WICHITA, Kan. (KSNW) -- An independent review of a fire that killed a young woman last year finds that there were shortcomings in how city and county departments responded and that those shortcomings "contributed to an unorganized rescue effort." However, the Jensen Hughes review team "cannot conclude that the shortcomings identified would have absolutely changed the ultimate outcome of this fatal incident." Paoly Bedeski (Courtesy: Jennifer Graham | Professional Photographer) Paoly Bedeski died in the fire at Brookhollow Apartment on October 13, 2023. She called 911 and gave dispatchers her apartment number, but the firefighters’ union says dispatch did not tell them someone was trapped in that apartment. When fire crews found her, it was too late to save her. One killed in Harvey County hunting incident Jensen Hughes, a public safety consulting firm, reviewed the radio transmissions, interviewed people involved, and reviewed policies, procedures and training records. "Jensen Hughes found no single point of failure by any of the agencies involved that could be solely attributed to the fatality of Ms. Bedeski," John Mammoser, Jensen Hughes' senior director, said. "Instead, we identified a number of systemic shortcomings that, when combined, contributed to an unorganized rescue effort." The audit says, "Had these significant shortcomings not occurred, it would have provided Ms. Bedeski with a better chance of early rescue and subsequent increased potential for survival." The last time she was known to be alive was when she stopped speaking on the 911 call, which was before the Wichita Fire Department was dispatched. Her call disconnected before firefighters arrived at the apartment complex. Three main Jensen Hughes findings: We believe that the Sedgwick County Emergency Communications call taker/dispatcher could not understand what Ms. Bedeski was saying when she stated her apartment unit number. However, the dispatcher did not use the instant recall feature to replay the audio. This may have allowed him to better understand her and relay the information to the Wichita Fire Department. Sedgwick County Emergency Communications dispatched the requested second alarm after a significant delay. However, we found that the Wichita Fire Department had an adequate number of firefighters on scene to conduct fireground operations of a garden-style apartment before the second alarm was dispatched. We found the Wichita Fire Department’s decisions associated with the initial fire attack, an uncoordinated search and rescue effort, ineffective command and control, in addition to the partial collapse of the stairway and subsequent Mayday delayed search efforts. Other factors Jensen Hughes listed other factors that likely contributed to the fatal outcome, but they were beyond the control of the first responders: Past evidence of building residents inappropriately discarding smoking materials on and around Building 300’s exit stairway. Exit stairway combustible construction and geometry. Wind conditions the morning of the fire. Evidence found on Ms. Bedeski's social media in the weeks leading up to the fire indicated that a smoke alarm in her apartment had a low battery. It is unknown if the detector was working properly at the time of the incident. In reviewing the available fire scene photographs provided by the Wichita Fire Department, patterns of fire impingement on the exterior doors and subsequent heat/smoke damage to the interior walls suggest the exterior door of Unit 306 may have been open during a portion of the incident while other apartment unit doors remained closed. Ms. Bedeski's decision to retreat to her (windowless) bathroom, for unknown reasons, is a contributing factor that resulted in her fatality. Despite the fire exposure to the adjacent apartment, Unit 305, being more severe, those residents survived by going to the front bedroom and jumping from the window prior to the arrival of the Wichita Fire Department. The independent review team also found some underlying challenges that the Wichita and Sedgwick County public safety system has faced for some time: Tension and animosity between emergency communications and some of the agencies it serves undermine trust and respect. The fire department appears to lack an emphasis on self-reflection and accountability within its culture. The Jensen Hughes team is currently presenting its 108-page report to Sedgwick County and the City of Wichita. Click here to see the full report. KSN News will update this story throughout the day with more specifics from the audit.