DC 911 sends another cardiac arrest call to the wrong address

Looking for a quality used fire truck? Selling one? Visit our sponsor Command Fire Apparatus

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.

• 12/21/2019 Dispatch to 1432 Girard Street NE instead of 1432 Girard Street NW for a reported building fire.
• 1/13/2020 Dispatch to 810 1st Street NW instead of 810 1st Street NE for a reported building fire.
• 2/1/2020 Dispatch to 106 13th Street NE instead of 106 13th Street SE for a reported house fire.
• 2/2/2020 Dispatch to 54 D Street SE instead of 54th Street & D Street SE for a stabbing.
• 2/19/2020 Dispatch to Georgia Avenue & 7th Street NW instead of Georgia Avenue & Elder Street NW for a pedestrian struck.
• 2/24/2020 Dispatch to 1940 2nd Street NE instead of 19 42nd Street NE for an allergic reaction.
• 2/27/2020 Dispatch to the 3600 block of Water Street NW in Georgetown instead of the 3600 block of Warder Street NW for difficulty breathing.
• 2/29/2020 Dispatch to 4226 Brandywine Street NW instead of 426 Brandywine Street SE for a reported cardiac arrest. (NOTE: Part 2 of the recording is here.)
• 2/29/2020 Dispatch to 3555 Wisconsin Avenue NW instead of 5355 Wisconsin Avenue NW for an overdose.
• 3/1/2020 Dispatch to 1901 1st Street NW instead of 901 1st Street NW for trouble breathing.
• 3/1/2020 Dispatch to the Days Inn at 54 New York Avenue NE instead of the hotel’s correct location at 2700 New York Avenue NE for a woman in labor.
• 3/4/2020 Dispatch to the wrong Florida Avenue & R Street NW multiple times for an overdose.
• 3/8/2020 Dispatch to 95 C Street SW instead of 95 M Street SW for chest pains.
• 5/14/2020 Dispatch to 3220 12th Street SE instead of 3220 12th Street NE for a gas leak. (NOTE: This call was then re-dispatched for a second time to 3220 12th Street SE, which was the correct location.)
• 5/17/2020 Dispatch to 3100 Wisconsin Avenue NW instead of 4100 Massachusetts Avenue NW for childbirth.
• 5/22/2020 Dispatch to 11 Anacostia Avenue NE instead of 11 Anacostia Road NE for a shooting.
• 6/3/2020 Dispatch to Southern Avenue & Owens Road instead of Southern Avenue & Bowen Road SE for a double shooting.
• 6/5/2020 Dispatch to the 400 block of Oglethorpe Street NW instead of the 400 block of Oglethorpe Street NE for cardiac arrest.
• 6/15/2020 Dispatch to 4545 Brandywine Street NW instead of The Brandywine Apartments at 4545 Connecticut Avenue NW for a reported apartment fire.
• 6/27/2020 Dispatch to 1700 Kalmia Road NW instead of 1700 Kalorama Road NW for an auto fire.
• 6/30/2020 Dispatch to 1717 Montello Avenue NE instead of 1717 Montana Avenue NE for abdominal pains.
• 6/30/2020 Dispatch to 19th Street & L Street NE instead of 19th Street & M Street NW for a man down.
• 7/7/2020 Dispatch to 12th Street & Constitution Avenue NE instead of 12th Street & Constitution Avenue NW for an overdose.
• 7/9/2020 Dispatch to 2400 Queens Chapel Road NE instead of 2400 Queens Chapel Road in Mount Rainier, MD for a lift assist.
• 7/13/2020 Dispatch to 1209 G Street NE instead of 1201 G Street NW for an allergic reaction.
• 7/18/2020 Dispatch to 201 I Street SE instead of 201 I Street SW for trouble breathing.
• 7/18/2020 Dispatch to 4607 Chesapeake Street NW instead of The Chesapeake Apartments at 4607 Connecticut Avenue for an oven on fire.
• 7/21/2020 Dispatch to 7th Street & H Street NE instead of 7th Street & H Street NW for trouble breathing. (NOTE: this wrong address was dispatched twice.)
• 8/2/2020 Dispatch to the Anacostia Community Boathouse instead of the Capital Cove Marina for a triple drowning. (NOTE: OUC confirmed for reporter Peter Hermann of The Washington Post that this occurred because of an error by a dispatcher.)
• 8/10/2020 Dispatch to 12th Street & Perry Street NE instead of 1600 V Street SE for a DC Fire & EMS ambulance struck by a vehicle being chased by police.
• 8/23/2020 Dispatch to a nonexistent 7th Street exit on I-695 or I-295 in SE instead of I-395S at 7th Street SW for a person who fell or jumped off an overpass and was hit by a vehicle.
• 8/25/2020 Dispatch to 4301 Wheeler Road SE instead of 4405 Southern Avenue (Prince George’s County) for a double shooting. (NOTE: In an interview with Kojo Nnamdi on September 2, OUC Director Holmes said, “We had distraught mother calling us trying to find her victim daughter. She didn’t know where she was. We sent responders to the address that she thought her daughter was at.”)
• 8/25/2020 Dispatch to Suitland Parkway & Firth Sterling SE instead of Suitland Parkway & Stanton Road SE for fatal car crash. (NOTE: A second wrong dispatch was to Suitland Parkway & Alabama Avenue SE for an auto fire. Part 2 of the recording is here.)
• 8/31/2020 Dispatch to Rock Creek Parkway & Beach Drive NW instead of Beach Drive and Porter Street NW for a car crash.
• 8/31/2020 Dispatch to 1724 Randolph Street NE instead of 1724 N. Capitol Street at Randolph Place NW for a shooting. (NOTE: In an interview with Kojo Nnamdi on September 2, OUC Director Holmes said ,”The caller gave us that wrong address. We verified it three times.”)
• 9/1/2020 Dispatch to 24 G Street NW instead of 24^th Street & G Street NW for a seizure.
• 9/2/2020 Dispatch to 108 Atlantic Street SW #204 instead of 108 Atlantic Street SW #204 for an unconscious person.
• 9/2/2020 Dispatch to 37 1^st Street SE Apt. 101 instead of 3720 1^st Street SE for a headache.
• 9/7/2020 Dispatch to 22 M Street NE Apt. 513 instead of 222 M Street SW for a confirmed cardiac arrest.