New report highlights DC 911’s lack of candor in internal investigations

DC Auditor shows key information left out of DC 911's self-investigations in multiple cases where people died

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READ – 911 Reform Status Report #2: Progress Made but Transparency Needed

STATter911 has long asked this question: With 911 errors and delays involved in now 13 deaths since August of 2019 why does Mayor Muriel Bowser continue to let DC 911 investigate itself?

The latest report released today by DC Auditor Kathy Patterson provides new evidence that the Office of Unified Communications (OUC) has withheld information crucial to these investigations. Patterson cited “the agency’s failure to be accurate and transparent in describing after-action reviews”.

You may recall the July 3, 2022, death of newborn Sevyn Schatzman-Chase. A DC 911 call-taker mistakenly entered the wrong address into the dispatch computer. The baby was in an apartment in the 2100 block of Savannah Terrace SE but the call-taker wrote the same street number but on Savannah Terrace. In the new report Patterson writes, “OUC failed to acknowledge that the call taker recorded the wrong address after the correct address had been displayed on a locator map.”

Specifically, OUC never made public that the location determining technology (LDT) pinpointed the call as being on Savannah Terrace very near the child’s home. It was never part of the internal report. The two previous auditor reports highlighted OUC’s poor use of LDTs like Rapid SOS.

From 3/23/2023 report by the Office of the DC Auditor

In the report’s cover letter and recent DC Council testimony, Patterson also points out OUC’s complete lack of candor in responding to another STATter911 report. This was a 911 call on Massachusetts Avenue NW classified as a non-emergency “lift assist”. It turned out to be a cardiac arrest where a man died. Patterson called OUC’s “final statement” into the October 10, 2022, incident “incomplete” and “inaccurate.”

OUC wrote in that final statement, “The Office of Unified Communications (OUC) is aware of the inaccurate social media report about this incident.”

The statement then provided selected quotes from the 911 call in an effort to support the actions of a call-taker. OUC denied STATter911 access to a transcript or recording of the 911 call saying it would be “an invasion of personal privacy.”

What the agency’s leaders didn’t know is that STATter911 already had the transcript and 911 call recording. STATter911’s follow-up report showed the call-taker missed important clues from the caller that this call required an emergency response. OUC’s leadership missed them too, leaving those quotes out of their final statement.

Patterson and the audit team point out that  “a new agency policy on incident reporting is inadequate and ‘a revised policy should require that after-action reports clearly articulate all investigative and remediation efforts.'”

Both former director Karima Holmes and current acting director Heather McGaffin have consistently claimed the agency is transparent. Actions by the agency’s leadership past and present show otherwise.

The only positive development on the self-investigation front is recent word from McGaffin that OUC would begin bringing in outside subject matter experts on internal investigations.

Transparency isn’t the only problem

The new audit report also shows slow progress by OUC in implementing recommendations from previous reports in 2021 and 2022. McGaffin recently gave a progress report to the DC Council and committed to finishing this work. Here’s what Patterson wrote:

Patterson also made note of DC 911’s continuing inability to meet national standards on call processing times:

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