Sedgwick County commission reviews Jensen Hughes post‑incident analysis of Brook Hollow fire

The Sedgwick County Commission on a December 2024 special morning meeting received a post‑incident analysis from Jensen Hughes into the Oct. 13, 2023 Brook Hollow apartment fire in Wichita that resulted in the death of resident Paoli Badesky and injuries to other occupants.

Jensen Hughes was asked by Sedgwick County and the City of Wichita to evaluate how the public‑safety system performed during and after the fire and to recommend system improvements. The final report and a slide presentation were delivered to commissioners at the meeting; the commission voted to receive and file the report.

The consultant team said the analysis found no single point of failure in any of the agencies involved but identified multiple, interacting shortcomings that together “contribute[d] to an unorganized rescue effort.” John Mimoser, senior director for Jensen Hughes, told commissioners: “Jensen Hughes found no single point of failure by any of the agencies involved that could be solely attributed to the fatality of Ms. Badesky.” He added that shortcomings could have affected how quickly searches and rescues were conducted, though the firm did not conclude those shortcomings would have definitively changed the ultimate outcome.

Why the review matters: the report was a joint request by the county and city and—by the consultants’ account—was being reviewed publicly by the commission for the first time at the meeting. It catalogs agency‑by‑agency findings and recommends operational, training and policy changes intended to reduce risk in future structure fires.

Key findings reported to the commission

- Dispatch and audio quality: Jensen Hughes found the Sedgwick County emergency communications dispatcher who took the initial 911 call did not relay the apartment unit number to firefighters. Brian Nelson, who led discussion of dispatch technology, said dispatch audio and headset configuration limited what the dispatcher could hear and that an available “instant recall” feature was not used. Nelson said: “This was not used by the dispatcher. This could have allowed the unit number to be understood and to relay this information to incident, but was not used.” The recording captured the caller saying a unit number, but playback on the dispatcher headset differed from the recorded signal.

- Alarm escalation and staffing: The consultants found a delay in dispatching the requested second alarm because multiple dispatch staff and a supervisor were initially unable to upgrade the alarm in the CAD (computer‑aided dispatch) system. Jensen Hughes recommended retraining; Sedgwick County administration arranged retraining within days of the incident, the consultants noted.

- Water supply and firefighting tactics: The Wichita Fire Department rapidly assembled personnel—Jensen Hughes reported the department met NFPA 1710 benchmark counts, reaching a total effective response force (the consultants cited a NFPA benchmark of 28 for this occupancy) within the benchmark time—but the report criticized early water‑supply choices and coordination. The first arriving engine exhausted its onboard tank water before a continuous supply was established, and other units had to hand‑jack large‑diameter hose. The consultants said those choices and delays contributed to the timing of search and rescue.

- Search, rescue and mayday handling: Jensen Hughes reported that searches did not follow the department’s operational manual priority (search nearest the fire and work outward). The consultants said some companies searched uninvolved buildings before finishing the primary search of the building on fire. A stairway partially collapsed, prompting a firefighter mayday and a switch to defensive operations; the report said incident command became more reactive and did not manage mayday radio procedures or announce incident benchmarks as required by the Wichita Fire Department’s operations manual.

- EMS and police roles: Sedgwick County EMS transported four patients and provided triage; the consultants recommended automatic dispatch of a transport ambulance on structure fires with high life‑safety risk, a practice the firm said would align better with NFPA 1710 guidance. The report said Wichita Police Department could provide early size‑up, traffic control and occupant notification if policies placed police on initial structure‑fire responses.

- Fire investigation: Jensen Hughes said the fire‑origin and cause investigation remained open and that the firm received limited investigation materials. The consultants reported apparent gaps in documentation and laboratory evidence handling and recommended strengthened training and resources for the fire investigation unit; the consultants also said some outside resources (canine accelerant teams, ATF) were requested but unavailable.

Details and context from the report and meeting

- Property and incident: The Brook Hollow complex, at 8165 E. Central, is a garden‑style apartment complex with about 12 two‑story buildings and about 72 units. The building where the fire began (identified in the report as Building 300) had a single exterior stairwell. The consultants said the structure likely complied with the 1970s Uniform Building Code at the time of construction; automatic sprinklers would be required for a newly constructed equivalent building today.

- Timeline noted by Jensen Hughes: The initial call from the resident in Unit 306 occurred at about 3:58 a.m.; the caller spoke for roughly 48 seconds and then the line went silent. Wichita units arrived within benchmark response times; Jensen Hughes reported that seven units were on scene before a formal incident command had been established, and that the department had reached a 28‑person effective response force within minutes. When the mayday occurred, command switched to defensive operations and interior searches were temporarily halted. Fire investigators left the scene around 10:10 a.m.; the final engine cleared about 11:05 a.m.

- Systemic and cultural observations: Jensen Hughes urged Sedgwick County and the City of Wichita to work past historical tensions among agencies and to benchmark and accredit systems externally. The consultants also recommended cultural changes promoting after‑action review, accountability and joint training for mayday management.

Commission action and next steps

Commissioner discussion at the meeting focused on dispatch audio, whether instant recall should have been used, the delayed second alarm and the ongoing status of the origin and cause investigation. Commissioners pressed for clarity on why the investigation remained open more than a year after the incident and for improved regional resources for fire investigation (including accelerant‑detection resources).

Chairman Beatty moved to receive and file the Jensen Hughes presentation and final report; the motion carried. The clerk recorded aye votes from Commissioner Dennis, Commissioner Howe, Commissioner Lopez and Chairman Beatty; Commissioner Meitzner’s roll call entry was recorded but the clerk’s verbal vote on the motion was not captured in the transcript excerpt provided.

The report contains agency‑level recommendations and appendices; Jensen Hughes told the commission its findings and recommendations could be refined if new, relevant factual material is provided to the consultants.

The commission meeting record and the Jensen Hughes report are now part of the public record; commissioners were told Jensen Hughes would present the same material to Wichita city leaders later that day.

Ending note

Commissioners and Jensen Hughes repeatedly framed the review as a tool to improve system performance and protect residents and responders. Mimoser closed the report summary by noting the firm’s willingness to revise findings if additional factual evidence is supplied.