike the home invasion in Texas, where the state's attorney general made public the details of the botched call, Comwave sought immediately to keep key pieces of evidence confidential. It was a request the CRTC allowed.

This included the recording of the 911 call, which held important details of how the emergency was handled and could potentially settle disagreements between the Luck family and Comwave over what was said on the phone. Comwave has indicated the family was hysterical and could not be understood. The Lucks say they gave their address to the operator several times.

In a May 14 letter obtained by The Globe, Comwave told the CRTC that making such details public could hurt its business and threaten customer privacy.

"Disclosure of the information in the 911 report and in the 911 tapes would severely prejudice the competitive position of Comwave and cause material financial loss to Comwave, and severely compromise the privacy of our customer," the letter states.

It is an argument that has kept much of the investigation out of the public eye. A June 20 letter from Comwave, nearly two months after the death, indicates the CRTC took the same position.

The letter, marked "Confidential," states: "Comwave is in full agreement with Commission staff that the 911 tape must not be disclosed."

For their part, the Luck family said it has not asked for the call to be kept confidential.

Following the death, the CRTC ordered Comwave to file its version of events on the tragedy. At the company's behest, the CRTC allowed most of the report to be blacked out under privacy laws.

When asked about the redacted sections of the report, Comwave chief executive officer Yuval Barzakay said in an interview that one blacked out portion of the document states that Elijah Luck's father, Melvin, was told he needed to update his emergency address on file. The reminder was given when Mr. Luck phoned Comwave to inform the company the family had moved to Calgary from Mississauga, Mr. Barzakay said.

However, the Luck family says it was Ms. Luck who phoned Comwave, not Mr. Luck, as the company states. Such discrepancies have clouded the investigation, though the regulator has not sought to probe these conflicting stories further.


The CRTC issued a report in late June blaming Comwave's call takers for mishandling the emergency in Calgary.

But in doing so, the regulator may have exposed a more troublesome problem with its rules.

For the past three years, the CRTC and the Internet phone industry appear to have been interpreting the sector's responsibilities differently when it comes to handling 911 emergencies.

Comwave's report indicates the family's 911 call was disconnected suddenly. The CRTC said its rules required Comwave's call centre to phone back immediately to confirm their location, instead of deferring to the emergency address on file to dispatch ambulances.

"If a 911 call is disconnected before the operator can verbally determine a caller's location, the operator must attempt to call back," CRTC documents say.

Comwave said this requirement differs from the original CRTC requirements set in 2005.

In a letter to the regulator on Sept. 26, Comwave said it is "deeply concerned by the depth of the misunderstanding that existed for more than three years between the Commission and our industry, unbeknownst to each other, on a subject matter as critically important as the 911 emergency calling service."

It is a glimpse into the debate now playing out behind the scenes in Ottawa. While federal regulators thought the industry was following one set of procedures - calling back immediately if a 911 call is disconnected or if there is confusion over the address - the companies were in fact conducting themselves differently, by using the emergency address. (In the Luck case, the call was disconnected twice. The first time, Comwave called back. The second time, it relied on the outdated emergency back-up address in Mississauga.)

"It took the sad mishap to alert the members of or industry to the differences between the commission's interpretation of our 911 service obligations and our own industry-wide interpretation," Mr. Barzakay said in the confidential letter.

In a recent interview, CRTC director Paul Godin said the regulator did not go back to check if companies were operating under the rules set out in 2005. Instead the CRTC decided to respond to complaints if any arose.

If the regulator believed its version of the rules were in fact governing the industry, Comwave argues, "None of the companies…were acting in accordance."

Despite the emergence of such concerns, the Canadian investigation has ground to a halt. The CRTC said two weeks ago it considers the matter closed.

When authorities in Texas investigated the case involving the 2005 home invasion in Houston, punishment was swift. An overlooked process that required Internet phone customers in Texas to activate 911 service before it could be used was quickly outlawed.

Though Texas agreed to settle out of court with Vonage, the Internet phone company involved, it attached a 15-page list of conditions that required changes to the way the calls would be handled in the future.

In Canada, there are concerns in the emergency response community that not enough has been done to prevent further problems.

"The Calgary tragedy was a series of unfortunate circumstances," Mr. Sampson said. "Unfortunately, sometimes it's not until an issue reaches a peak that folks pay attention to it."

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