The D.C. fire department has been marred by dysfunction in recent years, and no other instance is more emblematic of this dysfunction—and its ramifications—than the tragic death of Medric Mills in January. Mills, 77, was shopping with his adult daughter when he collapsed outside a fire station along Rhode Island Avenue NE. Despite pleas for help, no one from that fire station came to Mills’ aid. Rescue workers from another station eventually transported Mills to the hospital, where he was pronounced dead.

What had happened inside that fire station, said Deputy Mayor for Public Safety Paul Quander Jr. after overseeing an investigation, was a “total disregard for human life.” According to the investigation, a person came inside saying someone had collapsed, and the probationary officer working the front desk called his lieutenant over the PA system twice, with no response. Three other firefighters also heard the announcement, but no one went out to help. One went to the lieutenant to ask her what was going on, and she instructed him to get the exact address of the incident. The officer reportedly never came back, instead going to his bunk to read. He said he heard dispatchers sent another unit to Mills’ aid.

Dispatchers first sent a truck to the wrong address—in Northwest, not Northeast—and 10 minutes elapsed between the time the first 911 call was made in front of the fire station to the time a rescue worker arrived on the scene. It took 23 minutes before Mills was taken to the hospital. The five firefighters involved received relatively light consequences: The lieutenant retired with a full pension before she could be punished, one firefighter was suspended, one received a reprimand, and one was exonerated. The rookie probationary firefighter manning the front desk that day was fired this December. His dismissal, though, was over attendance issues.