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Why did it take DC 911 at least 20 minutes to send EMS units to help a Northwest man in cardiac arrest? Despite many requests, no one at DC 911 or in the administration of Mayor Muriel Bowser will answer that question on the record. Numerous sources tell STATter911 there’s concern that acknowledging new 911 errors will hurt Bowser’s efforts to get Karima Holmes re-confirmed as director of the Office of Unified Communications (OUC). But on background, the same sources within the 911 center and elsewhere in DC government say a 911 call-taker didn’t pick up important clues about the seriousness of the call — and apparently violated protocol. The man died.
This is at least the 11th incident in just over three years where 911 mistakes were made during someone’s final moments. All of them were uncovered by STATter911. Ten of the 11 deaths occurred while Holmes was OUC director.
The 911 call
The call came in at 9:42 p.m. on October 10th. According to multiple sources familiar with the 911 call, an elderly woman calmly said her male roommate was on the floor. The woman said she wanted to call for help before the man ended up on the floor, but he refused. The call-taker asked if the man was conscious. While the caller replied yes, she also said he wasn’t responding when she called out to him. The woman was asked if the only reason help was needed was to get him off the floor. She answered by saying the man needed his vital signs checked and other things. She wasn’t sure if he would be willing to go to the hospital. The caller also mentioned she couldn’t lift him because he was dead weight.
The 911 call-taker treated this as a non-emergency call. It took approximately 10-minutes for DC 911 to even dispatch the call to DC Fire & EMS. It was classified as a “lift assist”. A “lift assist” call is a non-emergency response routinely assigned to the ladder truck closest to the address. In this case, at 9:52 p.m., Truck 4 from 1300 New Jersey Avenue NW drove without lights and sirens the mile to 1301 Massachusetts Avenue NW. If this had been classified as even a low priority EMS call it likely would have received fire and EMS companies that are closer. They also would have responded with lights and sirens. While it’s unclear if any of their fire and EMS units were available at the time, there’s a firehouse less than two blocks from 1301 Massachusetts Avenue NW.
Eleven minutes after the dispatch — 21 minutes after the 911 call was received — Truck 4 made it to an upper floor apartment where firefighter/EMTs found the man in cardiac arrest. At 10:03 p.m., radio traffic shows Truck 4 requesting paramedics and an EMS supervisor (audio above from OpenMHz.com). This is the standard response on CPR calls. The EMS crews were dispatched within 30 seconds. Despite the efforts by fire and EMS to revive him, the man died. At this point, STATter911 has been unable to verify the man’s identity.
What went wrong
Sources in the DC government familiar with this call claim the 911 call-taker failed to pick up on key information relayed by the caller. Reacting appropriately to that information should have brought a higher priority emergency response with EMS units being dispatched, including the closest paramedics.
All say the most significant clue or cue was the man wasn’t responding when the woman called out to him. The call-taker should have asked follow-up questions to include if the man was breathing and had a pulse. The failure to ask those questions appears to be an OUC protocol violation. Here are some other observations by the sources:
- The 911 caller said she wanted to call for help before the man ended up on the floor, likely indicating she already noticed a medical problem. No questions were asked about his medical history.
- She wanted his vital signs checked and other things (she didn’t elaborate what they were). She wasn’t certain if he was willing to go to the hospital. All possible indications this was a medical issue and not just a lift assist.
- The woman referred to the man as dead weight. A possible indication the man was unconscious and unable to help himself at all.
Each day, DC 911 dispatches DC Fire & EMS Department crews on high priority cardiac arrest calls for people the public sees on sidewalks, benches, and grassy areas around the city. The vast majority turn out to be someone sleeping who doesn’t need or refuses medical attention. Firefighters and paramedics STATter911 talked with about this latest tragic call are frustrated that DC 911 missed such important clues and failed to ask the right questions during a real cardiac arrest. They claim there are many more such incidents the public doesn’t know about.
File a FOIA
STATter911 sent multiple emails over the last week requesting information or comment about the October 10 death. The emails included follow-up requests for information on four September non-fatal incidents where there were delays, wrong addresses, and other issues. Copied on the email were representatives from OUC, DC Fire & EMS, the Deputy Mayor for Public Safety and Justice, the Executive Office of the Mayor, and the City Administrator (currently also acting as the deputy mayor). Last Thursday, STATter911 received notice from OUC chief of staff Kelly Brown that inquiries about incidents will now be handled as Freedom of Information Act requests (see image below). DC has 15 days to respond to FOIA requests and can stretch that considerably longer using a variety of tactics.
Brown was asked in a reply if this new policy applies to everyone requesting information about 911 call handling or just to STATter911. In her Friday response, Brown didn’t answer that question but did say, “Accountability and transparency are of paramount importance to OUC, and we are obligated to ensure that we are in compliance with all District regulations that dictate the appropriate release of records to all parties from our agency.” STATter911 has not requested any records from these calls and has only been looking for comments and information from OUC leadership.
Brown also said to direct future inquiries to OUC’s new public information officer, Anna Noakes. In response to the same questions about who this new policy covers Noakes described how FOIA works and said, “This will be standard practice moving forward for all inquiries regarding specific calls or incidents. In doing so, it allows OUC to properly track inquiries and information, protects caller’s right to privacy, stay in line with District policies, and uphold transparency.”
Noakes response appears to indicate this new “standard practice” applies to everyone. But for clarity, STATter911 asked the question once more. STATter911 also asked what Noakes’s duties as PIO are if all public and press inquiries about calls and incidents are referred to OUC’s FOIA officer. So far, no reply.
Sources in various parts of the Bowser administration say there is a concerted effort to prevent discussion of negative OUC news by DC officials due to the expected confirmation hearing for acting director Karima Holmes. Mayor Bowser reappointed Holmes to the job in February. Holmes previously was OUC director from 2016 to 2021.
A 2021 audit by the Office of the DC Auditor focusing on OUC with Holmes as director found systemic problems in the agency. A recent update of that audit found Holmes was making little progress on recommended agency reforms.
Hearings past and future
Last month, the DC Council held an Oversight Roundtable that focused specifically on the audit, call-taking and dispatching. Six council members participated — an unusually high number for an OUC hearing. Most spoke of receiving complaints about 911 from their constituents. At the hearing, five of the deaths involving 911 errors were discussed. There was testimony from relatives of two of the people who died.
There were also questions from council members about a little known 2019 pilot program where DC Fire & EMS paramedics were assigned to talk with 911 callers reporting medical emergencies. Reports STATter911 received from company officers at the time is there was a clear improvement in classifying medical calls to determine which were high priority incidents such as cardiac arrest. The report from this study was never made public by the Bowser administration and apparently has not been viewed by council members.
There were also five witnesses at the hearing who focused on defending Holmes’s leadership of the agency. Two were 911 directors. They were from Alexandria, Virginia and New Orleans, Louisiana. Two others were OUC union representatives and the last was a salesman for the 911 software provider Rapid Deploy. The five were mostly unable or unwilling to provide insight on the call-taking and dispatching issues central to the hearing. Council members remarked their testimony would be more appropriate at the confirmation hearing.
No date has been set for the confirmation hearing, but the second half of the Oversight Roundtable is scheduled for November 10. Holmes was unable to attend the first hearing due to a family emergency. The only witnesses at the November event are Holmes and her senior staff.
Committee Chairman Charles Allen expressed great concern at the first hearing that OUC also wasn’t providing him information on recent incidents (video above). Allen said he made multiple requests that went unanswered. The Massachusetts Avenue call and the upcoming hearing gives Allen another chance to see if he can get OUC to provide clarity about another tragic incident. As STATter911 previously reported, transparency has not been a strong point during Holmes’s previous appearances before Allen.