NEW: DC 911 sends fire & EMS to wrong address for newborn in cardiac arrest

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A one-day old girl is dead and STATter911 has learned firefighters and medics who might have been able to save her lost precious time after DC 911 dispatched them to the wrong address. At a moment when seconds count, it took about 10 minutes before DC Fire and EMS crews determined the Office of Unified Communications (OUC) sent them to an apartment where no one was home. In addition, the mistake was compounded by not alerting fire and EMS when the call was updated with the correct address. It was left up to firefighters and medics to find the right location by scrolling through dispatch notes on a computer screen while responding to the call.

The July 3 incident is at least the eighth time in three years DC 911 made crucial errors that delayed the emergency response to an incident where someone died. No one can say with certainty if newborn Sevyn Schatzman-Chase or any of the other seven people would have survived with a faster response. Still, it’s clear the potential life-saving role of firefighters, medics and police officers is hampered by these delayed responses. Some of the same mistakes made in previous incidents were repeated as fire, EMS, and 911 tried to save the baby.

In this most recent case, when the first paramedics arrived at the correct Southeast apartment, they found the girl’s mother doing CPR on her child. The efforts to revive Sevyn continued to Children’s Hospital in Northwest where she was pronounced dead.

In a statement to STATter911, OUC admits the 911 call-taker initially “recorded the address incorrectly in the dispatch system.” OUC also says about eight minutes later — while still talking with Sevyn’s mother and giving her CPR instructions — the call-taker realized their mistake and put the updated address in the dispatch notes. But another mistake was made. According to OUC, the call-taker didn’t update the “location” field in the dispatch system. In other words, they didn’t clearly change the address of the call. The statement does not say if the second mistake is the reason dispatchers failed to immediately relay by radio the new address to responding fire and EMS units. Read OUC’s entire statement and timeline at the bottom of this post.

Timeline

When Shartise Schatzman and Dalante Chase woke up to find their one-day old girl not breathing Schatzman says she immediately called 911. Schatzman tells STATter911 she’s certain she told 911 her correct address on Savannah Terrace Southeast multiple times. But that’s not where help was sent.

OUC confirms Schatzman gave the correct address when the call was received at 2:26 a.m. Instead of Savannah Terrace, the call-taker entered Savannah Street into the computer dispatch system. Savannah Street is another road in the same neighborhood where Schatzman and Chase live. The two locations are less than a half-mile apart.

Radio traffic recorded by OpenMHz.com and OUC’s timeline shows about 90 seconds after the 911 call was received, DC 911 dispatched an engine, paramedic ambulance and EMS supervisor to a “cardiac” call on Savannah Street in Southeast Washington (listen above).

Engine 32 is the closest fire and EMS unit to both Savannah Street and Savannah Terrace. According to OUC, its crew was the first to arrive at the Savannah Street address — the wrong location — at 2:35 a.m. The firefighters didn’t get an answer at that apartment. Just before 2:37, Engine 32 asked the dispatcher by radio to call back the number to verify the address. At the same time, the EMS supervisor (EMS 3) called on the radio to Engine 32 saying he sees “Savannah Terrace” mentioned in the dispatch notes (listen above).

The “dispatch notes” refers to additional information about the call entered into the computer system by 911 call-takers and dispatchers. It displays, not only throughout the 911 center, but on computer screens in firehouses, along with emergency vehicles.

In its statement, OUC didn’t specifically confirm dispatchers failed to relay the address change by radio to firefighters and medics. But radio traffic and sources familiar with the incident confirm that’s exactly what occurred. Because of this, it was left to the responding units to scroll through the notes to discover this critical address update. STATter911 has documented numerous times where DC 911 failed to relay key information, including address changes, to DC Fire & EMS.

According to OUC, Medic 25, about three minutes behind Engine 32, was the first fire and EMS unit to arrive at the correct location — Savannah Terrace. OUC says this occurred at 2:36:23. This was 21 seconds before Engine 32 even reported Savannah Street was a bad address and EMS 3 talked about Savannah Terrace being in the notes. It’s quite possible the crew from Medic 25 read the notes themselves and diverted to Savannah Terrace, but officials have not confirmed that.

STATter911 asked OUC to view the underlying data they used to create the timeline. They declined. STATter911 has numerous sources connected to the response early that morning who question this part of the timeline. They believe Medic 25 arrived a minute or two after the radio transmissions from Engine 32 and EMS 3. The sources say there’s also data to back that claim.

In addition, OUC’s timeline shows that at 2:37:40, “Medic 25 goes over the radio and confirms that CPR is in progress” on Savannah Terrace. That’s more than 11 minutes after the initial 911 call. You may note that OpenMHz, whose other times are very close to the ones provided by OUC, shows that specific radio transmission occurred almost two-minutes later at 2:39:26 (listen above).

Computer aided dispatch data has been provided by OUC to the press and public in many previous incidents. It would clear up this conflicting information and add more clarity on how soon paramedics reached Sevyn. Again, OUC has declined to share that information with STATter911.

Recurring mistakes

This is the fourth incident this year uncovered by STATter911 where DC 911 made mistakes that significantly delayed fire, EMS or police during an emergency response where someone died. In six of the eight deaths we’ve learned about since 2019 911 workers either failed to promptly establish the correct address or didn’t relay updated location information.

DC 911 dispatchers failing to alert, by radio, responding emergency personnel to important information found in dispatch notes happens multiple times each day. From listening to the daily radio traffic, it’s most noticeable when responses are cancelled by the 911 caller. It’s the exception rather than the rule that a dispatcher alerts DC Fire & EMS units they’re no longer needed. Instead, it’s very common to hear units call the dispatcher and ask if they’ve been cancelled based on a note they caught on the computer while responding or after they arrived at the location.

In the past, dispatchers have failed to warn firefighters and medics about serious situations that were in the dispatch notes. This includes information a patient has a weapon or other potential for violence at an emergency scene. In the March 14 death of David Griffin in the Washington Channel there was a lot of information about Griffin’s actions not relayed to responding police, including an updated location. The public and an ambulance crew told DC 911 Griffin was out of control, jumping on cars, harming himself, and an apparent threat to others. None of that information was relayed to police who didn’t reach Griffin for 30 minutes. At that point, Griffin was already in the water.

Investigating itself in the Griffin case, OUC’s acting directing Karima Holmes said the delays sending police were not OUC’s fault — something that’s in stark contrast to the agency’s own timeline and information officially provided by DC Police. The only criticism Holmes had for her staff following Griffin’s death was that a police dispatcher failed to properly enter an address update. This is similar to what happened in the Savannah Terrace case. Read more about David Griffin’s death here.

Sevyn’s parents

DC 911 gave Sevyn’s mother CPR instructions over the phone. Schatzman says she continued compressions until Medic 25 showed up in her apartment and took the baby from her. The parents knew it was taking a long time for help to arrive but didn’t know mistakes were made until STATter911 contacted them last Saturday,

As you can imagine, Schatzman and Chase are struggling with their loss and this news. They’re also struggling with the expense of a funeral for Sevyn. Family and friends have started a GoFundMe page.

Below is the full response from OUC to STATter911’s questions about the death of Sevyn Schatzman-Chase:

I am responding to your inquiry below about the 7/3 call to the 2100 block of Savannah Terrace SE; Washington, DC 20020. Our mission is to provide accurate, professional, and expedited service to the citizens and visitors of the District of Columbia. We are committed to answering over 10,000 calls daily and three million calls annually.

We have reviewed this call, and below is our unofficial timeline of the incident. On July 3, 2022, at approximately 2:26:03am we received a call for emergency services in the 2100 block of Savannah Terrace SE. The OUC Call Taker verbally verified the address twice, recognized the need for cardiopulmonary resuscitation (CPR) within 59 seconds of the call coming in, and immediately started giving telephone CPR instructions. Initially, the OUC Call Taker recorded the address incorrectly in the dispatch system as the 2100 block of Savannah Street SE, about .4 miles from the verified address location of the 2100 block of Savannah Terrace SE. The OUC Call Taker updated the correct address in the dispatch notes in the dispatch system at approximately 2:34:21am. The OUC Call Taker did not update the location field in the dispatch system. A Metropolitan Police Department unit arrived at the 2100 block of Savannah Terrace SE at approximately 02:35:31am. Medic 25 arrived at the 2100 block of Savannah Terrace SE at 2:36:23am.

Our internal review revealed that the first OUC Call Taker verified the address verbally twice in accordance with our standard operating procedures. The OUC Call Taker initially selected the wrong address in the dispatch system, and corrected it in one of two fields in the dispatch system. The OUC Call Taker started telephone cardiopulmonary resuscitation, and continued providing instructions until Medic 25 arrived.  

The Office of Unified Communications continues to consistently develop and train its team members to meet our Agency’s mission. When necessary, we take appropriate personnel action in accordance with our policies and collective bargaining agreement. 

Unofficial Office of Unified Communications Call Timeline – Summary of Notable Activities

July 3, 2022 Incident on the 2100 Block of Savannah Terrace, SE 

Time	Notable Activity	Time from Previous Activity
2:26:03	First 911 call received	0 Seconds
2:26:25	OUC 911 Call Taker verifies the address with the caller twice as Savannah TERRACE, SE	22 seconds
2:26:55	OUC 911 Call Taker sends the call to be dispatched to Savannah STREET, SE	30 seconds
2:27:04	Call taker begins providing CPR instructions	9 seconds
2:27:33	FEMS units (Medic 25, Engine 32, and EMS 3) are dispatched to Savannah STREET, SE	29 seconds
2:33:34	Second 911 call received from a second caller; second caller provides address as Savannah TERRACE, SE	6 mins 1 seconds
2:34:21	First OUC 911 Call Taker continues to provide CPR instruction; verifies address for a third time and enters the correct address in the call dispatch notes but does not correct the incident location field	13 seconds
2:35:03	Engine 32 arrives at Savannah STREET, SE	29 seconds
2:35:31	Second 911 caller reports to the second OUC 911 Call Taker that MPD is on the scene at Savannah TERRACE, SE and that CPR is still in progress	8 seconds
2:36:08	Second OUC 911 Call Taker asks the second caller to verify the incident location; the second caller reports that the incident location is Savannah STREET, SE	35 seconds
2:36:23	Medic 25 arrives at the incident location Savannah TERRACE, SE	15 seconds
2:36:44	Engine 32 goes over the radio to request that the address be verified	21 seconds
2:37:00	EMS 3 goes over the radio and advises that the correct incident location is Savannah TERRACE	16 seconds
2:37:40	Medic 25 goes over the radio and confirms that CPR is in progress	40 seconds