The reviewer found no record of any investigator actually being called.
That failure mattered because Strake had reported seeing an alarm panel deliberately disabled during renovation work.
His statement, if preserved, could have helped investigators distinguish a maintenance failure from a decision to bypass a safety system.
An independent fire engineer later reviewed the original Bellwood investigation.
The engineer found strong evidence that the alarm panel was not functioning correctly before the fire began.
The available material did not establish who disabled it or whether the malfunction was the sole cause of the fatalities.
The fire itself had several contributing factors, including deteriorated exits and delayed warning to residents.
The engineer recommended updating the official findings to reflect those uncertainties.
The ambulance delay was evaluated separately by emergency medical experts.
They confirmed that a unit had been diverted away from the intended patient pickup and that the dispatch records were materially inaccurate.
They could not state with certainty that an earlier ambulance would have saved Jonah Reed.
They could state that the delayed response deprived patients of timely care and that the inaccurate logs had prevented a proper review.
Keisha read the report in a private meeting with an advocate.
She did not make a public statement that day.
When she finally called me, she said she had cried over the sentence that refused to promise Jonah would have lived.
Then she said she was grateful for it.
I don’t want a comforting lie to replace the old lie, she told me.
She wanted a full account of what could be established, even when it left painful uncertainties.
The same report described failures in the private ambulance company’s supervision and record retention.
It did not pronounce every crew member guilty or claim the entire company had acted with a single purpose.
Investigators referred specific concerns about record alteration and witness intimidation to appropriate authorities.
The city’s procurement review also continued.
The emergency communications project was delayed while another vendor repaired the faulty building systems and submitted a revised operating plan.
The delay cost money and embarrassed several officials.
It also meant nobody was using an inadequately tested dispatch room during a storm.
Rosa said that was a better embarrassment than explaining a failure after people needed help.
I agreed.
On a Friday afternoon, I visited the library’s archive room and looked at the empty place where the retired cassette had been stored.
