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DC 911 sends another cardiac arrest call to the wrong address

At least the fifth confirmed cardiac arrest call misdirected this year with few answers

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Yesterday (Monday) evening, DC 911 lost four minutes when it dispatched DC Fire & EMS three miles out of the way during a cardiac arrest call (recording above). The original dispatch had the wrong street number and quadrant of the city. The mistake was caught by an EMS supervisor responding to the call. She noticed the tablet in her vehicle suddenly displaying a new address. After the call was re-dispatched to closer units, an engine arrived on the scene and reported CPR in progress. STATter911 put in a request to learn if the bad address was due to an error by the 911 caller, the 911 call-taker, or a combination of the two. Previously, similar requests have gone unanswered.

Chronology

The call was dispatched to an apartment at 22 M Street NE at 5:25 pm. A DC Fire and EMS supervisor, known as EMS 1, reported to the dispatcher at 5:28 pm that a new address popped up on the screen while she was responding to 22 M Street NE. The new address, 222 M Street SW is about three miles away. At 5:29 pm — four minutes after the original dispatch — OUC sent a different set of units to the correct address. Engine 7 arrived at the correct apartment building at 5:32 pm. In a transmission to another EMS supervisor at 5:38 pm Engine 7 said, “We do have CPR being performed. Three shocks administered.”

This is at least the fifth time this year DC’s Office of Unified Communications (OUC) misdirected DC Fire & EMS on confirmed cardiac arrest calls. It’s also the 39th time since December STATter911 has documented OUC dispatching fire and EMS to a wrong location (see below for the list that includes links to radio recordings of each call). It’s extremely likely that list does not cover all of the fire and EMS calls dispatched to the wrong address. These are only ones I heard monitoring a scanner or was tipped to by DC Fire & EMS and OUC employees.

OUC speaks, but evades the key question

Both OUC’s director and the DC Council member in charge of OUC oversight were interviewed last week about the sudden increase in dispatches to wrong locations. Neither explained OUC submitting data to the Judiciary and Public Safety Committee in recent years with numbers dramatically lower than this year. Documents filed in January show only three wrong addresses for fire and EMS and one for police in FY19. Since FY15, OUC claimed 911 dispatched a total of only 21 fire, EMS and police calls to the wrong address or for the wrong purpose. STATter911 first reported this information a week ago.

In interviews Thursday on WAMU’s “The Kojo Nnamdi Show” and with WTOP Radio’s Neal Augenstein, OUC Director Karima Holmes said “Dave Statter is not my oversight” and “There is not a systematic problem with DC 911.”

The numbers game

Holmes and Council member Charles Allen didn’t address the basic question that prompted these interviews: How did the number go from 21 in five years for fire, EMS and police to 39 in less than 10 months for fire and EMS only?

Since becoming OUC’s director in January of 2016, Holmes has answered a DC Council question annually that requires her to list the number of times 911 dispatched fire, EMS and police to the wrong location or for the wrong purpose. In the two interviews Thursday, Holmes talked a lot about confused 911 callers often being responsible for wrong addresses. Holmes never acknowledged that even if it’s caller error, it’s still a wrong address that should be listed in the DC Council questionnaire. In fact, Holmes reported “Caller confusion” as the reason for one of four wrong locations during FY18. If that’s really the only time in five years a 911 caller was responsible for a blown address, it would seem to undercut the claims by Holmes about the prevalence of caller errors.

Despite this, Council member Allen appears unconcerned that either OUC had been underreporting wrong addresses for five years or that there is a dramatic and unexplained increase in 911 sending DC Fire & EMS to wrong locations. Here are Allen’s comments to reporter Augenstein:

Charles Allen showing no interest in investigating possible discrepancies in documents submitted to his committee by OUC is not a surprise. In November, Allen never questioned that Holmes left a key fact out of her testimony about the controversial Kennedy Street fire that killed two people. That fact was a 911 worker miscoding the call and further delaying the dispatch to DC Fire & EMS. Allen also told a reporter he had “no position” on OUC not complying with a National Transportation Safety Board recommended audit of 911 operations after the 2015 fatal fire at the L’Enfant Plaza Metro Station.

Other misdirected cardiac arrest calls

On June 5, OUC dispatched DC Fire & EMS to a cardiac arrest call on Oglethorpe Street in Northwest. The correct location was the same street number on Oglethorpe Street in Northeast. A 59-year-old woman died. On May 17, OUC dispatched fire and EMS to the wrong location for a woman who gave birth to a child in her Northwest apartment building. When fire and EMS arrived at the correct location — about 45-minutes after the initial dispatch — the newborn was in cardiac arrest. STATter911 has been unable to determine if the child was revived.

I brought up the childbirth incident with Kojo Nnamdi on Thursday. Holmes did not explain the cause (her explanations about caller error in two other incidents are in the list below). The agency’s public information officer has never responded to multiple requests for information about my lengthy list of wrong locations dispatched by OUC. Two other cardiac arrest cases this year were mentioned by Holmes in a hearing before Charles Allen in June. Without providing locations or other details, Holmes said one occurred because of a caller error and the other was a mistake by a call-taker.

We still need the rest of the story

Now, there’s a fifth confirmed cardiac arrest case in 2020 where fire and EMS were sent to the wrong address. In her interviews, Karima Holmes continues to complain that radio traffic shared by STATter911 doesn’t tell the whole story. She missed two good opportunities on Thursday to give us the rest of the story for these cardiac arrest cases and many others. Such transparency and accountability would have been a lot more enlightening than just blaming Dave Statter for OUC’s problems. As for me doing oversight, I would be happy to give that up if Mr. Allen would finally show an interest in effectively doing that job himself.

 

Fire & EMS calls dispatched to the wrong address by OUC

Audio recordings for each of these 39 incidents confirm DC Fire & EMS Department units were initially dispatched to an incorrect address by the Office of Unified Communications (OUC) with the call later sent to the correct location. The links for each call will take you to the radio traffic for that response. The causes for most of these mistaken dispatches — whether errors by OUC staff, 911 callers, or both — have not been publicly shared by OUC. In the few cases where OUC has reported a cause, it’s noted. Two misdirected cardiac arrest calls mentioned by OUC Director Karima Holmes at a June 9 hearing are not on this list because she provided no addresses, specific dates or other details. It’s extremely likely this list does not include all cases of 911 sending fire and EMS to bad addresses. These are just ones I’ve heard myself or were pointed out to me by people working at the DC Fire & EMS Department and OUC. All recordings are originally from the website OpenMHz.com.

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