The Los Angeles County Fire Department firefighter who died while fighting a house fire in Palos Verdes in January ran out of oxygen, had a heart attack, and had methamphetamine in his system, according to autopsy findings made public Wednesday.
Jonathan Flagler, 47, was found unresponsive inside a small bathroom inside the home on Tarapaca St. January 6, his oxygen mask still fitted to his face.
The LA County Coroner's office determined the cause of Flager's death to be cardiopulmonary arrest due to suffocation, and said the presence of drugs in his system may have been a contributing factor.
"This is a result of exhausting his compressed air supply while fighting a residential fire," wrote deputy medical examiner Juan M. Carillo, M.D.
Flager was positive for Covid-19 at the time of his death, and, "toxicology tests revealed the presence of medications and controlled substances, including methamphetamine."
"Its effects in this death cannot be excluded," Carrillo wrote, and determined Flagler's death was an accident.
An after-action review of the fire conducted by the LA County Fire Department found numerous mistakes in the way the fire was fought and managed, according to a number of senior officials familiar with the incident who were not authorized to speak publicly about the case.
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The officials said the review showed Flager was left alone inside the home after the initial fire in a bedroom was extinguished, contrary to training that firefighters should use the 'buddy system' and not leave anyone by themselves.
"That's a two way street, though," said one of the officials. "It's not clear whether Flagler objected to being alone inside."
The review said Flagler was using an axe to look for more flame while he was inside the bedroom.
Sheriff's deputies outside said they heard three loud thumps around this time, then saw the fire spread rapidly on one side of the house. The cause of the thumps wasn't clear.
The review also found, the officials said, that Flagler activated a personal alarm and made an emergency distress call over his two way radio -- but other firefighters at the scene didn't immediately hear them or begin efforts to rescue Flagler.
One official said other firefighters riding on an engine to the scene saw the emergency message and relayed it to the incident commanders at the house when they arrived.
"By that time, many minutes had elapsed," the official said, and it appears in the confusion the firefighters at the scene had lost track of Flagler.
The after-action report also pointed to a recent reprogramming of some of the Fire Department's radios as a factor in the delay in learning that Flagler was in distress.
A feature was recently disabled that previously would have made very loud audible tones to everyone with a two-way radio at the scene -- that a distress call had been sent.
Flagler's wife and children are planning to file a lawsuit against LA County for what they said were errors made in managing the fire.
“Our lawsuit will establish that the tragic death of Los Angeles County Firefighter Jonathan Flagler was caused when on-scene commanders failed to keep track of the firefighters inside the burning residence, maintain radio contact with those firefighters, and promptly rescue Jonathan," said Thomas J. Johnston, attorney for the Flagler family.
"The autopsy concluded Jonathan died because he suffered a heart attack when he ran out of air, and there were no other conditions related to that immediate cause of death,” Johnston said in a statement.
"He is and always will be my best friend," Flagler's widow Jenny said at his funeral.
"There will continually be a hole in my heart that will never fully heal. John was my soul mate, plain and simple," she said.
"It takes some people decades to find the person they're meant to be with. It takes some several tries to find them, and some never do. I am one of the lucky few that found him on the first try. All it took was one date, and I knew he was the man I was meant to spend the rest of my life with."
The LA County Fire Department declined to address the Coroner's findings, saying it was reviewing the report. A spokesperson also declined to address the after-action review as it has not been released publicly.
"Firefighter Flagler's sacrifice and memory will not be forgotten; he remains a respected fallen hero of our Fire Department and County family," the Department said.