Last month, Kristine Kirk was killed by her husband, Richard Kirk, while she was on the phone with a 911 operator. Afterward, the Manager of Safety launched an investigation into the 911 system's response in the incident, and earlier this month, an office spokeswoman told us she'd recommended against releasing the results of the inquiry on a Friday afternoon, a media dead zone when agencies notoriously issue unpleasant information. She agreed that the case was too important to treat in such a manner.

Well, guess what: The report was shared this past Friday afternoon, when it got little attention -- and the ambiguous conclusion offers a possible explanation why. While internal disciplinary proceedings are underway in the case, it appears the dispatcher may have followed protocol that wasn't changed until after Kristine's tragic death.

In our earlier coverage, we noted that on April 14, Kristine called 911 to say Richard was behaving strangely after possibly eating a marijuana edible; he was also on medication for his back. Kristine said Richard was hallucinating, talking about the end of the world and declaring his intention to shoot her -- which he did, while she was still on the line with the operator.

The call took in the range of twelve-thirteen minutes. Moreover, a police station is only a short distance away from the Kirks' home on St. Paul Street, near the DU campus, and officers were less than a mile away at the time of the shooting. If they'd been dispatched immediately, some observers believe a tragedy might have been averted.

This is hardly the only time 911 dispatch has come in for criticism. Last month, we reported that there have been sixty 911 dispatcher complaints over a two year period and at least one death -- that of Jimma Reat, who was with a group that had narrowly escaped an attack from occupants of another vehicle when a 911 dispatcher directed him and his companions to wait for a Denver police officer near the original scene. The men were soon spotted by the original assailants and Reat was slain.

In addition, a 911 investigation following the death of Loretta Barela was aborted when the dispatcher resigned. Manager of Safety communication director Daelene Mix (the spokesperson alluded to above) said this decision was made because of the determination that the dispatcher's error had been at fault in the case, for which Christopher Perea was convicted of murder, rather than there being a problem with the 911 system as a whole.

At the time of our previous conversation with Mix, the Kirk inquiry was incomplete -- but she revealed that "we've made some recent policy changes" that went into effect in late April/early May.

"Now, instead of one person having the discretion about when to dispatch emergency personnel to respond to a call, a supervisor within the 911 center is also notified," she said. "And instead of just monitoring these calls, the call taker is now physically alerting a dispatch supervisor. And police can now change the situation themselves. They have the discretion to make the call a code 10" -- immediate response with the use of lights and sirens.

These shifts create what Mix characterized as "a wide net of discretion, where there is more than one individual determining the appropriate response. And a lot of individuals who are part of that network have years and years of experience and situational awareness as it relates to emergencies."

The policy shifts aren't "a direct result of any one case," Mix maintained . Rather, they sprang from Manager of Safety Stephanie O'Malley's directive "to review policies that touch all our different agencies so that we can find ways to tighten them up."

Maybe so -- but the events described in the newly issued report about the Kirk shooting fit closely with the new guidelines.

Continue for more about the Manager of Safety's Office report about 911 response in Kristine Kirk's death, including additional photos, a video and an original document. According to the report, Kristine's call came in at 9:31 p.m. on April 14. She quickly mentioned that there was a gun in the house, but 7News points out that she initially thought it was secured in a safe.

Within 34 seconds, the dispatcher had assigned the call, the report says -- but it wasn't until fifteen minutes later that an officer with one of the units read dispatch notes indicating that a man, Richard, had grabbed a gun, and the woman, Kristine, was screaming. The officer is the person who asked for "cover to be 'stepped up,'" not the dispatcher.

The key fact here is that the information was seen by the officer on a computer screen as opposed to actually hearing it relayed by someone at the 911 call cener. "The dispatcher provides responding units with the initial information, then gives no further updates for thirteen minutes," the report reveals.

During that thirteen minutes, Kristine Kirk was shot to death.

The report concedes that the call taker entered the phrase "COMMENTS TO FOLLOW," alerting officers that more information was presumably on the way. But the document states that "the updates entered by the call taker and made available to the dispatcher were never aired." Presumably, they were made redundant by the announcement by the officer who'd seen the dispatch notes. His alert caused the responding officers to pick up the pace -- but by the time they arrived at the Kirk's residence, they were too late.

Nonetheless, the report concludes that "the response of the patrol officers was found to be reasonable and appropriate, given the limited information that was aired by dispatch. There was information relayed by the caller to the call taker that would have prompted an emergency response." But "the information, which was constantly being updated, was not provided over the air to the patrol officers."

A separate statement from Mix points out that "the Department of Safety has initiated disciplinary proceedings related to the incident, and a case has been filed with the DA." But judging by the report, investigators feel the fault in the response to Kristine Kirk had more to do with flawed procedures than the actions of the dispatcher -- and while this issue has been addressed, changes were made only after Kristine Kirk was dead.

Here's a 7News report about the latest developments, followed by the Manager of Safety's office report.

Send your story tips to the author, Michael Roberts.

More from our Colorado Crimes archive circa April 22: "Kristine Kirk murder and 911: Sixty dispatcher complaints in two years and another death."

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