Kristin Murphy, Deseret News
FILE - Bottled water at the home of Kathe Bolan, who has contaminated drinking water, in Sandy on Thursday, March 14, 2019.

SANDY — While contaminated water made 239 people sick in February, Sandy took too long figuring out who was impacted by the fluoride overfeed and too long to inform them, according to a new report.

"A notice not to drink the water until residents had completely flushed their home systems delivered to a larger notification area at an earlier time would have alleviated many of the harmful impacts. The stated rationale that city employees wanted to avoid a 'panic' was not warranted," the state-mandated report says.

The findings of law firm Parsons, Behle and Latimer, which were released by the city Thursday, also say that despite the disorganization and miscommunication, the city didn't actually hide information from the public.

Additionally, the man most visibly caught in the fallout from the incident, Sandy public utilities director Tom Ward, was reinstated Thursday following more than three months of paid leave after the outside investigation found that the city's response to the fluoride overfeed "was within industry standards."

The report highlights confusion and miscommunication in discussions among city officials that led to many affected residents not being notified until two days after the city learned a large area was contaminated.

On Feb. 7, two days after the contamination occurred and after some residents first reported bad-tasting water, a Sandy employee discovered a pump at a non-operating well had been switched on during a heavy snow storm, sending undiluted fluoride into the water. That employee immediately texted another worker, "I just came to check it. It was the only thing that made sence (sic)" and "We overdosed them," the report states.

On Feb. 13, eight days after the contamination happened, Ward learned that the area affected was much larger than originally believed. According to the report, Ward then wanted to send out a press release but "because of concerns about creating additional news stories or causing panic outside the affected area, a decision was made not to do a press release," the report states.

"Ward’s understanding was the matter was decided by Deputy Mayor (Evelyn) Everton. But, Deputy Mayor Everton reported that she only indicated she did not see the need for a press release if those affected were being notified," according to the report.

Everton told the Deseret News Thursday the delay in the press release was a result of a "miscommunication" between her and Ward.

"In hindsight, I wish that we would've taken the time to discuss releasing the press release. And I think my big takeaway from this event is something that I will improve in the future, is that we'll make sure to take advantage of the media to get that information out earlier," Everton said.

She added that public utilities workers "were really just more focused on flushing the system to remove more of the fluoride. That was their No. 1 goal, to restore clean drinking water," she added.

The Feb. 5 incident, which sent undiluted hydrofluorosilicic acid into part of the city's drinking water system, affected 1,500 households, schools and businesses, and sickened 239 people, according to a report by the law firm in April. The concentrate in its undiluted form is classified as a hazardous, poisonous material that, while it contains fluoride, also contains arsenic, lead, copper, manganese, iron and aluminum. It is a byproduct from phosphate mining operations.

The latest report notes that Sandy officials began warning just 24 homes intitially, then 90 homes, and confusion over how many homes were impacted ensued when the size of the affected zone "tripled."

"Because no record was kept of the households notified during the initial notification on Feb. 7, an exact number was not known and there was confusion about how many homes were visited, with estimates from one dozen, to two dozen, and up to around 60," according to the report.

After discovering the problem, public utilities workers flushed the water system and went about notifying residents in the area affected. Utilities workers who were interviewed for the report indicated they were focused on flushing the system as quickly as possible. Workers also went door to door, talked to residents and posted flyers at homes in the affected area. But some residents weren't home, and many didn't answer their phones, the report states.

After the city learned a much larger area was affected, it waited two days to hold a press conference and distribute a news release, and did so "at the behest of the state," the report states.

"Had Sandy made a media announcement after the initial high level of fluoride was discovered, it could have avoided some of the issues discovered in the wake of the event," the report concluded.

"In addition to the city’s technical non-compliance with regulatory requirements, the totality of the circumstances revealed by this investigation suggest that the city may have either underestimated or downplayed this event," according to the report.

After the incident, Sandy was hit with three drinking water violations by the Utah Division of Drinking Water on March 4.

Attorneys in the report recommended that the city:

• Involve news media early on in an event of that kind

• Establish a "comprehensive public notification system"

• Create a public notice template that's pre-approved with the Division of Drinking Water

• Centralize reporting of water complaints

• Update its public utilities emergency response plan

As for the newly reinstated public utilities director, the report says he "generally conveyed thoughtfulness" during the debacle and has "accepted responsibility" for his department's response.

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"We are glad to have Tom Ward back directing the Public Utilities Department," Mayor Kurt Bradburn said in a statement Thursday. "It is easy to look back at an event with hindsight and want to make different decisions, but I believe Tom made the best choices with the information he had at the time."

Other Sandy employees interviewed by the firm, including the mayor and deputy mayor, also "conveyed a sense of commitment to serving Sandy residents and concern that they were making correct decisions and taking appropriate actions to best serve those residents," the report concludes.