A list to help you understand DC911’s chronic dysfunction

An apparently frustrated US Park Police officer had to drive a stroke victim whose “condition was deteriorating” to the hospital on Friday. This happened after the officer waited 20 minutes for EMS, which never arrived at an intersection just a block from the White House. This was at least the 23rd time in the last six months that DC911 dispatched units to the wrong street address or wrong quadrant of the city. In Friday’s case, EMS was sent to two wrong locations, far away, in Northeast DC.

When will DC’s political leader finally level with their constituents that the Office of Unified Communications doesn’t work? When will the news media treat the continued failures of a crucial public safety agency in the nation’s capital as a major story that deserves continuing attention?

The list of 37 incidents below shows that DC911 is still in crisis and fails at the basics of the job. Yet, none of these incidents has sparked outrage by local leaders or even a single news story. It’s not just about 23 blown addresses. There are other patterns of mistakes. The list includes six instances in which dispatchers abandoned an emergency radio channel. That means they just flat out didn’t answer the radio for minutes at a time. That has happened at least 27 times since Director Heather McGaffin began running the agency in early 2023. There have also been at least ten incidents since December where dispatchers botched or delayed the upgrading of a call or didn’t send the correct assignment of fire and EMS apparatus. This includes failing to dispatch fireboats on a recent drowning at the District Yacht Club.

In this list, those marked * were reported on OUC’s Performance Dashboard. The quotes posted with those incidents are from OUC’s findings published on the dashboard. The rest of the incidents were compiled by STATter911. Two that are marked ** were reported by both OUC and STATter911. Twenty-one of the incidents I reported are not on the Performance Dashboard, despite a law that requires OUC to list them. I have the receipts to confirm that each incident occurred as reported (follow the links).

THE LIST

• May 22: US Park Police drove a stroke victim to the hospital after waiting 20 minutes for an ambulance that was twice sent to the wrong quadrant of the city. Police said the patient’s “condition was deteriorating.” While STATter911 does not know if a US Park Police dispatcher initially provided OUC with the correct location, the radio traffic shows that even if they were wrong, the mistake should have been caught by OUC at least 15 minutes earlier.
• May 18: Dispatchers left an emergency radio channel unattended for two minutes, missing 11 radio transmissions from five DC Fire & EMS units.
• May 16: Dispatchers failed to assign fireboats and a water rescue assignment to a reported drowning at a boat launch and docks on the Anacostia River.
• May 5: Dispatchers lost eight minutes sending help requested by firefighters trying to free a person trapped in a car following a crash one block from the White House. They sent the requested help to a different crash along Suitland Parkway SE near DC’s border with Prince George’s County.
• April 23: Dispatchers delayed sending help requested to extinguish the Metrobus fire in the 9^th Street Tunnel. It was so bad that a flustered dispatcher, who said they were having computer problems, apologized on the radio to the incident commander about the delay.
• April 22*: A call taker failed to make “additional efforts” to confirm the address for someone stuck in an elevator.
• April 21*: A call taker “entered the incorrect address” for a person stuck in an elevator.
• March 31: Four minutes were lost when dispatchers sent DC Fire & EMS to Northeast for a report of multiple overdoses at 13^th Street and New York Avenue NW.
• March 22: It took four radio calls over two minutes before a battalion chief got a dispatcher’s attention. He was trying to alert them to something they should have already known. That the notes entered by DC911 showed they had dispatched DC Fire & EMS units for a car crash that was in Prince George’s County.
• March 20*: A “call taker did not verify the address as trained” for a police call involving a burglary.
• March 9*: A “call taker misclassified the call and did not select the correct quadrant of the city” during an EMS call for a sick child.
• February 27*: A “call taker entered the incorrect address” for a police call involving a parking complaint.
• February 24*: A “call taker failed to enter the correct address ultimately provided by the caller” during an EMS response for a seizure.
• February 23*: A “call taker entered the incorrect address” during a police call for a hit and run of a parked vehicle.
• February 22*: A “call taker entered the incorrect address” for a police call involving a dispute.
• February 9**: Sixteen minutes were lost when DC911 sent EMS units to the wrong quadrant of the city for someone experiencing trouble breathing. Five of those minutes were lost because dispatchers failed to listen to a firefighter who tried to tell them the call was in Northwest and not in Northeast. OUC simply wrote that a “call taker selected the incorrect quadrant.”
• February 9: There were six minutes of confusion over the location of a stabbing. OUC wasn’t sure if it was in Northeast or Southeast, sending fire and EMS units to both locations.
• February 5**: OUC dispatched an assignment for a fire to 1200 15th Street NW that was meant for a fire at 1200 Clifton Street NW at Cardozo High School. OUC wrote that “a call taker entered the incorrect address.”
• January 31: OUC dispatched DC Fire & EMS to a motor vehicle accident on Ohio Drive SW. The motor vehicle involved turned out to be a train that hit a pedestrian. It took 14 minutes before the proper rescue assignment was dispatched. This mistake came a year to the week after the same error was made when a person was hit by a train at the Anacostia Metro Station.
• January 30: Dispatchers caused confusion by dispatching a second alarm assignment that was not requested by a DC Fire & EMS incident commander.
• January 23: Dispatchers sent a call for an unconscious person on the National Mall to an address five miles away.
• January 22: A radio channel was abandoned, causing a battalion chief’s seven radio transmissions over two minutes to go unanswered.
• January 21: Five minutes were lost sending additional equipment requested by an engine company to handle a hazmat incident at a building on Connecticut Avenue NW.
• January 14: Dispatchers abandoned an EMS radio channel, failing to answer an ambulance five times over two minutes. It took the intervention of the Fire Operations Center to get a response.
• January 14*: A caller provided an incorrect address for an accident where no one was hurt, but OUC wrote that “the call taker should have better used tools available to them to verify the location.”
• January 9: Thirteen fire and EMS units were sent to 22 M Street SW for a report of a fire. The correct location was 222 M Street SW.
• December 29: Five minutes were lost when a report of a pedestrian struck on Rhode Island Avenue in Northwest was dispatched to Rhode Island Avenue in Northeast.
• December 25: Dispatchers mishandled upgrading a fire call on Spring Road NW.
• December 25: Dispatchers mishandled upgrading a fire call on Q Street NE.
• December 20: An EMS radio channel was abandoned by dispatchers who missed seven radio transmissions in three minutes.
• December 17: OUC mishandled the upgrading of a call for a report of a woman struck on a scooter being trapped under a car on Connecticut Avenue NW.
• December 14*: A “call taker entered the incorrect address” for an EMS call involving a sick person.
• December 9*: A “call taker entered the incorrect address” during a police call for found property.
• December 8*: A “call taker entered the incorrect street type, street instead of place” during an EMS call for a person who fell out of bed and was injured.
• December 2*: A “caller provided the incorrect address, but the call taker should have better used tools available to them to verify the location” during a small kitchen fire.
• December 2*: A “call taker entered the incorrect address” for an EMS call for chest pains.
• December 2: Dispatchers abandoned an EMS radio channel for four minutes during a cardiac arrest call. The dispatchers also didn’t relay a call taker’s priority notes that the patient, home alone, was unresponsive until 19 minutes into the call. On April 14^th, OUC Director Heather McGaffin wrote Council member Brooke Pinto that despite these major delays, “appropriate action” was taken by her staff during the call. She provided no documentation to back up that claim, and the incident is not listed on the Performance Dashboard.

THE PATTERNS

The list above does not include three incidents of poor “customer service” reported by OUC. The STATter911 incidents come from mistakes I’ve monitored or have been reported to me by people working at OUC or DC Fire & EMS. While OUC has improved its public reporting of address mistakes, the agency’s list is far from comprehensive. I’m certain there have been other significant mistakes that have not been reported by OUC or me.

It’s important to understand when OUC writes that a “call taker did not verify the address as trained” or didn’t “use the tools available”, that this is a problem first identified in a 2021 report published by the Office of the DC Auditor. One of the findings from that report was that call takers were reluctant to use location-determining technology to help verify an address. The technology can alert call takers when there is a conflict between the address they entered into the dispatch computer and the location shown by the data received from the caller’s cell phone. Used effectively, it can help prevent address errors.

The January 23rd call for an unconscious person on the National Mall represents another chronic mistake. For years, DC911 call takers have confused addresses on the Mall along Jefferson Drive SW with Jefferson Street NW, located in a neighborhood five miles away. They have the same hundred blocks. The same thing occurs with Madison Drive NW, Madison Street NW, and Madison Place NW. It has occurred so many times that it has become predictable that call takers will make this mistake. That means it’s preventable. But OUC must make the effort to prevent it. That requires excellent leadership focused on training and accountability. Read more here.

The abandoned radio channels issue is another long-standing performance pattern at OUC. STATter911 first reported this problem in February of 2020. This is not a technology issue. This is a personnel problem. Without warning, an emergency radio channel is left unmonitored. It often happens during break periods when another dispatcher is supposed to be covering the channel for the person on break.

In early 2021, former interim OUC director Cleo Subido explained to DC Council member Janeese Lewis George (video above) that it often occurs when dispatchers make mistakes combining two radio channels or when a dispatcher is not at their console and is walking around using a portable radio. Subido told the Council she stopped both of those practices.  When that happened, the number of incidents dropped significantly. After Subido left in January of 2022, abandoned radio channels again became a frequent occurrence. Current director Heather McGaffin has testified that she does not prohibit the combining of channels or the use of portable radios.

STATter911 reported late last year that there are incidents of OUC staff sleeping at their consoles and using dispatch computers and cell phones to shop online and play video games. Heather McGaffin has testified before the DC Council that those things are prohibited at OUC. In April, a DC Office of Inspector General’s report on risk management confirmed that McGaffin’s claim is suspect. They wrote that “OUC’s Prohibited Items Policy contains
contradictions and is inconsistently enforced.”

These two lines from the report strongly suggest that the priorities at DC911 aren’t always as McGaffin portrays:

Supervisors and managers reported that cellphone usage  distracts staff from critical tasks and requires constant supervisory intervention to maintain focus on emergency operations. The unclear policy undermines operational discipline in an environment where staff attention and accuracy are essential for effective emergency response.

Through cameras on the operations floor that are recorded 24/7, the director can see exactly what dispatchers were doing when radio channels were not being answered. McGaffin has never publicly provided such an answer for any of the 27 incidents of abandoned radio channels reported by STATter911 since she took over.

This failure by McGaffin speaks to the more global problem of transparency. Despite a commitment during her 2023 confirmation hearing to being open and transparent, McGaffin has not followed through. It remains almost impossible to get candid answers about 911 mistakes, big and small.

As much as the director needs to start holding her staff accountable and putting a stop to these chronic mistakes, it seems to be long past time for someone to begin holding Heather McGaffin accountable.