NEW: DC 911 error sends fire & EMS to the wrong address on cardiac arrest call

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DC 911 tells STATter911 a call-taker is on administrative leave after fire and EMS were sent to the wrong address Monday for a woman in cardiac arrest. The woman, said to be in her mid-fifties, is dead. Approximately 11 minutes were lost before DC 911 discovered the mistake and sent units to the correct location.

DC 911 dispatched the call to an apartment at 122 I Street SE. The correct address was 11 blocks away at 1222 I Street SE in the Potomac Gardens apartment complex. Radio traffic shows that once DC 911 learned the right address dispatchers took an additional two minutes to dispatch the call correctly.

In a statement DC’s Office of Unified Communications said, “Our preliminary investigation shows that our call taker entered the numerals of the address incorrectly and sent it to be dispatched. At this time, we believe that once the FEMS unit arrived at the incorrect location, the unit made the request to OUC for address verification.  The call taker then corrected the location and brought the error to the attention of their supervisor.”

At OUC, 911 call-takers are supposed to use RapidSOS to help verify the location of a call. RapidSOS employs the data from a caller’s smartphone to map the location. The call-taker is expected to confirm that the address given by the caller is in the same area shown by RapidSOS. A key finding in last year’s DC 911 audit by the Office of the DC Auditor was the failure of call-takers to use RapidSOS routinely and effectively to verify addresses.

OUC says it’s still investigating if and how RapidSOS was used for the call on I Street, saying in its statement, “Jointly, the agencies are reviewing why the caller taker entered the address incorrectly, whether mapping and location accuracy technology was available and used, whether protocols were followed, including the provision of CPR instruction, if applicable, and the total response time. The call taker has been placed on administrative leave.”

Timeline

Time-stamped radio traffic recorded by OpenMHz.com (above) shows the call was dispatched as a cardiac arrest to an apartment at 122 I Street SE at 10:05 a.m. At 10:11 a.m., Engine 7 double-checked the address after arriving in the block unable to find an apartment building with that address. A minute later, Engine 7 asked the dispatcher to call back the person reporting the emergency because they’ve confirmed 122 I Street SE is a bad address. It was at 10:13 that the dispatcher reported there was a new address for the call — 1222 I Street SE. The new location is about a mile to the east of the bad address.

Notable in the radio traffic is that even after the dispatcher spotted the new address it took another 2-minutes and twenty-seconds before the call was dispatched to the correct location. The time of the new dispatch was 10:16 a.m., approximately 11-minutes after the initial dispatch to the wrong address. When they arrived at the new location firefighters found a woman in cardiac arrest in the apartment. DC government sources confirm they were unable to revive the woman.

Engine company self-dispatches

Something else occurred on this incident that’s similar to a tragic DC 911 mistake in 2020. DC 911 sent Engine 3 from the Capitol Hill firehouse at 439 New Jersey Avenue NW to the new I Street location. It’s unclear if Engine 3 was responding from quarters. If so, that location is more than twice the distance to 1222 I Street SE than Engine 7’s location in the 100 block. The radio traffic (above) shows Engine 7’s officer made the decision to respond to 1222 I Street SE because they were already on the road and likely closer.

On June 5, 2020, Sheila Shepperd died after collapsing at her home in the 400 block of Oglethorpe Street NE. DC 911 mistakenly sent fire and EMS to the same house number and street but in Northwest Washington. When they realized the error dispatchers sent other units to the correct address. The officer from Engine 11 put his company on the call knowing they could likely arrive before the other units.

A rough re-start for the acting director

Monday’s incident is the latest issue for OUC Acting Director Karima Holmes who returned to the lead the agency in March. Holmes ran OUC for five years starting in January of 2016. The re-appointment of Holmes was a controversial move by Mayor Muriel Bowser. The audit found systemic problems at DC 911 under Holmes.

Since Holmes’s return STATter911 has documented a series of DC 911 problems:

• March 10: It took 17 minutes for DC 911 to correctly dispatch all of the units required after a second alarm was called for a fire at an apartment building on Cathedral Avenue NW.
• March 10: It took three calls from the officer of Engine 14 over seven minutes before DC 911 sent the closest paramedic to an EMS call.
• March 11: DC 911 caused a chaotic five minutes on the radio after mistakenly sending more than 20 fire and EMS units to a call that required only one engine company.
• March 14: It took more than a half-hour to get DC Police to help a man in crisis. By the time officers reached David Griffin he had fled from an ambulance crew and ended up in the Washington Channel where he died.
• April 1: DC 911 failed to answer an emergency radio channel for more than six-minutes.  This was a recurring problem in 2020 when Holmes was director.
• April 11: DC 911 failed to answer an emergency radio channel for almost three minutes when Engine 27 was attempting to get a paramedic unit to respond on an EMS call.
• April 16: It took 36 minutes to get DC Fire & EMS to an injured person on the Anacostia Riverwalk Trail near the Aquatic Gardens in Northeast. DC 911 initially sent fire and EMS to a location in Southeast about three miles from Aquatic Gardens and then delayed sending an engine to the correct location.

Neither Holmes or OUC has publicly confirmed mistakes were made by call-takers or dispatchers surrounding the March 14 death of David Griffin in the Washington Channel. OUC’s initial findings claimed the  delay sending police was not 911’s fault. STATter911 has published an April 13 letter from Holmes sent to DC Council member Charles Allen confirming STATter911’s reporting that mistakes were made by dispatchers.

OUC has provided no information on the March 10 incident where 911 delayed sending the closest paramedic unit or the April 16 call near Aquatic Gardens. OUC did acknowledge errors after failing to answer radio channels on April 1 and April 11. OUC also says it has addressed the delay in sending the second alarm on March 10.