Lots of questions after delayed newborn CPR call in DC. Will we get answers?

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Why did it take almost 20 minutes to get help to a newborn in cardiac arrest Saturday morning in Upper Northwest Washington?

We know one of the contributing factors is fire and EMS units were sent to the wrong location. A dispatcher said on the radio the caller provided a bad address. That may be the case, but there’s a lot more to investigate with this call than the wrong location being dispatched. Many questions arise from listening to the radio traffic. Getting answers is another thing.

With the limited information available, so far, about the response, this article will not provide clarity on how and why it ended up taking so long for help to arrive. STATter911 is using this forum to publicly ask questions of DC’s Office of Unified Communications (OUC). The agency has historically been reluctant to answer these type questions. Specifically, OUC set up procedures last year that waste STATter 911’s time without providing ANY responses to requests for information (see the note that follows). Instead, this post will provide a chronology of the call using the radio traffic, along with context about DC 911’s previous handling of some of these issues. STATter911 hopes that by publishing this information it spurs OUC to release a transcript of the 911 call and a thorough timeline that answers all these questions.

STATter911 has not been able to confirm if the baby survived. Those who have followed DC 911 problems know that, sadly, STATter911 previously confirmed significant DC 911 mistakes and delays surrounding the deaths of three other infants in a little more than two years. Two of them were newborns. One of those was a baby delivered in an apartment just one block from Saturday’s incident.

Important note: In the past, STATter911 would have sought comment from OUC and confirmed more information before posting this story to the website. Due to the consistent lack of transparency by OUC’s leaders, along with procedures created to avoid answering questions our policy changed. Last October, OUC informed STATter911 that, going forward, to get even a comment from leadership about any 911 call, a Freedom of Information Act (FOIA) request must be filed. That gives OUC a minimum of 15 days to respond (but it can be stretched to much longer).

Four initial STATter911 FOIA requests were returned on the 14th day. All were denied under claims of privacy. Interestingly, in two of them, OUC published statements on its website about the very same calls. This included taking selective quotes from a 911 caller in an incident where someone died. So much for the privacy argument. This selective release of information has long been a hallmark of the dubious claims of transparency by OUC leadership. We informed OUC that STATter911’s new policy is that it will not waste time with OUC’s new policy. As always, if OUC wishes to respond to this story STATter911 will publish its complete response.

The dispatch

At 5:26 a.m. (audio above), DC 911 dispatched Ambulance 20 to an apartment (STATter911 redacted the apartment number in the recordings) at 4200 Massachusetts Avenue NW “for a sick patient.” There was no mention at this point that the “sick patient” was a newborn or that the newborn was in cardiac arrest. It will take the recording or timeline from the 911 call to determine what DC 911 knew and when they knew it.

Upgraded response

At 5:31 a.m. (audio above), five minutes into the call, DC 911 dispatched additional units to 4200 Massachusetts Avenue NW. That’s because the call was upgraded to a cardiac arrest. The big questions are when did a call-taker learn this was a cardiac arrest and how long after that were the additional units dispatched?

STATter911 has heard from sources familiar with the call saying they witnessed a delay between the time the call was upgraded, and the additional units dispatched. Again, the 911 call and the timeline will confirm if the delay was significant.

Note: You may notice the dispatcher appears to have misspoken when giving the time at the end of the dispatch. She said 5:25, which would have put that transmission before the initial dispatch. That and the transmission below confirm the dispatch of additional units came around 5:31. The timestamps from OpenMHz.com have always proven reliable and within a few seconds of OUC’s clock.

Seconds after the additional units were sent, Ambulance 20 called to say they were reading the dispatch notes (audio above) and discovered the call had been upgraded to a cardiac arrest. The dispatcher preempted Ambulance 20’s transmission, providing the same information. On the surface, this gives the impression telling Ambulance 20 about this critical information was an afterthought or forgotten until the ambulance crew noticed it and called in. Providing those important updates has been a constant challenge at DC 911. Again, transcripts and timelines will tell us how long before this radio transmission DC 911 knew it was a cardiac arrest.

“Supposed to be a newborn baby”

At 5:32 a.m. (audio above), more than 5 minutes after the call was initially dispatched, responding units were told for the first time that CPR was in progress on a newborn baby. You have to wonder if it really took a 911 call-taker that long to determine the patient was a newborn or if this was simply a delayed notification.

Wrong address

At 5:38 a.m. (audio above), Engine 20 reported they couldn’t find the apartment number they were dispatched to in the building at 4200 Massachusetts Avenue NW. A minute later the dispatcher said, “The caller said they gave the wrong address. It’s 4000 Mass Avenue NW.”

No matter the reason for the wrong location, the fact is 16 minutes were lost before DC Fire & EMS was provided the correct address. More precious time would be lost as fire and EMS exited the 7th floor of one apartment building and made their way to the 7th floor of another apartment building two blocks away.

“Confirming we have CPR in progress”

At 5:47 a.m. (audio above), about 20 minutes after the initial dispatch, Engine 20 confirmed they were finally in the correct building and apartment with CPR in progress.

Getting answers

This incident occurred at the same time DC 911 has a new leader. On February 3, Mayor Muriel Bowser promoted deputy director Heather McGaffin. She’s now the acting director at OUC. Mayor Bowser plans to submit McGaffin’s name to the DC Council for confirmation. Bowser was forced to withdraw the nomination of previous acting director Karima Holmes after it was clear Holmes would not be confirmed.

Under questioning from reporters (video above), McGaffin said OUC will “remain transparent and accountable” and said a second time they will “remain transparent.” Transparent and accountable are good things, but McGaffin’s use of the word “remain” is puzzling. OUC has rarely been either transparent or accountable.

This is now at least the third confirmed cardiac arrest call dispatched to the wrong address since January 25. Also, during that same time, STATter911 discovered DC Fire & EMS was sent to the wrong address for a confirmed shooting and was dispatched to two bad addresses for a reported trouble breathing call. In addition, Metrorail and DC 911 teamed up for a 13-minute delay dispatching a report of a train on fire Thursday night.

Despite McGaffin’s claims in the video, there’s nothing on OUC’s website about any of these calls. There hasn’t been a statement, report, timeline, transcription, recording or anything posted to the website about any incident since October 26, 2022. That was the day OUC released selective quotes from a woman’s 911 call where her roommate was in cardiac arrest. They purposely left out quotes that didn’t support OUC’s claim the call was handled properly. It was one of the same calls where OUC responded to a STATter911 FOIA request by claiming releasing any information about that call would be an “invasion of personal privacy.”

If all this is the type of transparency and accountability Heather McGaffin wants to see “remain” I have doubts we’ll get any reliable answers about Saturday’s tragic call. But I’d be extremely happy for McGaffin to prove me wrong. Real transparency and accountability at DC 911 are long overdue.